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HomeMy WebLinkAboutMiscellaneous - 1220 SALEM STREET 4/30/2018 1220 SALEM STREET 210/106.A-0183-0000.0 ` 1 ' i t COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS ' DEPARTMENT OF ENVIRONMENTAL PROTECTION Lvn TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 1 Owner's Name: j �,- 4 3-S/01- Owner's Address': 73/I i` t F, i nFP, - 2 2G03 11 Date of Inspection: -/�L—p 3 - Name of Inspector: (please Tint' Company Name: Mailing Address: Telephone Number: CERTIFICATION STATEMENT 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 Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signatures Date: I-24 -C:3 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. Notes and Comments � ""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. Tiile 5 tnsnerrinn Fnrm A/i tnnnn Page 2 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 17z& %�)j—' c VtVL, Owner: 0`!45S A r Date of Inspection: _ D —i 7 7— 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 15.3 03 or in 310 CMR 15.304 exist.Anv failure criteria not evaluated are indicated below. Commen ' 5 {{ � B. System Conditionally Passes: One or ore system components as described in the"Conditional Pass"s n need to be replaced or repaired. The sy em,upon completion of the replacement or repair,as approv y the Board of Health,will pass. Answer yes,no or not det fined(Y,N,ND)in the for the fol ing statements.If"not determined"please explain. The septic tank is metal and o 0 years old* or septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration o Itration tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying sep ' as approved by the Board of Health. `A metal septic tank will pass inspection if it is lly sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years of is avai le. ND explain: Observation of sewage bac p or break out or high static water vel in the distribution box due to broken or obstructed pipe(s)or due to a b en,settled or uneven distribution box. S m will pass inspection if(with approval of Board of Health . broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: e system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass pection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 1 l OFFICIAL INSPECTION FORM •NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -PART A CERTIFICATION(continued) Property Address: 12—Z.0 -y7 Owner: Date of Inspection: C. Furt\sexist n is Required by the Board of Health: Cwhich require further evaluation by the B•and of Health in order to determine if the system is failing lic health,safer•or the environment.1. Syunless Board of Health deter nes in accordance with 310 CMR 15.303(1)(b) that the sync Jong in a manner which ill protect public health,safety and the environment: — Cesspool or privy is :thin 50 feet of surface water _ Cesspool or privy is wt 50 feet a bordering vegetated wetland or a salt marsh 2. System will fail unless the Bo rd of Healt and Public Water Supplier,if any)determines that the system is functioning in a man r that protects a public health,safety and environment: _ The system'has a sep c tank; and soil absorptio ystem(SAS)and the SAS is within 100 feet of a surface water supply or butary to a surface water sup _ The system has septic tank and SAS and the SAS is w' in a Zone I of a public water supply. _ The system a septic tank and SAS and the SAS is within feet of a private water supply well. _ The cyst has a septic tank and SAS and the SAS is less than 10 eet but 50 feet or more from a private wat supply well".Method.used to determine distance "This ystem passes if the well water analysis,performed at a DEP certified laboratory, for coliform bact a and volatile organic compounds indicates that the well is free from pollution from that facility and th resence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other ilure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 7-10 /�-� ,.,� ' Owner: Date of Inspection: —1 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 V:day now r� 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 of tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. _ t , 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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 forma (Yes/No)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 Sstems: To be conside a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd- You must indicate ei "yes"or"no"to each of the following: (The following criteria ap to large systems in addition to the - eria above) yes no _ — the system is within 400 f f a s ce drinking water supply — _ the system is within 200 f of a to tary to a surface drinking water supply _ the system is locat in a nitrogen sensitiv (Interim Wellhead Protection Area-IWPA)or a mapped Zone Il of a pu tc water supply well _ If you have answer "yes"to any question in Section E the stem is considered a significant threat,or answered "Yes"in Section above the large system has failed. The own 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. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM_ INSPECTION FORM PART B CHECKLIST Property Address: Owner Date of Inspection: Check if the following have been done. You must indicate `ves"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 componenu 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 ? JV- 1A 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? K _ 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? 17 — 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: Yes no 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)[3 10 CMR 15.302(3)(b)) 5 Page 6 of 1 l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART C SYSTEM INFORMATION Property Address: Owner: `� :� Date of Inspection: - / = -Z, _# RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15103 (for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no): /�_� Is laundry on a separate sewage system(yes or no):_ f if yes separate inspection required] Laundry system inspected(yes or no):� Seasonal use: (yes or no): Water meter readings, if avai ble(last 2 years usage(gpd)):/U Sump pump(yes or no): Last date of occupancy: COMMERCIAL4"USTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): opd Basis of design flow(seats/persons/sgft.etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): - Pumping Records GENERAL INFORMATION Y Source of information..-4c S �� C //""LL- \ aco'3 Was system pumped as part of th nspection(yes or no): !V 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 A&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) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(ifknown)and source of information: U ^ � Were sewage odors detected when arriving at the site(yes or no): / Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:j Z 2 c 1zy �{ �, Owner: Vi ►� Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:____cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK:—(Iocate on site plan) Depth below grade: l` Material of construction: concrete—metal—fiberglass_polyethylene _other(explain) If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: --L Distance from top of scum to top of outlet tee or baffle:_ Distance from bottom of scum to bottom of outlet tee or baffle: 17 How were dimensions determined: ' n Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of le age,etc.): t L' GREASE TRAP:—(locate on site plan) Depth below grade:_ Material of construction:_concrete metal fiberglass_polvethylene—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: Comments(on pumping recommendations, inlet and outlet tee or-baffle condition,structural integrity, liquid levels as related 10 outlet invert,evidence of leakage,etc.): Page g of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: LZZL, Owner: ASS/V� Date of Inspection: 1/—( ' 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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: &—(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 6 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of b x, etc.):. t cam! PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (►ocate on site plan, excavation not required) If SAS not 1pcated explain why: Type )caching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number, dimensions: overflow cesspool, number: umovativeialternative system Type!name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil.condition of vegetation, etc.): CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and confieuration: Depth—top of liquid to inlet invert: Depth of solids laver: Depth of scum laver: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): 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,sighs of hydraulic failure, level of ponding,condition of vegetation,etc.): Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART C SYSTEM INFORMATION(continued) Property Address: / Owner:Date of of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells withi-n-t Veef. ocate —her public water sup rs the buildine. ( i , { a, e fes' i A Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOS_4L SYSTEM INSPECTION FORA . PART C SYSTEM INFORMATION(continued) Property Address: /2z } Owner: A rSS/ Date of Inspection: s1 c-,e- 3 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting properryiobservation 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 ow you established the high ground water elevati ® - _• 3--� � L. t � Com. evd t-0 �,T�k ree A L,V Au 6 �� TZ c + � - LCL, �t Te u i�t ,/�y�C-e-s � 2.3 Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection William F.Weld co-nar Trudy Coxe Argeo Paul Cellucel s.cntw LL Covemor David B.Struhs CQMM 10rW SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CATION Props Andreas ! Zo 5,4,L M srQt �� N t9 D Date of nspection: Address of Owner different) Name of Inspector. Benjamin C. Osgood Jr. Company Name,Address and Telephone Number. New England Engineering Services, Inc. 33 Walker Road, North Andover, Ma 01845 CERTIFICATION STATEMENT Tel. 508-686-1768 Fax. 508-685-1099 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: t�Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: S131, 7 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY. Check A, B, C,or D: A] SYSTEM PASSES: _ V� I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair, passes inspection. Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) _. The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exfiltration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a Fonforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 One Winter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 • Telephone(617)292-5500 . w �?Primed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: l 220 S AL E'M ST Al, 4A 14 Owner. pp,v A t_0 (Lo G E2 S Date of Inspection: sl 2_4 N7 Bl SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipes) or due to a broken,settled or uneven distribution boat. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distr[bution box is levelled or replaced _, The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Boatel of Health): broken pipe(s)are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Boatel of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or trbutary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 3) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(oontinued) PropeOwner. Address: /2 Z,, -57-4 LE nn -57-4 E E7' N, yon!b o JL R� /fA✓a 0a•u �iC 20 (rCRs Date of Inspection: I S �Z314'7 Dl SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMB 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to dogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. _ Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address; /2 2 0 S141-C­'$1 -ST Al, AIV 0 o 0i�-k, ^414 Owner. O l5sv ,4 a q 20(s E2 S Date of Inspection: Check if the following have been done: Pumping information was requested of the owner,occupant,and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. 14 As built plans have been obtained and examined. Note if they are not available with N/A. ZThe facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow The site was inspected for signs of breakout. jj!fAll system components,excluding the Soil Absorption System,have been located on the site. V The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions, depth of liquid,depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. JeLf'The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: r 2 20 S ft E^n Owner. 5—" ti. ' A N 9 O�9 e 2 A,414 Date of Inspection: �� �� `' U F a S s l�j Qy FLOW CONDITIONS RLr9IDEIVTIAL: Design llow:______gaUons Number of bedrooms: Number of current residents: Garbage grinder(yes or no)-_N Laundry connected to system(yes or no):_L Seasonal use(yes or no): A/ Water meter readuige, if available:_ 2 S? C"9. O AU E R ffCrE' g q 6 Last date of occupancy: CUi PeY,I COMMERCIAL/INDUSTRIAL: Type of establishment: Design llow:_gallons/day. Grease trap present: (yes or no)_ Industrial Waste Holding Tank present:(yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER:(Deacnbe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: 2 4eci rs System pumped as part of inspection: (yes or no) eg If yes,volume pumped: ¢alllons Reason for pumping: _'jo f�S Oj cT -7–ANk TYPE OF SYSTEM Septic tank/distribution bos/aoil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Other(explain) APPROXIMATE AGE of all components,date installed(if)mown)and source of information: /rl B O fl- e 2 Sewage odors detected when arriving at the site: (yes or no)&0 (revised 11/03/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 Z 2 v S 4 t✓E M 9 i 2 E FT N, /9 ov/�p v r R' M A Owner. D">N 4�Dao (.r L-A S � Date of Inspection: S)2 3147 SEPTIC TANK_ (locate on site plan) r� Depth below grader Material of construction: Zooncrete metal_FRP_other(e:plaia) ` Dimensions: /.6-Do 6-ALLoAl Sludge depth: 4 2 r` Z rr Distance from top of sludge to bottom of outlet tee or baffle: 9 Scum thickness: /,l" Distance from top of scum to top of outlet tee or baffle: 00r l Distance from bottom of scum to bottom of outlet tee or baffle: 20" Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage, etc.) zdejK ! N 0v eoAj 0 r sv rrl QV t 0 LE v 6 /Ifo{LM I- G e Cowtc -t 4e an iWI 74D eJ,-c Cue Scl' I-10 rccs SHfo vLD t 20 09/4- Z.f, 04C N t ?,- 16r bu c>e�c GREASE TRAP:_ (locate on site plan) Depth below grade: Material of construction:_concrete_metal FRP—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: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) (revised 11/03/95) 6 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PropertyAddrem /22v 5�lew� Sf /U. f�1Kjv Owner. 0 Ha Date of Inspection: �°g A s S`Z3�97 TIGHT OR HOLDING TANK_ (locate on site plan) Depth below grade: Material of construction:_concrete_metal_FRP—other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert:_ Comments: (note if level and distribution is equal,evidence of solidss over,evidence of leakage into 0 out of box,etc.) B"3c /S 1;11 aou.Y Caxe eo?c!' 7r �G rrs uP Jen 4ge An PUMP CHAMBER:_ (locate on site plan) Pumps in working order-(yes or no) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Addrem 12?o So It Owner: oaeje,/.a 20 ~S Date of Inspection: y SOIL ABSORPTION SYSTEM(SAS):_ (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: leaching pita,number._ leaching chambers,number._ leaching galleries,number. leaching trenches,number,length: Fry 101,t 17 Tle enc LS ZS leaching fields,number,dimensions: overflow cesspool,number: Comments: (note Conon of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.) CESSPOOLS:_ (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 constriction: Indication of groundwater. inflow(cesspool must be pumped as part 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: Commenta:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Addresx 12 2 D Sa��rr+ STir eT Owner. iv f1nJ D O cJc 2, Pvt.4 �c9n. 1cQ tJ`i Data of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within lop' Nlv�s e � N ^1; Z i 46 pts 719.0 CE V l To i ANK — 7�s� 2 T-- igti7K — � S � X �v DEPTH TO GROUNDWATER Depth to groundwater.�o feet //// method of determination or approximation•_ Ana w l e.4 c �T' �'T✓`tGc 4s�cX rry,.�. - -s-�. L ✓yt a At � (revised 11/03/95) 9 7REC�EIVED � Commonwealth of Massachusetts i 9 2013 FCity/Town of OWN OF NORTH ANDOVER System Pumping Record NORTH ANDOVLREALTHDEPARTMENT 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 to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out 1. System Location: forms on the computer,useonly the tab key Address / rf to move your cursor-do not City/Town State Zip Code use the return key. 2. Syste Owner: Name Address(if different from location --- ---- City/Town State Zip Cod Telephone Number B. Pumping Record 1. Date of Pumping >— 2. Quantity Pumped: Date Gallo—S�—� 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): -- -- -- - — 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ YesXNo 5. Condition of System: 6. System Pumped By: Name Vehicle License Number I AA�d d R('1/r/ Company 7. Location where contents were disposed: -&— ?to Date ng Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of RECEIVED -_ System Pumping Record NORTH ANDOVE Form 4 JUN - 9 2010 DEP has provided this form for use by local Boards of Health. Other forms m TW&MRIM1AIs4NDOVER information must be substantially the same as that provided here. Before usin Mfifrv.PREWNRIP4,6ur local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out 1. System Location: -T forms on the computer,useonly the tab key Addres , 1 to move your )�o6)y) `n U oyci _—.- cursor-do not City/Town State Zip Code use the return key. 2. System Owner: Name - ----- �° Address(if different from location) City/Town -_---- —_ State _ Zip Code - Telephone Number B. Pumping Record a)- t 0 2. QuantityPumped: � �—- -- — 1. Date of Pumping Date Gallons 3. Type of system: ❑ Cesspool(s) [ZSeptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): - --- ----- -- -- - _ — -- 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes [No 5. Condition of System: 6. System Pumped By: Jyy-, ------ - - ---- Name vehicle License Number Company 7. Location where contents were disposed: Signature of Hauler Ae/7 Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts �N City/Town of NORTH ANDOVER, MASSACHUSETTS System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. The System Pumping Record must be submitted to the local Board of Health or other approvin ! IVED A. Facility Information R Important: JAN 10 2008 When filling out 1. System Location: forms on the O�,ri �, +.ioRTH AN computer, use IA S(�. '� �.° H&= Lfr,DEPARTMENT only the tab key Address to move your "A), J�� // ©/�a cursor-do not — 1 t use the return City/Town State Zip Code key. 2 System Owner: r' Name — Address(if different from location) City/Town State Zip Code q-n a5S quo Telephone Number B. Pumping Record 0 16-60 1. Date of Pumping j t - 2. Quantity Pumped: —Mons Date y p Gallons 3. Type of system: ❑ Cesspool(s) PP Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? N Yes ❑ No If yes, was it cleaned? 19)Yes ❑ No 5. Condition of System: -- ©'V—. 6. System Pumped By: i224ewr or- NameVehicle License Number Wf�� '�Ve� Company 7. Location where contents were disposed* — — -- Signature of Hauler Date http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect t5form4.doc•06/03 System Pumping Record•Page 1 of 1 t ' Commonwealth of Massachusetts Cit %Town of NORTH ANDOVER MAS AGMSES System Pumping Record Form 4 SEP - 6 2006 TOWN OF N_..RTH ANDOVER DEP has provided this form for use by local Boards of Healt " to �gTM NT be submitted to the local Board of Health or other approving authority, ptng--Record mu, A. Facility Information - Im portant, When filling out 1. System Location: forms on the computer, use ,y only the tab key Address -'�- to move your �� -- --- ------ -- cursor•do not Cit /Town - . .___. use the return y State Zip Code —_ key. 2. System Owner: -- Addreso(if different from location) -"''"�-"'""'----�--.... ----------- ---- City/Town - --"�--- State — Zip Code - - _��'ash 193 Telephone Number - - B. Pumping Record K. 1. Date of Pumping Date D�--�uantity Pumped: .-.-. Gallons Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank El Other(describe): - -`---_..._._ ___...__...____ 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No r 5. Condition of System: 6. Sy em Pumped By: ame Vehicle License Number c5 a Company — 7. Location where contents were disposed: Si azure of Hau --__..._.__.._._..__..._.....-.. _.� Date - - http://www.masg,gov/dep/water/ 'pr ovals/t5forms.htm#inspect t5form4.doa 06/03 System Pumping Record-Page t of ` r J TOWN OF NgR.TH ANDOVERDAUE SYSTEM PUMPING RECORD SYSTEM OWNER&ADDRESS � I SYSTEIV!LOCATION t /aaa ��em �� r D TEuMPN : l� ------QUANTITY PUMPED:_ 54 0 CESSPOOL: NO__ -YES...._ __. Septic Talc: NO YES_✓ NATURE OF SERVICE: ROU'rINE_.,_.__E.ML-RGENCY OBSERVATIONS: COAD CONDITION FULL To CQVER 14EAVY GREASE - SM-TLES IN PLACE. ROOTS LEACEi ELD RUN13ACK EXCES$JVE SOLIDS__ FLOODED --� SOL.IDCAR.RYYOVER _O'I'LEREXPLAIN -� System Nnnped by � G. -40 COMMENTS: CONTENTS TRANSIaERRED TO n?d __._ 'o TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: JAN - 62003 SYSTEM OWNER&ADDRESS SYSTEM LOCATION (example: left front of house) DATE OF PUMPING: -C'I QUANTITY PUMPED I_` GALLONS CESSPOOL: NO YES SEPTIC TANK: NO_ YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED _ SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: COMMENTS: CONTENTS TRANSFERRED TO: FORM U - LOT RELEASE FORM .J©L6( 111 &_ Sl�o /,c I TRUCTIONS: This form is used to verify that all necessary approvals/wrmits from ards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. FILLS OUT THIS SECTION* APPLICANT �i'1� -S� PHONE_ LOCATION: Assessor's Map Number PARCEL SUBDIVISION LOT (S) STREET /2-2,a a-M ST. NUMBER ► -*..*...***,., .*****-****-***************OFFICIAL USE ONLY*­*-"*"**-*-*-"" RECO ENDATIONS OF TOWN AGENTS: ONSE NATION ADMINI TRATOR DATE APPROVED 2 DATE REJECTED COMMENTS S -77I U(� TOWN PLANNER DATE APPROVED DATE REJECTED r COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED i ;.SEpC SPECTOR-HEALTH DATE APPROVED j DATE REJECTED COMMENTS Z_<7 PUBLIC WORKS - SEWER/WATER CONNECTIONS DRJVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE