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HomeMy WebLinkAboutMiscellaneous - 1337 SALEM STREET 4/30/2018 1337 SALEM STREET 210/106.A-0126-0000.0 N i i I r , ti r +s rf ♦ M1r .f�- _^Yfl s,.0. 'a'VW>'�.Ohl ' ti"4a� s '� _ .._�. _ } i s r.�1!'{ a -r vs ��r.� � s.+ �'s��;,A"�c rel ti••+F-F�%�te`(� �' �,,,�` Y ,i ,}z. �n ,-, "`�': 7 t;f 'Ph.i s�, .r�ka ry is krA r1. . P° ^•; ' p�Na�7«' y{'a+ _ P:, q. ,:_t C S i r,`F G.+-,�s� �e ��•�gr � ��s �r r�,;''�v*F�y�'+x4���a MAP # PARCEL # ` r STREET CONSTRUCTIQN APPROVA HAS PLAN REVIEW FEE .BEEN PAID? YES NO PLAN APPROVAL: DATE APP. BY DESIGNER: - Q��© PLAN DA*I"E. CONDITIONS WATER SUPPLY: TOWN WELL WELL PERMIT DRILLER WELL TESTS: CHEMICAL DAZE APPROVED._____.__ BACTERIA I DAIE (IPPRUVED BACTERIA II DA1'E APPROVED COMMENTS: FORM U APPROVAL: APPROVAL TO ISSUE YES NO DATE ISSUED BY CONDITIONS: FINAL APPROVAL: . ALL PERMITS PAID YES NO WELL CONSTRUCTION APPROVAL YES NU SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO OTHER YES NU ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DATE:. �2Ir .r - ..arm � { \ - -•.. :' y •,,-i a � ^" a._.x>': ! .. :i•w.:R �.., r sk .t ;i 1 � j. � ., - :' IS THE INSTALLER -LICENSED? C , YES NO TYPE OF CONSTRUCTION: ? NEW PAIR ., " ...:.,NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW YES NO CONDITIONS OF..APPROVAL, YES NO (FROM FORM U) , ,`• Lr - •-...: ;. - ,ems `.ISSUANCE,•OF DWC PERMIT r ES NO • is ^�::•• : t. ' ,,,.� � - r' . . _ � , '• •' _ 1 DWC PERMIT. N0. _� *INSTALLER: /qu �U BEGIN INSPECTION ES 0:.71 ' EXCAVATION INSPECTION: ; NEEDED: PASSED BY <=.:CONSTRUCTION INSPECTIONS „ : NEEDED: •t . + �, j •, .. . . . ... i AS BUILT PLAN SATISFACTORY: YES: - APPROVA4. TO BACKFILL: DATE: � 9 HY FINAL . GRAD ING APPROVAL: DATE S BY FINAL CONSTRUCTION APPROVAL: DATE. ' �� By ` T f Commonwealth of Massachusetts Title Official Inspection ®rte — . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property.*d ess G fl.-P-Ak) A-4u Owner owner's Na 'A,,,q Information Is )661b 1� I/ Y�� Y'/�` 6 �— 1 —30 required for every page. Cltyfrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When Aa General Information filling out forms on the computer, use only the tab1. Inspector: key to move your C I Z cursor-do not use the return Na e o Inspector key. L res Co pan Name man Address Ram 6 (�c�CJ City/Town State Zip Code g7�- Lf 72'3 964. S 1 Z/ (� 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 Inspectior was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DER approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspector's SI ri . re Date The system inspect r_ .h I submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) if i, 0 days of completing this inspection. If the system is a shared system or has a design flow of 1 Q,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 us at that time.This inspection does not address how the system will perform in the future unde the same or different conditions of use. 15Ins•3113 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System Page 7 of 1' Commonwealth of Massachusetts �. Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Ad ss &S/-/.". Owner 0 nor information is )4,. required for every r -d� �° '�� 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: 1 have not found any information which indicates that any of the failure criteria described In 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are Indicated below. Comments: ff Ab B) System Conditionally Passes: ❑ On or more system components as described in the"Conditional Pass"section need to be rept ced or repaired. The system, upon completion of the replacement or repair, as approved by the Bo d of Health,will pass. Check the box fo " es", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"please Iain. The septic tank is metal and o20 years old'or the septic tank(whether metal or not) is structurall, unsound, exhibits substantial infilt qn or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replace th a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is struct Illy sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years 'I is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3113 T109 6 Official Inspection Form:Subsurface Sewage Olsposal System Page 2 or 17 v Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address +,t NjU A-iJ Owner owner's Nam ��� information Is A)-Di,,- /Y�� a�t�.�_ � required for every ,�._" � ��� . L page. CityfTown State Zip Code Date of Inspection Bo Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) stem Conditionally Passes (conk.): ❑ Observatio f sewage backup or break out or high static water level in the distribution box due to broken or obs u. ted pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(wi roval of Board of Health): ❑ broken pipe(s)are repla ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ N El ND(Explain below): ❑ The system requiredpumping mare 4 times a year due to broken or obstructed pipe(s),The system will pass inspection if(with approva � :Board of Health): ❑ broken pipe(s) are replaced ❑ Y N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑. (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. stem will pass unless Board of Health determines in accordance with 310 CMR 95.30 "(W,that the system is not functioning in a manner which will protect public healti- safety and the ronment: ❑ Cesspool or privy is with) eet of a surface water ❑ Cesspool or privy is within 50 feet of a bo er' vegetated wetland or a salt marsh t5ins•3l13 Title 6 of(dol inspection Fom.:..4 bsudace Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetfis Title 5 ffiicial Inspection _ p Form Subsurface Sewage Disposal System Form -Not far Voluntary Assessments -1337 Property Addre \ Owner - ; o er's Nam Information Is � ,. required for every / Q VL k �- page. CiVrown State Zip C� ode Date of Inspecilon B. Certification (cant.) 2•, System ill fail unless the Board of Health(and Public Water Supplier, if any) determines kat the system is functioning in a manner that protects the public health, safety and env . nment; ❑ The system has a is tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface waters ! 'or tributary to a surface water supply. E] The system has a septic tank a AS and the SAS is within a Zone 1 of a public water supply. ❑ The system has aseptic tank and SAS and' -.t AS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is fess t 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *k This system passes if the well water analysis, performed at a DEP certified laborat(iry;for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ r ,1 Backup of sewage into facility or system component due to overloaded or �t 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 E] Static liquid level in the distribution box above outlet invert or clogged SAS or cesspool rt due to an overloaded ❑ Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow (Stns•3/13 Tille 5 O(Sdol Inspection Form:Subsurrace Sewage Disposal Syslem•Page 4 of 17 Commonwealth of Massachusetts �:-- _- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address /L</N Owner Xws_Na s Information is SCI . � IM ._3requlred for every ., !��"`'"' ���.S page. City/Town State Zip Code Date of Inspection B. Certification (Cont.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Any portion of the SAS,cesspool or privy is below high ground water elevation. EJ 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 wel ❑ 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. [Thi: system passes if the well water analysis, performed at a DEA 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 terlaexist 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 I�.. a systems,you must indicate either"ye "or"no"to each of the following, in addition to the questio ':in Section D. Yes ❑ ❑ e system is within 400 feet of a surface eking water supply ❑ ❑ the sys .. is within 200 feet of a tributary to a su drinking water supply ❑ ❑ the system isR. ted in a nitrogen sensitive area(Interim Ihead Protection Area—IWPA) or a . %S;e one 11 of a public water supply we If you have answered"yes"to any question For the system is considered a significan reat. or answered"yes" in Section D above the large systs failed. The owner or operator of any r system considered a significant threat under Section ...*l d under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owne ould contact the appropriate regional office of the Department. t5ins•3113 Title 5 omdai Inspection Form;Subsudace Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts ^� . _ Tltle 5 Official Inspection For Subsurface Sewage Disposal System Form- Not for Voluntary Assessments PropertyAddress , Owner Owner's Nam -- inforrnatIon Is q _ u i required for every '� �. 14A/V _. �10 4 page, City/Town State Zip Code Me of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or."no"as to each of the following: Yes No ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ❑ Has the system received normal flows in.the previous two week period? I] Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ Were as built plans of the system obtained and examined? (If they were not available note as NIA) ❑ Was the facility or dwelling inspected for signs of sewage back up? ( ❑ Was the site inspected for signs of break out?. Fm ❑ Were all system components, excluding the SAS, located on site? Ilnil ❑ 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. ❑ spy Determined in the field (if any of the failure criteria related to Part C is at issue d� approximation of distance is unacceptable) [310 CMR 15.302(5)] C. System Information 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): ISIns•3113. Title 5 Official Inspection Fann:Subsurface Sewage Disposal System•Page 6 of 17 1 1 Commonwealth of Massachusetts Title 5 OfficialInspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Property Addres (�<,^J A, Owner Owner's�Nainformation ien 1 a )[] , vL�� ! (J-'Y-6 { 3required for every P _ �'t-"� 'd `r � page. Cltyllown State Zip Code Date of inspection D. System Information Description: Number of current residents: 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 K No Water meter readings, if available(last 2 years usage(gpd)): AJ1 — Detail: Sump pump? 01 Yes ❑ No Last date of occupancy: Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons day(gpd) Basis o ign flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Nc Industrial waste holding tank present 01 Yes ❑ N Non-sanitary waste discharged to the Title 5 system ❑ Yes ❑ Nc Water meter readings, if available: t5tns•3113 Tftlo 5 Or(idal Inspection Form:Subsurface 611ase Disposal System•Page 7 of 17 Commonwealth of Massachusetts _ Title 5 ufficial Inspection Form , Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Addr eft-C�--�►ti r•� Owner /V Owner's NaC�` A G information is �Av� ��-- f�3'f�" U�d � "t —3Q required for every City/Town own State Zip Code Date of Inspection page. D. System information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Cry 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: KSeptic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool n Privy lk Shared system(yes no (if yes, attach previous inspection records, if any) ❑ InnovativelAlternative 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 IIA system by system operator under contract [] Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Title 5 Official Inspection Form:Subsurface sewage Dlsposai system•Page B o(1 t51ns•3113 Commonwealth of Massachusetts Title 5 Official Inspection a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 3.44 Property Add re 1Lf'.v�L.14-/�J Owner Owner's rN�a j information is b H l�J ��t-�. _� required for every �3 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: roc 45 Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): h Depth below grade: / feet Material of construcfion: cast iron ❑40 PVC ❑other(explain): — Distance from private water supply well or suction line: feet j Comments(on condition of joints, venting,evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 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: Sludge depth: I ✓'``�'`� (Sins•3113 Title 6 official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 1 Commonwealth of Massachusetts _ '� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 13 ;�- Prope ddrefss^ 4 �\tel/y Owner Owne a e ~ information is �'t ��,1�_ '- required for every / ' page. Cltyll own State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) o?6 rt Distance from top of sludge to bottom of outlet tee or baffle ~ Scum thickness Distance from top of scum to top of outlet tee or baffle rr Distance from bottom of scum to bottom of outlet tee or baffle f 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.): cam.c Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete�'''~� :metal ❑fiberglass ❑ polyethylene ❑other(explain}: Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 15ins•3113 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Pago 10 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Property Ad ress — YZ-e.v�J ►-� Owner Owners N869 information is required for 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 Iding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below gr e: Material of constructi : ❑concrete ❑ m ' I ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: Yes ❑ No Alarm level: AlaJ 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 15ins 3113 Idle 5 QfBdal rnspedion Fom Subsurface Sewage disposal System•Page 11 of 17 Commonwealth of Massachusetts � - -; ale 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7. .................. Property Address — Owner Owner's Na information is required for every page. Ciwi own State Zip Code tate of Inspection D. System Information (cont.) 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.): v Pump Chamber(locate on site plan): Pumps in working order: Yes ❑ No* Alarms in working order: Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3113 7ille 5 official Inspection form:Subsurface Sewage Disposal System•Page V of 17 Commonwealth of Massachusetts --. Title iil Inspection a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments / 937 Property Ad ess Owner Owner's Na Information is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: +� leaching fields number, dimensional 496 X q� ❑ 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.): �ivL r2. c u1 t , /u� Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and onfiguration Depth—top of liqui inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ ❑ No t5ins•3113 Title 5 offidal Inspedlon Fors:Subsurface Sewage Dlsposat System•Page 13 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address J — -- A--<r N 4- iOwner ion is Owner's a required for every pzt-1 d vt�— / 64 Y– page. City/Town State Zip Code Date of Inspection D. System Information (cont.) mments(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 pondin condition of vegetation, etc.); I5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 e Commonwealth of Massachusetts Title fficial Inspection For Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 7 Property ess Owner Owner's a information is � � �k u,?� 4_, L(:73- e-,,`(:7 e-1 S required for every 'yam+ O C page. Citylrown 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 �J t5ins•3113 6 Tide 5 Official Inspedlon Form:Subsurface Sewage Disposal Syslem•Page 15 of 17 Commonwealth of Massachusetts v— Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments [331 5� Prope!!Y-' cess Owner Owner's N information is n 1� � v� �-- �-•- required for every 1� � �t_ � <3 fS page. City/Town State Zip Code Datb of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water:" feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: S 7�3 c'Lt Z25 ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: l Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ine-3113 Title 5 official Inspection Fora:Subsurface Sewage Disposal System-Page 16 of 17 it e _ Commonwealth of Massachusetts _ = u Title 5 Official Inspection Fey Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0 Y7 Property Address Owner Owner f (/ information Is o •1 G.�! /l �,_b ���� S � 7 —3G required for ever, �V l U Y page. City/rown 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 II i 15ins•3113 Title 5 OfQclel Inspection Funs:Subsurface Sewage Disposal System•Page 17 of 1; i G , v 2 II O rr�Mt } L} E,A 1ST)N G f rED ov : 102 Lac LINE, OF WfATER ! tNE, URS AND ()•T(L 1 IES S H 4 1 t. - E LINE, A OTHi R r 01_ YO CCv9TRUCTICN ,6 1 y „e. t C i The Commonwealth of Massachusetts City\Town of North Andover Es Certificate of Inspection In accordance with 780 CMR, Chapter 1 (The Sixth Edition of the Massachusetts State Building Code) and Chapter 304 of the Acts of 2004 (an Act to further enhance fire and life safely/), this temporary certificate of inspection is issued to the premise or structure or part thereof as herein identified. Identify Name of Establishment Certificate No. Issued to Pizza Factory 535-2016 535 Chickering Road Certificate Located at Expiration February 2017 Use Group Restaurant Allowable Classification(s) Occupant Load 20 Certificate of inspection is hereby issued by the undersigned to certify that the premise,structure or portion thereof as herein specified has been inspected for general fire and life safety features. This certificate shall allow for the temporary use as herein described and in conformance with any and all conditions as identified below. It shall be framed behind clear glass and\or laminated and posted in a conspicuous place within the space as directed by the undersigned. Failure to post the certificate,failure to comply with conditions or, tampering with the contents of the certificate is strictly prohibited. Conditions of Temporary Use Name of Municipal Name of Municipal Gerald Brown, Bldg. Insp. Date of January 21,2016 Fire Chief Building Commissioner Inspection Signature of Municipal Signature of Municipal Date of January 21,2016 Fire Chief Building Commissioner Issuance Town of North Andover, Massachusetts Form No.2 ,AORTN BOARD OF HEALTH O than y 1ti ti w F DESIGN APPROVAL FOR ss"C SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM yt�Lt�tr�, Applicant '4' "eSt No. Site Location-_. 3� Q (—. . Reference Plans and Specs._ Ute, E" ENGINEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. CHAIRMAN,BOARD OF HEALTH Qv/ Fee Site System Permit No. DATE Sheet of BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW FEE PERMIT # DATE RECEIVED APPLICANT ASSESSOR'S MAP ADDRESS PARCEL # LOT # 1� 7 ENGINEER STREET d 5� �� ADDRESS PLAN DATE REVISION DATE CONDITIONS OF APPROVAL: APPROVED DISAPPROVED I. %E65- /!) _ o� z . S Town of North Andover NORTH OFFICE OF 3�o`�, .o 0 COMMUNITY DEVELOPMENT AND SERVICES . - K p9q « 146 Main Street KENNETH R.MAHONY North Andover, Massachusetts 01845 �SSACHUS�� Director (508) 688-9533 TOWN OF NORTH ANDOVER BOARD OF HEALTH August 30, 1995 CERTIFICATE OF COMPLIANCE This is to certify that the individual subsurface disposal system constructed ( ) or repaired (x) by John Soucy installer at 1337 Salem Street, North Andover, Massachusetts has been installed in accordance with the provisions of TITLE 5 of the State Sanitary Code and with Board of Health regulations as described in the Design Approval Permit #758 dated August 21, 1995 . THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY. Board of Health Inspector BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Julie Parrino D.Robert Nicetta Michael Howard Sandra Starr Kathleen Bradley Colwell FOR— DATETIMEP.Mi M � OF PjH6NED:' V �' ,� RETURNE[l " PHONE Y.C1UA CALL AREA COO,Et� NU_MBE EXTENSION ' MESSAGE �/ I�LASECALL WILL CALL 1 p `AGAIN L IJc`C! CAME..To a itz a 4) 5EE YOU WANTS TO SEE Y0 SIGNED TOPS FORM 4003 1 NOTES _ i Form No.3 Town of North Andover, Massachusetts BOARD OF HEALTH NOR7M LL-19 �1_ • 3: a,,. '...,_e OL A ��•e,,r,;:.�t� DISPOSAL WORKS CONSTRUCTION PERMIT SSACHUSE Applicant 1 TELEPHONE AME DURESS Site Location Permission is hereby granted to Construct ( ) or Repair ( an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. c T 4HA1RMAN,BOARD OF HEALTH Fee D.W.C. No. d I PLAN REVIEW CHECKLIST ADDRESS 13�5 7 ENGINEER GENERAL 3 COPIES STAMP ✓ LOCUS NORTH ARROW SCALE CONTOURS t/ PROFILE �� SECTION BENCHMARKS SOIL & PERC INFO (/ ELEVATIONS WETS. DISCLAIMER_I.,,:,,— WELLS & WETLANDS WATERSHED?A/0 DRIVEWAY �Elev) WATER LINE FDN DRAIN SCH40 TESTS CURRENT? SEPTIC TANK MIN 150OG . 17 INVERT DROP GARB. GRINDER(+200% EDF) 25 ' TO CELLAR ✓ " MANHOLE TO GRADE,)(" ELEV GW D-BOX SIZE # LINES FIRST 21 LEVEL STATEMENT INLET& OUTLET (2 t' OR . 17 FT) TEE REQ' D? 06-� LEACHING MIN 660 GPD?y RESERVE AREA4 ' FROM PRIMARY? ---' 2% SLOPE 100 ' TO WETLANDS V' 100 ' TO WELLS c/ 4 ' TO S.H. GW 35 ' TO FND & INTRCPTR DRAINS 325 ' TO SURFACE H2O SUPP 4 ' PERM. SOIL BELOW FACILITY MIN 12" COVER L-� FILL? '/ (#5 ' if above natural elev; 10 ' if below) BREAKOUT MET? TRENCHES MIN 660 gpd SLOPE (min . 005 or 6"/1001 ) >31COVER?-VENT SIDEWALL DIST. 2X EFF. W OR D (MIN 6 ' ) IS RESERVE BETWEEN TRENCHES? IN FILL? MUST BE 101 MIN. 4" PEA STONE? BOT X LDNG + SIDE X LDNG = TOT (L x W x #) (G/ft2) (DxLx2x#) (G/ft2) Copyright O 1993 by S.L.Starr PITS MIN 660 LEACHING MIN 1 (131x16 ' ) PIT MANHOLE/PIT GW MIN 4 ' BELOW BOTTOM EXC 2x EFF W OR D 12"-48" STONE BOT + SIDE x LOAD = TOTAL (L x W x #) (2x(L+W)xD x #) (G/ft2) CHAMBERS MIN 660 LEACHING GW MIN 4" BELOW COVER >3 FT - VENT MANHOLES 12"-48" STONE SPLASH PADS SLOPE . 005 BED/TRENCH (Bed max. 60 ' X 601 ) MIN 13 ' X 16 ' PIT I BOT + SIDE X LOAD = TOTAL (L x W x #) (2 x (L+W) xD x #) (G/ft2) FIELDS MIN 660 GPD- 900 ft2 BED ✓ ' GW MIN 4 ' BELOW BOTTOM OF FIELD PIPE ENDS JOINED? c/ 4" PEA STONE? Z/ DIST LINE SLOPE . 005? >31COVER-VENT SCH 40 c/!I MIN 12" COVER ✓� RATE LDG x•,3.3 X 6 6 0 = 39Y,8 900 X = TOTAL G/ft2 REQ'D (ft2) LXW DOSING TANKS AND PUMPS DIMENSIONS X X = PUMP CAPACITY Spm L W D Vol. �k /I / T4) DISCHARGE SIZE DISCHARGE RATE DISCHARGE TIME Spm MANHOLES TO GRADE ALARM SEP. CIRC. L--'� GW Min. 1' below inlet) HWL LWL CHECK VALVE L---'- BLEEDER HOLE (-�JMANUAL OP. SWITCH Copyright m 1995 by S.L.Starr E}� fir Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property � . 3raiL �^ TOWN OF NORTHANDOVER/ � � ; Owner ' s name U c ti �, f3 c, � �, BOARD OF H ATH Date of Inspection jUN 1 40 PART A CHECKLIST Check if the following have been done: -1/ Pumping information was requested of the owner, occupant, and Board of Health. 'None of the system components have beer, pumped for at least two weeks and the system has been receiving normal flow rates during that period . Large volumes of water have not been introduced into the system recently or as part of this inspection, !1As built plans have been obtained and examined. Note if they are not available with NIA. l The facility or dwelling was inspected for signs of sewage back-up. The site was inspected for signs of breakout. V_ All system components , excluding the SAS , have been located on the site . The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. !i,� The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS . 2 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential number of bedrooms y number of current residents y garbage grinder, yes or no Y._ laundry connected to system, yes or no ^` seasonal use, yes or no If nonresidential , calculated flow: Water meter readings , if available : y34' o q It el Last date of occupancy GENERAL INFORMATION Pumping records and source of information : System pumped as part of .inspection, yes or no if yes, volumeP umP ed 1oc� R� Reason for pumping: �- Type of system _L,�:-- 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) ) Y Other (explain) Approximate age of all components. Date installed, if known. Source of information: IJ,S'1'13 l l c ----------- A/0 Sewage odors detected when .arriving at the site, yes or no � l 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: (Locate on site plan) depth below grade :—LLL– material rade : LL material of construction : ,yconcrete metal FRP other(explain) dimensions : L'/r sludge depth ---k" distance from top of sludge to bottom of outlet tee or baffle ILL 'scum thickness distance from top of scum to top of outlet tee or baffle distance from bottom of scum to bottom of outlet tee or baffle Comments : (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc. ) 3/9"r F3 T� � �/n �rr�v..0 94F ' i2�p t/�<t: ►i ��/ r_r.M 4.4 17'l f?Y `TC t .'i ..S t7,.; L D ! R u r DISTRIBUTION BOX: ( locate on site plan) depth of liquid level above outlet invert Comments : (note if level and distribution is equal , evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc. ) aF wR-1 r2 PUMP CHAMBER: (locate on site plan) pumps in working order, yes or no Comments : (note condition of pump chamber, condition of. pumps and appurtenances, recommendations for maintenance or repairs, etc. ) la SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type leaching pits and number leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions r - y v 16 4-C> overflow cesspool , number Comments : (note condition of soil , signs of hydraulic failure, level of ponding., condition of vegetation, recommendations for maintenance or repairs, etc. ) CESSPOOLS (locate on site plan) : D number and configuration depth-top of liquid to inlet invert depth of solids layer depth of scum layer dimensions of cesspool materials of construction incication of groundwater inflow (cesspool must be pumped as part of inspection) Comments : (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation,, recommendations .for maintenance or repairs, 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, A condition of vegetation, recommendations for maintenance or repairs,etc. ) 12 ? 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes , no, or not determined (Y, N, or ND) . Describe basis of determination in all instances . If "not determined" , explain why not) Backup of sewage into facility? Al Discharge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the distribution box above outlet invert? ✓vLiquid depth in cesspool z6" below invert or available volume< 1/2 day flow? Required pumping 4 times or more in the last year? number of times pumped f0 l Septic tank is metal-, cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS , cesspool or privy: � i?, below the high groundwater elevation? ✓`_ within 50 feet of a surface water? N' within , 100 feet of a surface water ,supply or tributary to a surface water supply? within a Zone I of a public well? r within 50 feet of a bordering vegetated wetland or salt marsh T (cesspools and privies only, not the SAS) ? /t/ within 50 feet of a private water supply well? less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis? If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen . 23 z "7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOM PART D CERTIFICATION Nate of Inspector C. UL ZT,z Company Name Company Address �333 A K r q A,/ 4, Certification Ptgtpnent I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance. and repair are consistent with ny. training and experience in the proper function and itanitenance of on-site sewage disposal systems . Check one : I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluat.eri =.`eas stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15 . 303 . The basis for this determination is provided in the FAILURE CRITERIA section of this form . Inspector ' s Signature Date Original to system owner Copies to: E,ulyer (if applicable) Approving authority