HomeMy WebLinkAboutMiscellaneous - 134 FARNUM STREET 4/30/2018 ! 134 FARNUM STREET
210/107.A-0072-0000.0 i f
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TOWN OF NORTH ANDOVER
d APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received-
3
ACHU
eceivedSACHU
Date Issued:
IMPORTANT:Applicant must complete all items on this page
a
w:
fn
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building [IOne family
11Addition ❑ Two or more family ❑ Industrial
❑ Alteration No. of units: Q Commercial
Repair, replacement NAssessory Bldga Ij Others:
❑ Demolition ❑ Other /bX/Z.
M k 0-- - d
,lyr
DESCRIPTION OF WORK TO BE PREFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: 014e— Phone: r' � �Z
��•it
Address:
.............
1 4 1 lip,
n-w 1i E"
pp 7 �xi
b k
H . 5fi�k ................................. ...
ARCHITECT/ENGINEER 4Z Phone:
Address: Reg. No.
FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $$2! -30,`J" FEE: $
Check No.: Receipt No.:
NOTE: Persons contracting with unre istere ontractors do not have access to the guaranty fund
xilatar:'� A :r�/ .A r � STlat ,e�a �
TOWN OF NORTH ANDOVER
y APPLICATION FOR PLAN EXAMINATION
Permit N0:
.Date Received � � 74.0AnT[o�P"'`•
�SSACHUSE�
Date Issued:
IMPORTANT:Applicant must complete all items on this page
r � ;
a
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
❑ New Building ❑ One family
❑ Addition ❑ Two or more family ❑ Industrial
❑ Alteration No. of units: 11 Commercial
Repair, replacement NAssessory Bldg e- E! Others:
❑ Demolition ❑ Other /C>X/Z-
raws
gyW11" ...
DESCRIPTION OF WORK TO BE PREFORMED:
(Gt G i s G .rt-i ve -
I � -
-T ,Identification Please Type or Print Clearly)
. OWNER: Name:T/?-vc--e— Phone: �,�' _ t��YO 7z .
fr
Address: /-L1
n
i..n8 F"^.Y'�R :4'Mi�V..J'C+�ry`y}a�. Y.;'Ra4_ `^tr "F'i •P..¢..�w.?
ARCHITECT/ENGINEER�/tJ/fit' Phone:
Address: Reg. No.
FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $$2! 3'ro-'Vo FEE:
Check No.: Receipt No.:
NOTE: Persons contracting with unre istere ontractors do not have access to the guaranty fund
-- •�� %--cl uiiCu rwl marl u Stamped Plans H
TYPE OF SEWERAGE DISPOSAL
Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑
Well ❑ Tobacco Sales ❑
Food Packaging/Sales ❑
Private(septic tank,etc. ❑ . Permanent Dumpster on Site ❑
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF _ U-FORM
DATE REJECTED DATE APPROVED
PLANNING &.-DEVELOPMENT ❑ ❑
COMMENTS
DA JECTED DATE APPROVED'
CONSERVATION
COMMENTS (OJI
11
DATE REJECTED DATE APPROVED
HEALTH ❑ ��� �
COMMENTS �r C-Z �fJGz`�t`oma^
10
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
i
Planning Board Decision: Comments
Conservation Decision:
Comments
Water & Sewer Connection/signature & Date
Located at 384 Osgood StreetT 54
Driveway Permit
'a �.i. `�� `..e.NT. T� .ib�' 2 �t ,a'u711G5�'
i`� }` � 'ar i
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MORTGAGE I S S PEC rl o N PLAN
NO. 134 FA RNUM ST
/N
N. ANDOVER . MASS.
MIDDLESEX SURVEY /NC. LAND SURVEYORS
I3/ PARK ST. N. -READING , MASS .
SCALE,* I" e !008 DA TE_.' JULY /8, 1996
CERTIFIED TO.* ANDOVER BANK 8R1CHAA9A. kXVLYNlV
LOT 4
440
NOTE'S '
FFSt�TSP � �� USED TO
ESTABLIS� R �� �
2)LOT L INES ARE COMPILED INFORMA®ION
TI TLE RE¢' R�NCE
REGLS TRY ®
DEED. 800K 3298 BSS A�IYKN®WLR*®GE INFORMATION
/ HEREBY CERTIFY
AND BELIEF THAT THE STR4VC'TU S ONTHIS A AN ARE
LOCATED ON THE GROUND APPpR® IMAT LY
99MOiU EA1 AT T'HE�1 ® C ST CWN
p ! T/N A FLO h►AZA ,q ,q
AND THE PAROL NOTIN
SHOWN ON F E. M. A MAP COMMUNITY NO
ZONE.' X EFFECTIVE DATE.' 6d2-93
NO P90T0
Commonwealth of Massachusetts
"City/Town of-NORTH ANDOVER MASSACH R �
Y TS
System Pumping Record FEB o 8 2006
y` Form 4
" TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP.has provided this form for use by local Boards of Health. Th ping ecord 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
computer, use
only the tab key Address
to move your
cursor-do not
Use the return City/Town State Zip Code
key. 2. System Owner: `
Name
Address(if different from location)
City/Town StateZip Codes
Telephone Number
S3.
. Pumping Record
. Date of Pumping Date Z 2. Quantity Pumped: ( �
Gallons
Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Ye No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name Vehicle License Number
Company
7. Location where contents were disposed:
z� U
Si of #1 r Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Town of North Andover f NORTH
Community Development and Services Division a16.
�
Office of the Health Department 40
400 OSGOOD STREET • �, .�,,::�.�>` •
North Andover,Massachusetts 01.845CH T4s"" eta
ShG HUs
Susan Y.Sawyer,REHS/RS
Public Health Director (978)688-9540-Phone
(978)688-8476- Fax
Date: April 25,2005
Address: 134 Farnum Street,North Andover,MA 01845
Re: Application for: Deck
Dear: Mr.&Mrs. Scudder
Your application for a new deck at 134 Farnum Street has been reviewed by the Health
Department. The application was denied on,April 25,2005 for the following reasons:
1. X Missing information
2. ❑ Passing Title 5 inspection of septic system required
3. ❑ Location of structure not acceptable
4. ❑ Undersized septic system
To address the problem(s):
If#1 is checked, please supply:
a. Floor plan of existing and proposed addition—all rooms
b. Certified plot plan showing house,septic system and proposed project in scale
If#2 is checked:
a. Have the septic system inspected by a certified Title 5 inspector to determine the size of the system and
whether it is operating properly: OR
b. Tie-in to municipal sewer
If#3 is checked:
a. Relocate the project
If#4 is checked:
a. Provide additional information proving that the existing septic system meets current capacity
requirements. Please consult an engineer to determine the flow capacity of the septic system.
Please feel free to call the Health Office at 978-688-9540 with any questions you may have.
Sincerely,
r LIJ
Michele E. Grant
Cc: Building Department
File
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 NURSE 688-9543 PLANNING 688-9535
r.
TOWN OF NOR'T'H ANDOVEk JAN 0 6 2001
SYSTEM PUMPINU R.ECOKL
SYSTEM OWNER& AnDRESS
SYSTEM LOCATION
DATE OF PVMFgNQ: U..__.._Q(JANTITY PUMPED;
t3SPOOL: NO_ Y.gg
.. ...... / Septic Tank: NO YES
NA rUKE OF SBRVICE: KoU'r1N1r v'�MIrRUfrNC'1'
OBSERVATIONS: ,
000D CONDITION l� L.L .TYJ COVER �
HEAVY OU.ASE BAFFLES IN PLACL
ROOTS _ LBACHFIUD RUNBACK
B assiVE SOLIDS ___ FLOODED
SOLID CARRYOY�R„_._.OTNER EXPLA IN
WIAMENTS.
�.:uN 1't m'S rKANsyeRKEL) I't�
COMMONWEALTH OF MASSACHUSETTS
`• ,.. EXECUTIVE,OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
t
V�
V
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:
Owner's Name:
Owner's Address: DEC _ 9 2003
Date of Inspection: a 2 - ssi"�
Name of Inspector: (please print��C'l(`(?�
__.
Company Name;- � CC
Mailing Address: PC '
Telephone Number: -N / l
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:
XPasses
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: 2-3-03
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
' DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
! authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
- _ w
Page 2 of 11
r OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: fit?
AMM #
Owner:C 1
t,
Date of Inspection:
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: Xt-75
I have not found any inforf/Zi,in.9Whicindicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure-chteria 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 l
repaired:The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. j
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 t
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in,the distribution box due to broken or
7 obstructed pipe(s)&due td--abroken,'seftled or uneven distribufion box. System will pass inspection if(with
approval of Board of Health):
broken pipes)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:
2
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Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIIFIJCATION(continued)
Property Address: A3T
i
owner: 04-,-;
Date of Inspection:
C. Further Evaluation is Required by the Board of Health: X)4
Conditions exist which require fin they evaluation by the Board of Health in order to determine if the system
is failing to protect public health;safety or the environment.
1: Sysmifi will pass unless`Board:of Health determines m accordance with 310 CMR'B.303(l)(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
g
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 aseptic 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
_ bacte�ia.attd volatile organic compounds.indicatesaat he well is.free fromollution=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:
3
Page 4 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: (.,,GL
Owner.X.z( i PP—P
Date of Inspection: 0--� G2�
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 sewaAe into:facility_or system-component di e.to ovedoaded,or clogged SAS or cesspool•
charge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow
✓ Required pumping more than 4 times in the last year NOT due to.clogged or obstructedpipe(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 coliform bacteria and volatile organic compoaHds
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 sv_stem fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
4-4
E:._-Ur-geS
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
r
yes no
the system is within 400 feet of 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.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST.
Property Address:/k
P
1 P
oylo
Date of Inspe
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No G
.� .. _ k
. 'um' iri information was-Provided 'the owner occu ant or board of Helth
— — p g Y p ,
L''_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 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-?
L/– Was the facility owner(and occupants if different from owner)provided with information on the proper y
maintenance of subsurface sewage disposal systems? ".
x
. The size and location of the..Soil Absorption System(SAS)on the site has been'deterinined based ott _..
Yew, no
Existing information.For example,a plan at the Board of Health.
_ — Determined in the field(if any of the failure criteria related to Part C is at issue approxim ation.of distance
is unacceptable)[310 CMR 15.302(3)(b)]
r
5
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Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
/f/liF�dy��
Owner:ted
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Number of current residents:
oes residence have a
Is laundry on o separate yste (yes or no) `(if yes�separate in pection requ redd] `
,• garbagetr
Laundry system inspected(yes or no):_
Seasonal use:(yes or no): HU
Water meter readings,if av ilable(last 2 years usage(gpd)):
Sump pump(yes or no): YA5
Last date of occupancy:
COMMERCIALANDUSTRIAL
Type of establishment: y
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):—
Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe): "
GENERAL INFORMATION
Pumping Records
Source of information: t�i1G�r/1 ird
Was system pumped as part of the inspection(yes or no): �
If yes,volume pumped: allons--How was quantity pumped determined? �vciG M�Ti2
Reason for,;
c ",r¢�vrTdE{cr f�t2_
TYPE-6F SYSTEM }
eptic tank,distribution box,soil absorption system i
_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)
_Tight tank _Attach a copy of the DEP approval.
_Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):
6
ff Page 7 of 11
' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: L
Owner•rrj �i') /S
Date of Inspection: /A _f412 .
BUILDING SEWER(locate on site plan)
Depth below grade: ,r
Materials of construction: (,.dk iron _40 PVC_other(explain):
�w. .
pistance from.private water supply�.ell:or suc aori.line;
Comments `on condition of joints,.letting,evidence of leakage,etc.):
e96100 cp'q r1a
SEPTIC TANK:_(locate on site plan)
n
Depth below grade:
Material of construction:_ oncrete_metal_fiberglass_polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate) r
Dimensions: . (F'r '.,I�'
Sludge depth: 20,/,
Distance from top of sludge to bottom of outlet tee or baffle:_ ;7
'
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: 't
How were dimensions determined: Q 14 S /1",65
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrityjiquid levels ks
as related to outlet invert,evidence of leakage,etc.):
",f�,�F��E'S' � -r�t�� 6 acs� P�.�r vi r�r��✓
moi°Cu,u srstr fk a� /1 ,� t/ R a r
" •GREASE TRAP: locate on pan) f
Depth below grade:
Material of construction:_concrete_metal_fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
7'Y' ey{,r,,.,..,. ;..a
, ..::4 f :..�. �� ,. .,.�,...at."'" tuT.� �. `'Ir.y,h+aiW4-,.,.w�..'Sz-' ,5..+,��:n.....-.�.r . ,��,,...F-.vr+"-'tl,K+►..+..,y.. ^w.— ,,,'^'v
yy ti
Page 8 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
s SYSTEM INFORMATION(continued)
Property Address:
Owner: nr-�r7
Date of Inspection: Jb) _zR—C—? .
TIGHT or HOLDING TANK:a(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
ry s;u Material of costruction. concrete_ _ metal-'.�.`_fiberglass�pol�retylene ' . th r(expl'amu
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 'i
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.): /
(7 /,"_ �il/at F' ,►ex'`'r��. .� ,.a„x,,�:,#„
• l' Wil. ..
PUMP CHAMBER:A46cate on site plan)
x
Pumps in working order(yes or no): `'
E �
Alarms in working.order(yes or no): ,*
omments mote"condition of pump cham&r,conditioh of pumps and appurtenances,etc.): *�
8
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Page 9ofII
Y
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
k PART C .
SYSTEM INFORMATION(continued)
Property Address_
Owner a
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS):. -=(locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:_
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology: 1
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
914 o r� YlJ6L�4yL�4 Fisc/��2 r
CESSPOOLS: '"4(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: a ,
Materials of construction:
Indication of groundwater inflow(yes or no): ,
Comments(note condition0soil,signst®f hydraulic failure;]&efofpon ,ding,condition ofvegeta ion,etc.):
,
PRIVY: (locate on sitelan)
P
Materials of construction:
Dimensions:
A Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
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a Page 10 of 11
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIONYORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: d
Date of Inspection: 03
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 1,00 feet Locate;where.public water s%upply enters the bµilding.,.
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Page 11 of 11
3;
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner ' fin —
Date of Inspection:^
SITE EXAM '
Slope
Surface water
Check cellar ��,a 1 ( ,i` t_ F
Shallow wellsx. ' •�,._ s�;- -t , :
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked.with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
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Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
WIIIIam.F.Weld
Governor
Trudy t^,oxe
Secretary,EDEA
David B. Struhs
Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION L` l®0, l„4,,,
Property Address: 13 Address of Owner:
Date oflnspection: 901 � (if different)
Name of Inspector:
Company Name, Address and Telephone Number:
CERTIFICATION STATEMENT �►— fee (60' 7V7.
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Date: 4/-
The
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D:
A] SYSTEM PASSES:
_&/I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection. If
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not)
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
(revised 8/15/95) 1
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500
N, iA,*Printed on Recyded Paper
��q
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATIPN (c�o�ntinui ed)���v
Property Address•.
evil v � ffJ
Owner: ,/,�,f ole 1-f
Date of Inspection: 4-21.1 - 74
B)SYSTEM CONDITIONALLY PASSES (continued)
_ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
i
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
i
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: •
F
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to.protect the
public health, safety.and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 fee! to a surface water supply or tributary to a
surface water^supply.'
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is
free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than:5
ppm.
D] SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded.or clogged SAS or
cesspool.
(revised 8/15/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: Q
Owner:
Date of Inspection: ,. f, _9 �+
D)SYSTEM FAILS (continued): c.•l �1
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
_ Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping.more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS: + `
The following criteria apply to large systems in addition to the criteria above:
The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety
and the environment because one or more of the following conditions exist: .
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone 11 of a
public water supply welh
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 8/15/95) 3
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4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
fit/O4 V'?
Property Address:
Owner: C'l�
Date of Inspection:
Check if the following have been done:
'= Pumping information was requested of the owner, occupant, and Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
As built plans have been obtained and examined. Note if they are not available with.N/A.
f•V
he facility or dwelling was inspected for signs of sewage back-up.
�he system does not receive non-sanitary or industrial waste flow
o�he site was inspected for signs of breakout.
_""All system components, excluding the Soil Absorption System, 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
t material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
_TheAize and location of the Soil Absorption System on the site has been determined based on existing information or
Krroximated by non-intrusive methods.
The facility o.%ner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System
(revised 8/15/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:.
Owner: S"l H a e
Date of Inspection: /
N le FLOW CONDITIONS
RESIDENTIAL:
Design flow: Qallons!
Number of bedrooms: 1
Number of current residents:
Garbage grinder(yes or no):-`Y 14"
Laundry connected to system (,yes or no):--ye'S
Seasonal use (yes or no):_N U
Water meter readings, if available: A4 4 `
Last date of occupancy: " c c,,)`,
P
COMMERCIAL/INDUSTRIAL:
t
Type of establishment: ►
Design flow: gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy`.
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)_
If yes, volume pumped gallons f
Reason for pumping:
TYPE f 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)
Other(explain)
APPROXIMATE AGE of all components, date installed(if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)
(revised 8/15/95) 5 .
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1341 10A 1.14 �
Owner:
.Date of Inspection:
SEPTIC TANK: tie .
(locate on site plan)
r
Depth below grade:
Material of construction: concrete_metal _FRP—other(explain)
Dimensions: k 1 .�
Sludge depth:_
Distance from top of sludge to bottom of outlet tee or baffle: 4p-1Scum thickness: 5 $1
Distance from top of scum to top of outlet tee or baffle: tj
Distance from bottom of scum to bottom of outlet tee or baffle:`
_ Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
_ GREASE TRAP:_
(locate on site plan) .
Depth below grade:
Material of construction: _concrete _metal _FRP other(explain)
Dimensions:
Scum thickness.
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of sn,m tn bottom of outlet tee or battle:
i
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of,leakage, etc.)
(revised 8/15/95) 6 .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: l �"
Date of Inspection:
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade:
Material of construction: _concrete_metal —FRP.—other(explain)
Dimensions:
Capacity: gallons
Design flow: eallons/day
Alarm level:
r .
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert:
r-- —�
Comments:
(note if level and distribution equal, evidence of solids carryover; evidence of leakage into or out of box, etc:)
. . �A G:c� a GM�TtZ�c1'�a�t �o . �g Gs ca L �I�'C
PUMP CHAMBER410
(locate on site plan)
Pumps in working order.(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 8/15/95) 7
_ ..4' ..
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
'
SYSTEM INFORMATION (continued)
we POO
Property Address:
Owner: ! to
Date of.Inspection:
SOIL ABSORPTION SYSTEM (SAS): ,e 5
(locate on site pian, if possible; excava;on not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:"i' ,
leaching chambers, number:_
leaching galleries, number: ���,��(4
leaching trenches, number,length:Q T11Pq c6 q doe 1 S
leaching fields, number, dimensions:
' overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
�G.yr•-t �"LL�v c/ �-/r f�fG".,c� � � a'o1r D�k� v ✓ ac
CESSPOOLS: _
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 8/15/95) 8
xf.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continue 17,A4 L70
Property Address. 1341 lit:--4apl 94
Owner: o e '7 '
Date of Inspection: L4
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
/a/L rc ate S'a
x
' t
-
t��t�
r�f
G 0 I s
i
DEPTH TO GROUNDWATER
Depth to groundwater:___'y Lfeet
method of determination or approximation:
(revised 8/15/95) 9
Addresst3�„Qy.um s- Title of File page of
Date File Open: Date file closed:
Doc Document/Action Title Date of Refer to other Purpose of Document/Action and notes:
action Document/ document/
Num. Action Department
Board of Appeals — Board of Health — Planniing Board — Conservation Commission — Building Department
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it r 1 0 Al JDo k"� MA.
VE ASSACHUSE
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EP,has provided jhls form for u8e by local Boards of Health, The System Pumping Roc T,
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pproving authority,
A;. Faclllty .lnforrtlon
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Ckq�(favn,.� ' Slate
Telephone Number
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sl, RUMPI lg R g'0rd o�E
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1; Dato:o(Pumpin9 b` 2, Quant.)y Pumped:
Yp.e P(.ayalemt, Cesspool(s) ` Optic Tank
Tight Ta
V : � J1�\I�\.i��'IJI�V�1y 111,„,t,i�r.1✓J 1'•ri..t,r'
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❑ Yes o Y as It cleaned? s
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Syclem Pumping Rscom
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Commonwealth of Massachusetts
W City/Town of No.Andover
W° System Pumping Record
Form 4
M
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form.they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the n / gLJnn
computer, use ` � �� J
only the tab key Address
to move your
cursor-do not No.Andover _ Ma 01845
use the return City/Town State Zip Code
key. 2 System Owner: )CM C
VQ
RBCBIilBL�
Name
JAN U ZU12
'ef07 Address(if different from location)
TOWN OF NORTH ANDOVER
CitylrownState E'4 T
Telephone Number
B. Pumping Record
1. Date of Pumping ate 2. Quantity Pumped: 4Gaons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Y -No
5. Condition of System:
6. em Pumped By:
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment PI o. Mill Bradford, Ma 01835
` Signature of Ha Q4� Date
Signature of Re ivi g Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
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