HomeMy WebLinkAboutMiscellaneous - 1225 SALEM STREET 4/30/2018 (2) 1225 SALEM STREET
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ZLot & Street % aJ`� Map/Parcel
CONSTRUCTION APPROVAL
Has plan review fee been paid: YES NO Permit#
Plan Approval: Date: Approved by:
Designer: Plan Date:
Conditions:
Water Supply: Town Well
Well Permit: Driller:
Well Tests: Chemical Date Approved
Bacteria I Date Approved
Bacteria II Date Approved
Plumbing Sign-Off: Wiring Sign-off:
Comments:
Form "U" Approval: Approval to Issue: YES NO
Date Issued By:
Conditions:
Final Approval:
All Permits Paid? YES NO
Well Construction Approval? YES NO
Septic System Construction Approval? YES NO
Certification? YES NO
Other? YES NO
Any Variance Needed? YES NO
FINAL BOARD OF HEALTH APPROVAL:
DATE:
APPROVED BY:
r �
J
SEPTIC SYSTEM INSTALLATION
CONDITIONS:
Is the installer licensed? YES N-8
Type of Construction: N W RE
New Construction: Certified Plot Plan Review YES NO
Floor Plan Review YES NO
Issuance of DWC permit:
Conditions of Approval from Form U YES NO DWC Permit Paid? - CNO
YE NO
DWC Permit# H0/ NO
Begin Inspection: YES NO
Excavation Inspection:
Needed: – /J <7 —
Passe By.
Construction In ection:
Needed:
As Built Plan Satisfactory:
YES:
Approval of Backfill: Date: iyBy:_
Final Grading Approval: Date:
By:
Final Construction Approval: Date: By:
Certificate of Compliance: Approval: Date:
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments' t
1225 Salem Street 1!1
Property Address
Richard Anderson
Owner Owner's Name
information is
required for North Andover MA 01845 1/20/2016
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 �Q
computer,use 1. Inspector:
only the tab key
to move your Neil J. Bateson
cursor-do not
use the return Name of Inspector _t +
key. Bateson Enterprises Inc.
Company Name
111 Argilla Road
Company Address
Andover MA 01810
Cityrrown State Zip Code
978-475-4786 SI 15
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 expe fence 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 ❑ Co ditionally Passes ❑ Fails
❑ Needs u er Ev luation by the Local Approving Authority
1/20/2016
Inspect rs&g4ature V 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
W —
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1225 Salem Street
Property Address
Richard Anderson
Owner Owner's Name
information is
required for North Andover MA 01845 1/20/2016
every page. City[Town 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,•' 1225 Salem Street
Property Address
Richard Anderson
Owner Owners Name
informationis North Andover
required
wirfor for MA 01845 1/20/2016
every page. Cityfrown 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
D.IM
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1225 Salem Street
Property Address
Richard Anderson
Owner Owner's Name
information is North Andover
required
wired fo for MA 01845 1/20/2016
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
❑ ® 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
t5ins•3113 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
1225 Salem Street
Property Address
Richard Anderson
Owner Owners Name
information is
required for North Andover MA 01845 1/20/2016
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. (This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000g pd.
❑ ® 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 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
1225 Salem Street
Property Address
Richard Anderson
Owner Owner's Name
information is North Andover
required
wired fo for MA 01845 1/20/2016
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 plan the system obtained and examined? (If they were not
available note 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 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
1225 Salem Street
Property Address
Richard Anderson
Owner Owner's Name
information atiis North Andover
required for MA 01845 1/20/2016
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
No design or as built plans at B.O.H. Only have old Title 5 Inspection papers
Number of current residents: 2
Does residence have a garbage grinder? ® Yes ❑ No
Is laundry on a separate sewage system? (Include laundry system inspection EI Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage Yes
9 ( y 9 (gpd))�
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1225 Salem Street
Property Address
Richard Anderson
Owner Owner's Name
information is
required for North Andover MA 01845 1/20/2016
every page. Citylrown 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 2003
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&tees
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•3113 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
sV.�y 1225 Salem Street
Property Address
Richard Anderson
Owner Owner's Name
information is
required for North Andover MA 01845 1/20/2016
every 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:
Original system. D-Box&outlet tee was replaced 6/10/1999, info at B.O.H.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.6
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.):
Unable to see piping , finished cellar
Septic Tank(locate on site plan):
Depth below grade: 05feet
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:
18"
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 1225 Salem Street
Property Address
Richard Anderson
Owner Owners Name
information is North Andover
required
wired fo for MA 01845 1/20/2016
every 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
15"
Scum thickness
10"
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
5"
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 tee ok. Depth of liquid at outlet invert. No evidence of
leakage. Outlet cover needs to be replaced broken.
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
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-3/13 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
M s 1225 Salem Street
Property Address
Richard Anderson
Owner Owner's Name
required for
is North Andover
required for MA 01845 1/20/2016
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-3113 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
1225 Salem Street
Property Address
Richard Anderson
Owner Owner's Name
information is
required for North Andover MA 01845 1/20/2016
every page. Cityfrown 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. No evidence of carryover. No evidence of leakage.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
OF Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y 1225 Salem Street
Property Address
Richard Anderson
Owner Owner's Name
information is
required for North Andover MA 01845 1/20/2016
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions:
1 field 20'x 40'
❑ 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•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
.19
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
•�''� 1225 Salem Street
Property Address
Richard Anderson
Owner Owners Name
information is
required for North Andover MA 01845 1/20/2016
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.):
a
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
19- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1225 Salem Street
Property Address
Richard Anderson
Owner Owner's Name
information is
required for North Andover MA 01845 1/20/2016
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
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t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 or 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1225 Salem Street
Property Address
Richard Anderson
Owner Owner's Name
information is North Andover
required
wired fo for MA 01845 1/20/2016
every page. Cityrrown 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: >6
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#36, Paxton Soil, Water>6'deep.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3113 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
�< 1225 Salem Street
Property Address
Richard Anderson
Owner Owner's Name
information is North Andover
required for MA 01845 1/20/2016
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 file
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal ped g pose System•Page 17 of 17
--._..__...._,...............
Town of North Andover
Tax Map # 210-106.A-0118-0000.0
Parcel Id 17263
1225 SALEM STREET
ANDERSON, RICHARD
1225 SALEM STREET
NORTH ANDOVER, MA
01845
Class 101 Single Family Property Type 1 Residential
Zoning2 1 Residential Zoning3 1 Residential
Size Total 1.01 Acres
FY 2016
UB Mailing Index
Name/Address Type Loan Number Active/Inact. From Until
ANDERSON,RICHARD Payor
1225 SALEM STREET
NORTH ANDOVER, MA
01845
UB Account Maint.
Account No Cycle Occupant Name Active/Inactive
Bldg Id. 17322.0-1225 SALEM STREET Last Billing Date 1/6/2016
3160399 03 Cycle 03 Active
UB Services Maint.
Account No.3160399
Service Code Rate Charge Multiplier/Users
MISCFEE ADMIN FEE 0.635/8 7.82 1/
WTR WATER 01 ALL METER SIZE 49.40 /1
UB Meter Maintenance
Account No.3160399
Serial No Status Location Brand Type Size YTD Cons
16336532 a Active 00 METE METE w Water 0.63 0.63 332
Date Reading Code Consumption Posted Date Variance
12/8/2015 851 aActual 13 1/20/2016 19%
9/2/2015 838 a Actual 10 10/16/2015 2%
6/5/2015 828 a Actual 10 7/24/2015 1%
3/6/2015 818 a Actual 10 4/28/2015 -7%
12/4/2014 808 aActual 10 1/15/2015 -15%
9/9/2014 798 a Actual 13 10/15/2014 -4%
6/6/2014 785 a Actual 13 7/16/2014 10%
3/7/2014 772 a Actual 12 4/11/2014 30%
12/5/2013 760 aActual 9 1/17/2014 14%
9/6/2013 751 a Actual 8 10/15/2013 -9%
6/7/2013 743 a Actual 9 7/24/2013 -4%
3/6/2013 734 a Actual 9 4/22/2013 -8%
12/7/2012 725 aActual 10 1/9/2013 2%
9/7/2012 715 a Actual 10 10/15/2012 22%
6/6/2012 705 a Actual 8 7/16/2012 -18%
3/7/2012 697 a Actual 10 4/14/2012 -4%
12/5/2011 687 a Actual 10 1/17/2012 -13%
9/7/2011 677 a Actual 12 10/13/2011 24%
6/6/2011 665 a Actual 10 7/20/2011 0%
3/2/2011 655 a Actual 9 4/13/2011 3%
12/6/2010 646 aActual 9 1/12/2011 -12%
9/8/2010 637 a Actual 11 10/15/2010 -3%
6/4/2010 626 a Actual 11 7/15/2010 2%
3/3/2010 615 a Actual 10 4/14/2010 -1%
12/7/2009 605 aActual 11 1/12/2010 9%
9/4/2009 594 a Actual 10 10/15/2009 2%
6/3/2009 584 a Actual 9 7/20/2009 -52%
3/10/2009 575 a Actual 21 4/29/2009 51%
12/4/2008 554 aActual 13 1/20/2009 23%
Commonwealth of Massachusetts
City/Town of .
System Pumping.Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may •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.
A. Facility. Information
1. System Location: Left/Right front of house(ge Right aro Nous. , Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Rig ar of building, Under deck
. Address
City/rown State Zip Code
2. System Owner.
Name*
Address(d different from location)
Citylrown ' state Zip Code
Telep•one Number
I
B. Pumping Record .
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? ❑ YeA 21f0 If yes,was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
/un
6.. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
aLS-Q Lowell Waste Water
SignItLfe cf Heul Date
0orm4.doo-06/03 system Pumping Record•Page 1 of 1
PETER F. REILLY
AFFILIATED WITH F.P. REILLY AND SONS, INC.
206 ANDOVER STREET, SUITE 11
ANDOVER, MA 01810
(978) 475-4370
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION
Property Address: 1225 Salem Street, North Andover, MA 01845
Name of Owner: Rudolph Koczera
Address of Owner: same
Name of Inspector: Peter F. Reilly
(I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: F.P. Reilly & Sons
Mailing Address: 206 Andover St., Suite 11, Andover, MA 01810
Telephone Number: (978) 475-1237 / (978) 475-4370
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the
information 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:
✓ Passes
N/A Conditionally Passes
N/A Needs Further Evaluation By the Local Approving Authority
N/A Fails
Inspector's Signature: Date: June 1 1, 1999
kF. y
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 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.
NOTES AND COMMENTS
y OF�p OF
ICDA 1
r
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION (continued)
Property Address: 1225 Salem Street, North Andover, MA
Owner's Name: Koczera
Date of Inspection: 6/11/99
INSPECTION SUMMARY:
A. SYSTEM PASSES: Check A, B, C or D
✓ 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.
COMMENTS:
System was functioning properly.
B. SYSTEM CONDITIONALLY PASSES:
N/A 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.
Indicate yes, no, or not determined (Y, N, ND). Describe basis of determination in all instances. If "not
determined", explain why not)
N The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of
a Certificate of Compliance (attached) indicating that the tan was installed within twenty (20) years prior
to the date of the inspection; or the septic tank, whether or not metal, is 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 conforming septic tank as approved by the Board of Health.
N Sewage backup or breakout or static high water level observed in the distribution box is due to broken
or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass
inspection if (with approval of the Board of Health):
N/A broken pipe(s) are replaced
N/A obstruction is removed
N/A distribution box is leveled 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 Board of Health):
N/A broken pipe(s) are replaced
N/A obstruction is removed
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION (continued)
Property Address: 1225 Salem Street, North Andover, MA
Owner's Name: Koczera
Date of Inspection: 6/11/99
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 the public health, safety and 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:
N/A Cesspool of privy is within 50 feet of a surface water
N/A Cesspool or privy is within 50 feet of a bordering vegetated wetland or 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:
N/A The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet
to a surface water supply or tributary to a surface water supply.
N/A The system has a septic tank and soil absorption and the SAS is within a Zone I of a public water
supply well.
N/A The system has a septic tank and soil absorption and the SAS is less than 100 feet but 50 feet
or more from a private water supply well, unless a water 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. Method
used to determine distance N/A (approximation not valid).
3. OTHER
N/A
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION (continued)
Property Address: 1225 Salem Street, North Andover, MA
Owner's Name: Koczera
Date of Inspection: 6/11/99
D. SYSTEM FAILS:
You must indicate "Yes" or "No" to each of the following:
N/A I have determined that the system violates one or more of the following failure conditions
exist as defined in 310 CMR 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.
Yes No
No Backup of sewage into facility or system component due to an overloaded or clogged SAS or
cesspool.
No Discharge or ponding of effluent to the surface of the ground or surface waters due to an
overloaded or clogged SAS or cesspool.
No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS
or cesspool.
N/A Liquid depth in cesspool <6" below invert or available volume < % day flow.
No required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped: none
No Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater
elevation.
N/A Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply.
N/A Any portion of a cesspool or privy is within a Zone I of a private water supply well.
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well.
N/A 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.
E. LARGE SYSTEM FAILS:
You Must indicate either "Yes" or "No" to each of the following:
The following criteria apply to a large system in addition to the criteria above.
N/A The design flow of system is 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:
N/A The system is within 400 feet of a surface drinking water supply
N/A The system is within 200 feet of a tributary to a surface drinking water supply
N/A The system is located in a nitrogen sensitive area (Interim Wellhead Area (IWPA) or a mapped
Zone II of a public water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2).
Please consult the local regional office of the Department for further information.
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART B - CHECKLIST
Property Address: 1225 Salem Street, North Andover, MA
Owner's Name: Koczera
Date of Inspection: 6/11/99
Check if the following have been done. You must indicate either "Yes" or "No" as to each of the
following:
Yes No
Yes Pumping information was requested of the owner, occupant and Board of Health.
Yes 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.
N/A As built plans have been obtained and examined. Note they are not available with N/A.
Yes The facility or dwelling was inspected for signs of sewage backup.
Yes The system does not receive non-sanitary or industrial waste flow.
Yes The site was inspected for signs of breakout.
Yes All system components, excluding the SAS, have been located on the site.
Yes 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.
N/A Existing information (Example: Plan at BOH).
N/A Determined in the field if any of the failure criteria related to Part C is at issue, approximation of
distance is unacceptable [15.302(3)(b)1.
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION
Property Address: 1225 Salem Street, North Andover, MA
Owner's Name: Koczera
Date of Inspection: 6/11/99
FLOW CONDITIONS
RESIDENTIAL:
Design Flow: >330 gpd (110 gallons/bedroom/day
Number of bedrooms (design): unknown
Number of bedrooms (actual): 3
Total Design Flow: unknown
Number of Current residents: 2
Garbage grinder (yes or no): yes
Laundry (separate system) (yes or no): no; if yes, separate inspection required
Laundry system inspected (yes or no): N/A
Seasonal use (yes or no): no
Water meter readings, if available
(last two years usage (gpd): est. 100 gpd past two years
Sump Pump (yes or no): no
Last date of occupancy: current
COMMERCIAL/INDUSTRIAL:
Type of Establishment: N/A
Design Flow gpd (based on 15.203): N/A
Basis of Design Flow: N/A
Grease trap present (yes or no): N/A
Industrial waste holding tank present (yes or no): N/A
Non-sanitary waste discharged to the
Title 5 system (yes or no): N/A
Water meter readings, if available: N/A
Last date of occupancy: N/A
OTHER: (Describe) N/A
Last date of occupancy: N/A
GENERAL INFORMATION
PUMPING RECORDS and source of information:
last pumping: about 4-5 years ago according to owner
System pumped as part of inspection (yes or no): no (pumped following inspection)
if yes, volume pumped: N/A gallons
Reason for pumping: N/A
TYPE OF SYSTEM
✓ Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
NO Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other (explain)
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 1225 Salem Street, North Andover, MA
Owner's Name: Koczera
Date of Inspection: 6/11/99
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Original system installed in 1972.
Sewage odors detected when arriving at the site (yes or no) NO
BUILDING SEWER: (locate on site plan)
Depth below grade: 8"-12"
material of construction: cast iron ✓ 40 PVC other (explain)
Distance from private water supply well or suction line N/A
Diameter: 4"
Comments: Condition of joints, venting, evidence of leakage, etc.) -
Building sewer was watertight and appeared sound.
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 6"-10"
material of construction: ✓ concrete metal Fiberglass Polyethylene other (explain)
If tank is metal, list age N/A Is age confirmed by Certificate of Compliance N/A (Yes/No)
Dimensions: rectangular- 1,000 gallons
1"-2" sludge depth
24" distance from top of sludge to bottom of outlet tee or baffle
0"-1" scum thickness
5" distance from top of scum to top of outlet tee or baffle
14" distance from bottom of scum to bottom of outlet tee or baffle
How dimensions were determined: measurement
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, recommendations for repairs, etc.)
Tank was watertight and functioning properly. Pumping was recommended and done following inspection.
GREASE TRAP: N/A (locate on site plan)
Depth below grade:
material of construction: concrete metal FRP other (explain)
Dimensions:
N/A scum thickness
N/A distance from top of scum to top of outlet tee or baffle
N/A 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, recommendations for repairs, etc.)
N/A
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 1225 Salem Street, North Andover, MA
Owner's Name: Koczera
Date of Inspection: 6/11/99
TIGHT OR HOLDING TANK: N/A (Tank must be pumped prior to, or at time of inspection)
(locate on site plan)
Depth below grade:
material of construction: concrete metal Fiberglass Polyethylene other (explain)
Dimensions: N/A
Capacity: N/A gallons per day
Design Flow: N/A gallons per day
Alarm Present: N/A
Alarm level: N/A Alarm in working order N/A (Yes or No)
Date of Previous Pumping: N/A
Date of previous pumping: N/A
Comments: (condition of inlet tee, condition of alarm and float switches, etc.)
N/A
DISTRIBUTION BOX: ✓ (locate on site plan)
0" depth of liquid above outlet invert
Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out
of box, recommendation for repairs, etc.)
The d-box was level and functioning properly. Five lines were not distributing equally. Little solids carryover
evident. Box was deteriorated and was replaced following the inspection.
PUMP CHAMBER: N/A (locate on site plan)
N/A Pumps in working order (Yes or No)
N/A Alarms in working order (Yes or No)
Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.)
N/A
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 1225 Salem Street, North Andover, MA
Owner's Name: Koczera
Date of Inspection: 6/11/99
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: not applicable
Type
leaching pits and number N/A
leaching chambers and number N/A
leaching galleries and number N/A
leaching trenches, number, length N/A
leaching fields, number, dimensions five (5) lines - overall size about 800 s.f. (20'x40')
overflow cesspool, number N/A
alternative system (name of technology) N/A
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.)
Soils over leaching area were good, no evidence of breakout.
CESSPOOLS: N/A (locate on site plan)
Number and configuration N/A
Depth-top of liquid to inlet invert N/A
Depth of solids layer N/A
Depth of scum layer N/A
Dimensions of cesspool N/A
Materials of construction N/A
Indication of groundwater inflow (cesspool
must be pumped as part of inspection) N/A
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
recommendations for maintenance or repairs, etc.)
not applicable
PRIVY: N/A (locate on site plan)
Materials of construction N/A
Dimensions N/A
Depth of solids N/A
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
recommendations for maintenance or repairs, etc.)
not applicable
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 1225 Salem Street, North Andover, MA
Owner's Name: Koczera
Date of Inspection: 6/11/99
SKETCH OF SEWAGE DISPOSAL SYSTEM:
indicate at least two permanent references, landmarks, or benchmarks
locate where public water system enters house
locate all wells within 100' N/A
SVe-• I
I
lU oT �
To else/
stALE Se/ Gat—
Bw+t
R 8
Sewer
r
r
20. oC
i Sep��c
yo, YARD
SEPTIC TANK TIES: A to Inlet (1) 31'1" B to Inlet 36'7"
A to Center (C) 28'9" B to Center 39'2"
A to Outlet (0) 26'8" B to Outlet 42'5"
D-BOX TIES: A to Box 23'0" B to Box 50'2"
NOTE: The system is in the rear yard.
r
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 1225 Salem Street, North Andover, MA
Owner's Name: Koczera
Date of Inspection: 6/11/99
NRCS Report Name N/A
Soil Type N/A
Typical depth to groundwater N/A
USGS Date website visited 4/1/99
Observation Wells checked Wilmington
Groundwater depth: Shallow Moderate ✓ Deep
SITE EXAM Slope level in area of system
Surface water none observed
Check Cellar dry
Shallow wells none observed
Estimated Depth to Groundwater > 1' (below bottom of SAS)
Indicate all methods used to determine High Groundwater Elevation:
N Obtained from Design Plans on record
Y Observation of Site (abutting property, observation hole, basement sump, etc.)
Y Determined from local conditions
N Check with Local BOH
N Check FEMA Maps
N Check pumping records
Y Check local excavators, installers
N Use USGS Data
Describe how you established the High Groundwater Elevation.*
Soils and grade changes in the area appear to confirm adequate groundwater separation.
*Inspector's Note: Soil Evaluation is the currently recognized method for determining or establishing the high
groundwater elevation. Since I am not a licensed or certified soil evaluator, I am not qualified to determine or
establish the high groundwater elevation beyond the public information available, such as recent design plans of the
site or the nearby area. My estimation of the high groundwater elevation is based on a due diligence effort to obtain
all available information both on and off the site and my experience as a certified subsurface disposal system
inspector. (see attached Disclaimer)
A
DISCLAIMER
This passing septic inspection under Massachusetts Title V is in no way
a guaranty or warranty of the inspected septic system. The inspection is
a "snapshot in time" and does not constitute a complete assessment of
the quality or potential longevity of the septic system. The pass/fail criteria
are specific and outlined in detail in this report. Under the limited criteria
of a Title V inspection, it is impossible to determine how long any septic
system will last. The inspector made a diligent effort to certify the septic
system based on the criteria required under Title V.
Under Massachusetts Title V, soil evaluation is the accepted method of
determining the high groundwater elevation. This inspector is not a
certified soil evaluator and is therefore not qualified under Title V to
determine or establish the high groundwater elevation. The method used
to estimate the high groundwater for this inspection was based on the
public records and methods of observation described on the previous page.
Groundwater levels can vary greatly from season to season, year to year
and soil evaluation is considered the most reliable method of groundwater
determination under Title V.
Petr F. Rei ly
Inspector
June 11 , 1999
TOWN OF NORTH ANDOVER
BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
DATE OF COMPLIANCE:
06/15/99
This is to certify that
the individual subsurface disposal system
constructed ( ) or repaired (X)
by
Mike Reilly
at
1225 Salem Street
has been installed in accordance with the provisions of Title V of the State Sanitary Code
and with the North Andover Board of Health regulations as described in the Design
Approval Site System Permit# 1101 dated 06/10/99 for D-Box only and Tee.
The Issuance of this certificate shall not be construed as a guarantee that the system will
unction satisfactorily.
VO-IX 6/-,i t2
Board of Health Inspector
SYSTEM PUMPING REPORT
NAME OF PUMPING COMPANY � r REPORT FOR MONTH OF f m '
CONTENTS CONDITION
OWNERS GALLONS *H G TRANSFERRED OF
DATE ADDRESS NAME PUMPED C D S TO SYSTEM
LOT- C--Z t-;��C�lj
� \- ie� 5 n
`-0 -��. SCS �� CptC� l.s� �'�.
p C--,3 l �� l�rn fit' Scxa�n �`�C>h 6 v�• � �'
q.
* C = Ces pool D = Drywell = Septic Tank G = revise- Tra H = alding Tank .
�b✓
��i3 a x oar
Town of North Andover, Massachusetts Form No. 3
NORTH BOARD OF HEALTH
of 1
19
• F A
DISPOSAL WORKS CONSTRUCTION PERMIT
,SgACHUSEt
App licant
NAME ADDR S TELEPHONE
Site Location &
Permission is hereby granted to Construct ( ) or Repair (,I/an Individual Soil Absorption
• Sewage Disposal System as shown on the Design Approval S.S. No.
C H A I RM-AN—, 90A-,R 49F U€k.Eru;>'^
f
Fee �� '� D.W.C. No.
i
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE: 6110199 CURRENT INSTALLER'S LICENSE#
LOCATION: 12-2-5 Sa/e_ls, 5_�4-
LICENSED INSTALLER: A)p ,/,/e ke-
SIGNATURE: TELEPHONE#
CHECK ONE:
REPAIR- v NEW CONSTRUCTION:
IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUILT.
Administrative Use Only
$75.00 Fee Attached? Yeses/ No
Foundation As-Built? Yes No
Floor Plans? Yes No
Approval Date:
//,9A1;r
n TOWN OFNORTH ANDOVER/
(j C +q,t k— �QG�' b BOARD OF HEALTH
COMMONWEALTH OF MASSACHUSETTS
A EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
d
DEPARTMENT OF ENVIRONMENTAL PROTECTION
�r
v�
V�
0
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A O
CERTIFICATION
Property Address: 1225 Salem Street
North Andover,MA
Owner's Name: John&Joanne Lynch
Date of Inspection: 6/19/03
Name of Inspector: John Soucy AUG `L �J 2003
Company Name: Soucy Sewer Service,Inc.
Mailing Address: 830 Livingston Street
Tewksbury,MA 01876 ---
Telephone Number: 978-851-8839
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:
X Passes
Conditionally Passes
Needs F her Evaluation by the Local Approving Authority
Fails
Inspector's Signature:
Date: 6
The system inspector shall sufacopy f this in(hall
ction report to the Approving Authority(Board of Health or
DEP)within 30 days of compectionthe system is a shared system or has a design flow of 10,000
gpd or greater,the inspector owner 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.
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1225 Salem Street
North Andover,MA
Owner: John&Joanne Lynch
Date of Inspection: 6/19/03
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X 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.
Answer yes,no or not determined(Y,N,ND)in the 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.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
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
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address 1225 Salem Street
North Andover,MA
Owner: John&Joanne Lynch
Date of Inspection: 6/19/03
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
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 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 form.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1225 Salem Street
North Andover,MA
Owner: John&Joanne Lynch
Date of Inspection: 6/19/03
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_ X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X 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
_ n/a Liquid depth in cesspool is less than 6"below invert or available volume is less than V2 day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ X 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 form.]
(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 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.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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 11 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.
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 1225 Salem Street
North Andover,MA
Owner: John&Joanne Lynch
Date of Inspection: 6/19/03
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
x _ Pumping information was provided by the owner,occupant,or Board of Health
x Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
x _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out?
x _ Were all system components,excluding the SAS,located on site?
X _ 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?
X — 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
x _ Existing information.For example,a plan at the Board of Health.
x 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(3)(b)]
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 1225 Salem Street
North ANDOVER,MA
Owner: John&Joanne Lynch
Date of Inspection: 6/19/03
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):_4_ Number of bedrooms(actual):_4_
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents: 4
Does residence have a garbage grinder(yes or no):—es
Is laundry on a separate sewage system(yes or no): no [if yes separate inspection required]
Laundry system inspected(yes or no): no
Seasonal use:(yes or no): no
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no): no
Last date of occupancy: current
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sqft,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):
GENERAL INFORMATION
Pumping Records
Source of information: Home Owner
Was system pumped as part of the inspection(yes or no): ems
If yes,volume pumped: 1000 gallons--How was quantity pumped determined?Gauge on truck
Reason for pumping: maintenance and inspection of tank interior.
TYPE OF SYSTEM
X 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)
_Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if known)and source of information:
1972- 1973
Were sewage odors detected when arriving at the site(yes or no):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: 1225 Salem Street
North Andover,MA 01845
Owner: John&Joanne Lynch
Date of Inspection: 6/19/03
BUILDING SEWER(locate on site plan)
Depth below grade: 12"
Materials of construction:—x—cast iron _40 PVC other(explain):
Distance from private water supply well or suction line: N/A
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: X (locate on site plan)
Depth below grade: 8"
Material of construction: X 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: 5'x 805'
Sludge depth: 3"
Distance from top of sludge to bottom of outlet tee or baffle: 37"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 14"
Distance from bottom of scum to bottom of outlet tee or baffle: 13"
How were dimensions determined: tam
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.): Remove Garbage disposal
GREASE TRAP: n/a (locate on site plan) N/A
Depth below grade:_
Material of construction:_concrete_metal_fiberglass_polyethylene_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 to outlet invert,evidence of leakage,etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1225 Salem Street
North Andover,MA
Owner: John&Joanne Lynch
Date of Inspection: 6/19/03
TIGHT or HOLDING TANK: n/a (tank must be pumped at time of inspection)(locate on site plan)N/A
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:_X_(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
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.):
PUMP CHAMBER: n/a (locate on site plan) N/A
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: 1225 Salem Street
North Andover,MA
Owner John&Joanne Lynch
Date of Inspection: 6/19/03
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching chambers,number:
leaching galleries,number:
_leaching trenches,number,length:_
X leaching fields,number,dimensions: 20'x 40' .
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.): No Sign of Hydraulic Failure.
CESSPOOLS: n/a (cesspool must be pumped as part of inspection)(locate on site plan) N/A
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 or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: n/a (locate on site plan) N/A
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1225 Salem Street
North Andover,Ma
Owner: John&Joanne Lynch
Date of Inspection: 6/19/03
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 within 100 feet. Locate where public water supply enters the building.
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7�w?1 MN rr I 1
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� t ff,,i1�4 A R D
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ar
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• 1 (�`+'\ i'l�j, !.t��14 1,. �.'�• ti -i.. r l \;�`al� �rl;}
to Inlet (1) 1 31 B to Inlet 36
t''
B to Center 39�2
B to Outlet 425
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Box ►� �qri B to Box 5Q 2
• ;;�' j��^ ,'ur�'�R�i� "��brr�t�7.., v ,,( r 1� ,j a�o-a F .,i' ',
:7he system is in thv rasa yard:
W"RMfflTN9, .WX r 11Y ,�1'. u t N r ,?1
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1225 Salem Street
North Andover,MA
Owner: John&Joanne Lynch
Date of Inspection: 6/19/03
SITE EXAM
Slope
Surface water
Check cellar x
Shallow wells
Estimated depth to ground water 3ft feet plus.
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:
X Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Used hand auger approx 30'from s.a.s. in low area
..
1 1 71 55
WATER BILLING HISTORY 3160399—SINCLAIRE METER #1: 3160399
--------------------- 1225 SALEM ST
Internet # CYCLE SERVICE PRIOR ' CURRENT USE WATER SEWER FEES TOTAL
EAplorer
1 2000-13 10/01/1999 40 98 58 158.34 0.00 0.00 158.34
2 2000-23 01/12/2000 98 137 39 106.47 0.00 0.00 106.47:
3 2000-33 03/29/2000 137 162 25 68.25 0.00 0.00 68.25.
My Briefcase 1 4 2000-43 06/13/2000 162 190 28 76.44 0.00 0.00 76.
5 2000-9F 08/23/1999 40 88 48 131.84 0.00 0.00 131.04
6 2001-13 09/11/2000 190 222 32 87.36 0.00 11.00 98.36;
7 2001-23 01/05/2001 0 27 50 136.50 0.00 11.00 147.5
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, ft'epWt to the Approving Authority(Board of:Health or
a `# r 30:days,of wtnP ' g this ins . 'on.If tho system ystem is a shared system or has a design flo%jof 10,000
R f' utspector and a system.ownershalh uhiniit-the
report to the
r Po appropriate regional off'ice of the 4 4rAal Should be sent tp the system OWmef and copies sent to the buyer,if applicable,and the approving
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1 .-:�.�q �r`ty., •i,,. i, ••'�S ;C+•';, I ,�k Yl'�.v� AFr<.Ti�'.�): .•�'',�s' �-.I..
h� 4�`lfk! irX<i i } Grp" Y a _"t t;sr � Jitasa 4'
t n,.. s:h� q � i � JyLxle , } }r�"yi
�, s t s}tp_,rsY fs'' iter 'f',G '
J '>; it�FgY �ui eV(7.3{ eWF{{{� ?
Wt �..
.,�. �5 ,.a!r��M^+1 H .�t{)���r,•t�,l(� ><tx{�.:� d ,�,..; f �,�ty.� �.�.i.^
'QRMf�-NOT'FOR VOLUNTARY'ASSESSMENTS
x rA't r.r,r x � ip esi ' vi..
A S �?KAGE.DISP4SA ;,SXSTEM INSPECTION FORM
PARTA QT
RTi`
rzsiP'+i �� IXhJ�49akp P r+41r �,v. H 1 A.'.
(WAtinue '
d)
'} t •��� � '{..� �x�{�'{' �J �';?,�'^}3,,C:,afry�q ex l AtG 1.' r . . .. -. `'Z�wt�•t.
S! }�C.'i+•1�i" F A j"^�'iT+'^� 4�X-04��/�f •' f 2t
�� Tics
irefittthw'exalt lay,•tb Board of Health in order to d F.
.safoty or the environment• determine if the system �.
�� � ��y�l;lt���L•f<11{A'S+ 1'4 {'1..�1p�hH��•,}t�,,4�4lwa •f•/� :.,. ,. .. :t.1 � /.'•,. ..
P y'n� bTa•1Rwllw! �Rfealtit.dete J ri
r�1�)1t accordance with 310 CMR 15.303 Z
Wbkb l )'thSt the
}�, r k protect public health,safety and the environment:
'F
� -4 or lutes hi( t,«i1�SO .Qf
e3 o
PQo, Pavy wixlua S0 feet of a bordo�tg YeSetated wetland or a salt marsh
t sx��xi x+
7n- i r eirG�;F{fa•a1,} ftAi�p,a!K . �li�., 1'a:.Jif! �{iilH�F i•e !' 1., , �
'14Frh
a h �`a�•l>.,f4{ ,jr� °"�.¢ �' fT'�.."2"!�MA,.#Nrfi�`R:����T�{t�'���¢w} �t!'r.: , .I. .. . • j.'4.�
t yi
unisis
�toye�BoA*r�dsof H}�ealth(aptl'Public Water Supplier,if any)determines that the
P y�
'�{ r
UM thf,public health safety and environment
30.
gyp•. F �W tJ Y+k' :• i .�a t.a r, ys al i� !!1 {�.�.3e1.��.t.j.;•;V
e
' Mos. "" ' u c a�Ak as :aotl 'sySkM(SAS)and the SAS is within 100 feet of a
A.81,1tho water amply
'itto it
�ditbQ'WJA within a Zone 1 of a public water supply.
( �t�,,y:c dl f�r�'°f,���F♦y�{cA��,J S��qq1 1�'�'R C '.. i _ , t � .fit...
� Y � ,fit ,T a has a septic t G and SSAS att�d tbQ
'>4 l c; is Within 50 feet of a private water supply well.
t4�{t•;;:,h' ij,�d� �d3bvr� fr44A4<J� ,.x.f e ip i , t
r
41 G` r
q {/a ,'Q ,� SA S}is lass than 100 feet but 50 feet or more from a
+ +e�� i/ 1�11tfi «r+�1�tQ $t�t�ce
J
#� r ht�;`�y��,t'�#'jz ,.r�iy,4�; �t ,�,,: •� gvt,�J�(� 4� tali�'+�T4rlre�±
ay Iota P 00 WOE"Y4 pVfgrMW at a DEP certified laboratory,
a la �►Po iadicates drat the is free from for coliform
t pollution from that facility and
o* ' 8nia�o�on s.equal to or less than 5
} provided
a* PPm+P th no other
Ys1�,tpust be attached to this form.
'!�'�'H '�(` �'�t!�5�'ae�,rjy��Yiij`,�r AY F• � f r 4 ilk'
A * a*�'7 y�'rJ•ry� �1��1^ � (t� �.1' ��F j t�'�} ; `� ,A � tr �t
. ,,. � ,�� � 2!�lr,��"4� t't�ir•F,, ,� .�i -r,: 1Fn r�'G ;T }"�� f ` t,� ';�3,ytlyf,
� - '�'" q p z J -:t 6! %4 {ter �M ir4 � 1 •
�/S
#,.�,, Yr'it�„{""•t{Ir� tyzj},Iw/."}j{ti4�e v l,.I.r`}a(
�. ! L�.�'`�r r>3$�`j'' � '44 r !i'�rAf- 'Afro c t-f( cel�.�.• r tam ty`b - .
h 4
J t ftyf4 F3 f���a k,,G j
trw`��
1 f ♦♦ l�f r word {, ,pr..`, r,�e G,.,,r } --Y (r -
��'
RP MfA�a(0.411' 64'A'
4 f`MM � q, f 11tt��p �,Ar tt ` ( .. i-%✓b�1Fw
§t
s
' `y �f'�y{e�etya�,Fcde ,I�a4i;���'ur•2,-..ji''�3.'•N�a '� ��`.:r� f$7.,�.,._' �-
'� ,�.•,t a1 fit.�S 7. 1 1.
fl 4 f• 'fir a 7'*r t' >e Y ais `' l 1 1 r, , p�,, 5`ri ,! .
s �t � t �.�` i 7ye�t'�! fi��'+"S;�L 4fP'r���r t k to(t•1tr�a,� fj}
1 S
,.
FORK41"NQ` •�..,O` VOLUNTARY ASSESSMENTS
;'.
4 Y�c
tMU7AVRRiCAJMAGE DISPOS SYSTEM FORM
.�
�•
2t1+r Y. R�T.�+�}!} sem++1: arr it r8ir 4� PARTA'''
II'.Id4;� hit :?�g�,j)tyftrs^i^etj ilzlar t I t 4 ■^/�-1 7■
CERTIFICA N 's
�'IO ON Y .
rL '�f eifi an. try }H•". � �1-r '�q;y k
} ��•�.��j�Y'`3w+�s�s ':�r�kyrtl�tRl:lt� i�� YI-.` ..,4,6 �:.:4 :�� ,rk1}�,T;r IA ..
app>i�tbk
".w fto740 oachof tbe'followingons:
: . +r 111,msAect� fI,
p � � 1ec is4t'�•�^gks�.Ys,s ew.. � .• +.' y .;-:''. -...:4k + s,��. ;
�>V"r , I xY , system`comA4aout due to overloaded or clogged SAS or cesspool
; �t '"'t"' c or l��of eflueut to ft-V *4 of 140 ground or surface waters due to an overloaded or
r� 1r "y;r ��"1 .�UhaSc>o+lged SAS oroessp001 . .
lulutdv the d�ctnb a
'tip nv? boX a*Vq au*'avert due to an overloaded or clogged SAS or
parol below Myert-Or available volume is less than Y day flow
PumFm&score thea 4 tunes is the last
-t;
x� y y 0f ygar 1( T due to clogged or obstructed T
FWpped,_,..,.. Pipe(s).Number
Qfthc. ,"OP"1 or privy is WQW'high ground water elevation.
t , Y•FOroa
of
cessppol or prtyy.is within 100 feet of a surface water su 1 or z
rYAW�uppiY;,.4 tv�i 11;13 -„ a , -• PP Y tributary to a surface
r 1g11iG 1i4x;:t'�. li
,. ,Y, ; ! Fel pftvysis.witbia.a : of a public well.
4 Y p oon of a
:xt ,case ti°� pool or privy's wilt$Q feet of a private water supply well.
XP +ou.ofa,c,MpoolarFivy'Is.kss
:fifl;t Y1`1OO feet but greater than 50 feet from a rivate water
wtd¢ ►PFy Wl ,Wltll uo P
, , aoceptjW water quality! ysts [This system passes if the well water analysis,
x r .���:�«;per�'wt4 at s AEP�co�rtlfed ls4orato
ry,for coliform bacteria and volatile o
k,f foal tbe-wsn ls-f"from poUatloa from that facility and the presence of ammonnic ia
nda
tU"�'* =�DItmte nitrogen is!anal to or Iei14wo S _.
}, I s "I copy,of tha twalysis wyat 4e alta h PPm'Provided that no other failure criteria
k Oki
r c ed to this form.]
7Atsysktn L1 .I have
R�: tbst O'ne or more of the above failure criteria exist as
3,j0 GM15.303,tl>erGfore the System fails,The system owner should contact the Board of r
Will bF llecessaty to gon+ect the failure.
#���+�i•�Ra�•�il�i��=a+1�1�1��[ �t �!�,1�t+t `.t.�.l>rt cft ati
w •
��Jlfro�.,ti�:�;� Rei{tl.l;. Z: li)” t�t14. tIh 3:I. ;iii'.�. .. � yy
10 {+R iyffemttbe aygtga;:Att serve a facility with a design fl i; ..
t tY g now of 10,000 gpd to 15,000 <<
of the fol]owtag
## {{ piX f0 largo systems 14A"0011 7!f♦critte.. .rga above) 1 ';:.•* s �F`i 1} yr`"s, 'p ,, F ¢ , t4the
,.t• •f r `� y�• � ��i +i}4N fSq�t'i�^ y�, tr >k i,.� + y, in. r ,. i•�' �.
,•.t �7 s���'����t^3. :���`I 1sL�i� r`il R,}1. � + G�t t
f Xdon .iQidSl Q - � i ••
:�'{ -�'• L "`a'"•rW ml't•v �t�RY+�? •:ani tC of rp 1! +fN'q Si .&WplY '• , s Ui.
�
F � i }.�%i2'FaFrlJv j!wwater supply
L` M 4 41t ogee sU40vs am 040rim Wellhead Protection Area—I WP }
* _ A publis<Wata1'supply well �. A)or a mappFd, ,
sh
k t E' Y:.9 SRetiAA FMC I$considered a significant "
. pX6 gn cant threat,or answered
f�1ed.,The owAq'or operator of an largeSutton B or failed uta$paioiD>a s14411 u Y ge system considered a
Upgrade,the system in accordance with 310
f rY QWj 'should � pia �0n�office of the De artm. CMR
..aa. St•.f%t(R��j .x�+��� (n d I I r partm0Qt. 1
4 �
h�� � t �•}��' jC,t,�'�gra A+.tt °j .taw S . a i
• t��i�^�pt �t�Ij` � �.'�� �SSrjrr„1 �r�t�� t�t.,�'' rSn� ��1, . i u :�
. ... �< 5 .,, 1:Tkfey j7. t'•,•;�c,�� 4y�'E. ,..!rny.,i `r�j•� .4
,
NA -2 - h§ r i y'S' +'' '+ ks, R`i, "s`s
J
}:!A.,
?s.A.L Q
A7F.oC ( y.V: DM_ "W�;NJ MlT.^, O.' VOLUNTARY ASSESSMENTS -
N r
A 14 4WA►GE DISPOSAL,.SYSTEM TEM INSPECTION FORM
PART.
*'e'+PECKLIST . . i.
F g
t9{� 1tq�t«hl
•�Y� }�t-' �)..+,�`��r�Ctr.'ra p., tv,+ t } r. � t�'�1f}� �}'.;. .y�7'i .•.
N .+ •{ cbr r$ 1 ,fT.yWly W.i.i « 1.�}! Y� +�S.r,d�;yya•
Check followin a been done You must indu r es"or"no"as to each of the following:
y F. S 5Flk
1¢itt1
!= A'� ^}'- 71Fhtj
1 h. ({ .r 7 P. ••^�tl,ry i}7' '�..� } �.
1 {
m �.. r47; ,� ?4Pa$ w pmvidGd b .the
rLhrar Y oWAer,90cupan:,or Board of
F; ?,�A,�;1f tbp Quota 001"ActsP=PG0 DYt iQ thO previous two weeks? n ,
`� T+'FV�� 6r t�T�'t�!'t lAAp�i , ''�• s•ki � i:a. ;�i'.
Mows W ,pfg*46 two week period?
it"•�tr j &t 1d?X}`= `��! -+ ! -.a ., ' '--- ° �r.',. ' i
^ .� rr Y �1G Y � ►ater u? uc5ad toS m re a
of bgeu.
'�',�,�F;,1F. P „�'IY:I�,�,� ;�t � � '.� �' : �. T •�' .-•. � � . ,.., � cantly oras part of this inspection?
,�'' ' d,, r; w bwltlans of the
system obtained and , ..,
oxatnined?(If they were not available note as N/A) r�
Wggt'7*' we
,'!� *P for 034,9f sewage bacu
.,. aM� back ? + .
J h gaa�PACntS�OXC1RdWg t1,C Sl1,S�10oated on Site?RM
'
' ( e1 t�nlc mauholas uncovpd,o and the interior
! 'tcs,rMate W of 9o45nctio dimensi of the tank inspected for the condition
r k},Nk 4 4 ,,a ? _,h nsupth of liquid,depth of sludge and depth of scum?
, .
i0104cillty oww
a3 ,t 1 save P tf diffaWAt*914 owner)provided with information on the proper
qy„ F2yW�'1�w
k � 5'! �.y"�SGF.i! 37{ l4./"j°r.l=+s4y t� •y*r'-+ -
} q�,¢ sIttj'pi,'I'..�
y" SIL+i� qua R
! �� d t�04 9f the;SoU Absorptio4 SDkl�(SAS)on the site has been determined 1 S w • G based on: ri
:+Sifii �Y{r
ar :$p44t te Baerd;of I.'
Health.
S,2 a`g4y�; 9�y.FfYj� �t�r�l5f`� t+}t'l!a.i j t� }, ;�e ✓ �" ';' '� d 1'�«e.
r
Jud gold(if aay of the int {elated to Part t�•.
15,3(�(3�/{�1 } s C is at issue approximatiokof distance
4 � t5 �,i'4 Ya+F.Gt 5��� C r t/�� t1}f �A �t
f gr? 1�Jy'i{/.€�tY I+.. 4l� '' 1 IFF51 .l 'd'�l 11Mt t•i1 w
.'F" ,�tRll�l.'•'` aS� Lp 111; +6 ({.l4p ii,
CYP�d�i3l ah�'r .tRr A ( v 1 <y ,
�•
R�aM`�R .;.,r.i t dF r rt 7 d i i�,'^{. 4>1 ��€ir' �.1� R"'�f""" +Kr"' g+'+'*i'�•�+LLLL;y+mr .f..... .-. .. I�' ;,'���:
�� r��w•!�'"yL v 1 - .rr a� t y;.,S' _ :a Y �^!_�!r'S�t r
t "' f.!'�Si1� ht'b l"' '1;41 '�*' 1, Tfr T'M4 T'T`Y ern om-• ... ^6'':.If
3 �}��rff '�y •r�,,rat, y �.k , h ti ti 3r
� ,..'1 a..l+i'{ (`�,:d { r + {447 {44 1r117p hl! 1',1• �,��
3 ,I-y id fiFt
}(��4{i�d��tx}�M1�"(•7(4�!"t' �R1(�$e5y iy°'�;"`h't�t�41`�t+,n,r�'` , �!�{,+:
Jn' ;i"y b ><ur�'s M to a i t •�. x y y r �-it�=t
��1 hYV ''11 tl•'��`R"14' f'r y+,��•�' y� t r' S vat r,:• {i[lt,,_f
A �F ,'fNX t� �'�•' �{'Z- ,
1pp � � ' ,fk fe"iµ I'dtt• tr 'tj�i Ge _�
j y
',:..t �t �. , �,}rr �+i I��tll +*�,�""',,,�a'�lkl �i•,'� ,I 'r ft3t F` 1 � :,�¢�i•
6 t 'r > f"'_ t� Z)� t r ,', jf i' Gt k. r Yyt2N: v •.>' ,..,.
P0 4
F � i%
� j,>, '� 15rpl� 'IQ�1Tr FARM=`"�iOT 'AR VOLUNTARY .�
�►C�:SEWAGE AIS ASSESSMENTS '
POS }`.
AL SYSTEM INSPECTION FOM
tt"i�1`)P"4%.
ov - PART V'', .
V
f kt,F � nt dF wr{vv A y •i't K r F ..SYSTEM
� ORMATION y
n� 1
x
fit,} {
tip bF ��rr�� Jed �?t �: •^ /�• c �, ;,f
dJ
b;.
� �,fpFS� ttIQVr: oii 31A CNt 'So3u fo ar of b�droo '( tual): {
{i'ir+� j A'Nw�? r of.mat idents. ( example. l 1 Q 13Pd x#of bedrooms)• H D
- ' agar •90 C tr •I
BR.Ay I:(yes or ao)• '' 1
�:,�(4 :sepal;ce ia�pectioa required] .
'. ,.
���,,�r� l ',�ppu �' lw$�;'�a_ le(fit 2 years usaga .., a>rz,
-,'((yyam�Qr AQ\• )• .
w
;31�A
5,203):-
or
203).
��I�•�f �
.or �..
; ate ------
MOW(yam
diischstged
Title system(yeS or no):HER '
fr,,�'rk�HMj�{��,��
"b> t f If E t 1' t I � � 'r{ } i1 +v:r` {fi! r � ., , ,.;+�,'5"'•.
sop' �iMAQN r
'o +a Pte► lar ,-- ;
P�ci.dans.,He Was
coed?
t a R � quagty Pumped determined?
>�.f�lj;?ntHne+.tl,wR�`{TQF�r/'t J3'f�`�fL�,5.c , �,� J• F� } ' ,
,!R'"�'!Ifr1n��S r'�yti'�a a A s.t r>, Y n� ;'i i •t � fi ' �; ,
.t..�,, �Il.�rpMYM Iry�+/WM�4)�i7�+k�
j'•!':,}�'s1,7+1t•.y• yy)�1 ,', l,'i �,1 4Q I,i' ti•-'
h ptGvioua iAsPo9a records,if any)
1t;:_) 91Q +t+tit a. PY out operation and maintenance contract(to
be
' ( ,.
+gip)+of ABPg�}�
t}1x a• 8 'Tj•�v'�!•�'n r 1 i
+ir..✓.s ,ax,f t �?•;tt ��7yt��1 a j)@ x�. I t t t t � .} f •' 1•a^
Ny r,L • 1 1. ) "'�."Jp.
aAd,source of information: : +.
77a f q}
•'�3��J�4••1t4,Ax7.1:�f4t{{�•e� � .+ ,• G,v f: '_I�r.
R'( ., iR1. ' T}T;�'rF� !•y o.y�1&
a "ytry�n .�I
Ar.7t
+`y�
1�•r jjxta�SJ.+9 'i}?+..err ` i,,Yi' 6t`
_�3 �f y !H#d`JytiSY"�,r�14e�3r�f�i`°V^ r � t 'a+i�'_�j�I.ri {t e S 1 ; 3 eb r. Y.A.• 3�.G� .. ... -
w 5 � �Jf �w+
t�h' `� SS � x•4,'��t"t�l d .4�iTlS �r„" a f � �.�L4, t r ia
"fkJf..f�.'I �� ''.: tw.�lrt��?{ y� �,^.�•t ggl�ta A r F S "si�;� _ rnu
�Tr�lt f
J 4.s�trlo�l 1'4 4��,,i'k ,! rr_..• rd�ti.1.:x •'�r r Y 1r�' 1 -...
t}� � lt I01i
yryFT INSPETIC
ORMOOR VOLUNTARY ASSESSMENTS
.S SURFA E f {
,EWAGE.DISPOS;AL'SYSTEM INSPECTION FORM
1 eSt's4t •r 4L r r t { #tfS jr tAsq t .
PART.C o,
..
tf•M, ri �F, IAZ Iaa,Y PI Mt.J }+{Ar •�tJ Y SX.'S^�'T!T�.!'_� ORNATj•w���fi141LON(continued)
s
1<L• yr - b lu Y 'SSe '
1 �
•Srj,pr :(:! /{j ky �t r r�-. � ,sK.T J. >, r -I.
��
c ,r"� {
o.'(>"r d T �•A ri 1 , { - r
:.�`i r�r
�C
P ►PP y,.well.A ua'on lug•
}hr�'f P�y t R�{�PAd1t1 A of o ,'i!C�lt1Ag,
evidence r
deBRe Qf leaka�g
t
r
t> t
'Wlk
a
!a
1W ,
j fi a:
��`rrf
�7"�r{a�
vT k i 3� c'fiTT�'^'�1'•M.� lan Jj, Y 1 C ! Y 1 a.,, .,
{ J ,?4�„tK�+�{�•A�i+n°llfr t4��Af ` // .+ < .�y, I r". r
iF�lf��Mt'T' t �.i t• r4 h•r! .. 1 �r.,�Y
lyethylene 1Y .:
r.
age Doted by a G of Compliance(yes or no):_(attach a co of
4 copy
r j�*`rj.'1�.:?{ia+ •,,
t�Otutt 0
6i4 tee orb, l�;
1r,;SA JaC4:'tta()4/
to top`of outlet tea qr bade ` '
4tlFt teeWh 904=v
-, ;
and oft topbalk condition,s irate " ,liquid levels
-777771C ,
✓A :1'J f�Fi�fi^ �.y 1 r , jki•* A K•.
,7 .
i � t
'�}};^K �.�'(�r�9.'�'�„`( �11e� '7�C'Y'�te p1YY).�e`�tJ��R 1J7��� �rt♦ q�'
!', �
i••t-Jf�t-!//��,dPjjD5+M♦ot, #w1
r;
,.
btglass lyethylene_,other
.�
i >
r _
ISyt.t :i. Ar�s,l 1 54+.'�..T IJ'{ •s.r. -+ ` r � ''lit.'
¢ K3910p Of Okt Ct.•twor baft
1 Wtt tQ bottom of outlet ----�..,.....
_tee
o ba4er
• o aad o b?O or bale condition,structural integrity,liquid leveler,'
f �.tr ,�t�{'j�w�.�` }.��'yay,�S?{} !'vMra�It ♦ ,:� C t• •,{',�;'" ' t ,�-:
.. 7.77 7
�r
t�a`r 97 t7 r k xfl �1 Ct t�" YS t Y�I
-
�,�'y4>ri�tn
�j
r a'q
Ar+f a e t rt,xt r2 Y,^Ft 4+c a hJ I th,7?{�4 3�"�"2 w IDI 'r �r. ,l4 it i r`t•t a4W = - -
prMi a'•, � { ,*. . �1M�t '-v FY'j
i ����'. •'! �
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WATER BILLING HISTORY 3160399—SINCLAIRE METER #1: 3160399
--------------------- f 1225 SALEM ST
Internet # CYCLE SERVICE PRIOR CURRENT USE WATER SEWER FEES TOTAL
Explorer
� .
1 2000-13 10/01/1999 40 98 58 158.34 0.00 0.80 158.3�a
2 2000-23 01/12/2000 98 137 39 106.47 0.00 0.00 106.47,
3 2000-33 03/29/2000 137 162 25 68.25 0.00 0.00 - 68.25
Nly Briefcase 4 2000-43 06/13/2000 162 190 28 76.44 0.00 0.00 76.4
5 2000-9F 08/23/1999 40 88 48 131.04 0.00 0.00 131.0
6 2001-13 09/11/2000 190 222 .' 32 87.36 0.00 11.00 98.36
7 2001-23 01/05/2001 0 27 50 136.50 0.00 11.06 147.5
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