HomeMy WebLinkAboutMiscellaneous - 136 CARLTON LANE 4/30/2018 (2) 136 CARLTON LANE
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Commonwealth of Massachusetts t
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
w 136 CARLTON LANE
Property Address
RICK PIECEWICZ
Owner Owners Name /
information is
required for every N. ANDOVER MA 01845 9/22/15 c �y
q
page. City/Town State Zip Code Date of Inspection V L L y
Inspection results must be submitted on this form. Inspection forms may not be altered in any ld
way. Please see completeness checklist at the end of the form.
Important:When A. General Information T
CEIVED
filling out forms
on the computer,
use only the tab 1. InspectorAT� OI-CT 08 2015
key to move your
cursor-do not John J. SoucyT CA"OF NORTH ANDOVER
use the return Name of Inspector HEALTH DEPARTYk-N I
key.
Soucy's Sewer Service Inc.
r� Company Name
78 North Broadway
Company Address
Salem NH 03079
Cityrrown state Zip Code
603-898-9339 13397
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
21nspN ds urther Evaluation by the Local Approving Authority
CcJC�r 9/22/15 or's Signature Date
T inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
136 CARLTON LANE
Property Address
RICK PIECEWICZ
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 9/22/15
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM01136 CARLTON LANE
Property Address
RICK PIECEWICZ
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 9/22/15
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
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°wM 136 CARLTON LANE
Property Address
RICK PIECEWICZ
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 9/22/15
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
d Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
136 CARLTON LANE
Property Address
RICK PIECEWICZ
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 9/22/15
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3113 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
w 136 CARLTON LANE
Property Address
RICK PIECEWICZ
Owner Owner's Name
information is
required for every N.ANDOVER MA 01845 9/22/15
page. Cityfrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built 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?
® ElWas the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
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
136 CARLTON LANE
Property Address
RICK PIECEWICZ
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 9/22/15
page. City/Town 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 years usage(gpd)):
Detail:
SEE ATTACHED
Sump pump? ❑ Yes ® No
Last date of occupancy: Date
Commerciallindustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.).-
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
136 CARLTON LANE
Property Address
RICK PIECEWICZ
Owner Owner's Name
information is
required for every N.ANDOVER MA 01845 9/22/15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: CURRENT
Date
Other(describe below):
General Information
Pumping Records:
Source of information: Soucy's Sewer Service Inc
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1500
gallons
How was quantity pumped determined? Gauge on truck
Reason for pumping: Maintenance and Inspection
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 136 CARLTON LANE
Property Address
RICK PIECEWICZ
Owner Owner's Name
information is
required for every N.ANDOVER MA 01845 9122/15
page. CityTTown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
1984
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 18"feet
Material of construction:
® cast iron ❑40 PVC ❑other(explain):
Distance from private water supply well or suction line: N/A
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
NO SAGGING. PIPE APPEARS TO BE WATERTIGHT.
Septic Tank(locate on site plan):
Depth below grade: 4
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:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 136 CARLTON LANE
Property Address
RICK PIECEWICZ
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 9/22/15
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
39"
Scum thickness
2"
Distance from top of scum to top of outlet tee or baffle 7
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? TAPE&SLUDGE TOOL
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
TANK IS STRCTURALY SOUND. NO APPARENT LEAKAGE. TEES ARE GOOD.
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
tSns-3113 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 136 CARLTON LANE
Property Address
RICK PIECEWICZ
Owner Owner's Name
information is
required for every N.ANDOVER MA 01845 9/22/15
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
PUMP TANK ANNUALLY
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
136 CARLTON LANE
Property Address
RICK PIECEWICZ
Owner Owner's Name
information is
required for every N.ANDOVER MA 01845 9/22/15
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
11
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 REPLACED PRIOR TO INSPECTION. SEE PERMIT.
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:
151ns•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
136 CARLTON LANE
Property Address
RICK PIECEWICZ
Owner Owner's Name
information is
required for every N.ANDOVER MA 01845 9/22/15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: S 4 8
SHALLL OW PITS
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ 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.):
PIT"E"3'/STATIC LEVEL ON BOTTOM. PIT"F" COMPLETELY DRY YET ACCEPTING FLOW. NO
SIGNS OF HYDRAULIC FAILURE.
Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
� t5ins-3113 Title 5 Official Inspection Forms 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
M 136 CARLTON LANE
Property Address
RICK PIECEWICZ
Owner Owner's Name
information is
required for every N.ANDOVER MA 01845 9/22/15
page. Cityrrown 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.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
i
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
136 CARLTON LANE
Property Address
RICK PIECEWICZ
Owner Owner's Name
information is N.ANDOVER MA 01845 9/22/15
required for every
page. City/Town State, Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
❑ drawing attached separately
� a
� 1
t5ins•3113 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�M 136 CARLTON LANE
Property Address
RICK PIECEWICZ
Owner Owner's Name
information is
required for every N.ANDOVER MA 01845 9/22/15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: 6'
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
DUG HOLE WITH AUGER IN FRONT LOW DROP OFF AREA, APPROXIMATELY 30' FROM
ROAD,4' NO WATER( 3' ELEVATION DIFFERENCE TO S.A.S. LOCATION )
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 136 CARLTON LANE
Property Address
RICK PIECEWICZ
Owner Owner's Name
information is
required for every N.ANDOVER MA 01845 9/22/15
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
❑ Inspection Summary:A, B, C, D, or E checked
❑ Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
❑ System Information—Estimated depth to high groundwater
❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Summary Record Card 9cmaled on 91.3/2015 330.11 Peyl by Maureen McAuley Page I
Town of North Andover
Tax Map # 210-106.0-0098-0000
Parcel Id 17733
136 CARLTON LANE
PIECEWICZ, RICHARD& LINDA
136 CARLTON LANE
N.ANDOVER, MA
-0.18.45
Class 101 Single Family
Zonlng2 I Residential Property I
.Size Total 1.16 Acres Zoning3
FY 2016
........... ...... ...................
UR Mailing Index
Name/Address Type Loan Number Ac
PIECEWICZ,RICHARD&LINDA Payor
136 CARLTON LANE
N.ANDOVER,MA
01845
LJ13 Account Maint.
Account No Cycle Occupant Name
Bldg ld-14197.0-136 CARLTON LANE Active/Inactive
Cycle 02 Last Billing Date 6/4/2015 Active
UB Services Maint.
Account No.2100189
Service Code Rate Charge Multi pt ler/Users
MISCFEEADMIN FEE 0-635/8 7,82
WTR WATER 01 ALL METER SIZE 175.52
UB Meter Maintenance
Account No,2100189
Serial No Status Location Brand
Type Size YTD Cons
13242331 a Active ERT HH
METE METE w Water 0.630.63
Date Reading Code Consumption Posted Date 685
8/4/2015 1174 a Actual Variance
5/4/2015 1136 a Actual 38 166%
213/2015 1122 a Actual 14 612212015 -It%
11/312014 1106 aAotual 16 3/2012015 -35%
25 12/15/2014
811/2014 1081 a Actual 36 9111/2014 -35%
515/2014 1045 a Actual 163%
21412014 1031 a Actual 14 6/1.2/2014 -7%
16 3117/2014 -55%
10131/2013 1015 aActual
81V2013 981 a Actual 34 12/20/2013 -22%
44 9/1872013 205%
511/2013 937 a Actual
13 611812013 -13%
2/7/20113 924 a Actual
18 3/13/2013 -51%,
10130/2012 906 a Actual
33 12113/
812/2012 873 aActual 2012 14%
5/212012 843 aActual 30 9/26/2012 167%
21212012 832 a Actual 11 6/20/2012 -24%
15 3/1412012 -36%
11/112011 817 a Actual
8/212011 23 12115/2011
794 a Actual -40%
39 9/14/2011
18 %
5/2/2011 4
755 a Actual 13 611312011
-11%
2/4/2011 742 a Actual 16 3/15/2011 -60%
11/1/2010 726 a Actual 38 12/1312010 -14%
8/3/2010 688 a Actual 45 9/11312010 218%
513/2010 643 a Actual 14 6191201012%
-
21112010 629 a Actual 16 3/11120 10 53%
�
111212009 613 a Actual 34 112M/2009
22%
8/3/2009 579 a Actua 1 27 9111/2000 68%
5/7/2009 552 aActual 17 6/16)2009 5%
2/3/2009 535 a Actual 16 3/16/200.9 .440/c
11/3/2008 519 a Actual 29 1211012008 -27%
Commonwealth of Massachusetts Map-Block-Lot
' 106 Co098
BOARD OF HEALTH ------------------I------
, PermitNo
North Andover BHP-2015-0384
FEE
$125.00
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is.hereby granted John Souc---------------------------------------------
---------- ----
-------------
to(Construct)an Individual Sewage Disposal System.
at No 136 CARLTON LANE
as shown on the application for Disposal Works Construction Permit No. BHP- - Dated. September 16,2015
corl
Issued On Sip-16-2015 BOARD OF HEALTH
FILE COPY
PUBLIC HEALTH DEPARTMENT
Town of North Andover
Community Development Division
CERTIFICATE OF
COMPLIANCE
As of: 9/22/15
This is to certify that the individual subsurface disposal system received a
SATISFACTORY INSPECTION of the:
Complete Repair of D-Box
By: John Soucy
At:
136 Carlton Lane
Map 106.0 Lot 0098
J1r r AnIdover, MA 01845
Th�I�ssuance of this certif ca e sliall hot be cdnstrued as a guarantee that the system will function satisfactorily.
i
II
VJichele Grant
Nublic Health Agent
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 918.688.9540 Fax 918.688.8416 Web www.towoofnorthandover.com
N R'
North Andover Health Department
(ommunity and Economic Development Division
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: 136 Carlton Lane MAP: 106.0 LOT: 0098
INSTALLER: John Soucy
DESIGNER:
PLAN DATE:
BOH APPROVAL DATE ON PLAN:
INSPECTIONS
TANK INSPECTION: 9/22/15 D-Box
DATE 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
H-10 loading
❑ Monolithic tank construction
❑ Water tightness of tank has been achieved by
visual testing
❑ Inlet tee installed, centered under access port
❑ Outlet tee installed, centered under access port
(gas baffle/effluent filter)
❑ inch cover to within 6" of finish grade
installed over one access port
❑ Hydraulic cement around inlet & outlet
Comments:
PUMP CHAMBER
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ 1500 gallon Pump Chamber installed
❑ H-10 loading
❑ Monolithic tank construction
❑ Inlet tee installed, centered under access port
❑ Pump(s) installed on stable base
❑ Alarm float working
❑ Pump On/Off floats working
❑ Separate on/off floats
❑ Drain hole in pressure 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:
CONTROLPANEL
❑ Alarm & Pump are on separate circuits
❑ Alarm sounds when float is tripped
❑ Location of control panel: basement
❑ Alarm signal located inside: basement
Comments:
DISTRIBUTION-BOX
X Installed on stable stone base
X H-20 D-Box
❑ Inlet tee (if pumped or >0.08'/foot)
X Hydraulic cement around inlet & outlets
X Observed even distribution
X Speed levelers provided (not required)
❑ Schedule 40 PVC Pipe
Comments:
• � '}" " . Map-Block-Lot
Commonwealth of Massachusetts
106.00098
BOARD OF HEALTH -----------------------
• Permit No
G..
North Andover BHP-2015-0384
yti FEE
$125.00
-----------
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted John Soucy
to(Construct)an Individual Sewage Disposal System.
at No 136 CARLTON LANE
d
---------------------------------------------------- ----
-�x----------------------------------------- ---------------------------------
as shown on the application for Disposal Works Construction Permit No. BHP- - Dated September 16,2015
E C C
-------- -------- -----------------------
Issued On:Sep-16-2015 BOARD OF HEALTH
r
Application for Septic Disposal System 9/15/15
TODAY'S DATE
Construction Permit - TOWN OF
NORTH ANDOVER, MA 01845 25.00 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 "Repair or replace an existing system component—What? "U' BOX 14—
to move your
cursor-do not
use the return A. Facility Information
key. 136 CARLTON LANE
Addressor Lot# MA (11845
N. ANDOVER RECEIVED
City/Town
2.-*TYPE OF SEPTIC SYSTEM*: SEP 16 2015
➢ ❑Pump ❑Gravity(choose one)
***If pump system, attach copy of electrical permit to application*** TOWN OF NORTHANDOVER
❑Conventional System (pipe and stone system) HEALTH DEPARTMENT
➢ ❑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)
➢ ❑Pressure Dosed(D-Box Present)S.A.S.
➢ ❑Does the system require an effluent filter? Yes No
if yes, does plan specify make and model of filter? YES =(no further info. needed)
NO=(installer must specify brand of filter before D WC issuance)
What is the Make? What is the Model.
2. Owner Information
RICK PIECEWICZ
Name
Address(if different from above)
City/Town State Zip Code
f R.PIECEWICZ@COMCAST.NET 978-314-1200
Email address Telephone Number
3. Installer Information
JOHN SOUCY SOUCY SEWER SERVICE INC
Name Name of Company
78 N BROADWAY
Address
SALEM NH 03079
Citylrown State Zip Code
603-216-7175
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
t a
Application for Septic Disposal System
TODAY'S DAT
Construction Permit - TOWN OF
NORTH ANDOVER, MA 01845 $25.00-Full pair
Component,/
PAGE 2 OF 2
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 sewag posa/system in accordance with the provisions of Title 5 of the
Environme al C de, as well as the Local Subsurface Disposal Regulations for the Town of
North A over. understand that until a final Certificate of Compliance has been issued by
this and of H alth, the instal system is not approved.
Z_� 11 L�/, /
a Date
`, 'plic ion Approv tyoard of Health Representative)
Name Date I
Application Disapproved for the following reasons:
For Office Use Only:
1. Fee Attached? Yesl No
2. Project Manager Obligation Form Attached. YesAl No
3. Pump System? If so,Attach coPv of Electrical Permit Yes No
Applicant received copy of
"Electrical Inspection Notes for Septic Systems" Yes No
Handout.
4. Revien ed approval letter, all paperwork received. Yes No
Missing-
5. Foundation As-Built?(new construction only). Yes No
(Same scale as approved plan)
G. Floor Plans?(new 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 p/roperty at:
(Address of septic system) For plans by
(Engineer)
Relative to the application of
(Installer's name) And dated
(Original ate
Dated 9 /1(�)/
o ay 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 V.Lior 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(1'� 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: healthdep_t@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. 1 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 solely responsible 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: P �— )(Tday's Date)
70 C �C'cd t L4D�
(Name–Print) a ( e– e
Board e.4 Health
Z14�r'Fi� '.mdover,,Kass'
r '
SUBSURFACE DISPOSAL DESIGN CHECK LIST
CT I G�I�LrO�
APPROVED DATE DISAPPROPED DATE
Providdd: Reasons: ND i
��al C5gIN,2Gg �15GLQ�ME
r 2 . �
Title"V FAIL OK .-
Reg 2.5 The submitted plan must show as a minimum:
the lot to be served-area,dimensions lot #,abutters
location and log deep observation hoes-distance to ties
� j location and results percolation tests-distance to ties
ddesign calculations & calculations showing required leaching area
7. (e) location and dimensions of system-including reserve area
f) existing and proposed contours
(g) location any wet areas within 1001 of sewage disposal system or
disclaimer-check wetlands mapping
(h) surface and subsurface drains within 1001 of sewage disposal
system or disclaimer
(i) location any drainage easements within 1001 of sewage disposal
system or disclaimer-Planning Board files
(3) knom sources of water supply within 2001 of sewage disposal a
system or disclaimer
k) location of amy proposed well to serve lot-1001 from leaching facilit;
77 1) location of water lines on property-101 from leaching facility
) location of benchmark
(n)- driveways
(o) garbage disposals
) no PVC to be.used in--construction
q _profile of system-elevations of basement, plumb, pipe, septic tank,___
distribution-box-inl.ets..and_outlets, distribution field piping and--
Other elevations
r)_ maximum groundwater elevation in area sewage_disposal system
(s) plan must be prepared by a Professional Ragineer or other
professional authorized by lax to prepare such-plans
Reg 6 Se tic Tanks
�(a}
capacities-150% of flow, water table3 tees, depth of tees,
access, pumping
1/ 1(b) cleanout
c) 101 from cellar sml.l or inground swimming pool
(d) 251 from subsurface drains
Reg 10.2 Distribution Boxes `
(a)
slope greater than 0.08
Reg 10.4 b) sures
Board of Health �_ _. ggpTlC SXSTEM
North An 4er Naas.;: -' INSTALLATICSQ CMg LIST
APF
OPTED DAT$ DI PHOV
AOATI ED Ob ML
`72
eBFfUn.4s - —/7
CK
1. Distance Tot
a. Wetlands •
b. Drains
C.. Well
2. Water Line Location
3. No PVC Pipe
4. Septic Tank
a. _Tees -_Length & To Clean Out Cowers
b. Cement Pipe .to Tank -- On Both Sides of Tint
5. Distribution Box
a. Covers & Box - No Cracks
b. All Lines Flowing Equal Amounts
c. No Back Flow
6. - Leach Field or Trench
a. Dimensions
b. Stone Depth
c: Capped kids
d. Clean Double-Washed Stone'
7. Leach Pits
_ . a. Dimensions
b. Stone Depth
c. Splash Pads .
d. Tees
e. Cement Pipe to Pit - Both Sides
f. Clean DoubYe Washed Stone
8. No Garbage Disposal
9. -Final Grading Inspection
10. Barricading Coverod System
Il Z► 1l. As Built Submitted
L _ a. Lot Location
C; b. Dimensions of System
C. Location with Regard-to Pere Test
= d. Aevations
e; Vater Table
i
�L\ Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
r` Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Board of Health or other approv' or :1VED
A. Facility Information SEP 1 1 2007
Important:
When filling out 1. System Location:
forms on the �y� r�HEq�j H DEf AR io TFR
computer,use La rt `-' La n Q_
only the tab key Address �a``1 (�
to move your -)(-) A/�im I\� Ova
cursor-do not `City/Town State Zip Code
use the return
key. 2 Sy m Owner:
I CL 9, Q_ C Z-
Name
+ Address(if different r�
from location)
City/Town Stat �� ?ip,Code
Telephone Number ('TI �6i
B. Pumping Record
1. Date of Pumping Date rV 2. Quantity Pumped: 'llons;
3. Type of system: ❑ Cesspool(s) Al Septic Tank ❑ Tight Tank
❑ Other(describe): ��//
4. Effluent Tee Filter present? E] YesXNo If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
C�
6. Systeln Pumped By: 7 `
Namei Vehicle License Number
( �a L rvVUL
Company
7. Locationwherecontents were disposed:
C
Si azure of Haul Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
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�' , Massaoltusetls �U� / p
stem pulnpingRecorc!
Sysleu;Uwtw Syslem Localion
W
PON of Pumping:
Quahlily Pumped: ( � gallons
Cesspool.. �No � Yes Septic"Tank: No Yes'A-
Syslem 11uoliped by: 5c[t'84oO License#
r.__��...� ......-e.�os Iinnllpfu I1�S� C� •
Cl,lilenls Uanslerrred to � a��a■ ��� ■ ��_+
Vale: __.. Inspector:
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