HomeMy WebLinkAboutMiscellaneous - 1190 SALEM STREET 4/30/2018 1190 SALEM STREET
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SS,C roperty Record Card
Click Seal To Return Parcel ID :210/106.A-0121-0000.0 FY:2010 Community:North Andover
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Summary
Available �
Residence - -- -
Detached Structure
Condo
Commercial
Location: 1190 SALEM STREET
Owner Name: ROHDE,KATHLEEN M
Owner Address: 1190 SALEM STREET
City: NORTH ANDOVER State: MA Zip: 01845
Neighborhood: 6-6 Land Area: 1.01 acres
Use Code: 101-SNGL-FAM-RES Total Finished Area: 2240 sqft
ASSESSMENTS CURRENT YEAR PREVIOUS YEAR
Total Value: 477,200 507,800
Building Value: 270,200 299,100
Land Value: 207,000 208,700
Market and Value: 207,000
Chapter Land Value:
LATEST SALE
Sale Price: 1 Sale 11/04/2001
Date:
Arms Length Sale F-NO-CONVNIENT Grantor: CHRLECHARLES
Code: RHODE
Cert Doc: Book: 06459 Page: 0180
http://csc-ma.us/PROPAPP/display.do?linkld=1518748&town=NandoverPubAcc 6/14/2010
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North Andover Health Department
(ommunity and Economic Development Division
October 26, 2017
Address: 1190 Salem Street
All North Andover Residents with Septic Systems and Garballe Disposals
Please note that due to a recent review of a Title 5 Report, your property has been identified as
maintaining a working garbage disposal that is being used in conjunction with a septic system.
The Health Department is concerned for the longevity of your septic system.
Garbage disposals are never recommended where septic systems are used, but if they are
installed, the system must be specifically designed to handle the waste from them; your system
can not handle the waste.as designed. Please note that continued use of this disposal could
quickly cause a pre-mature failure of your septic system, resulting in a large expenditure to
replace it. The North Andover Health Department recommends that you remove it from your
home as soon as possible.
Some information regarding regular maintenance of your septic system is attached. Please call
the Health Department at 978.688.9540 if you have any questions, or e-mail your questions to:
healthdeptgnorthandoverma.gov.
Thank you for taking the time to consider the impact that your current setup has on your septic
system and the environment.
Sincerely,
ti
frian LaGrasse, CEHT
Director of Public Health
120 Main Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.9542 Web http://www.northandoverma.gov
Commonwealth of Massachusetts RECEIVE®
Title 5 Official Inspection Form OCT 25 2011
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments TOWN OF NORTH ANDOVER
1
HEALTH DEPARTMENT
190 Salem Street
Property Address
Ryan Leahy
Owner Owner's Name
information is
required for every North Andover Ma. 01845 10/20/17
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.
e
Important:When
filling out forms A. General Information
on the computer,
use only the tab 1. Inspector: ! �
key to move your
cursor-do not Ron Jenkins
use the return Name of Inspector
key.
R. Jenkins & Sons
Q Company Name
58 Pleasant St.
Company Address
MIT
Rowley Ma. 01969
City/Town State Zip Code
978-314-0503 S14268
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
10/20/17
Ins ector'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.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
wM 1190 Salem Street
Property Address
Ryan Leahy
Owner Owner's Name
information is
required for every North Andover Ma. 01845 10/20/17
page. Cityrrown 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:
® 1 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:
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):
t5ins-3113 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
^M 1190 Salem Street
Property Address
Ryan Leahy .
Owner Owners Name
information is
required for every North Andover Ma. 01845 10/20/17
page. 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 ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.a 1190 Salem Street
Property Address
Ryan Leahy
Owner Owner's Name
information is North Andover Ma. 01845 10/20/17
required for every
page. Cityrrown 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
El ® 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 1h day flow
t5ins•3/13 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1190 Salem Street
Property Address
Ryan Leahy
Owner Owner's Name
information is
required for every North Andover Ma. 01845 10/20/17
page. City1rown 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 of a.surface drinking water supply
❑ ❑ the system is within 200 feet 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 Forth: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 1190 Salem Street
Property Address
Ryan Leahy
Owner Owner's Name
information is
required for every North Andover Ma. 01845 10/20/17
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
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): N/A Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): N/A
t5ins-3113 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
M 1190 Salem Street
Property Address
Ryan Leahy
Owner Owner's Name
information is
required for every North Andover Ma. 01845 10/20/17
page. City[Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 3
Does residence have a garbage grinder? ® Yes ❑ No
kIs laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage (gpd)): 72,022 total
Detail
72,022 total gallons 1730 = 98.66 gallons per day
Sump pump? El Yes 0 No
Last date of occupancy: OccupiedDate
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspecfion Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
R Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1190 Salem Street
Property Address
Ryan Leahy
Owner Owner's Name
information is
required for every North Andover Ma. 01845 10/20/17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Last pumped 5/25/17, info. from home owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ 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•3l13 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 1190 Salem Street
Property Address
Ryan Leahy
Owner Owner's Name
information is
required for every North Andover Ma. 01845 10/20/17
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Septic tank and leach field is 35 years old installed 1982, D-box is 7 years, old installed 2010 info.
from last Title 5 Report
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 24"feet
Material of construction:
® cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: n/a
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
finished basement, very limited piping to see, no indications of leaks
Septic Tank(locate on site plan):
Depth below grade: 10"
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) ❑ Yes ❑ No
Dimensions:
10'x5'x5'deep
Sludge depth:
3"
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
9-3 Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'4M
1190 Salem Street
Property Address
Ryan Leahy
Owner Owner's Name
information is
required for every North Andover Ma. 01845 10/20/17
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
31"
Scum thickness 0
11
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? Measuring stick and ruler
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Condition of inlet baffle good, outlet tee good, structural integrity good, liquid was level to bottom of
outlet invert tank should be pumped yearly
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
I
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Tiffe 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1190 Salem Street
Property Address
Ryan Leahy
Owner Owner's Name
information is
required for every North Andover Ma. 01845 10/20/17
page. Cityrrown 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 ❑ polyethylene ❑ other(explain).-
Dimensions:
explain):Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.).-
Attach
tc.):Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°r 1190 Salem Street
Property Address
Ryan Leahy
Owner Owner's Name
information is
required for every North Andover Ma. 01845 10/20/17
page. CityfTown 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 was level and distribution was equal,no evidence of leakage into or out of box,no evidence of
solids carryover
Size of d-box is 16"x16"x14"deep, box is 26" below grade with 15" riser
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•3113 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1190 Salem Street
Property Address
Ryan Leahy
Owner Owner's Name
information is
required for every North Andover Ma. 01845 10/20/17
page. Cityfrown 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:
1 20x'45'
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology.
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
dry loamy soil, no signs of hydraulic failure,no ponding, leach field is on right side of house under
mowed grass
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 ❑ Yes ❑ No
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
. � Commonwealth of Massachusetts
usetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1190 Salem Street
Property Address
Ryan Leahy
Owner Owner's Name
information is
required for every North Andover Ma. 01845 10/20/17
page. Cityrrown 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.):
i
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1190 Salem Street
Property Address
Ryan Leahy
Owner Owner's Name
information is
required for every North Andover Ma. 01845 10/20/17
page. Cityrrown 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
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t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
. � usetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
w„ 1190 Salem Street
Property Address
Ryan Leahy
Owner Owner's Name
information is
required for every North Andover Ma. 01845 10/20/17
page. Citylrown 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: >4'feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
info. from last Title 5 Report
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Info. from last Title 5 Report dated 5/29/2010 from Bateson Enterprises Inc. 111 Argilla Rd. Andover
Ma.
Essex County Soil Map, sheet#30, Canton oil, Water>6'deep
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3/13 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'4M , 1190 Salem Street
Property Address
Ryan Leahy
Owner Owner's Name
information is
required for every North Andover Ma. 01845 10/20/17
page. Citylrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Summary Record Card generated on 101251201711:21:32 AM by Tara Huday Page 1
Town of North Andover
Tax Map # 2'10-106.A-0121-0000,0
Parcel Id 17266
1190 SALEM STREET
LEAHY, RYAN P. Since Jan 2011 -
LEHAY, NICOLE R.
1190 SALEM STREET
NORTH ANDOVER, MA
01845
Class 101 Single Family Property Type 1 Residential
Zoning2 7 Residential Zoning3 1 Residential
Size Total 1.01 Acres
FY 2018 _
UB Mailing Index until
Name/Address 'type Loan Number Active/fnact From
RYAN&NICOLE LEAHY Owner
1190 SALEM STREET
NORTH ANDOVER MA 01845
ROHDE,CHARLES N. Previous Customer Inactive 9/30/2010
1190 SALEM STREET
N.ANDOVER,MA
01845
UB Account Maint, ActiveAnactive
Account No Cycle Occupant Name
Bldg Id.17318.0-1190 SALEM STREET Last Billing Date 10/i0l2017
I 3160395 - 03 Cycle 03 Active
UB Services Maint.
` Account No.3160395
Service Code Rate Charge Multiplier/Users
MISCFEEADMIN FEE 0.63518 7.82 1/
WTR WATER 01 ALL METER SIZE 76.00 11
i
UB Meter Maintenance
i Account No.3160395 Brand Type Size YTD Cons
} Serial No Status Location
0 ERT HH METE METE w Water 0.63 0.63 725
16336492 aActive 0 Consumption Posted Date Variance
Date- Reading Code 20 10118l2017 38%
9/712017 1256 a Actual 14 7125!2017 5%
615/2017 1236 a Actual
316/2017 1222 a Actual 13 4!12/2017 5%
12/7/2016 1209 aActual 14 1/23l20t7 -19%
i
17 10124!2016
9/612016 1195 aActua! -9°/°
29°1°
613!2016 1178 aActual 18 812/2016
13 4/22/2016 -46%
313/2016 1160 a Actual
7147 a Actual 27 1!20!2016 421°
12/8/2015 43 1011612015 100%
9/2/2015 1120 aActual 22 7124/2015 17%
6/5/2015 1077 a Actual 4%
1055 a Actual 19 4128/2015
3!6!2015 -30%
17 1!15!207 5
12/4/2014 1036 a Actual 290/0
9!9120.74 1019 aActuai 27 70115!2014 6%
6!612014 992 a Actual 7116!2014
20 -7 9%
317/2014 972 a Actual 19 4!11!2014
1215/2013 953 aActual 23 1/17/2014 1
916/2013 930 a Actual 23 1011512013 24%
6!7/2013 907 a Actual 19 7124/2013 14010
31612013 888 aActual 16 412212073 32%
! 12/712012 872 a Actual 25 1/9/2013
9/7/2012 847 a Actual 26 1011512012 6%
821 aActuaf 24 7!16!2072 2 %
6/6/2072 20 4/14/2012 -44/o
3/7/2012 797 a Actual
8054 of��,T�11, '.
•fes •�O
l
3?, c
Town of North Andover
``�;• HEALTH DEPARTMENT
SSAemu
CHECK#: DATE: /0 a5 40/7
LOCATION: //90 Sa./e./h 5-1,�
p. H/ONAME:
CONTRACTOR NAME: l)enhin,a
Type of Permit or License: (Check box)
r
❑ Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service-Type.-
13
ype:❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal(Septic)Hauler $
❑ Recreational Camp $
❑ Sun tanning $
❑ Swimming Pool $
5
❑ Tobacco $
❑ TrashlSolid 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 $
i Title 5 Report (�,S S $5
P
❑ Other:(Indicate) $
Hea Agent Initials
White-Applicant Yellow-Health Pink-Treasurer
1
�A►DDlication for Septic Disposal System
° `�'• .,I• o�Construction Permit —,TOWN OF TODAY'S DATE
�`�5 •f" ORTH ANDOVER, MA 01845 $250.00—Full Repair
AC $125.00-Component
14Ug
Important: Application is hereby made for a permit to:
When fining out — El Construct a new on-site sewage disposal system*
forms on the
computer,use
only the tab key ❑ Repair or replace an existing on-site sewage disposal system*
to move your �epair or replace an existing system component—What?
cursor-do not
use the return
key. A. Facility Information
I[�I Address or Lot#
City/Town 'J FrT4qM"
2.-*TYPE OF S TIC SYSTEM*: N 2 2010
❑Pump ravity(choose one)***If pump system,attach copy of electrical permit to applicati NORTH ANDOVER
H DEPARTMENT
Conventional System(pipe and stone system)
❑ Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system.
❑Pressure Distribution S.A.S.(No D-Box)(Attach Draft Maintenance Agreement)
❑Pressure Dosed(D-Box Present)S.A.S.
2. Owner Information
Name _
54- '
Address(if different from above) n
City/Town StatY�-
Zip Code
Telephone Number
3. Installer Information
Name Name of Comp �ON E
Address
/f l f ` �t'� 111 ARG RQAa
INC
�A , MA 01810
City/Town State
o� Zip Code
/'r— FlIJ-J--1e
Telephone Number(Cell Phone#W possible please)
4. Designer Information
Name Name of Company
Address
City/Town State
Zip Code
Telefsshone Number(Best#to Reach)
Apprication for Disposal System Construction Permit page 1 of 2
t
SEPTIC SYSTEM INSTALLER-PROJECT MANAGEMENT OBLIGATIONS
As the North Andover hcensedinstaU.er for the construction'for the septic system for the property at:
(Address of septic system) For plans by
(Engineer)
Relative to the.application
(Installer's name) And dated
(Original date).
Dated llf
Io ay s ate With revisions dated
(Last revised date)
I understand the following obligations for management of this project:
1. As the installer, I am.obligated to obtain.all permits and Board of Health approved plans prior to
performing any work on a site. I must have the approved plans and the permit on site when any work is
being done.
2. As the installer,I.must call for any and all inspections. If homeowner, contractor,project manager, or any
other.person not associated with my company schedules an inspection and the system is not ready, then
item three shall.be.applicable.
3. As the installer, I am required to.have the necessary work completed prior to the applicable inspections as
indicated below. .I understand that reque: *g an inspection without completion of the items in accordance
with title 5 and the$oard of Health Regulations may resultin a$5000 fine beiing levied against me and/or
my company
a. Bottom of Bed:=_Generally,this.is the first(151j inspection unless...there is a retaining wall,which
should be done first The installer rriust request the inspection but does not have to be present. .
b. Final.Construction Inspection–Engineer must first do their inspection for elevations, ties, etc.
As-built of verbal OK (or e-mail to:healdidel2t@townofnorthandover com).from the engineer must
be submitted to:the Board of Health,after wlucli installer.calls for an inspection time. Installer must
be present for this.inspection,. With a pump system,all electrical work.must be ready and able to
cause:pump to work and alarmt6 function.
C. Final Grade Installer must request inspection when all grading is complete. .Installer does not
have to be on.site.
4. As the installer,I understand that only I inay perform the work (other than simple excavation)and I am required
to complete the installation of the system identified in the attached application for installation.: ':I further
understand:that work done b ' :'h unlicensed to installse ticteitute
reasons for denial of the s stem and oI... -
rrevo cation or s.0 PPsion of m hcense..to o erate in.the T.own.of
North Andover si ficant fines.to ail persons involved.are also ossible.
5.. As the.installer,I understand thatI mustbe on-site during theperform
steps: ance of the.following construction
a. Determination that.the proper elevation of the excavation has been reached.
b.. Inspection of the sand and stone to be used.
c. Final inspectrou by Board ofHealtb staffor consultant.
d. Installation.oftank,D Box,pipes, stone, vent,pump chamber,retairsirzg wall and other
components.
6. As the installer,Iunderstand that I.am solei res orisilile for the installation of the s stem as per the
a roved dans. No instructions b the homeowner eneral.contractor oran .other'13ersons shall-absolve
me of this obli tion.
Undersigned Licensed Septic.Installer: (Today's Date) —lam
ame.– :ririt
t
r° Application.for Septic Disposal Svstem
r G 4*"O'►11'p
pConstruction Permit TOWN OF TODAY'S DATE
$250.00-Full.Repair
ORTH ANDOVER MA 01845
S
"C US - $125.00 -Component
9S �tCHU5�4
PAGE 2OF2
A. Facility.Information continued....
5. T e of Building: esiden i //,//-?,/,9
Vp 4 t al Dwelling or❑Commercial
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the afore-described
on-site sewage disposal system in accordance with the provisions of Title 5 of the
Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of
North Andover, and not to place the system in operation until a Certificate of Compliance has
been issuedIV Board of Health.
Nam — Date
I
Applicatio pproved By: (B rd of Health Representative)
/Alication
d
Date Disapproved for th follow
reasons:
9
For Office Use Only:
1. Fee Attached. Yeses/.' No
2. ProlectManager Obligation Form Attached. Yes_ No
3,
Pump ystem,? If so,Attach copvofElectricalPermit Yes_
4. Foundadon As-Built?(new construction ronly): .es No
(Same scale as a PProved lan
P )
5. Floor Plans?(new construction only): Yes_ No
Application for Disposal System Construction Permit•Page 2 of 2
Commonwealth'&Massachusetts
D
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assess7entsj)U 2�1n
1190 Salem Street 'TOWN OF NORTH ANDOVER
Property Address HEAL I
Kathleen Rohde
Owner Owner's Name
information is
required for North Andover MA 01845 6/14/2010
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 A. General Information
forms on the
computer,use 1. Inspector:
only the tab key
to move your Neil J. Bateson
cursor-do not Name of Inspector
use the return
key. Bateson Enterprises Inc.
Company Name
111 Argilla Road
Company Address
Andover Ma 01810
City/Town State Zip Code
978-4754786 SI15
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
6/14/2010
InspectoPs kignature U 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 d or reater, the inspector and the system owner shall submit the
9 9P 9 P Y
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 perforin in the future under
the same or different conditions of use.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealths of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
, 1190 Salem Street
Property Address
Kathleen Rohde
Owner Owners Name
information is
required for North Andover MA 01845 6/14/2010
every page. Cityrrown 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:
After permit from B.O.H., install new d-box with riser, inspection from B.O.H., septic system now
passes Title 5 Inspection
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):
t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form2010
7TOWN
w �►
. p
Subsurface Sewage Disposal System Form Not for Voluntary Assessment '
1190 Salem Street T
Property Address H DEPARTMENT
Kathleen Rohde
Owner Owner's Name
information is
required for North Andover MA 01845 5/29/2010
every page. City/Town 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: A. General Information
When filling out
forms on the
computer,use 1. Inspector:
only the tab key
to move your Neil J. Bateson
cursor-do not Name of Inspector
use the return
key. Bateson Enterprises Inc.
Company Name
111 Argilla Road
Company Address
Andover Ma 01810
Cityrrown State Zip Code
978475-4786 SI15
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
I _
5/29/2010
Ins ec is ignature 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.
t5ins-09/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 1190 Salem Street
Property Address
Kathleen Rohde
Owner Owner's Name
information is
required for North Andover MA 01845 5/29/2010
every page. Cityrrown 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:
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):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
a w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1190 Salem Street
Property Address
Kathleen Rohde
Owner Owner's Name
information is
required for North Andover MA 01845 5/29/2010
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
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 ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1190 Salem Street
Property Address
Kathleen Rohde
Owner Owner's Name
information is
required for North Andover MA 01845 5/29/2010
every page. Cityrrown 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 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-box needs to be replaced &riser install on d-box.
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 %day flow
l5ins-09108 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
M , 1190 Salem Street
Property Address
Kathleen Rohde
Owner Owner's Name
information is
required for North Andover MA 01845 5/29/2010
every page. Cityrrown 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.
El ® 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 of a surface drinking water supply
❑ ❑ the system is within 200 feet 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 Zane 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•09/08 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
1190 Salem Street
Property Address
Kathleen Rohde
Owner Owner's Name
information is
required for North Andover MA 01845 5/29/2010
every page. City/Town State Zip Code Date of Inspection
C. Checklist
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): N/A Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): N/A
t5ins•09108 Title 5 Official Inspection Forth: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
M 1190 Salem Street
Property Address
Kathleen Rohde
Owner Owner's Name
information is
required for North Andover MA 01845 5/29/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
Does residence have a garbage grinder? ® Yes ❑ No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)): Yes
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•09/08 Title 5 Official Inspection Forth: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
, 1190 Salem Street
Property Address
Kathleen Rohde
Owner Owner's Name
information is
required for North Andover MA 01845 5/29/2010
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Pumped sept. 2009, owner
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1000
gallons
How was quantity pumped determined? Measured tank
Reason for pumping: Inspect tank& baffles&tee
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 1190 Salem Street
Property Address
Kathleen Rohde
Owner Owner's Name
information is
required for North Andover MA 01845 5/29/2010
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Tank original, d-box&field installed 6/19/1982
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.):
4"cast iron in rafters, no leaks visible. Cannot see piping leaving foundation, finished cellar.
Septic Tank(locate on site plan):
Depth below grade: 0.5
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) ❑ Yes ❑ No
Dimensions: Tx 5'x 4'
Sludge depth:
3"
t5ins•09/08 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 1190 Salem Street
Property Address
Kathleen Rohde
Owner Owner's Name
information is
required for North Andover MA 01845 5/29/2010
every page. Cityrrown 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
24"
Scum thickness
4"
Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom of outlet tee or baffle
13"
How were dimensions determined? Tape Measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumped septic tank. Inlet baffle ok. Outlet baffle corroded on top. Outlet tee ok. Depth of liquid at
outlet invert. No evidence of leakage.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene
F-1 other(explain):
Dimensions:
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
Date of last pumping: Date
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1190 Salem Street
Property Address
Kathleen Rohde
Owner Owner's Name
information is
required for North Andover MA 01845 5/29/2010
every page. Citylrown 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 ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 1190 Salem Street
Property Address
Kathleen Rohde
Owner Owner's Name
information is
required for North Andover MA 01845 5/29/2010
every page. Cityrrown 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.):
D-Box level &distribution equal. Evidence of carryover, pumped d-box to clean. Cover broken,
replaced it. d-box has bad corrosion , needs to be replaced. D-box needs to have riser installed.
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.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
N Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1190 Salem Street
Property Address
Kathleen Rohde
Owner Owner's Name
information is
required for North Andover MA 01845 5/29/2010
every page. Citylrown 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: 1 field 20' x 45'
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soil ok. Vegetation ok. No sign of ponding to surface.
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 ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1190 Salem Street
Property Address
Kathleen Rohde
Owner Owner's Name
information is
required for North Andover MA 01845 5/29/2010
every page. City/Town 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-09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System.Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 1190 Salem Street
Property Address
Kathleen Rohde
Owner Owner's Name
information is North Andover MA 01845 5/29/2010
required for �.
every page. 'Cityrrown 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
G
0_�3P$
_
0 s\ s-�a
[7%v k
LIJJ03
s.
-� = a� X1-1
x = `31 '
10
.f
t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
G v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 1190 Salem Street
Property Address
Kathleen Rohde
Owner Owner's Name
information is
required for North Andover MA 01845 5/29/2010
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
>4
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: 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:
Essex County Soil Map
You must describe how you established the high ground water elevation:
Essex County Soil Map, Sheet#30, Canton oil , Water>6' Deep
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
.1190 Salem Street
Property Address
Kathleen Rohde
Owner Owner's Name
information is
required for North Andover MA 01845 5/29/2010
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® 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 fele
I
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
Commonwealth of Massachusetts
Cityffown of
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be,substantially the same as that provided here. Before using this form, check with your
local Board of Health tq determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or-atbLi r approving authority.
A. Facility Information
1. System Location: Left side of house, Right side of house, Left front of hous ight front of�aus—fie
Left rear of house, Right rear of house. Left rear of building. Right rear of building.
Address S-kee� �Jb r\-��A � (
Cityrrown �l State Zip Code
2. System Owner:
Name
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
i
B. Pumping Record
5=aG} - (O
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes D-fO--- If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
G%JfH�
Lo II Waste Water
Vi=a y�-tv
SignDate
t5form4.doc•06103 System Pumping Record•Page 1 of 1
Summary Record Cardgenerated on 6/11/2010 2:30:32 PM by Lisa Evans Page 1
Town of North Andover
Tax Map # 210-106.A-0121-0000.0
Parcel Id 17266
1190 SALEM STREET
ROHDE, CHARLES N.
1190 SALEM STREET
N. ANDOVER, MA
01845
Class 101 Single Family Property Type 1 Residential
Size Total 1.01 Acres
FY 2010
UB Mailing Index
Name/Address Type Loan Number Active/Inact. From Until
ROHDE,CHARLES N. Payor
1190 SALEM STREET
N.ANDOVER,MA
01845
UB Account Maint.
Account No Cycle Occupant Name Active/Inactive
Bldg Id. 17318.0-1190 SALEM STREET Last Billing Date 4/2/2010
3160395 03 Cycle 03 Active
UB Services Maint.
Account No.3160395
Service Code Rate Charge Multiplier/Users
MISCFEE ADMIN FEE 0.635/8 7.82 1/
WTR WATER 01 ALL METER SIZE 22.80 /1
UB Meter Maintenance
Account;No.3160395
Serial No Status Location Brand Type Size YTD Cons
16336492 a Active 00 ERT HH METE METE w Water 0.63 0.63 105
Date Reading Code Consumption Posted Date Variance
6/4/2010 649 a Actual 13 100%
3/3/2010 636 a Actual 6 4/14/2010 -40%
12/7/2009 630 a Actual 11 1/12/2010 -36%
9/4/2009 619 a Actual 17 10/15/2009 41%
6/3/2009 602 a Actual 11 7/20/2009 38%
3/10/2009 591 a Actual 9 4/29/2009 -47%
12/4/2008 582 a Actual 16 1/20/2009 -24%
9/5/2008 566 a Actual 22 10/10/2008 60%
6/3/2008 544 a Actual 13 7/16/2008 1%
3/6/2008 531 a Actual 13 4/11/2008 -320X
12/7/2007 518 a Actual 18 1/22/2008 -220/
9/13/2007 500 a Actual 25 10/12/2007 860/c
6/13/2007 475 a Actual 14 7/20/2007 -100/<
3/9/2007 461 a Actual 15 4/16/2007 -240%
12/6/2006 446 a Actual 19 1/19/2007 -80X
9/7/2006 427 a Actual 20 10/20/2006 330/
6/12/2006 407 a Actual 15 7/10/2006 98
0/1
3/17/2006 392 a Actual 8 4/17/2006 -550/.
12/15/2005 384 a Actual 18 1/17/2006 -420/
9/12/2005 366 a Actual 32 10/14/2005 2080/
6/7/2005 334 a Actual 9 7/15/2005 -310/
3/15/2005 325 m Manual estimate 15 4/5/2005 -130/
12/8/2004 310 a Actual 15 1/14/2005 -2701
9/15/2004 295 a Actual 24 10/8/2004 200/.
6/9/2004 271 a Actual 11 7/30/2004 720/.
4/16/2004 260 a Actual 15 5/17/2004 00/.
PIP
AX
WV
00
�
, 1
Ic
19 U H L LL
(acloJIII' 1 ,
T6-.WN OFNORTH -ANpOVER
SYSTEM PUMPING RECORD .{
2003
11 I'EM U WN>rR & ADDRESS „ SYSTEM LOCATION —_ -}
(example: Ieft fron( o{' house) .
I
/1/,
UATC OF PUMPINC: y
QUANTITY PUMPEDd�L,� Lf,c» ,,
.. i:S PO0L: NO r/ YES SEPTIC TANK: NO
YES
NATURE OF SERVICE; ROUTINE EMERCENCY
()IJSrRYATIONs:
GOOD CONDITION, FULL TO COYCI?
HrAVY CREASE BAFFLES IN I'1.AC1?
ROOTS LEACHFIELD RUNBACK...
EXCESSIVE SOLIDS FLOODED'
SOLIDS CARRYOVER =pj�HER (EXPLA.IN)
i
STEM PUMPED RY: !71
C U.1;1'Yl I:NTS:
i
UNTI,'N'I'S TRANSf CitRED TO:
f
�r Commonwealth of Massachusetts Map-Block-Lot
���,•"°° '��b��a106.A0121
` Board of Health
-----------------------
Permit No
AW
• * BHP-2010-0606
North Andover
a a
y
6 --
" `°� P.I. FEE
�SSF.I. $125.00
-----------------------
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Todd Bateson
to(Repair-DISTRIBUTION BOX)an Individual Sewage Disposal System.
at No 1190 SALEM STREET
as shown on the application for Disposal Works Construction Permit No. BHP-2010-06 Dated June 02,2010
##,%t*"%Py-----------------
Issued On: Jun-02-2010 Board of Health
Map-Block-Lot
Commonwealth of Massachusetts
106.A0121
Board of Health
North Andover
` .�...` CERTIFICATE OF COMPLIANCE
THIS IS TO CERTIFY,That the Individual Sewage Disposal System (Repair-DISTRIBUTION BOX)
by Todd Bateson
-----------------------------------------------------------------------------------------------------------------------------------------------------------
Installer
. at No 1-190-SALEM-STREET
has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the
application for Disposal Works Construction Permit No. BHP-20107060 Dated___June_02,2010
---------------------------------------
Printed On:Jun-14-2010 Board of Health
t 4808
,r��, 8 (jy{
pF _. 9
s
Town of North Andover
HEALTH DEPARTMENT
SSS CHUS
CHECK#: ��-��� DATE:
r7
LOCATION: l/�o
H/O NAME: exc
CONTRACTOR NAME:
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 $
❑ 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 $
LTJ' Title 5 Report $ Y'0�
❑ Other:(Indicate) $
` Health Agent Initials
White-Applicant Yellow-Health Pink-Treasurer
•f
5069
to
0 $- ~,_ p
Town of North Andover
HEALTH DEPARTMENT
,s'SACMUStt
CHECK#: DAT: oZ/LD
LOCATION: V
H/O NAME: / --
CONTRACTOR N E: d�J
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 $
❑ Trash/Solid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
❑ Septic-Soil Testing $
❑ Sep ' -Design Approval /��Q $
Septic Disposal Works onC�struction( 0 $ �p
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
❑ Title 5 Report $
❑ Other:(Indicate) $
a.—
Health Agent Initials
\White-Applicant Yellow-Health Pink-Treasurer
p10RTF/
TLED 16�•vO
0
0
D LOCMIL lWKM y1'
0" TIED wP��.(5
SSAC HU15
PUBLIC HEALTH DEPARTMENT
Community Development Division
CE1'TJ FIC0TE OF CO.9VI<1'GI.�ir VCE
As of:
June 30, 2010
This is to cert that the individuafsu6surface dzsposafsystem received a
SA71STACT0RT I5VS lT EM0X of the:
(placement of a Component:
T gStri6ution fox
Foy an On Site Sewage DisposalSystem
0y•
ToddBateson
At:
1190 Salem Street
9Wap-106.,X; Parcel— 0121
Worth,Xndover, 911,9 01845
The Issuance of this cert f cate shaft not be construed as a guarantee that the system wiff
functionsotlsfactorily.
Ssan T Sr, E�fS
' �(u6CicWealth Director
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
f'
TOWN OF NORTH ANDOVER F NOR711
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT A
1600 OSGOOD STREET;Building 2-36 r
NORTH ANDOVER, MASSACHUSETTS 01845 f+ys° C <�y
SACNU58
Susan Y. Sawyer,REHS/RS 978.688.9540—Phone
Public Health Director 16) //L 978.688.8476—FAX
ONSITE WASTEWATER SYSTEM CONSTRUTI N NOTES
LOCATION INFORMATION � )
ADDRESS: 17 Q� MAP: LOT:
INSTALLER:
DESIGNER:
PLAN DATE:
BOH APPROVAL DATE ON PLAN:
INSPECTIONS
TANK INSPECTION:
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
❑Existing septic tank properly abandoned
❑Internal plumbing all to one building sewer
' ❑Topography not appreciably altered
Comments:
SEPTIC TANK
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ 1500 gallon tank has been installed
H-10 loading Monolithic construction
❑ Water tightness of tank has been achieved
(Visual or Vacuum Test or Water held for 24hrs)
❑ Inlet tee installed, centered under access port
❑ Outlet tee (gas baffle or effluent filter) installed,
centered under access port
❑ 24" inch cover to within 6" of final grade installed over
one access port, must be over outlet of tank if effluent
filter is present
❑ Hydraulic cement around inlet &outlet
Wastewater System Documentation—Feb 2006
Page 1 of 6
TOWN OF NORTH ANDOVER F NoRTN
pr O 4Tyao Ie '�
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT ~ 1
1600 OSGOOD STREET;Building 2-36
NORTH ANDOVER'MASSACHUSETTS 01845 .
SacHusY
Susan Y. Sawyer,REHS/RS 978.688.9540—Phone
Public Health Director 978.688.8476—FAX
Comments:
PUMP CHAMBER
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ Combo Tank installed. Size:
❑ 1000 gallon Pump Chamber installed
H-10 loading
Monolithic construction)
❑ Inlet tee installed, centered under access port
❑ Pump(s) installed on stable base
❑ Alarm float working
❑ Pump On/Off floats working
❑ Separate on/off floats
❑ Drain hole in pressure line
❑ 24" inch cover to within 6" of final grade installed over
pump access port
❑ Water tightness of tank has been achieved
Visual testing
❑ Hydraulic cement around inlet & outlet
Comments:
ADVANCED TREATMENT TECHNOLOGY
❑ Type of treatment device:
❑ Installed per manufacturers requirements
❑ All components working in accordance with.
manufacturer's requirements
Comments:
Wastewater System Documentation—Feb 2006
Page 2 of 6
^ t �
TOWN OF NORTH ANDOVER of IORTH
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT p
1600 OSGOOD STREET;Building 2-36
NORTH ANDOVER, MAS SAC SE TS 01845
. S9CHU5
Susan Y.Sawyer,REHS/RS ��� 978.688.9540—Phone
.Public Health Director l/� (o / 97 .688.8476=FAX
D-Box
[/ Installed on stable stone base
Inlet tee (if pumped or >0.08'/foot)
❑ Hydraulic cement around inlet & outlets
Observed even distribution
Speed levelers provided (not required)
Comments:
SOIL ABSORPTION SYSTEM
❑ Bottom of SAS excavated down to soil layer, as
provided on plan
❑ Size of SAS excavated as per plan
❑ Title 5 sand installed, if specified on plan
❑
3/4-11/2" double washed stone installed
❑ 1/8-1/2" (peastone) double washed stone installed
❑ Laterals installed and ends connected to header
❑ Laterals vented if impervious material above
❑ Orifices @ 5 & 7 o'clock positions
❑ Gravel-less disposal systems: type, number and
location as per plan
❑ Elevations of laterals installed as on approved plan
❑ 40 Mil HDPE barrier installed
❑ Retaining wall (boulder/ concrete /timber/ block)
❑ Final cover as per plan
Comments:
Wastewater System Documentation—Feb 2006
Page 3 of 6
" TOWN OF NORTH ANDOVER NaRTH
Office of COMMUNITY DEVELOPMENT AND SERVICES or°a" VO
HEALTH
HEALTH. DEPARTMENT
1600 OSGOOD STREET; Building 2-36
NORTH ANDOVER,MASSACHUSETTS 01845
gcHus
Susan Y. Sawver,REHS/RS 978.688.9540—Phone
Public Health Director 978,688.8476—FAX
PRESSURE DISTRIBUTION
❑ -- inch manifold
❑ laterals installed with end sweeps
size:
material:
❑ Squirt test ft in height
❑ Equal distribution to all laterals
❑ orifice size inch as per plan
Comments:
CONTROLPANEL
❑ Alarm & Pump are on separate circuits
❑ Alarm sounds when float is tripped
❑ Location of control panel:
❑ Rated for exterior if placed outside
Comments:
Wastewater System Documentation—Feb 2006
Page 4 of 6
e `
TOWN OF NORTH ANDOVER &ORrk
Office of COMMUNITY DEVELOPMENT AND SERVICES 4'o0`_ `°�O0
HEALTH DEPARTMENT
1600 OSGOOD STREET; Building 2-36
NORTH ANDOVER,MASSACHUSETTS 01845C
HGHU�✓
Susan Y. Sawyer,REHS/RS 978.688.9540—Phone
Public Health Director 978.688.8476—FAX
CRITICAL SETBACK DISTANCES
Mark those distances checked in the field against the design plan. and regulatory
setback
Tank SAS Sewer
❑ Property line 10 10 --
❑ Cellar wall 10 20 --
❑ Inground pool 10 20 --
❑ Slab foundation 10 10 --
❑ Deck, on footings, etc 5 10 --
❑ Waterline 10 10 101
❑ Private drinking well 75 1002 50
❑ Irrigation well 75 100
❑ Surface Water 25 50
❑ Bordering Vegetated Wetland ,
Salt Marsh, Inland/Coastal Banka 75 100
❑ Wetlands bordering surface
water supply or trio. (in Watershed) 150 150
❑ Trib. to surface water supply 325 325
❑ Public well 400 400
❑ Interim Wellhead Prot. Area
❑ Reservoirs 400 400
❑ Drains(wat. supply/trib.) 50 100
❑ Drains (intercept g.w.) 25 50
❑ Drains (Other)Foundation. 10(5) 20 (10)
❑ Drywells 20 25
1 Suction line 222(2)
2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance(NA 5.02).
3 As defined in 310 CMR 10.55, 10.32, 10.54,and 10.30,respectively,pursuant to 15.211(3),also by NA wetland
bylaws
Wastewater System Documentation—Feb 2006
Page 5 of 6
v
TOWN OF NORTH ANDOVER OF NORTH q
Office of COMMUNITY DEVELOPMENT AND SERVICES � `"`4a� �
HEALTH DEPARTMENT A
1600 OSGOOD STREET;Building 2-36
NORTH ANDOVER,MASSACHUSETTS 01845
SNCNUSE
Susan Y. Sawyer,REHS/RS 978.688.9540—Phone
Public Health Director 978.688.8476—FAX
SYSTEM ELEVATIONS
INVERT ON DESIGN PLAN FIELD INVERT ELEV.
Building Sewer OUT
Septic Tank IN
Septic Tank OUT
Pump Chamber IN
Pump Chamber OUT
Distribution Box IN
Distribution Box OUT
Lateral 1 HIGH
Lateral 1 LOW
Lateral 2 HIGH
Lateral 2 LOW
Lateral 3 HIGH
Lateral.3 LOW
Lateral 4 HIGH
Lateral 4 LOW
Lateral 5 HIGH
Lateral 5 LOW
Wastewater System Documentation—Feb 2006
Page 6 of 6
Alla
� s �
I
i
C
1190 Salem Street
4/10=S. Sawyer spoke with homeowner, Kathleen Rohde, regarding Title V questions. Planning
on having an inspection done soon and wanted information. Gave her licensed inspector list
and general information on if it fails the inspection.
I
IAORT1{ ,,••
O`�tLEC 16�•rO
OL
O
F- 70
T �R co c lwKK 7' T
�f Q°R�rEo
�SSACHUS��
PUBLIC HEALTH DEPARTMENT
Community Development Division
CE TjFICATE OF COW-Dl-LAME
As of:
June 30, 2010
This is to cert that the individua(su6surface dzsposaCsystem received a
SATIS FAC'rl'ORT IM(PECr ON of the:
ft&cement of a Component:
Ustri6ution �oaC
Tor an On Site Sewage Disposa[System
Oy.
Todd(Bateson
t•
1190 Safem Street
Wap-106.A; Parcel— 0121
North Andover, 90 01845
The Issuance of this certificate shaCC not 6e construed as a guarantee that the system will
functions tisfactorify.
S1� d
san
(� 6CicYleafth Director
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com