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Home My WebLink AboutMiscellaneous - 1253 SALEM STREET 4/30/2018 (2) ...� 1253 SALEM STREET � J 210/106.q_0133-0000.0 �l 1 II Commonwealth of Massachusetts CRE F City/Town of NORTH ANDOVER W System Pumping Record 06 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 forms 1. System Location: on the computer, use only the tab 1253 SALEM STREET key to move your Address cursor-do not NORTH ANDOVER MA 01845 use the return key. City/Town State Zip Code 2. System Owner: LINDA BRODETTE Name seam Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 6/5/ o 14 2. Quantity Pumped: 15l100Datens 3. Component: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: GOOD CONDITION 6. System Pumped By: JAMES H CURRIER II H79 406 Name Vehicle License Number X SEPTIC & DRAIN Company 7. Location where contents were disposed: GLSD 6/5/14 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5fonn4.doc•11/12 System Pumping Record•Page 1 of 1 4061 MORTH 3:O.t...o •1hOt O Tgwn of North Andover "+�'• ,X HEALTH DEPARTMENT CHustt CHECK#: DATE: LOCATION: 40 H/O NAME:4W �� / L CONTRACTOR NAME: c /lullae:Z�10-011' Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title5� pector $ ❑�Tt � Report $�' ❑ Other. (Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer f 'a 1-11a�,I y Paul Pisano Inc. ,t� �� INVOICE G Backflow Inspections Title Five Inspections All emergency Plumbing Issues RECEIVED 48 Princeton street D A n de (5 )04 0 f Z 3 N O V 10 2009 Telephone 978-335-5661 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT ******24 HOURS ON CALL SERVICE******* INVOICE ,2001 DATE: OCTOBER 30,2009 TO: FOR: Maryann Cunningham_ _ Title five inspection '1253 Salem Street 'North Andover,MA 01845 DESCRIPTION HOURS RATE ,Title five inspection 1.5 350. 350.00 v Town of North Andover fee (this does not go to the Inspector) 50.00 There will be 2 reports generated for the.passing system; One (original) will go to the Town Board of Health,the second (copy)will go to the owner of the property. The owner is NOT required to do anything except utilize the report as needed; it is your Legal official inspection report. Make all checks payable to: Paul J.Pisano Total due in 15 days. Overdue accounts subject to a service charge of 1% per month. Thank you for your business! o c� O5cod S �5 Id) o I U r, •3 6 /g qS TOTAL 400.00 458 = AORTH i Of,'Lo Town of North Andover HEALTH DEPARTMENT ,s$ACNUSt� CHECK#: _��' DATE: LOCATION: H/0 NAME: CONTRACTOR NAME: ��"`' �� Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5�Inspector $ 0-1 f) 'Title 5 Report $�U " ❑ Other. (Indicate) $ Health Agent Initial- White-Applicant Yellow-Health Pink-Tree.. �1 T Commonwealthof Massachusetts Title 5 Official Inspection Form - VSs Subsurface Sewage Disposal System Foran-Not for Voluntary Assessments Property dr J owner Owner's Name ( ✓ information is \ �� required for ' every page. City/Town Ste 4Ziper-Date of I 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 A General Information When filling out A. forms on the computer,use 1. Insp RECEIVED only the tab key to move your cursor-do notn or to O�9 use the return Name key. Company N e TOWN OF NuRTH ANDOVER P,I lu 0 HEALTH DEPARTMENT ,,-----� Compan cess City/Town • ,,. State Zip C e Telephone Numt*r _ License NumberLop � B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: Passes ❑ Conditionally Passes ❑ Fails r Evaluation by the Local Approving Authority hel Inspe s t Date syste nspector shall submCit a copy of this inspection report to the Approvin 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-00= Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property d re — W Owner Owner's Namr a A 1A bA I CYA information is required for !' every page. Cityrrown 2rp Date of InsAmyn B. Certification (cont.) Inspection Summary:Check A,B,C,D or E/always complete all of Section D A) System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Check the box for"yes","no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1 Jf.A A Propertyressy LN Owner Owner's Name I�u� ` v information is .\J required for every page. Cityrrown State tp Cod Date of Inspecti B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pape 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments e,5-z, MMyWAIIU4:44 , Ad Owner Owner' Na O ``reinformation is ,/ *Sta quired for V CI4r every page. City own Zip Date of 196pic&16 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's*. Method used to determine distance: *'This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) 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 t51ns•09/08 Title 5 Official Inspection Forth: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 Pro Add Owner Owe s Na e information is required for • every page. Cityrrown Zip Cod Date of s n State B. Certification (cont.) Yes No ElRequired pumping more than 4 times in the last year N07 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. ❑ U Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes"or"no"to each of the following,in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins•09M Title 5 Offndal 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 Property Addr /l! �+� Owner Owners Na of/ r information is required for every page. CitylI own Sta Zip Code Date of on C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No a L❑ Pumping information was provided by the owner,occupant,or Board of Health ❑ Q--- Were any of the system components pumped out in the previous two weeks? [, ❑ Has the system received normal flows in the previous two week period? ❑ �- Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ Were as built plans of the system obtained and examined?(If they were not N available note as NIA) �� ❑ Was the facility or dwelling inspected for signs of sewage back up? [a,-'❑ Was the site inspected for signs of break out? 9--' ❑ Were all system components,excluding the SAS, located on site? 4�-� ❑ 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. Gk— E] approximation 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): Number of bedrooms(actual): 57 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): ,E�_> => t5ins•09108 TRIe 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Foran-Not for Voluntary Assessments �4 lh�Al df—S-7 ,• Property Addre rid Owner Owner's Name information is kl�r required for every page. City/Town41e Zip Cd6e j Date of In action D. System Information Description: Ll IdIlix C�wz/i aAk.'e Number of current residents: Does residence have a garbage grinder? 0 Yes No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes [y-No i Laundry system inspected? g-les; ❑ No Seasonal use? ❑ Yes pyo Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes Last date of occupancy: Date CommercialAndustriai 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•08/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property dress Owner Owner's)71 e information is required for every page. City/Town State Zip Date o I pecti D. System Information (cont.) Last date of occupancy/use: 1/'0'1 Date Other(describe below): General Information Pumping Records: Source of information: �� Was system pumped as part of the inspection? ❑ Yes Pr No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank,distribution box,soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Altemative 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 UA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. Other(describe): Twp /a t5ins-09108 Title 5 Official Inspec ion Forth: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 PropeO Adress Owner Owner's k11&A*h information isd required for A7 &//, every page. Cityfrown Stat Zip Date of in on D. System Information (cont.) ApproTi�e age of all compo ents, date installed(if known)prid source of information: " Were sewage odors detected when arriving at the site? ❑ Yesf� No Building Sewer(locate on site plan): ' ` Depth below grade: feet Material of construction: cast iron y J� ❑40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Commen (on condition of joints,ve ting,evidence of leakage,etc.): V c�� Septic Tank(locate on site plan): Depth below grade: `/- feet Material of construction: Wconcrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain) If tank is metal,list age: y ars Is age confirmed by a Certificate of Compliance?(attach a copy of certificna Yes E] No Dimensions: Sludge depth: ZAZ-"( t5ins-09108 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 .S ll Property dress Owner Owner's Ve information is �. required for every page. Citylrown S e Zip C e Date I pecti D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee obaffle Scum thickness Distance from top of scum to top of outlet tee obaffle Distance from bottom of scum to bottom of outlet tee obaffle r How were dimensions determined? Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): !( K 'k 1AJ JV U �IrL /V of q � 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: Dace t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal S stem Form-Not for Voluntary Assessments �� zs Property A rens Ak Owner Owners Name information is (� 1 �� required for I,.�_�! (, _Iy� every page. Cityrrown State jUp Cod1h Date of Ins 'on D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as rel ted too let inveft,evide of leaks e,etg,):/ Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan)-.0 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•0908 Title 5 Offlaat Inspection Form:Subsurface Sewage Disposal System•Page t t of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property�9dr ,es ' Owner Owner's Na0e information is d p required for N L0 every page. Cityfrown *StaZip Godd Date of Ins do D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): (9 Depth of liquid level above outlet invert r 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(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Soil Absorption System(SAS)(locate on site plan,excavation not required): If SAS not located,ex Iain why: Alol ✓ Al t5ins•09M Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property dr s 994 /4 A4 W7 Owner Owner s e information is �(� f required for u every page. City/Town $is Zip C e Date of Ins con D. Systemformation (cont. rlicku Type. leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number,length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegeta n, etc.): . ld �! S151AId/ Al -'alZ441 /]V� S!J Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): SX Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09)08 We 5 Official Inspection form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Alvi Property Ad s Owner Owner's Name / information is required for every page. Citylrown State Zip a Date of InspeaW D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.): (Z I AAW E f C Privy(locate on site plan): Materials of construction: ///""" Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.): t5ins•09= Title 5 Of6dal Inspection Form:subsurface sewage Disposal system•Page 14 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Add Owner Owners Nam information is _ /� `J� required for /1/ every page. City/I Own s6Ot zipw Date of Ins 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 6APJAI A U.. t re+tae MWU t— Kt�41� 11 z� (A) r a-r 14 fit "M • � N 1 P 8A ,f„ $ �r fi c P �TA. Ae 14 +-4! 46 4o' c t5ins•09/08 , Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 A loo of s4 SwutTe.0 4alirf- T�0 _73 - To �f-1 C 1N ,JAe--a -n, -re> (4-csf oxAfk-T,.,j) i, ` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Prope Ad r—/ Owner Owner's Name information is / required for l Q every page. Citylrown State Zip a Date of InspecXn E. Report Completeness Checklist Inspection Summary:A, B, C, D, or E checked nspection 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'09108 title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 wrr..'P"'?r=ry..' r+'.'!•7w1*nBo,Aw°'..a ` "''°+-�.-w. ', `.'°„"mss'.''P.i"'y"'" a "'yy' '1k7'" ^ " 5' ,+• .: ^r++".. ..y-... -r.. .. -. ._ .. ate , THE COMMONWEALTH. 0 MASSACHUSETTS { SETTS DEPARTMENT OI' EONMENTAL PROTECTION I E Irt XNOWN T IAL' . Paul J: Pisano Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection. October 25 ,1996 Vr tor of the Ysion of Waff Pollution Control _ \ Commonwealth of Massachusetts RECEIVE �.� City/Town of NORTH ANDOVER MASSACHUSETTS System Pumping ,Record SEP o S 2009 Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 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 approving authority. A. Facility Information Important: When filling out 1. System Location: forms the J�` computeto S r,use ( J Cl2c" IS+. only the tab key Addr ss to move your ' cursor-do not use the return City/Tow State Zip Code key. 2. System Owner: Name Address(if different from location) City/Town State Zip Code _ 35o3 Telephone Number B. Pumping Record -1 1. Date of Pumping Date ( -3 2• Quantity Pumped: /0(30 Gallons 3. Type of system: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes 2-No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6-001—A 6. System umped B Na e Vehicle License Number Company 7. Location where contents were disposed: _ G.L.S.D. Lawrence, MA__ 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 Commonwealth of Massachusetts RECEIVE Title 5 Official Inspection For ° Not for Voluntary Assessments SEP - 7 2005 4 Subsurface Sewage Disposal System Form TOWN OF NORTH ANDOVER HEALTH DFPARTMFNT Inspection results must be submitted on this form or on the official Title-5- on-Forma ` 611512000.Inspection forms may not be altered in any way. A. Certification Important: When filling out 1. Property information: forms on the I ZS 3 STQC-E-T-- . computer,use only the tab key Property Address to move your Cpl?I) cursor-do not Owners Name use the return key. l ZS3 SNI44n 5-1 Q a -r Owners Address m tOZli A"DoV%zlZ. YnPi-11610 Cfiy/Town Sta Zip code Date ( � Date of Inspection: teU rl()5T 13, Zw� ISI 2. Inspector eoCI-1 d 1 T ZS a4"— Name of Inspector Crot^t PAo►�lwvAt-M- t'�IG11.1v1;iZ��l� SIC, Company Name Z1 cArn b210Gv 5 50tTC taco Company Address 11 Cityrrown State Zip code -I&-V-11 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: 9 Passes ❑ Conditionally Passes ❑ Fails ❑ Ne _ er �IuaLfinby he Local Approving Auth rity ZU405T 130 ZOOS Inspectors Signature Date The system inspector sh submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 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. t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 1 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) I2'33 Ske�M S-rQ�-' Pro�rty Addressl 018qs_ Citylrown Stat Zip Code Q'DI� 41TZS04C �u�u 57' 13, 230`5 Owner's Name Date of Inspection Inspection Summary:Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates 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: t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) Iz53 50{^ STRG Prgress 4 _ 0DOV�X 04, Cityrrown State Zip Code 601TI+ 41 i ZSC-4� U�UST 13) ZOO Owners Name Date of Inspection B) System Conditionally Passes(cont): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ❑ distribution box is leveled or replaced 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: 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 t5insp.doc-11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 3 of 16 • Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) IZ53 SAS(D") PpertyAddress1 n XQ;i J ;A0'D0lj�a1 YnA- (2) City/TownSta a Zip Code ia�ia l OITZSo�+6 stew sT 13, Zo o Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health(cont.): 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well*. Method used to determine distance: "*This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria 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: t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) IZS-3 SAk-�*-M Pr=ress f M& of CitylrownStat ZipCode CID11)4 t��7-ZSCH-� �ue,,U 5-r Owner's Name Date of Inspection D)System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No El ® 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 I C-7 ❑ Static liquid level in the distribution box above outlet invert due to an overloaded Mor dogged SAS or cesspool Liquid depth in cesspool is less than 6'below invert or available volume is less . o �E3 than%day flow Required pumping more than 4 times in the last year NOT due to clo or ❑ ® obstructed pipe(s). Number of times pumped: zoo 1 '?LAW. ❑ [A 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. ❑ C& 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 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. tfiinsp.doc-1112004 Title 5 official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont) R5-3 SR-n 5-)Qt.--CT- Property 5 Rt.--CT'Property Addres t>owl L'DoU�Z Citylrown S e Zip Code eQrn4 1 ITZW4 lu�,ujr 132 Zooms Owners Name Date of Inspection �I¢t 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 El 11 Area 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. t5insp.doc•11/2004 Title 5 Official Inspection Form;Subsurface Sewage Disposal System Page 6 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Checklist Iz53 S4Ep) P'ro�rty Addres lyo?�r,-t IQDO �% MA- a�$�I� Cityrrownstat Zip Code L" 1-N 1 ITZSCOC �� ST 13� 2 0 S Owner's Name Date of Inspection Check if the following have been done.You must indicate'yes'or"no"as to each of the following: YES NO ❑ Pumping information was provided by the owner, occuDant,or Board of Health ❑ to Were any of the system components pumped out in the previous two weeks? CK ❑ 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? Were as built plans of thgg systerp obtained and examined?(If they were not El CR available note as N/A) N0=&_ AJAl�ME- ❑ Was the facility or dwelling inspected for signs of sewage back up? D§ ❑ 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? ® ❑ 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: � ® El Existing information. For example, a plan at the Board of Health.0 W^ 1Z �Gco i7�5 ❑ 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)) t5insp.doc•1 UM4 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 7 of 16 Commonwealth of Massachusetts Title 5 official inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information PM'Qn4 rty Addre s _ MOOv��Z 018`0 Citylrown Sta Zip Code Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Z Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? aoIX-creD-10 �I01'� �� Yes ❑ No Seasonal use? ❑ Yes ® No Warteyy met r readings, if available(last 2 years usage( )):SI M C(E I Zj�,3 3SloS1(110-s� Sump pump? ❑ Yes ® No Q ccopl to Last date of occupancy: Date Commerciallindustrial Flow Conditions: 1\1ar AU Q-P,6L'E- 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: Last date of occupancy/use: Date Other(describe): t5insp.doc•11/2004 Me 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) IZ5 3 S4-wn � Pipperty Add, RT1� MA- (318y's City/Town State Zip Code 6, TA 1 r rz-s o \ U riuST 13�Zoo 5 Owner's Name Date of Inspection General Information Pumping Records: �W►��►Z Source of information: Was system pumped as part of the inspection? ® Yes ❑ No If yes,volume pumped: 1000 gallons How wasuanti � SuR�D 011J h�?2uG 1J121 Uu 2 q ty pumped determined? Reason for pumping: + Type of System: ❑ Septic tank,distribution box,soil absorption system >' Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes,attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. Other(describe): Z NiEcn-r coo cRt� C-,QC )UA1z --_(5,fqN;� 13 FoR Dc"i t�Il S� Approximate age of all components, date installed(if known)and source of information: 3 I `(AIZS; _D/7ly I P4 ST6�1-U4V I k4 � - `f'• FL>JT O W►•1y'1Z Were sewage odors detected when arriving at the site? ❑ Yes N No t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 Commonwealth of Massachusetts lugTitle 5 Official inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) Z53' SA�t�j >al C'U"C, Pr party Addr s G� ��, tV.Ioo��Z F City/Town Stat Zip Code o 60n-a 1 : 4ITTZSw5 IS 0Owner's Name Date of Inspection T 4 i) Building Sewer(locate on site plan): LPpC?%Depth below grade: feet -, '— Material of construction: ❑cast iron ❑40 PVC ❑other(explain): Distance from private water supply well or suction line: feet „ Com ents(on condition of joints,venting, evidence of leakage,etc.): IZ)5E It Septic Tank(locate on site plan): 1 I Depth below grade: feet 13�h Material of construction: ;concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain) �\fl. CI�zr� 1y'J If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) El Yes No ❑ Dimensions: U�K'Q� G �1�=' _ `G Sludge depth: 2 Iru1Q�� 5z-uv lqv Distance from top of sludge to bottom o baffle A�_l C. Scum thickness D�� Distance from top of scum to top of saft4iwamw baffle Sv utj) (wAT--V-LW EL) L 56cu Zi1671" ETAOLDistance from bottom of scum to bottom of baffle How were dimensions determined? T1p:-: ty15� t5insp.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) Izs3 M;)Address'l _ Citylrown S Zip Code Ln1� 4,rzsofi-t— /,UI►vsr 6) zoos Cwonees Name Date of Inspection Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage etc)* Tn1lk' 5117 I DISI J31L^ Wrf)4 A- �S�U�ri i; fL,O 510KIS oy- (JEW 14A K c�Ac-KS OTL S%AYAG� U QV D In(fLS r, cx. Xr I uWOZT� C00C 3AFfV6 Is SOUOD E, SECUQ'E, Grease Trap(locate on site plan):�LA 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 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): ►� A_ Depth below grade: Material of construction: ❑concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain): t5insp.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) I Zs Pr party Address 14 1Od\),,z MA o 18a-s— City(rown to �Code 6-101 1 KblT25r-R(:J13,ZOOS Owner's Name I Date of Inspection Tight or Holding Tank(cont.) 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.): Distribution Box(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(locate on site plan): �Aa> Pumps in working order. ❑ Yes ❑ No Alarms in working order. ❑ Yes ❑ No t5insp.doc.1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 Commonwealth of Massachusetts Title 5 Of cl inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) tzS3 SN�O/1 (��TREE" " ,Ptoperty Addres�� 11 '�W� h1 Ooyk� iz Cityrrown ST Zip Code CDn) - 41T250f /�U6V5T )3, zoo Owner's Name Date of Inspection Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan, excavation not required): PIT- If SAS not located, explain why: Lc')�G4 IK�C� 973 L 0 cAT�SD 37 it n c,. i T)r 5>'y)4�LL V443ov4 n Type: 1N�ET leaching pits number z' ❑ leaching chambers number: p f�' ❑ leaching galleries number: g ❑ leaching trenches number, length: / Q2 Elleaching fields number,dimensions: IT ❑ overflow cesspool number: ❑,.. innovative/alternative system 23'(Z'r Typetname of technology: Imo' H1 �Gt z" / nts(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of '� t vegetation, etc.). 3)- A LGA(nn 5040 ' CLASS M �50 1\,, 1�0 S1G►-Js 0�- WCOPAJ�,)C RIU. RC �vu5t� dQ I 7N, Ff2Qj -fr 1-fA2i D12� 5u1�- COObITlor,.15. A117ASS CO"O ITI 1,4 5_ LAW&� IS Rz4uV L OaY, b aT c C ACEy Gt 1 1�' 15 r J Q QU I O l.P Z-�- - t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 Commonwealth of Massachusetts Title .5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) P party Addr s Rrj1 �M1�w�sZ 018U5 cityfrown St a Zip reode 6DN t4i-r?SD � Q41 UT 131 Zoo Owner's Name Date of Inspection Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): t�/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 ❑ 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,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 Commonwealth of Massachusetts Title 5 Off call Inspection Form Not for Voluntary Assess vents Subsurface Sewage Disposal System Form C. System Information (cont.) Zs3 S MA, 77:,00Uxz oibgs CitylTown S to Zip Code eDIT+I 4TZWW 6 use' �3, ?JOS- Owners Name Date 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 within 100 feet. Locate where public water supply enters the building. 1 l I � �W�• t I-EE-5 r► ��VL�� 7 � �'`� �c� ��'o I, � = 2u j /_0� i g7 7r- AD Zl,�,l �Ttk-1v {YIJI? 12 "5 1 tJl t-��j C�=(�t 1- AD = r�3 CC -3S"" 1'17, co)SNGso5TO,,,�61�`i�J 4ca��► '' V J �, 59'-0"11 PNX VE,1-tr`j qn C F. O 1 S S l000�c?VS 1 �Xl p J11C -rAWI<. �}t,l U a Q m — Y Y neG lA 1lYv\ X N 18' G457 71?0 1001+ mAv*40 � c�v�1� QTc c f P t5insp.doe•11/2104 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 16 ME}hJlJf}- 5w1"rc1A'0a) Y`nECtJA1.J)S vA I's I-A00 P-Wl e-) 0'4CC / A-1C-) 1Z. -fo 5�'&l U. �l UkAcl�ildc) ?R 1 'DISiT2l�j�u�1 L!/�� io -NE: 00AM -PI►3 c,)%'IZ6 -IESi-ED wTT); GP.Q: )� FL —10 15-f 57VI W rT:H 40 ,�WG�� r�3. 00 ()' 5 1 j 1(3e orr Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 05-3 SAS tq--RGST- T-I-).1 rly d �t�v�^S� CKyrrowmSta Zip Code G-D)� r�,TZSG� l k �sY �3, 2AZI Owner's Name Date of Inspection Site Exam: Slope 10 Surface water �c 0► f- Checkcellar 'DI21� �o SU(Y)p G�vV� c6-00)`nuO �I a , c1 r Ip ` c� c600Gnr Eo 'ro (-CAW Shallow wells Estimated depth to ground watert 9 Rr" 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: 1 ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: y C }2�,i.(1Q{js 2 �v1GI�3�12)►�5 (moi JzgS - �,��-ro E-.5,Rw.T, 41, : 3`�''-�11''Iv i�',H,W.T, �Pr,-N i .5.14.W.r, (TITLE j ii,45ei�7ov6 �SSUmlrul� ! t`AI►�, -DEPN a1` i�l' tixtS-n S G;Wc wlI A►-I p2uk_, (off% Q15k—z. 1� 7IA�E 412uvt,2) 91- -,)JT Lb-AC4�iO� '?rr3-q?, AD�5, rr Is 747-r )s A(?�20. �, " �l v�-J .1� S'(�? ✓ C,&410-0, t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 Form 4 -- Sy Pumping Record Commonwealth of Massachusetss : Massachusetts System Pumoirw Record System Owner System Location Type: EmerV=y Routine Cesspool: W Yes Septic tank: W Yes Date of Pumping: ( Quantity Pumped: �, Gallons System Pumped By: Wind River FhW?vnmento% LLC Permit#: Contents transferred to: Contents Disposed at: 4446�A4 J4t,��C Date: Pumper Signature: Condition of System/Other Comments Dep Approved from - 12/07/95 N � CURRIER FORM 4-SYSTEM PUMPING RECORD SEPTIC & DRAIN SERVICE 107 FOREST STREET;MIDDLETON,MA 01949 (978)774-2772 COMM NWEALTH F MASSACHUSETTS MASSACHUSETTS SYSTEM PUMPING RECORD SYSTEM OWNER: SYSTEM LOCATION: DATE OF PUMPING: / ' 2 QUANTITY PUMPED:ED._ �� Lt� GALLONS CESSPOOL: NO Er YES SEPTIC TANK: NO E:] YES �- SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE CONTENTS TRANSFERRED T0: F DATE: 9�zr' ' 99 INSPECTOR: 7 ',�:.!",.`'��T^'h{A�4;;y1 5.,. a,. v C•uh SYrZr4 ,aw r,,.'1 t 5,.5 h r7;1 VS •'., •,l� l" b .� � 1 � r �F,f,''�. ` ';�75 1��{{(}}C�TJ, •9111,rrC�.:""�+�`'i��,��5 / l �l'I'('1,' 'I,••;hK,,5 tp rl 1�' `I �+5 ,1`'J,I {�lY�f,LyTi r,',,a1,1;4� (Jt�i� 1r15 !LI��'1' \ �',;�'Y�<t}.A(i�l�•"ry�l'((1'�J,if`''t''Y. + 777161/1.5 ;t]v f. /�• �,� y},�„ N� M I Y ' f r 1, `y� l i11�1✓ r`i�°r h)l i tr�, i �,. .l . ..'� 1 +, 1:1111!'.'(;:,11 l!�I`�'`lr,d�'f,�fv +'f1dd1j15,`•�.!ri•�r'+.;,': ;5 .. . . 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Commonwealth of Massachusetts W City/Town of NO. ANDOVER System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health 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 ��, � ; Important: When filling out 1. System Location: f ;., L {4. , s.. forms on the 1253 SALEM ST. computer,use only the tab key Address +' `D�twi SFt;F!An;DCv�, to move your NO. ANDOVER MA HE'Q& -,'�,f?TfvjP tT cursor-do not — use the return City/Town State Zip Code key. 2. System Owner: yraa LINDA BRODETTE Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 10/24/11 2 Quantity Pumped: 1500 Date Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: James H. Currier H79 406 Name Vehicle License Number J's Septic& Drain Company 7. Location where contents were disposed: GLSD 10/24/11 Signature,6f Hauler Date t5form4.doc-06/03 System Pumping Record-Page 1 of 1 .......... r