Press Alt + R to read the document text or Alt + P to download or print.

No preview available

The URL can be used to link to this page

Home My WebLink AboutMiscellaneous - 1180 TURNPIKE STREET 4/30/2018 (3)h CD o i y fi x I� 1; rt 1 f J I CLIJ �cS�1J541 C,jp�� ca, = r5 WATER SUPPLY: =-NWELL WELL PERMIT DRILLER WELL TESTS: PLUMBING SIGNOFF COMMENTS: CHEMICAL DATE APPROVED BACTERIA I DATE APPROVED BACTERIA II DATE APPROVED WIRING SIGNOFF FORM U APPROVAL: APPROVAL TO ISSUE YES NO DATE ISSUED ZD BY CONDITIONS: FINAL APPROVAL: ALL PERMITS PAID YES NO WELL CONSTRUCTION APPROVAL YES NO SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO OTHER YES NO ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: BY: .I t MAP LOT # PARCEL # 3 STREET CONSTRUCTION APPROVAL HAS PLAN REVIEW FEE BEEN PAID? YES NO PLAN APPROVAL: DATE. APP. BY DESIGNER: ~D1J��C��1 PLAN DATE�a2��7 CONDITIONS WATER SUPPLY: =-NWELL WELL PERMIT DRILLER WELL TESTS: PLUMBING SIGNOFF COMMENTS: CHEMICAL DATE APPROVED BACTERIA I DATE APPROVED BACTERIA II DATE APPROVED WIRING SIGNOFF FORM U APPROVAL: APPROVAL TO ISSUE YES NO DATE ISSUED ZD BY CONDITIONS: FINAL APPROVAL: ALL PERMITS PAID YES NO WELL CONSTRUCTION APPROVAL YES NO SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO OTHER YES NO ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: BY: -� SEPTIC SYSTEM INSTALLATION IS THE INSTALLER LICENSED? ES NO TYPE OF CONSTRUCTION: REPAIR NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW YES NO CONDITIONS OF APPROVAL YES NO (FROM FORM U) ISSUANCE OF DWC PERMIT ES NO DWC PERMIT PAID?n)r ES NO DWC PERMIT N0. 9 �t (Q INSTALLER: /114,11 A0 BEGIN INSPECTION r-' 0'` YES Nb: EXCAVATION INSPECTION: NEEDED: PASSED ,%/ AL Z-- �Z 7 BY � v CONSTRUCTION INSPECTION: NEEDED: AS BUILT PLAN SATISFACTORY: YES: , Z _-� o APPROVAL TO BACKFILL: BY G FINAL GRADING APPROVAL: DATE /-' BY f/ FINAL CONSTRUCTION APPROVAL: DATE:,4447--p BY U) CO LLI cr0 0 Q J W U o � m U w ago O N 0 (1) m O O CL 0 0 0-H D nM. 0 m c CD CU � O 00 N O Y U O J ED 1 N N O O O W c6 co V C4 N LL N 4 I O U J J N I-- �. N 0000 W 7 M O O O O O Z W 0i LL 00 Nil! 0 o N Z a 0 C) c m Oa(0 O Cl) 00 .... J J mJ m N F'O am Y cu E'F X a O_ w C r 'O a O m a) mn U a) O wCYU S0 O Oa Z m )'1 1 t+ 1 N :L O O J -i Z v ZU0 I! 1 Lu DC7 Ooo !� c0 L` coo U Z v o O Q =cn v Qm —vv W 0 00 � Z m H} O F-- LO N 'IT r-- ii- �aS — Zfn Q 0 W �aU N a�w C14_ amm l � Y ai J V N Q a O U Q.� .2 O-' T•p Q > O O Z a o� i ~ O U Q) � O W O� a� a> a? 2 m �U�w 3 m U o � Q� vv H cn in co U) C9 LY H in LLJ : C Q a) O T" orn O T UH a r ns o CD rn Q`D_ Fob O (D N lnrn U 2 �a H' N (D LO C0 X U) McO Z cn N U CL ai cu mai a) v o v o a cn< om ai0� co v v O m U U C V... tV N V d M Cl) cb IL O N N Q Lu ca aI 7 �N N¢ .•�-Oii m N O m b. co E zQ u, co U) .i ' N C N UY 0 0 "' QmLLco w2cS000 ND (D �� pMj Z N � N �_ U u3 N LL C/) N _O W ai LL W N CQ N N LL Q��o Qa- O c: C Q¢ Q E -O NN,O0 LL ChaCmai _ N LvL a ( N Z O CLL- 60OOO CO m0O B LmO L dL ZO U DQDw}o0- a U U) V- N OQ W 00 V N� AcG CND N O U a LL Z O w o Z W X Co LL vi N ui iL U (n LL J W Q Q E E t L t Or m mcn m O (D W HW� fn Oomm ma, u'.� 00C a L LL � U LL CO W _ m��Y C� N N N."--� Lv m wZw ; 1-22Y 6&f5 Tv�„ P°KP N N N N N N N N N N N N N N N N N N N W CO OD W CO W .G �D "O N N N N W W W W W W W W W W F F F F F -. '� O 0 0 0 0 0 W W F W W W LJ1 O O F F W O'• F F O Fs 5 D D W F "D T N N F tJl rl O T OD 3.-oD a n D D D 0 '0 a D -i o v e n mx x x x x --{ n x z z S A� O O O fD N O S Z C C C C C O O S S C �_ �_ 7 7 rt R' � 7 7 7 fD C ^ N N l0 LD 40 {L 7 7 fA fy l0 ^ —. _ 0 -S - 3 rt N 7 S S S S S -- -- VI N S fD N fD 6 B rD S fD N -- -- — In fD .+ N fD fD fD M fD fD [Al N In 7 N " Gl Gt Cl " O O rt CD -r �+ Ate' O N fD L . . . l_ M fD fD 6 3 3 w fy fD fD fD C S 'D '-s 0 N fD fD fD f➢ fD fD fD N N N C C fD N fD O `C co 7 7 7 'S `< S 7 7 7 7 7 7 7 `C' `C 7 7 7 7 N w f1 f1 7 7 'S f1 f1 f1 w 7 W fD 7 7 7 7 7 L 7 fD fD -- - fD fD fD 0 O' -n -n �+ �+ 7 7 fD fD M + 7 7 M fD j 7 7 7 ..� fD m fD fD fD N fD fD Z 1rD a4/i 0, kc. �o7-�" Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. 0Q rerwn Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1180 Turnpike Street Property Address Jennifer and Robert N Owner's Name North Andover MA 01845 5/30/2017 City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be al any way. Please see completeness checklist at the end of the form. 9` ' i, 12sG 'rinAI A. General Information Inspector: James D Aguiar Jr. Name of Inspector Tri -Spec Corporation Company Name PO Box 1549 Company Address Westport City/Town 508-676-7784 Telephone Number B. Certification MA State 4332 License Number 02790 Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 5/81/2017 _ I nsplqtor's I t Date z The system inspects I submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ***`This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1180 Turnpike Street Property Address Jennifer and Robert Keegan Owner's Name North Andover City/Town B. Certification (cont.) MA 01845 State Zip Code 5/30/2017 Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ❑ I have not found any information which indicates tha y of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. y failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): System is functioning as designed, No Back-ups or High -Liquid Levels have been detected However, -the Septic Tank and Dbox Inspection covers were both cracked and broken (they were both - haphazardly repaired by a previous Inspector in July of 2016' using landscape blocks from a stockpile located at the home) Additionally, deterioration and structural cracking was found in both the Septic Tank and the Dbox, both of these System components need to be replaced, both covers were temporarily replaced and sealed with plastic to prevent collapse and water infiltration. Both components should be replaced expediently to prevent damage to the System. _ t t5ins.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1180 Turnpike Street Property Address Jennifer and Robert Keegan_ Owner's Name North Andover MA 01845 5/30/2017 City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): !*'see above notation... The liquid'levels were all normal with no signs of back-up or hydraulic failure. The Septic Tank and Dbox need to be replaced to prevent any permanent damage from occuring to / this Svstem. -J ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determL6 in accordance with 310 CMR 15.303(1)(b) that the system is not =of n as manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 59ace water ❑ Cesspool or privy is wifhin 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 3 of 17 Commonwealth of Massachusetts N W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 0. 1180 Turnpike Street Property Address Jennifer and Robert Keegan Owner Owner's Name information is North Andover MA 01845 5/30/2017 required for every -- — _ — — page. City/Town State Zip Code Date of Inspection B. Certification (cont.) J_ 2. System will fail unless the Board of Health (and Public Water'supplier, if any) determines that the system is functioning in a manner that l,"ctects the public health, safety and environment: ❑ The system has a septic tank and soil absorption sy em (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a su ace water supply. ❑ The system has a septic tank and SAS and AS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS a d the SAS is within 50 feet of a private water supply well. ❑ The system has a 'septic tank and SAS nd the SAS is less than 100 feet but 50 feet or more from a private water supply w� *. Method used to determine distan ** This system passes/bsent er analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicd the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,o other failure criteria are triggered. A copy of the analysis must be attached to this for 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/ day flow t5ins.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1180 Turnpike Street Property Address Jennifer and Robert Keegan Owner Owner's Name information is North Andover _ MA 01845 5/30/2017 required for every v _ page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet ofa s r-facedrinking water supply ❑ ❑ the system is within 200 feet df a tributary to a surface drinking water supply ❑ ❑ the system is Iocated�pp a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or aSnapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D akS'ove the large system has failed. The owner or operator of any large system considered a significathreat under Section E or failed under Section D shall upgrade the system in accordance with4l0 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc - rev. 6/16 11 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 1180 Turnpike Street Property Address Jennifer and Robert N Owner Owner's Name information is required for every North Andover page. City/Town C. Checklist n MA State 01845 5/30/2017 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ ® ❑ ® ❑ Pumping information was provided by the owner, occupant, or Board of Health Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 — Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): BOH PD per t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1180 Turnpike Street Property Address Jennifer and Robert Keegan Owner Owner's Name information is required for every North Andover page. City/Town D. System Information Description: Number of current residents: MA _ 01845 State Zip Code 5/30/2017 Date of Inspection Does residence have a garbage grinder? Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft./1e: etc.): Grease trap present? Industrial waste holding tank p Non-sanitary waste discharged Water meter readings, if availa ® Yes ❑ No ❑ Yes ® No l ❑ Yes ❑ No ❑ Yes ® No 215 GPD Ilons per day (gpd) ❑ Yes ® No current Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts : . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1180 Turnpike Street _ Property Address Jennifer and Robert KeegZn Owner Owner's Name information is North Andover MA 01845 5/30/2017 required for every _. page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: Date last pumped 2015'- per BOH records gallons ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Yes ® No ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts H w Title 5 Official Insp Subsurface Sewage Disposal System For 1180 Turnpike Street D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 20 years - system installeded in 1997' Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): — Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): *appears functional Septic Tank (locate on site plan): Depth below grade: *less than 12" feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 1500 Gal 2" Sludge depth: ❑ Yes ❑ No t5ins.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 ection Form m - Not for Voluntary Assessments Property Address Jennifer and Robert Keegan Owner Owner's Name information is required for every North Andover —_. MA 01845 5/30/2017 _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 20 years - system installeded in 1997' Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): — Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): *appears functional Septic Tank (locate on site plan): Depth below grade: *less than 12" feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 1500 Gal 2" Sludge depth: ❑ Yes ❑ No t5ins.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Insp Subsurface Sewage Disposal System For 1180 Turnpike Street D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? 18" 31- 6-1 "6" 12" field pole - visual Comments (on pumping recommendations,`inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): *System is functioning as designed, No Back-ups or High -Liquid Levels have been detected. However, the Septic Tank Inspection cover was cracked and broken (it was haphazardly repaired byi a previous Inspector in July of 2016' using landscape blocks from a stockpile located at the home) Additionally, deterioration and structural cracking was found in the Septic Tank top and sidewalls above the water line, The Tank appears liquid tight below the water line with normal liquid levels. The cover was temporarily replaced and sealed with plastic to prevent collapse and water infiltration. "When the current homeowner was discussing the location of the Septic System in the yard with me -� he was quick to indicate that the previous inspector damaged the Tank cover when he was removing it and did not replace it." Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fibergZSF] polyethylene ❑ other (explain): Dimensions: Scum thickness Distance from top of scum Distance from bottom Date of last pumping: of outlet tee or baffle m to bottom of outlet tee or baffle Date t5ins.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 ection Form m - Not for Voluntary Assessments Property Address Jennifer and Robert Keegan Owner Owner's Name information is required for every North Andover MA 01845 5/30/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? 18" 31- 6-1 "6" 12" field pole - visual Comments (on pumping recommendations,`inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): *System is functioning as designed, No Back-ups or High -Liquid Levels have been detected. However, the Septic Tank Inspection cover was cracked and broken (it was haphazardly repaired byi a previous Inspector in July of 2016' using landscape blocks from a stockpile located at the home) Additionally, deterioration and structural cracking was found in the Septic Tank top and sidewalls above the water line, The Tank appears liquid tight below the water line with normal liquid levels. The cover was temporarily replaced and sealed with plastic to prevent collapse and water infiltration. "When the current homeowner was discussing the location of the Septic System in the yard with me -� he was quick to indicate that the previous inspector damaged the Tank cover when he was removing it and did not replace it." Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fibergZSF] polyethylene ❑ other (explain): Dimensions: Scum thickness Distance from top of scum Distance from bottom Date of last pumping: of outlet tee or baffle m to bottom of outlet tee or baffle Date t5ins.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts u - . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M a 1180 Turnpike Street Property Address Jennifer and Robert Keegan Owner Owner's Name information is North Andover MA 01845 5/30/2017 required for every — — page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on,,.site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass Dimensions: Capacity: Design Flow: Alarm present: Alarm level: Date of last pumping: Comments (condition of gallons polyethylene ❑ other (explain): gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No Date and float switches, etc.): "Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1180 Turnpike Street Property Address Jennifer and Robert Keegan _ Owner's Name North Andover _ MA 01845 5/30/2017 City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert normal Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage, into or out of box, etc.): *DBox liquid level was normal, No Back-ups or High -Liquid Levels have been detected. However, the DBox cover was cracked and broken (it was haphazardly repaired by a previous Inspector in July of 2016' using landscape blocks from a stockpile located at the home) Additionally, deterioration and structural cracking was found in the DBox top and sidewalls above the water line, The DBox is liquid _tight below the water line with normal liquid levels present. The cover was temporarily repaired, shored with wood and sealed with plastic to prevent collapse and water infiltration. r Pump Chamber (locate on site plan): Pumps in working order: Alarms in working order: Comments (note condition of pump chamber, condition es ❑ No` ❑ Yes ❑ No* mps and appurtenances, etc.): " If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: l5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17 Commonwealth of Massachusetts - W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1180 Turnpike Street _ Property Address Jennifer and Robert Keegan Owner Owner's Name information is North Andover required for every page. City/Town D. System Information (cont.) Type: ❑ leaching pits ❑ leaching chambers ❑ leaching galleries ® leaching trenches ❑ leaching fields ❑ overflow cesspool ❑ innovative/alternative system MA _ 01845 State Zip Code 5/30/2017 Date of Inspection number: number: number: number, length: number, dimensions: number: 3@50' Type/name of technology: --- - Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): "no signs of hydraulic failure are present - a Garbage Disposal is present in this home and it does not appear that the System was designed for a Garbage Grinder... It should be removed from the home to preventa-System damn e_------------ - - -` Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and confic Depth - top of liqu Depth of solids lay Depth of scum lays Dimensions of ces Materials of constr Indication of groundwater inflow t5ins.doc • rev. 6/16 ❑ Yes ❑ No Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1180 Turnpike Street Property Address Jennifer and Robert Keegan Owner's Name North Andover City/Town D. System Information (cont.) MA 01845 5/30/2017 State Zip Code Date of Inspection Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids — Comments (note condition of soil, signshydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Z Commonwealth of Massachusetts N - Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1180 Turnpike Street Property Address Jennifer and Robert Keegan Owner Owner's Name information is required for every North Andover MA 01845 5/30/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand -sketch in the area below ® drawing attached separately r t5ins.doc • rev. 06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 N Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary, Assessments 1180 Turnpike Street Property Address Jennifer and Robert Keegan Owner Owner's Name information is North Andover MA 01845 5/30/2017 required for every --- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: greater than 4' from bottom of system feet Please indicate all methods used to determine the high ground water elevation: /Z/ C 107 Obtained from system design plans on record If checked, date of design plan reviewed 1997' Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Board of Health documents - groundwater does not appear to be a concern at this location - leaching area is elevated to ensure proper j roundwater she aration Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc - rev: 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17 Commonwealth of Massachusetts M Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1180 Turnpike Street _ Property Address Jennifer and Robert N Owner Owner's Name information is North Andover required for every page. City/Town an MA 01845 State Zip Code E. Report Completeness Checklist 5/30/2017 Date of Inspection ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 el TL All it 7N � wA N3rte, t le Ok YN 37— U3 . t,4 Wr a'W Ct m `,IVa o w �.a -h < 11 Y ti wU3U 9n U ti ff 1- CI ljZ 13c 1tR ..t .. W x W > yti24 c F_— °C Z Qw! ti �' a o (1--j Q' T q 4 W O Q,— 11 �J 4i 2 q r' U I! w ti I W maw w O e.s �� — m Q W y j•,r� "r 1 N •y� % 4 Jj- N SLI m QS2x o W r y O O w CL 2 L W O - a W W V V W .m �� N OD ' V 2 ert c y n I ¢? �,,..1� i YY..• O C) y a ivi z Lu Z� a LLJ w _ �t Lai 6 . ;Z W S 7905 o � Town of North Andover HEALTH DEPARTMENT s,emust CHECK DATE: LOCATION: -Z/an Aj as --n!_ i`. H/0 NAME: &e e!g a- n -` CONTRACTOR NAME: or Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco ,' s $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ � Title 5 Report Oill C ss ❑ Other: (Indicate) $ I He agent Initials White - Applicant Yellow - Health Pink - Treasurer J'sSIEPTIC&DRAIN Residential / Commercial Septic Tanks • Cesspools • DTvells - Leaching 11elds Installed, Cleaned or Repaired North Andover Board of Health August 3, 2017 220 Main Street North Andover MA. 01845 RjeCzIVF j) AUG 1 r TOWN OFNOA?01? �y"A1100 TpFPR 4S R To whom it may concern; Today we re- inspected 1180 Turnpike Street, and found the two covers on the septic tank and distribution box to be cracked. We replaced both covers, around the top of the septic tank we parged up some small cracks with hydraulic cement. The dbox is showing some signs of deterioration but working properly, the liquid level is correct and the box is not leaking. Sincerely, lames H. Currier II Owner Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1180 TURNPIKE STREET RECEIVE® AUG 15 2017 T STERH�PANDOVER ATENT BOB KEEGAN Owner Owner's Name information is NORTH ANDOVER MA 01845 8/3/17 required for every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important When filling out forms A. General Information on the computer, use only the tab 1. Inspector key to move your cursor - do not JAMES H CURRIER II use the return . Name of Inspector key. J'S SEPTIC & DRAIN Company Name 131 FOREST ST Company Address MIDDLETON MA 01949 Cityfrown State Zip Code 978-774-6685 S12327 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance -of on site sewage disposal systems. I am a DEP approved system Inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 8/3/17 lns tors Signat� Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. J � 4 „fir+-;�:_t�.pT,•. .y� e..�.4 �.' Corn:nnnwea'th of Massachusetts Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1180 TURNPIKE STREET Property Address XUAN TRUONG Owner Owner's Name information is NORTH ANDOVER MA 01845 7/6/16 required for every page. City/Town State Zip Code Date of Inspection Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. RECEIVED A. General Information AUG 0 12016 1. Inspector: �- TOWN OF NORTH ANDS_ tTH JAMES H CURRIER II Name of Inspector J'S SEPTIC & DRAIN Company Name 131 FOREST ST Company Address MIDDLETON City/Town 978-774-6685 Telephone Number B. Certification MA State S12327 License Number 0194 Zip Coda I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 7/6/16 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t51ns • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Jig Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1180 TURNPIKE STREET Property Address XUAN TRUONG Owner's Name NORTH ANDOVER MA 01845 7/6/16 Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM WORKING PROPERLY B) System Conditionally Passes: Ll One or more system components as described in the "Conditional Pass" section need to be ;-„ ia��ad or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1180 TURNPIKE STREET Property Address XUAN TRUONG Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 page. City/Town State Zip Code B. Certification (cont.) 7/6/16 Date of Inspection ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ ❑ ❑ broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ❑ Y ❑ Y ❑ Y ❑ N ❑ N ❑ N ❑ ❑ ❑ ND (Explain below): ND (Explain below): ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1180 TURNPIKE STREET Property Address XUAN TRUONG Owner's Name NORTH ANDOVER MA 01845 7/6/16 City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1180 TURNPIKE STREET Property Address XUAN TRUONG Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 7/6/16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ❑�Q° Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ❑ �� Any portion of a cesspool or privy is within a Zone 1 of a I,)ublic well. ❑ ❑0 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ❑� Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or ►ess than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 fe t o a surface drinking water supply ❑ ❑ the system is within 200 fee of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17 ` Commonwealth of Massachusetts Title 5 Official Inspection Form a a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1180 TURNPIKE STREET Property Address XUAN TRUONG Owner Owner's Name information is NORTH ANDOVER required for every page. City/Town C. Checklist MA 01845 State Zip Code 7/6/16 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ❑ Were as built plans of system obtained and examined? (if they were not N/A available note as ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information F,-��irilentig4 Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 GPD t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17 Commonwealth of Massachusetts u . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1180 TURNPIKE STREET Property Address XUAN TRUONG _ Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 7/6/16 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Detail Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.). Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: ® Yes ❑ No ❑ Yes ® No ❑ Yes ❑ No ❑ Yes ® No 141.41 GPD Gallons per day (gpd) ❑ Yes ® No CURRENT Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1180 TURNPIKE STREET Property Address XUAN TRUONG Owner Owner's Name information is NORTH ANDOVER required for every page. City/Town D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: MA 01845 7/6/16 State Zip Code Date of Inspection General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Date APPROX 1 YEAR AGO PER OWNER gallons Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Yes ® No ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments F 1180 TURNPIKE STREET Property Address XUAN TRUONG Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 7/6./16 - page. City/Town State Zip Code Date of Inspect.on D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: PLAN DATED 2/4/97 Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: PUBLIC H2O feet Comments (on condition of joints, venting, evidence of leakage, etc.): PLUMBING IN GOOD CONDITION, NO EVIDENCE OF LEAKAGE. Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 10" feet ❑ Yep: F� No ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'6"X5'8" 1500 GALLON Sludge depth: 8 t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1180 TURNPIKE STREET Property Address XUAN TRUONG Owner Owner's Name information is NORTH ANDOVER required for every page. City/Town t5ins - W 3 MA 01845 7/6/16 State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 27" Scum thickness 0-1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? SLUDGE JUDGE Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): TANK DOES NOT NEED PUMPING AT THIS TIME. INLET AND OUTLET TEE'S IN PLACE. LIQUID LEVEL CORRECT. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet ❑ polyethylene ❑ other (explain): Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17 Commonwealth of Massachusetts H . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1180 TURNPIKE STREET Property Address XUAN TRUONG Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 7/6/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Capacity: Design Flow: Alarm present: Alarm level: ❑ fiberglass ❑ polyethylene ❑ other (explain): gallons gallons per day ❑ Yes ❑ No Alarm in working order: Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ❑ Yes ❑ No "Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17 Commonwealth of Massachusetts w - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1180 TURNPIKE STREET Property Address XUAN TRUONG Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 7/6/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): BOX IS LEVEL AND WORKING PROPERLY, LIQUID LEVEL CORRECT NO EVIDENCE OF SOLID CARRYOVER. BOX IS 12" BELOW GRADE. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 3/13 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts Titie official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1180 TURNPIKE STREET Property Address XUAN TRUONG Owner Owner's Name information is NORTH ANDOVER MA 01845 7/6/16 requireor every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system 50' Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SOILS DRY, NO SIGN OF HYDRAULIC FAILURE, VEGETATION NORMAL Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow t5ins • 3/13 ❑ Yes ❑ No Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1180 TURNPIKE STREET Property Address XUAN TRUONG Owner Owner's Name information is NORTH ANDOVER required for every page. Cityrrown MA 01845 7/6/16 State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 17 WE Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1180 TURNPIKE STREET Property Address XUAN TRUONG Owne.'s Name NORTH AND3VER MA 01845 7/6/16 City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1180 TURNPIKE STREET Property Address XUAN TRUONG Owner Owner's Name information is NORTH ANDOVER required for every page. City/Town D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells MA 01845 7/6/16 State Zip Code Date of Inspection Estimated depth to high ground water: 6 feet Please indicate all methods used to determine the high ground water elevation: 3 Obtained from system design plans on record If checked, date of design plan reviewed. 2/4/97 Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: TEST PIT DATA ON FILE WITH B.O.H. Before filing this Inspection Report, please see Report Completeness Checkiist on next page. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Dispos,d System • Page 16 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1180 TURNPIKE STREET Property Address XUAN TRUONG Owner's Name NORTH ANDOVER MA 01845 7/6/16 City/Town State E. Report Completeness Checklist Z Inspection Summary: A, B, C, D, or E checked Zip Code Date of Inspection Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 011 '11-� $J " No. mq r, I/ I crd Card gonerateo on 6112016 11.36 33 AM by Tara N'Iney Town of North Andover Tax Map # 210-107.A-0280-0000.0 Parcel Id 18102 1180 TURNPIKE STREET TRUONG, XUAN H Since Jan 2009 6307 HADLEY ROCK DRIVE KATY, TX 77494 Type Loan Number payor Owner Previous Customer Owner Previous Customer Property Type Zoning3 Active/Inact. From Inactive 8/27/2010 Inactive 9/22/2014 Inactive 2/5/2015 Inactive 5/15/2015 r.vwunt No _ — Cycle Occupant Name Active/Inactive Bldg Id. 13664.0 - 1180 TURNPIKE STREET Last 81111ng Dote 5/11/2016 1090342 01 Cycle 01 Active UB Services Maint. Account No. 1090342 Service Code Rate Charge Muitlpller/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 53.20 A UB Meter Maintenance Pape 1 1 Residential 1 Resldantlal Until Account No 1090342 Serial No Status Location Brand Type Slza YTD Cons 13242884 a Active 00 METE: METE w Water 0,53 0,63 554 Data Reading Code Consumption Posted Date Variance 4/21/2016 1018 aActual 14 5/25/2016 -6% 1/21/2016 1004 a Actual 15 2/19/2016 -22% 10/21/2015 989 aActual 19 11/20/2015 20% 7/2212015 970 a Actual 12 8/14/2015 83% 5/14/2015 958 f Final BIII 2 5/14/2015 •42% 4/23/2015 956 a Actual 15 5/19/2015 -6% 1/22/2015 941 aActual 16 2/20/2015 173% 10/23/2014 926 a Actual 2 11/14/2014 -61% 9/22/2014 923 f Final Bill 10 9/22/2014 -21% 7/2312014 913 aActual 19 8/13/2014 31% 4/22/2014 894 a Actual 14 5/15/20/4 -10° ` 723/ -850 a Actual ` 0148% 10/23/2013 864 aActual 15 11/18/2013 ��0'� -18% .�J It 1 4 v 4 1G•ti� 2•it� 16•G 1�•uu 2.003 12•u 1 5 0 C,C, 011 crd Card goneraled on 61284016 11.38:33 AM by Tare Hurley Town of North Andover Tax Map # 210-107.A-0280-0000.0 Parcel Id 18102 1180 TURNPIKE STREET TRUONG, XUAN H Slnce Jan 2009 6307 HADLEY ROCK DRIVE KATY, TX 77494 Type Loan Number Payct Property Type Zoning3 No, 0864 P. 1/1 Active/Inact. From Page 1 1 Residential 1 Residential Until Owner Inactive 6/27/2010 I36 -Li. 146° ? Prevlous Customer Inactive 9/22/2014 Owner Inactive 215/2015 130` Previous Customer Inactive 5/15/2015 No Cycle Occupant Name Active/Inactive Bldg Id. 13664.0 - 1160 TURNPIKE STREET Lost Billing Date 5/11/2016 1090342 01 Cycle 01 Active UB Services Maint. Account No. 1090342 Service Code Rate Charge Multlpllar/Users MISCFEE ADMIN FEE 0.63518 7.82 1/ WTR WATER 01 ALL METER SIZE 53.20 /1 UB Meter Maintenance Account No 1090342 Serial No Status Location Brand Type Size YTD Cons 13242684 a Active 00 METE METE w Watet 0,63 0.63 554 Data Raading Code Consumption Posted Date Variance 4/21/2016 1018 aActual 14 5/25/2016 .6% 1/2112018 1004 a Actual 15 2/10/2016 -22% 10/21/2015 989 a Actual 19 11/20/2015 20% 7/22/2015 970 a Actual 12 8/14/2015 83% 5/14/2015 958 f Final BIII 2 5/14/2015 •42% 4/232015 956 a Actual 15/2015 -60/0 1/22/2015 941 a Actual 18 2/20/2015 173% 10/23/2014 926 a Actual 2 11/14/2014 -61% 9/22/2014 923 f Final BIII 10 9/22/2014 -21% 7/23/2014 913 a Actual 19 8/13/2014 31% 4/2212014 894 a Actual 14 5/15/2014 101° 1/23/2014 — a Actual 16 2/14/2014 8% 10/23/2013 884 aActual 15 11/18/2013 X61 1J il 53 'A IINJ V) lit 89a :t tn R jzj 1787-1- Lu �— Vi 'Q In A co 121 >- Q3 CZ LAJ N, C) eg, Q Z zi 4z LLJ e•mQW VI Q) Nth qqI Lai Q- coo LQ li Q Q 53 O 'A IINJ V) 89a :t tn R jzj 1787-1- Lu �— Vi 'Q In A co 121 >- Q3 CZ LAJ N, C) eg, Q tz V) O 'A IINJ 89a :t tn R jzj 1787-1- Lu �— Vi 'Q In A 121 >- Q3 CZ LAJ N, eg, Q tz V) LLJ e•mQW VI Q) Nth qqI Lai Q- coo li I O 'A 89a :t tn R jzj 1787-1- Lu �— Vi 'Q In A 121 >- Q3 CZ LAJ N, tz V) LLJ e•mQW VI J. Q CQ 1787-1- LAJ V) LLJ Q) Nth qqI Lai Q- wO 7! ti Z) ®r LQ . . ........ Ci CL Mt Lai Je �1) L.j ct \A HAYES ENGINEERING, INC. 603 SALEM STREET FORM 11 - SOIL EVALUATOR FORM WAKEFIELD, MA 01880 Page 3 (617) 246-2800 • FAX (617) 246-7596 Determination or Seasonal Hi h Water Table Method Used: ❑ Depth observed standing in observation hole .....IJA... inches ❑ Depth weeping from side of observation hole .. NA'�. inches ❑ Depth to soil mottles ......1." inches ❑ Ground water adjustment ._......... feet Index Well Number ................... Reading Date ................... Index well level .Adjustment factor .............. Adjusted ground water level .............. .... ... __..... Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not, what is the depth of naturally occurring pervious material? Certification I certify that on 0010 M (date) I have passed the examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. Signature Date ENGINEERING, INC. 60303 SALEM STREET FORM 11 - SOIL EVALUATOR FORM WAKEFIELD, MA 01880 Page 3 (617) 246-2800 ` FAX (617) 246.7596 Determinatiofa or Seasonal High Water Table Method Used: ❑ Depth observed standing in observation hole: ... inches ❑ Depth weeping from side of observation hole ....A/#... inches ❑ Depth to soil mottles ....7.Y....Y inches ❑ Ground water adjustment ....... _... .... feet Index Well Number ................... Reading Date ................... Index well level ................... .Adjustment factor .................. Adjusted ground water level ....... .... ..... .......... ... ........_ . Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not, what is the depth of naturally occurring pervious material? Certification I certify that on Ocry - M(date) I have passed the examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. Signature ' -'- - ate 19Xt5— 170 6d) I\ JI r`yI J - � � �--- -!_ moo:-- ---------- -�-� � --- V �: N �. V' x' O`•'04. 1 +,90 10:29 FPO t1 EMS/ 11451D.ER.'S GUIDE TO 8873103 p,ry3 MAY THU 07;20 ---. HAVES ENGINEERING - ----- ----- .--- ---- ----------- FAX.: ..0..,16172467596 P. 02 FORM XZ - SOIL EVALUAWR PORii _ ... Page 2 Qn- iteBev iew unop Hole Number.f,J... ©sie:..��/��5� �� -b Location (id •' Time: ............'... Weather u y on ite PI fund Use . ..................... !o . S s( Cation U.'� v %i Surface Stones c?KQ� Vega ...._ .................. ..... Landform ....................................... _... ........................ . . ......................... ................................... Position on landsca ..... , Pp (sketch on the back) Distances from; .................. Open Water Body >/O. , feet Drainage way .................. feet possible Wet Area !a C', feet Property Ling ....... ,.... feet Drinking Water Welt N! feet Other .. „ ....... feria! (0e0102.ici I r, e— . ----- . . -pepth to Bedrock: >� FROM EMS/INSIDER'S GUIDE TO 8873103. P p2 MAY -02-116 THU 07:20 HAYES ENGINEERING FAX NO. 16172467596 0 i MAY -C2-96 FOP-Af 11 - SOIL EVALUATOR FORM Page 1 On-site Review Date: ... .............. Weather $� Y� r-1 Deep Hole Nurnber-r.... C) Location (ides ify on site plan) "".I.....I....................... ........... ....... ........... ........................ ..qLand VOC M. ........U...f..f.aI ce.. $ .to.n.. Ie"... ............. .*... . ...... .............. Vegetation 00;.0VLy't'4 S ...- .. ......I..... Landform .,f.?'A"M'.O.*'R*—:..................... ............. . ..... . Position on landscape (sketch on the back) ...... Distances from: .... .......... OpenWator Body J/P .... feet Drajnagt Way...IX- .. feet 1*0861bte Wet Area feei Property Line. feet Drinking Water Wel! fee, Other . . ............... Aa� ,,Parent Material (geoloqiO Depth to SedrocP 2V -1h to Gr2undwater: Stand:nrl HAYES ENGINEERING, INC.: 603 SALEM STREET FORM 11 - SOIL EVALUATOR FORM WAKEFIELD, MA 01880 Page 1 (617) 246-2800 • � " FAX (617) 246-759916— c1 No.Date ............. .......... ............. Commonwealth of Massachusetts Massachusetts U /A� Location Address or Lot R New Construction ,t___ Repair ❑ Office Review owmr•s Namc. Ev e^ � j S� e� r o (A-� Address. and 1 t (� S(La t perr\ e� Tclephorc C � 00 .9 C>6ia -- Published Soil Survey Available: No ❑ Yes Year Published . H?/' Publication Scale .I:.'.�S�yU Soil Map Unit.T.'? Drainage Class :y�' Soil Limitations _ . ........... . __ ... __........._....._.............:....._ . ...... Surficial Geologic Report Available: No ❑ Yes ❑ Year Published _ .. Publication Scale ............... Geologic Material (Map Unit) ... .. ..... ........... ...... ..... ____ ........_.__................................. . Landform.......... ......... ._..... _... ........ ......................... ........ _ . _............ .. ------ ...._.... .............. __ _ Flood Insurance Rate Map: Above 500 year flood boundary No ❑ Yes 0� Within 500 year flood boundary Nor Yes ❑ Within 100 year flood boundary No LJ Yes ❑ Wetland Area: National Wetiand Inventory Map (map unit) Wetlands Conservancy Program Map (map unit) . ............. ......... ........ ._._ .................._ .._._ ................. Current Water Resource Conditions (USGS) Range : Above Normal ❑ Other References Reviewed: Month ... .. Normal ❑ Below Normal FORM 11 - SOIL EVALUATOR FORM Page 2 On-site Review Deep Hole NumberT—..Lf ....... Date: ...-.!�T' e:....�2..Weather � t' yl �o Location(identi on site plan) ........................................... .......-.......-....-......-..........-...................................... �t ......... Slope M ...... Surface Stones .--......... Land Use .................... � ....... SdY1'�-...:............................. ........................ .... Vegetation Landform _ ............................... . Landform.. e (1 C- .—..........._ ......__................... ......: Position on landscape (sketch on the back)................................................._................_ ......... _......_..................................... Distances from: Open Water Body .... feet Drainage way .... l*..... feet Possible Wet Area feet Property Line .... feet Drinking Water Well P.0... feet Other _ _........ DEEP OBSERVATION HOLE LOG Depth from Surface (Inches) Soil Horizon Soil Texture (USDA) Soil Color (Munsell) Soil Mottling Other (Structure, Stones, Boulders, Consistency, % Gravel) I -�L" Lfar Parent Material (geologic) Depth to Groundwater: Standing Wate- in the Hole:.. (ill Depth to Bedrock: .......� Weeping from Pit Face: .. Z` Estimated Seasonal High Ground Water: r Page 1 of 1 a <Previous, Zoom In -'Zoom Outs Rotate Left Rotate'Right Browntech Image Plugin 2.03 Download Complete! Hn c Fcc i e COMMONWWWOMMCHUSEM Essexj ea, February 20, 200' 'then personally appeared the above-named Rai H. Truo4q, j and he acknowledged the foregoing ins to he his a: free act and deed, �a T'homae -a f freyI ta lac My caesion expires: 11/2,/2005 f �F A 1W w AA � a t� E)Mt �•. http://72.72.82.242/ALIS/W W400R.HTM?WSIQTP=SY60V&W9CTLN=00222&W9RCC... 7/9/2012 V) It 00 BK 6680 PG 149 I, HAI H. TRUONG Qom' UJ� of North Andover, Massachusetts LL" in consideration of One ($1.00) Dollar grant to Xuan H. Truong and Hai H. Truong, both of 1180 Turnpike Street, North Andover, Massachusetts 01845, AS JOINT TENANTS AND NOT AS TENANTS IN COMMON, with quitclaim covenants The land with the buildings thereon located in North Andover, Essex County, Massachusetts being shown as Lot 2 on a plan of land entitled "PLAN OF LAND LOCATED IN NORTH ANDOVER, MA RECORD OWNER: ESTATE OF MAMIE M. SCHRODER, EXECUTRIX: EVELYN SCHRODER APPLICANT: MESSINA DEVELOPMENT 44 GREAT POND DRIVE, BOXFORD, MA. SCALE: 1" = 40' DATE: NOVEMBER 11, 1996 REVISED: 12/3/96 CHRISTIANSEN & SERGI PROFESSIONALENGINEERS LAND SURVEYORS 160 SUMMER ST. HAVERHILL, MA 01830 TEL. 508-373-0310". See said Plan #12990 recorded in the Essex North District Registry of Deeds for a more particular description of said lot. Said lot contains 43,600 square feet of land, more or less, according to said plan. Said premises are conveyed subject to and with the benefit of any and all easements, restrictions, reservations and conditions of record, if any, insofar as the same are now in force and applicable. For grantors title see deed dated March 30, 2000 and recorded in North Essex Registry of Deeds Book 5715, Page 235. FEB 21'02 Executed as a sealed instrument 20th day of February, 2002 Essex, ss. " J HAI H. TRUONG �— COMMONWEALTH OF MASSACHUSETTS February 20, 2002 Then personally appeared the above-named Hai H. Truong, and he acknowledged the foregoing instrument to be his free act and deed, r Be e Thomas Caffrey, to ublic My commission expires: 11/2 /2005 FORIM 11 - SOIL EVALUATOR FORM On-sitePage 2 z�~ /�`��. Deep Hole Number /—.��- Date: -��-'/�/� Tlnno�-'\c.��YNWeather 7�P? -, Position onlandscape (sketch onthe back) .............. ....... ............. .......... ---......... ................. ' --------------'--- Distances from: Open Water Body ^ z feet Drainagewayfee{ Possible VVmt Area «o feet Property Une ------' feet Drinking Water Well /}Alt. feet Other '''-..... .......... --- DEEP OBSERVATION HOLE LOG Depth from Surface (Inches) Soil Horizon Soil Texture (USDA) Soil Color (Munsell) Soil Mottling Other (Structure, Stones, Boulciers, Consistency,. % Gravel) |'��--'_------- Parent Material (geologic) 4��o) -� - /\^^ � Depth to Bedrock: ' ��*� Depth to Groundwater: StandiogWate� inthe Hole: ,~,�Weeping from Pit Face: v�^, ` q Estimated Seasonal High Ground Water: 7q HAYES ENGINEERING, INC. FORM 11 - SOIL EVALUATOR FORM 603 SALEM STREET WAKEFIELD, MA 01880 Page 1 (617) 246.2800 • FAX (617) 246-7596 No. 7773 _. Date...../ ...... .. . ............... A104 -605D Commonwealth of Massachusetts 4, gopjygr -,Massachusetts L= ion Address or 't L� \ �1� ` ��11� Owrci s Name. ev-6 y'd Address . and / /� cR/"� Telephorc r. New Construction 14 Repair ❑ Office Review Published Soil Survey Available: No ❑ Yes 0� Year Published Publication Scale Drainage Class ...�. Soil Limitations ... ........... Surficial Geologic Report Available: No ❑ Yes ❑ Year Published _. Publication Scale ............... Geologic Material (Map Unit) _. ._.... ... ...... .......................... ........ Landform._.._ .......... _ ._._.._................. ..... _ ..-------- ._ ....... _ _ ................... Flood Insurance Rate Map: Soil Map Unit .........a.r Above 500 year flood boundary No ❑ Yes Within 500 year flood boundary No ©' Yes ❑ Within 100 year flood boundary No Yes ❑ Wetland Area: National Wetland Inventory Map (map unit) _.. _ __ ..._ ........_............... _. Wetlands Conservancy Program Map (map unit) ............................... . Current Water Resource Conditions (USGS): Month ...1114. Range : Above Normal ❑ Normal ❑ Below Normal 0� Other References Reviewed: °.t"�° '• rho F w p « ,�sACNUsft Town of North Andover, Massachusetts BOARD OF HEALTH Form No. 2 14 19_� DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant �J�� Z�. �- Test No. Site Location I n 1 (I L4 Reference Plans and Specs. Z 194,47 ENGINEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. !! Fee �d CHAIRMAN, BOARD OF HEALTH Site System Permit No. Form No. 4 Town of North Andover, Massachusetts BOARD OF HEALTH W=� 1 • • S CERTIFICATE OF COMPLIANCE This is to certify that the Individual Soil Absorption Sewage Disposal System constructed ( X) or repaired ( ) by David Maynard INSTALLER at 1474 Turnpike St., (Lot 2) SITE LOCATION has been installed in accordance with Board of Health Regulations as described in the Design Approval Site System Permit No. 904 dated 2/14/97 19 The issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. LOCATION SEPTIC PLAN SUBMITTALS )i 1:;_ r-), NEW PLANS: YES ` REVISED PLANS: YES DATE: a- I t DESIGN ENGINEER: $60.00/Plan $25.00/Plan When the submission is all in place, route to the Health Secretary APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: // - / � 7 CURRENT INSTALLER'S LICENSE#� LOCATION:y 7 LICENSED INSTALLER: w� i SIGNATITIE:: TELEPHONE# CHECK ONE: REPAIR: NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. Administrative Use Only $75.00 Fee. Attached? Yes No Foundation As -Built? Yes No Floor Plans? Yes / No Approval Date: 7 e MORTH oA °�Ai�O I.tPy� 9SSACHUSE� Applicant Town of North Andover, Massachusetts BOARD OF HEALTH Form No. 3 lUo ✓ , 19 19 9 -% DISPOSAL WORKS CONSTRUCTION PERMIT a_ NAME - - ADDRESSI TELEPHONE Site Location 7�-,-,z &�, l4 e. Si— z� Permission is hereby granted to Construct (X) or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the De/sign Approval S.S. No. O --Y Fee / -� CHAIRMAN, BOARD OF HEALTH D.W.C. No. - V4611 71. PLAN REVIEW CHECKLIST ADDRESS -ZDT a ( 1474 7-ej.2/VP/ C ENGINEER -1:)UFe6--5iU6 GENERAL 3 COPIES STAMP LOCUS 7/ NORTH ARROW SCALE CONTOURS �-'�J PROFILE C -f (SC) SECTION ✓ BENCHMARK SOIL & PERCS ELEVATIONS WETS. DISCLAIMER WELLS & W TS L-� WATERSHED?� DRIVEWAY t/ WATER LINE t/ FDN DRAIN M&P SCH40 TESTS CURRENT? 6A5' SOIL EVAL 6 ,'- G066°.5aA3 SEPTIC TANK MIN 150OG .17 INVERT DROP � GARB. GRINDER_v0_(2 comps +200) 10' TO FDN L---- MANHOLE C/ ELEV ✓ GW_d�C ## COMPS. / GB 1/ D -BOX SIZE # LINES -2L FIRST 2' LEVEL STATEMENTL—'' INLET1�,� - OUTLET _ /7 (2" OR .17 FT) TEE REQ'D .:�65 LEACHING MIN 440 GPD?,,/ RESERVE AREA, 4' FROM PRIMARY? `� 20 SLOPE 100' TO WETLANDSy. 100' TO WELLSc--�' 4' TO S.H.GW ,., (5'>2M/IN) 20' TO FND & INTRCPTR DRAINS L---',400' TO SURFACE H2O SUPP �- 4' PERM. SOIL BELOW FACILITY MIN 12" COVER BREAKOUT MET? TRENCHES MIN 440 gpd� SLOPE (min .005 or 6"/100') C-� SIDEWALL DIST. 3X EFF. W OR D (MIN 6')L ------ RESERVE BETWEEN TRENCHES?IN FILL?Z---/ MUST BE 10' MIN. L-"-"-4" PEA STONE? """VENT? (>3' COVER; LINES >501) BOT *:570 + SIDE 6� = 7(5 e) X LDNG = TOT 14-50-7 (L x W x ##) (DxLx2x#) (G/ft2) Copyright Q 1996 by S.L. Starr Town of North Andover a AORTh , OFFICE OF 3? ° •'"• �� COMMUNITY DEVELOPMENT AND SERVICES 146 Main Street : i . o North Andover, Massachusetts 01845 �4_°�,.., ��•,�� WILLIAM 1. SCOTT Director April 14, 1997 Mr. William Dufresne Merrimack Engineering 66 Park Street Andover, MA 01810 Dear Bill: Re: Lot #2 (1474 Turnpike Street This is to inform you that the proposed plans for the site referenced above have been approved. If you have any questions, please do not hesitate to call the Board of Health Office at the number below. Sincerely, Sandra Starr, R.S. Health Administrator SS/cjp cc: Bob Messina BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 FORM U - VERIFICATION FORM INSTRUCTIONS: This form is used Ito verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ***********,,*****Applicant fills out this section***************** APPLICANT: A /� I�SSIAJ a bf (i ( _,j . �I_/V C - Phone -51- 3 / 0z LOCATION: Assessor's Map Number / 0 7G Parcel 3 Subdivision Lots)_ Street S'c3%e(K -+uVND11,6P •191 /1 41 St. Number ********************** *Official Use Only************************ RECOMMEN ONS S: Date Approved *101b Conservation Adit�irs or �' , Date Rejected Comments 9 3f ko Date4proved� own Planner Date Rejected Comments Date Approved Food Inspector -Health Date Rejected Date Approved 16o�?d Septic Inspector -Health Date Rejected Comments Public Works - sewer/water connections - driveway permit Fire Depar ment� 107-'1't &. Received by Buil g Inspector 4 of Date 0 E03 -31 � v FORM U - LOT RELEASE FORM rnL) no Z INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *APPLICANT FILLS OUT THIS SECTION* *** PPLICANT k- J TR OJOid vPHONE 6 �� $ �� ✓/LOCATION: Assessor's Map Number ,,PARCEL SUBDIVISION LOT (S) �,. STREET 11 TO 2,v 101'K( S F, ,ST. NUMBER If �O """OFFICIAL USE ONLY*************** RECO DATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR COMMENTS TOWN PLANNER COMMENTS FOOD 1t SEPT COMMENTS OR -HEALTH OR-HEALT DATE APPROVED DATE REJECTED //r'- DATE APPROVED DATE REJECTED- DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Gs�!{!JC C ��5 tq l Q N I F N /F FzASpSHEKA� 1 18Q069 a4N V_ 441.76' , :�lEZ zK SS• 64 � s lvl �� CONS't�t.�i7l�til aup.t ll #ktl80r1i 'X, -- - This mortgage inspection plan is for mortgage purposes only, it isnot an instrument survey. Hence it is not to be used to establish property lines, fences, driveways, hedges, etc., or to be used for any purpose other than its original intent I hereby certify TD T}aE mE4 x;m Z,p -w N(f7 1? wr_ 1_. ' J.. 1_oT 2 4 3, 60n Sf th2'i Z�r� 1I A-) NO k review of the Flood Insurance Rate Map, Mortgage Community -Panel Number WAS GOND Inspection dated'has been conducted Plan and to the best of our interpretation this property is * located within the flood Zone. that the principal building on this plan is approximately located on the ground as shoum, and it cortjorms to the dimensional setback requirements of the zoning and building laws of the city/toum of ND)O� AN'L?VU6)Z when and to the r trillions on record. 'i1e # AC -23 ANN Of 4c(y Location I I P COSMO I�lOQJ� kNr7Di/ MA DAMIANO �r-MBEX 19.Ig97 CAPOBIANCO H Scale: 1 in. � (� ft. Date 17704 Plan Reference PL AM # 12q _I0 0SUIt'q � MORTGAGE INSPECTIONS INC. SUITE 311,265 MEDFORD ST.. SOMERVILLE. MASS. Job # 0 MERRIMACK ENGINEERING SERVICES INC. Engineers o Surveyors a Planners 66 Park Street ANDOVER, MASSACHUSETTS 01810 (508) 475-3555 // Fax (508) 475.1448 TO 15 7A 1.L D��- 06 ,- V-9 V F F,A V i� IJ & d -T14 AtiJ Dvv 910- WE 12 WE ARE SENDING YOU ❑ ❑ Shop drawings ❑ Copy of letter .' pytcl �,� O°e ;'Er r❑ Or is `atelcover via Prints ❑ Plans L��Iffu[En O1P 4 o d MLJ UCTULr IL DATE/^` /� _ 17C JOB NO. ATTENTION RE: , ❑ Samples the following items: ❑ Specifications COPIES DATE NO. DESCRIPTION &I '!�Tr2_ CT!%1 THESE ARE TRANSMITTED as checked below: ®mor approval ❑ For your use ❑ As requested ❑ For review and comment ❑ FORBIDS DUE REMARKS ❑ Approved as submitted ❑ Approved as noted ❑ Returned for corrections ❑ Resubmit ❑ Submit _ ❑ Return copies for approval _ copies for distribution corrected prints 19 ❑ PRINTS RETURNED AFTER LOAN TO US COPY TO SIGNED: If enclosures are not as noted, kindly notify us at once. Town of North Andover, Massachusetts Form No. 1 NORTIy BOAKD OF HLAL I H OF St LEO .� V\oo E171- y APPLICATION FOR SITE TESTING/INSPECTION Appl _ rvAIV] t ,ry AUUKLJS I LLLPHUNE Site Location �_- c �r��Q� �C .t�, Engineer Test/Inspection Date and Time Fee_ CHAIRMAN, BOARDOF HEALTH Test No. (' -� S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No.