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Home My WebLink AboutMiscellaneous - 1276 SALEM STREET 4/30/2018 (2) - °A 1276 SALEM STREET 210/106._A_01 g&0000.0 I�� •V S�SxL"ED'��e PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 6/24/2014 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Complete Repair of D-Box By: Daniel Giard At: 1276 Salem Street Map 106.A Lot 0188 North Andover, MA 01845 The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. SIU/4 Sawyer 1111 4ublic Health Agent 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 fax 978.688.8476 Web www.townofnorthandover.com Rq ._. North Andover Health Department Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 1276 Salem St. MAP: 106.A LOT: 0188 INSTALLER: Dan Giard DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS N.WINSPECTION: D-Box 6/24/14 ATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed 1-140 loading ❑ Mon it hic tank construction ❑ Water ti tness of tank has been achieved by visual testi ❑ Inlet tee insta ed, centered under access port LOT 9 LOT 7 z � " � r,�tix-�, � ♦, �-f3UX ,o EXI.S r OWELL. LOT _C9 ---- 4RE.4= 49,63!-fs.F c 150 00 54� S . T 510PE IWOUI)FE"ENT 050 04E616N Y ELCVWT%ON AT OP OF iV EX/5T/N6 E DIW.ION .4T. . . . . . . . . 2EQUle�0 EZ jf/.4T1ON CH DE514:�N 45 BUILT45 ��alZ INI/. PIPE OUT Ovc* 041,5C 14790 1N!!P/PE' /NT0 T4NK I4 7.40 �U, -�l1RFIC o INV P/PE OUT OF 7-4/VK . 147-15 148. 93 /NI/. PIPE .INTO D B0. X . 146.95 14705 INV, PPE OdT 01-- 0,30,Y_ TK/E4N6C.H781 /46.Si r�E�� Z ,4�. , %c ' NORTH A N1ATkG / - /N V. EMO 0' '�F TR Eiv«r /46.50 /46.41 FOR : e ,ro93FS R�ALTY �rP&57 41A TER FL E V4T/ON TRCNC1/ i /40.5 �,,� ,� 5 C.4 L E / = 40 ' D4 TE:, ISO V 13, /984 N�y3 C,I)e/ST>QNSEN ' EN6/NEMIN6, -INC. /1/OTF. TII/S 10,1_4N /5 NOT ,4 &,,41i?1P,4NTY 1/4 ENOZ,4 .4!/E:j 11,,41/Eel ILL, AW OF TX/Lc SYSTEM 31-17 ,4 liE2/FlC.4T/OiV OF TI-IC L OUTION OF TSE EY15 7"/NC � ST�C'UCTUIZES. _ • ❑ Outlet tee installed, centered under access port gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade Inst kled over one access port ❑ Hydra ,lic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base [I Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction F-1I�`et tee installed, centered under access port ElPurp(s) installed on stable base ❑ Alarm at working E] Pump O ff floats working E] Separate on ff floats ❑ Drain hole in pr sure line ❑ cover at final'grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ Alarm & Pum re on separate circuits ❑ Alarm sounds w p float is tripped ❑ Location of control p nel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION-BOX Installed on stable stone base H-20 D-Box Inlet tee (if pumped or >0.08'/foot) Hydraulic cement around inlet & outlets Observed even distribution ' Speed levelers provided (not required) Schedule 40 PVC Pipe Comments: Commonwealth of Massachusetts Map-Block-Lot �` • 106.A0188 ----------------------- BOARD ------- --------- BOARD OF HEALTH Permit No ' North Andover BHP-2014-0665- ---- ------ -- P.I. FEE F.I. $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Daniel A.-Giard to(Repair)an Individual Sewage Disposal System. at No 1276 SALEM-STR- EET ------ ------------------ ---- ---------------------------------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. 13HP-20147066 Dated June 23 2014 10"Opy------- ---------------------------------------'" Issued On: Jun-23-2014 BOARD OF HEALTH ...........................................••---....---------•-••---------------..............., ,. 1276 SALEM STREET Reference No: BHJ-2014-000036 Department: Permit No: BHP-2014-0665 North Andover BOARD OF HEALTH ................•-•----------•--•-----•----........................•............-•-•---• Account No: 1001001.1.5.0510.00 FeeType: ..........•-••...............•••••- DWC-Component Repair PERMIT Receipt No: REC-2014-001683 .•-•........................••••••..................................................--... ................................... ; Paid By: Paid in Full On: Mon Jun 23,2014 Daniel A. Giard ................................................................•••-.................... Check No: 577 Received By: ................................... Lisa Blackburn CUSTOMER'S COPY Amount: $125.00 i J ttORty� Application for Septic Disposal System 3 --> TODAY'S DATE Construction Permit - TOWN OF " $ 250.00–Full Repair * ••a, o. � " ORTH ANDOVER, MA 01845 iSShcNus�s $125.00-Component Important: Application is hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on the computer,use ❑ Repair or replace an existing on-site sewage disposal system* only the tab key to move your g Repair or replace an existing system component–What? cursor-do not _ use the return key. A. Facility Information /c�'7& 5,g-/-e IL-11 Address or Lot# E. City/Town 2.-*TYPE OF SEPTIC SYSTEM*: ❑ Pump [B'Gravity(choose one) ***If pump system, attach copy of electrical permit to application*** ❑ Conventional System (pipe and stone system) ❑ Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D-Box)(Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D-Box Present)S.A.S. 2. Owner Information Name f' Address(if different from aboyk City/Town // State Zip Code Telephone Number 3. Installer Informnnatio/n Name Name of Company /3b —Iq �A /�PTa a' Address P. �Q,�� md ,� u� City/Town State Zip Code Telephone Number(Cell Phone#if possible please) 4. Designer Information Name Name of Company Address \ City/Town ``.\ State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit-Page 1 of 2 I M°RtM Application for Septic Disposal System Of t4eo,a 1�+ TODAY'S DATE Xonstruction Permit - TOWN OF ORTH ANDOVER MA 01845 $ 250.00-Full Repair 'tyS�CNy 4' 7 $125.00 -Component PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: (Residential Dwelling or❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place the system in operation until a Certificate of Compliance has been issued by this Boar f Health. Name Date Applica 'd'rn Approved By: (dard of Health Representative) l ANm Date plication Disapp ovede following reasons: IV For Office Use Only: 1. Fee Attached.P Yes No 2. Project Manager Obligation Form Attached? Yes No 3. Pump Svstem? If so,Attach copy ofElectrical Permit Yes No 4. Foundation As-Built?(new construction ronly): Yes No (Same scale as approved plan) 5. Floor Plans?(hew construction only): Yes No Application for Disposal System Construction Permit•Page 2 of 2 SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: (Address of septic system) For plans by (Engineer) Relative to the application of e✓1}+1P Lra q (Installer's name) And dated rigina ate Dated � � �? 3—/ (Today's ate With revisions dated (Last revised date) I understand the following obligations for management of this project: 1. As the installer,I am obligated to obtain all permits and Board of Health approved plans Prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner,contractor,project manager,or any other person not associated with my company schedules an inspection and the system is not ready,then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection,without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a$50.00 fine being levied against me and/or my company. a. Bottom of Bed—Generally, this is the first (VS inspection unless there is a retaining wall,which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection—Engineer must first do their inspection for elevations, ties, etc. As-built of verbal OK(or e-mail to: healthdept�c@townofnorthandover.com) from the engineer must be submitted to the Board of Health,after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system,all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade—Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation)and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible. 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board of Health staff or consultant. d. Installation of tank, D-Box,pipes, stone, vent,pump chamber, retaining wall and other components. 6. As the installer,I understand that I am solerresponsible for the installation of the system as per the approved plans. No instructions by the homeowner,general contractor,or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: {o >-d� 3 -- f y (Today's D ! (Name—PrintT ( ame— tgne µORTp - 68'17 Town of North Andover HEA TH DEPARTMENT sS�CHUSt CHECK#: DATE: �p r LOCATION: b 41104 a I M H/O NAME: 1 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 $-� Title 5 Report $ ❑ Other:(Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer Commonwealth of Massachusetts ` A�t Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments h 1276 Salem Street Property Address Edward McLaughlin Owner Owner's Name information is required for North Andover MA 01845 5/30/2014 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms,�,mg t tered in any way. Please see completeness checklist at the end of the fo 0-ClEI 150 Important: A. General Information II 14 When filling out t UN y u forms on the computer,use 1. Inspector: TOWN OF NUKIH ANDOVER only the tab key HEALTH DEPrkRTMENT to move your Neil J. Bateson cursor-do not Name of Inspector use the return key. Bateson Enterprises Inc. Company Name 0/0 111 Argilla Road Company Address Andover MA 01810 rears Citylrown State Zip Code 978-475-4786 S115 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs FYIrther aluation by the Local Approving Authority 5/30/2014 Inspe o gnature 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.--: Y PP PP � 9 ty•: ,.. 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 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 1276 Salem Street Property Address Edward McLaughlin Owner Owner's Name information is required for North Andover MA 01845 5/30/2014 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 13) 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 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1276 Salem Street Property Address Edward McLaughlin Owner Owner's Name information is required for North Andover MA 01845 5/30/2014 every page. Cityrrown 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 � Commonwealth of Massachusetts u�.�''y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1276 Salem Street Property Address Edward McLaughlin Owner Owner's Name information is required for North Andover MA 01845 5/30/2014 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: Outlet tee in septic tank, d-box&collapsed pipe needs to be replaced. D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 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 1276 Salem Street Property Address Edward McLaughlin Owner Owner's Name information is required for North Andover MA 01845 5/30/2014 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No Required pumping more than 4 times in the last year NOT due to clogged or ❑ ® obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or ❑ ® tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000gpd- ❑ ® 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, r "yes"o answered es in Section D above the large ge system has failed. The owner or operator of any large e 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 j 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 M 1276 Salem Street Property Address Edward McLaughlin Owner Owner's Name information is required for North Andover MA 01845 5/30/2014 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health Ilif ❑ ® Were any o the e 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 j ® ❑ available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information y at on Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 600 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1276 Salem Street Property Address Edward McLaughlin Owner Owner's Name information is required for North Andover MA 01845 5/30/2014 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d Yes 9 ( Y 9 (gP ))� 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•3113 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts D. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1276 Salem Street Property Address Edward McLaughlin Owner Owner's Name information is required for North Andover MA 01845 5/30/2014 every page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Pumped 2012, owner Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A p system b system operator under contract Y Y Y P ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 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 1276 Salem Street Property Address Edward McLaughlin Owner Owner's Name information is required for North Andover MA 01845 5/30/2014 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 30 years old, 11/13/1984, as built plan. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.8 feet Material of construction: ® cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" Cast iron through wall, 3" PVC in house, no leaks visible Septic Tank(locate on site plan): Depth below grade: .8 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'x 5'x 4' Sludge depth: 3" t5ins-3113 Title 5 ficial 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 t ,•� 1276 Salem Street Property Address Edward McLaughlin Owner Owner's Name information is North Andover required for MA 01845 5/30/2014 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 N/A Scum thickness 311 Distance from top of scum to top of outlet tee or baffle N/A=Outlet tee off Distance from bottom of scum to bottom of outlet tee or baffle N/A 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.): Inlet tee ok, not used, pipe enters side of tank. Outlet tee corroded off. Depth of liquid at outlet invert. No evidence of leakage. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: El concrete ❑ metal El fiberglass ❑ polyethylene ❑ other(explain): I Dimensions: I 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal g po System•Page 10 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 1276 Salem Street Property Address Edward McLaughlin Owner Owner's Name information is required for North Andover MA 01845 5/30/2014 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene E] 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-3/13 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 1276 Salem Street Property Address Edward McLaughlin Owner Owner's Name information is required for North Andover MA 01845 5/30/2014 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box badly corroded, has holes in side. Evidence of leakage&car .ryover. D- box needs to be replaced. 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.): I I * 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1276 Salem Street Property Address Edward McLaughlin Owner Owner's Name information is required for North Andover MA 01845 5/30/2014 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: 3 trenches 55'long ❑ leaching fields number, dimensions: ❑ 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. One trench has collapsed pipe ten feet from d- box. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1276 Salem Street Property Address Edward McLaughlin Owner Owner's Name information is required for North Andover MA 01845 5/30/2014 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.): i i Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Commentsnote condition of soil i ( , signs of hydraulic failure, level of ponding, of vegetation, 9 etc.): I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °r 1276 Salem Street Property Address Edward McLaughlin Owner Owner's Name information is required for North Andover MA 01845 5/30/2014 every page. City(rown 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 w�kr Or)uen � �,LS i I DU Ir a Y 531 13 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 • Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1276 Salem Street Property Address Edward McLaughlin Owner Owner's Name information is required for North Andover MA 01845 5/30/2014 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: >4feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record 4/26/1983 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: Design plan ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: I You must describe how you established the high ground water elevation: Test pit data on design plan I Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/73 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 I : Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1276 Salem Street Property Address Edward McLaughlin Owner Owner's Name information is required for North Andover MA 01845 5/30/2014 every page. Cityrrown 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 I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 I Town of North Andover Muey Pagel Tax Map # 210-106.A-0188-0000.0 Parcel Id 17331 1276 SALEM STREET MCLAUGHLIN, EDWARD 1276 SALEM STREET N. ANDOVER, MA 01845 Class 101 Single Family Zoning2 1 Residential Property Type Size Total 1 Acres Zoning3 1 Residential FY 2014 1 Residential UB Mailing Index Name/Address Type Loan Number A MCLAUGHLIN, EDWARD ctive/Inact. From 1276 SALEM STREET Payor Until N.ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Bldg Id.17402.0-1276 SALEM STREET Active/Inactive 3170072 03 Cycle 03 Last Billing Date 4/2/2014 UB Services Maint. Active Account No.3170072 Service Code Rate MISCFEE ADMIN FEE 0.63 5/8 Charge Multiplier/Users WTR WATER 01 ALL METER SIZE 7.82 1/ 34.20 /1 UB Meter Maintenance Account No. 3170072 Serial No Status Location Brand 18736627 a Active ERT HH Type Size YTD C Date METE METE w ons Reading Water g Code 0.63 0.63 3/10/2014 Consumption Posted 397 808 a Actual Date Variance 12/6/2013 799 aActual 9 4/11/2014 17% 9/10/2013 789 a Actual 10 1/17/2014 -41% 6/10/2013 771 a Actual 18 10/15/2013 76% 3/12/2013 761 a Actual 10 7/24/2013 76% 12/10/2012 749 a Actual 12 4/22/2013 17% 9/12/2012 735 aActual 14 1/9/2013 -27% 6/11/2012 715 aActual 20 10/15/2012 3/13/201211 7/16/2012 76% 704 a Actual 12/14/ 9 4/1 22% 695 a Actual 4/2012 -34% 9/12/2001111 1 681 aAc1`ual 14 1/17/2012 6%6/2011 27 10/13/2011 -45% 3/9/2011 654 7/20/2011 a Actual 10 145% 644 a Actual -9% 12/10/2010 633 a Actual 11 4/13/2011 9/8/2010 16 1/12/2011 -28% 6/4/2010 617 a Actual 47 10/15/2010 -65% 570 a Actual 22 7/15/2010 96% 3/8/201 b 548' a Actual 12/10/2009 530 a Actual 18 4/14/2010 22% 9/9/200915 1/12/2010 25% 6/4/2009 515 a Actual 500 a Actual 15 10/15/2009 5% 0%0/2009 3/12/2009 487 a Actual 13 7/2 12/5/2008 475 a Actual 12 4/29/2009 25% 9/8/2008 462 aActual 13 1%20/2009 16% 6/4/2008 426 a Actual 36 10/10/2008 -61% 3/10/2008 411 a Actual 15 7/16/2008 115% 12/12/2007 399 a Actual 12 4/11/2008 29% 9/4/2007 383 aActual 16 1/22/2008 -17% 6/14/2007 335 a Actual 48 10/12/2007 -72% 3/13/2007 321 a Actual 14 7/20/2007 289% 11 4/16/2007 25% -7% I /Board of Health, BE?TIC SZSTEH North An¢overzHaad. INSTALLATICK CHECK LIST LOT 'S �P OVID DATE DISAPPrROVED EXCAVATICN OK FAIL 7 46 FAIL OK 1. Distance Tot a. Wetlands b. Drains c.. Well 2. Wat Sac line Location t 3• No .-VC Pipe 11. Sed tic Tank ?: a. - 'ees -_Length k To Clean Out Covers i. b. 1ternent Pipe to Tank Gla Both Sides of Tank 5• Distribution Box a. Covers do Boic - No Cracks b. All Lines 'Flo ging Equal Amounts C. No Back Flow 6. Leach Field or Trench a. Dimensions b. Stone Depth c. Capped Fads d. Clean Double Washed Stone 7• LF zch Pits a. Dimensions b. Stone Depth Sp" .sh'Pads d. Tees e. Cement Pipe to Pit - Both Sides f. lean Double Washed Stone i 8. No Garbage Iii spo sal 9. -Fir al Grading Inspection 10.' Barricading Covered System 11. As Built Snbmitted j � a. Lot Location b. Dimensions of System C. Location Ath Regard-to Pere Test d. Elevations e. Water Table F Therefore, the I1ACC hereby finds that t;ae foliowing conditions necessary, in accordance with the Performance Standards set forth In the regulations, to protect thoseint gists checked above.�Tho NtCC ' oiders that all work shall be perform in accordance with said conditions and with the Notice of Intent referenced above.To the extent that the fol. lowing conditions modify or differ from the plans,specifications or other proposals submitted with the Notice of Intent, the conditions shall control, • } NJ, General Conditions �;:,'�4,�„,1, 1. Failure to comply with all conditions stated herein,and with alt•relatod statutes and other regulatory meas- ures, shall be deemed cause to revoke or modify this Ordor. �tl„” 2. This Order does not grant any property rights or any exclusive privileges:it does not authorize arty injury' to private property or invasion of private rights.' 3. •This Order does not rellevo the permittee or any other person of the necessity of complying with aA "-;;;�: r other applicable federal, state or local statutes.ordinances,bylaws or reguhtions• 4, Tha work authorized hereunder shall be completed within three years from the date of this Order unless either of the following apply t • ' i`n (a) the work is a maintenance dredging project,as provided for in the Act;(Jr (b) the time for completion has been extended to a specified date more than tt7ree years,.but less titian five years, from the date of Issuance and both that date and the special circumstances warranting the extended time period are set forth in this Order. ;Vit' J4: S. This Order may ne extended by the issuing authority for one or more periods of up'to three years each t upon application to the Issuing authority at least 30 days prior to the expiration date of the Order. 8. Any rill used in connection with this project shall be clean fill,cont2ining no trash,refuse.rubbish or de�. ;J bris. including but not limited to lumber.bricks,•plaster,wire,lath,; aper, cardboard,pipe, tires.ashes. sem' � .Yy refrigerators,motor vehicles or parts of any of the foregoing. `'' 7. No work shall be undertaken until all administrative appeal periods 4rom this Order have elapsed or. +,, ,.{ �x such an appeal has been Ned,.until all proceedings before the Department have been completed. << -! 8. No work shall be undertaken until the Final Order has been re-:,orde.d in the Registry of Deeds or the Land Court for the district in which the land is located,within the chain of iitle of the affected property.In the )f ' case of recorded land, the Final Order shall also be noted in the Registry's Grantor Index under the name ' • of the owner of the land upon which the proposed work•Is to be'dooe. In the case of registered land.the Final Order shall also be noted on the Land.CCertificate of Tltle of the owner of the land upon which • ourt NACC I . • ' the proposed work is to be done.The recording information shall be submitted to.the fa {. on the form at the end of this Order prior to commencemept of the work. r ."r ft 4 it A sign shall be displayed at the site not less than two square feet or more than three square feet in size, bearing the words,"Massachusetts Department of Environmental Gluality Engineering, File Number 242- 01. f} Quality Engineering is requested to make a determination and , tr 10.Where the Department of Environmental ty g 9 to issue a Superseding Order, the Conservation Commission shall be a party to ail'agency proceedings r; 3 and hearings before the Department. 11, Upon completion of the work described herein,the applicant shall forthwith request in writing that a',,, a, ; Certificate of Compliance be issued stating that the work has beeh satisfactorily completed. 12.11ie want shall conform to the following plans and special conditions: h p�).J 1; .� 5.2 ri tF's' s _. ___