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HomeMy WebLinkAboutMiscellaneous - 1424 SALEM STREET 4/30/2018 (2) _� 1424 SALEM STREET _ 2101106_ 0000.0 �i J- w r iµ� ii r, �ftll "t-•FF' 1.. ., ftp ewt,1. ' .. ....�' .. .J° � �=ff1i'1� t} F -"!rr t r{y) �ry§rT¢�. �' dR � •���i .n� � �t� _ f'a..• r t - .. �;1" 't tiy�'c��} q;. .' z. . t �gpy,,. - ,,„ytt�}r�+�����"y'�.�if.--��r'''^�- - . lM,AI-, t � r?• �' r.:,y- , '. n t tYr-.•y'. MAP # ` ,r n LOT # ; PARCEL # ; STREET _�_..._—._... �ONSTRUCTIO.N_APPROVAL HAS PLAN REVIEW FEE .BEEN PAID? YE NO PLAN APPROVAL: DATE I `fes APP. BY DESIGNER: PLAN DATE. CONDITIONS WATER SUPPLY: TOWN WELL WELL PERMIT DRILLER WELL TESTS: CHEMICAL DAZE APPROVED B ' TERIA I DATE (1PPROVEU BACTERIA DATE nPPRUVED COMMENTS: FORM U APPROVAL: APPROVAL TO ISSUE YES NO DATE ISSUED BY CONDITIONS: FINAL APPROVAL: . ALL PERMITS PAID YES NO WELL CONSTRUCTION APPROVAL YES NO SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO OTHER. YES NU ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: BY: :y.:(rrY't,,.+' ? � r� ,'f♦ i ay-, a :,i;., gni * a r;!'S.'.1�' ; �-t�. .... �, - . ` x -ISTHE INSTALLER JL.ICENSED? f '+ �� �t YE5 NO -TYPE OF iCONSTRUCTION: +? NEW E - ~ NEW CONSTRUCT CERTIFIED PLOT PLAN REVIEW YES NO CONDITIONS OF..APPROVAL YES NO ' 4L (FROM .FORM U) ' '`:.. :ISSUANCE OF DWC PERMIT . c • ' S NO `' ': _. •1 1'2':1' ...; 'T„ .. - • .•`. .. _ '••..• ... . DWC PERMIT` N0. 1 . INSTALLER: :... BEGIN INSPECTION E 0: ' EXCAVATION , INSPECTION: ; NEEDED: l , BY • < ;CONSTRUCTION INSPECTION= NEEDED: AS BUILT PLAN SATISFACTORY: YES: .APPROVAL. TO BACKFILL: DATE: BY >.FINAL . GRADING APPROVAL: DATE /pq/ BY FINAL CONSTRUCTION APPROVAL: DATE: BY COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 1424 Salem Street. North Andover,MA 01845 e -- Owner's Name: Robert Dowling ;r._;. .. r Owner's Address: Same Date of Inspection: 04-18-2004 AY'.1 6 2005 OWN OF NORTH ANDOVER Name of Inspector: (please print)John Soucy HE LTH DEPARTMENT Company Name: Soucy Sewer Service,Inc. Mailing Address: 830 Livingston Street Tewksbury,MA 01876 Telephone Number: 978-85141839 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: X_ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 641-19--0065 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 f in p y o inspection and under the condition f P� s o 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. NOTE: This Title 5 is NOT a guaranteetwarranty of the future function of the septic system. Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1424 Salem Street North Andover,MA 01845 Owner's Name: Robert Dowling Date of Inspection: 04-18-2004 Inspection Summary:Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15:1303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1424 Salem Street North Andover,MA 01845 Owner's Name: Robert Dowling Date of Inspection: 04-18-2004 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 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 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 j private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1424 Salem Street North Andover,MA 01845 Owner's Name: Robert Dowling Date of Inspection: 04-18-2004 11 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than'/Z day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 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. 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) 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 11 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. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1424 Salem Street North Andover,MA 01845 Owner's Name: Robert Dowling Date of Inspection: 04-18-2004 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No x _ Pumping information was provided by the owner,occupant,or Board of Health x Were any of the system components pumped out in the previous two weeks? x — Has the system received normal flows in the previous two week period? i — x Have large volumes of water been introduced to the system recently or as part of this inspection? i X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X — Was the facility or dwelling inspected for signs of sewage back up? x _ Was the site inspected for signs of break out? x — Were all system components,excluding the SAS,located on site? x _ 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? x _ 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: I Yes No x Existing information.For example,a plan at the Board of Health. I — x Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] I I Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1424 Salem Street North Andover,MA 01845 Owner's Name: Robert Dowling Date of Inspection: 04-18-2004 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 5 Does residence have a garbage grinder(yes or no):yes Is laundry on a separate sewage system(yes or no): no [if yes separate inspection required] Laundry system inspected(yes or no): no Seasonal use:(yes or no): no Water meter readings,if available(last 2 years usage(gpd)):Well Water. Sump pump(yes or no): no Last date of occupancy: recent COMMERCIAL/INDUSTRIAL N/A Type of establishment: 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: Home Owner Wassystem pumped as part of the inspection(yes or no): no If yes,volume pumped: 1000 gallons--How was quantity pumped determined?Gage on truck Reason for pumping:Noum out at this time,last pump was on 11-03-2004 TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool —ivy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ____Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: 11-30-1995 Were sewage odors detected when arriving at the site(yes or no):No Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1424 Salem Street North Andover,MA 01845 Owner's Name: Robert Dowling Date of Inspection: 04-18-2004 BUILDING SEWER(locate on site plan) Depth below grade: 24" Materials of construction: X cast iron _40 PVC other(explain): Distance from private water supply well or suction line: 100ft+ Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: x (locate on site plan) Depth below grade: 24" Material of construction: X concrete_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) Dimensions: 4'x8'x8' Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle: 32" Scum thickness: 4" Distance from top of scum to top of outlet tee or baffle: 4" 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.): GREASE TRAP:_(locate on site plan) N/A 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.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1424 Salem Street North Andover,MA 01845 Owner's Name: Robert Dowling Date of Inspection: 04-18-2004 TIGHT or HOLDING TANK:_(tank must be pumped at time of inspection)(locate on site plan)N/A Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): 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: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: equal 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.): Flow Checked Okay PUMP CHAMBER: X (locate on site plan) Pumps in working order(yes or no): es �_ Alarms in working order(yes or no):yes Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Components in alarm worked properly. Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1424 Salem Street North Andover,MA 01845 Owner's Name: Robert Dowling Date of Inspection: 04-18-2004 SOIL ABSORPTION SYSTEM(SAS): X (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: X leaching fields,number,dimensions:21'x 95' 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.): No Sio of H draulic Failure. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)N/A Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan)N/A Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1424 Salem Street North Andover,MA 01845 Owner's Name: Robert Dowling Date of Inspection: 04-18-2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. } aaw ii'X qs' Le& h i / i A 1(�sisteeSA 1ADD GtAi'. �Cde1 I i E Q F 3- B = 1-q,3' A = az xl' �xestin9 �?o�nt C,= 13, W j �l t Lt iS mvae i�`� r T . �epf+�t revised 912/gg V •. r Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1424 Salem Street North Andover,MA 01845 Owner's Name: Robert Dowling Date of Inspection: 04-18-2004 SITE EXAM Slope Surface water Check cellar x Shallow wells i Estimated depth to ground water 24" plus. Please indicate(check)all methods used to determine the high ground water elevation: X Obtained from system design plans on record-If checked,date of design plan reviewed:May 23`d 1995 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: High ground water elevation determined from test hole dated 5-23-1995. t t•` � Commonwealth of Massachusetts a it of NORTH ANDOVER MASSA HUSE ' System Pumping Record Form`14 SEP ' 6 2006 cge DEP has provided this form for use by local Boards of Health. T e 8n� F.�,�vf �, - rd mu; be submitted to the local Board of Health or other approving authority }���E'�a /✓ rvr A. Facility Information - Important: When filling out 1. System Location: forms on the computer, use only the tab key Address - ---- to move your cursor-do not State use the return City/Town key. Zip Code 2. System Owner: Name - --- - — - Address(if different from location) _ - - '--- - i, City/Town ---------... __ _ ---- State ' _ ---- P Zi Code Telephone Number B. Pumping Record - - - Date of Pumping -- 2. Quantit Date Pumped: _____...- Y P Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank tom" Qther(describe): -._.... —..._..._ �w� . ►�, c 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No r 5. Condition of System: -P--- - -------- __ 6. Sy em Pumped By: Name -- -- Vehicle License Number --Alae Company - 7. Location where contents were disposed: • ureofJ�r htpa/www.moSm ---- -- -- Dateaskgv/ vals/t5for . pU �� ---- - --- - -- -... ect t5form4.doc-06/03 System Pumping Record- Page 1 of Form No.4 Town of North Andover, Massachusetts BOARD OF HEALTH Oct. 30 19 95 CERTIFICATE OF COMPLIANCE This is to certify that the Individual Soil Absorption Sewage Disposal System constructed ( ) or repaired (x) by John Soucy INSTALLER at 1424 Salem St. , N. Andover, MA 01845 SITE LOCATION has been installed in accordance with Board of Health Regulations as described in the Design Approval Site System Permit No. 76q dated Sept. 22 , 19 95 The issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. BOARD OF HEALTH I ) rna(� �nars A�& � o�`�� -� IQCA �;5 bnCz. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS r d DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVE® JUN 14 2005 TOWN OF NORTH ANDOVER TITLE 5 HEALTH DEPARTMENT OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION [--1kEC7E1VEDProperty Address: 1424 Salem StreetNorth Andover,MA 01845 JUN Owner's Name: Robert Dowling Owner's Address: Same TOHEALLTH DEPARTMENT ANDOVER OF NORTH Date of Inspection: 04-18-2005 Name of Inspector:(please print)John Soucy Company Name: Soucy Sewer Service.Inc. Mailing Address: 830 Livingston Street Tewksbury,MA 01876 Telephone Number: 978-851-8839 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 m P P P P Y 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: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 0'4-1 r— 615' 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. NOTE: This Title 5 is NOT a guarantee/warranty of the future function of the septic system. T Page,2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1424 Salem Street North Andover,MA 01845 Owner's Name: Robert Dowling Date of Inspection: 4-10 8-2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1424 Salem Street North Andover,MA 01845 Owner's Name: Robert Dowling Date'of Inspection: 04-18-2005 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 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 any)determines that the system is functioning in a manner that protects the public health,safety and environment: _The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well .Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: I� Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1424 Salem Street North Andover,MA 01845 Owner's Name: Robert Dowling Date of Inspection: 04-18-2005 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool w X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _2L Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 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• 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) 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. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1424 Salem Street North Andover,WU 01845 Owner's Name: Robert Dowling Date'of Inspection: 04-18-2005 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No x _ Pumping information was provided by the owner,occupant,or Board of Health — x Were any of the system components pumped out in the previous two weeks? x _ Has the system received normal flows in the previous two week period? — x Have large volumes of water been introduced to the system recently or as part of this inspection? x _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) x _ Was the facility or dwelling inspected for signs of sewage back up? x _ Was the site inspected for signs of break out? x _ Were all system components,excluding the SAS,located on site? x _ 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? x _ 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: Yes No x _ Existing information.For example,a plan at the Board of Health. x Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)) Page 6 of I I OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1424 Salem Street North Andover,MA 01845 Owner's Name: Robert Dowling Date of Inspection: 04-18-2005 FLOW CONDITIONS RESIDENTIAL 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_ Number of current residents: 5 Does residence have a garbage grinder(yes or no):yes Is laundry on a separate sewage system(yes or no): no [if yes separate inspection required] Laundry system inspected(yes or no): no Seasonal use:(yes or no): no Watermeter readings,if available(last 2 years usage(gpd)):Well Water. Sump pump(yes or no): no Last date of occupancy: recent COMMERCIAL/INDUSTRIAL N/A Type of establishment: Design flow(based on 310 CMR 15.203): bpd 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: Home Owner Was system pumped as part of the inspection(yes or no): no If yes,volume pumped: 1000 gallons--How was quantity pumped determined?Gape on truck Reason for pumping:No Hump out at this time,last pqmp was on 11-03-2004 TYPE OF SYSTEM X Septic tank distribution box soil absorption stem p � rP Y Single cesspool —Overflow cesspool —Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: 11-30-1995 Were sewage odors detected when arriving at the site(yes or no):No Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1424 Salem Street North Andover,MA 01845 Owner's Name: Robert Dowling Date of Inspection: 04-18-2005 BUILDING SEWER(locate on site plan) Depth below grade: 24" Materials of construction: X cast iron _40 PVC other(explain): Distance from private water supply well or suction Be: 100ft+ Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: x (locate on site plan) Depth below grade: 24" Material of construction: X concrete_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) Dimensions: 4'x8'x8' Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle: 32" Scum"thickness:419 Distance from top of scum to top of outlet tee or bailie: 4" Distance from bottom of scum to bottom of outlet tee or baffle: 14" How were dimensions determined: Tave&Sludize 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.): GREASE TRAP:_(locate on site plan) N/A 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.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1424 Salem Street North Andover,MA 01845 Owner's Name: Robert Dowling Date of Inspection: 04-18-2005 TIGHT or HOLDING TANK:_(tank must be pumped at time of inspection)(locate on site plan)N/A Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): 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: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: equal_ 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.): Flow Checked Oka PUMP CHAMBER: X (locate on site plan) Pumps in working order(yes or no):_yes_ Alarms in working order(yes or no):yes Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):Components in alarm worked properly. i Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1424 Salem Street North Andover,MA 01845 Owner's Name: Robert Dowling Date of Inspection: 04-18-2005 SOIL ABSORPTION SYSTEM(SAS): X (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: X leaching fields,number,dimensions:21' x 95' 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.): No Sian of Hydraulic Failure. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)N/A Number and configuration: Depth top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:_ (locate on site plan)N/A Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1424 Salem Street North Andover,MA 01845 Owner's Name: Robert Dowling Date of Inspection: 04-18-2005 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 supply enters the building. &law al"X qS' Leach / � q�u 6zwaoe.Pwwi� p uP 1EE:;st;nq f08C G41. Took .j E o r� A J - C 8'' Z - A = az. y' 1 O tt tS ova% ►oet�,(P�+.s.(+ r� (2t�. pf,'e revised 9/2/98 NseNat11 I v Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1424 Salem Street North Andover,MA 01845 Owner's Name: Robert Dowling Date of Inspection: 04-18-2005 SITE EXAM Slope Surface water Check cellar x Shallow'wells Estimated depth to ground water 24" plus. Please indicate(check)all methods used to determine the high ground water elevation: X Obtained from system design plans on record-If checked,date of design plan reviewed:May 23`d 1995 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: High ground water elevation determined from test hole dated 5-23-1995. Town of North Andover, Massachusetts Form No.s Y f pOR)h BOARD OF HEALTH ' Q5 - 19 ' A =��-• `' DESIGN APPROVAL FOR ss"C" SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant Y)nLj4 JL.0 06AJJAh-,)Test No. Site Location--w w d2U .CZ� ��►M 7 Reference Plans and Specs. \\� 46-4 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 Fee-W Site System Permit No. 10 TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: SYSTEM OWNER & ADDRESS SYSTEM LOCATION ------ DO ac) � (example: left front of house) a �c/- / DATE' OF PUMPING: '7� QUANTITY PUMPEDZjQ6GALLONS CESSPOOL: NO � YES SEPTIC TANK: NO YES V NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: / GOOD CONDITION t FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: I COENT S: CONTENTS TRANSFERRED TO: SACHUSETTS COMMONWEALTH OF MAS TOWN OF'N. ANDOVER SYSTEM PUMPING REPORT '. NAME OF PUMPING COMPANY 'IShl.4 c c a 15 c5fa��2✓<5'2��7 i<P ��r REPORT FOR MONTH OF CONTENTS CONDITION OWNERS GALLONS *H G TRANSFERRED OF DATE ADDRESS NAME — :"'PUMPED C D S TO ".:''}SYSTEM I yai-( �k.�►wt SA--. �r�c� D' �r� C n I DO o S l-c�w�'e-viicifw j 1 S , 1—' D� © H �� Al e # i ICS BOARD 6F . a 1999 1. I i i I I I i .• , .� - ^ . � n - Town of North Andover, Massachusetts Form No.3 40R711 BOARD OF HEALTH OL _7 19 O 9 '°,,r,o.°`� DISPOSAL WORKS CONSTRUCTION PERMIT ,SSACHUSE'� Applicant " ME �Q AD RESS TELEPHONE Site Location • F Permission is hereby granted to Construct ( ) or Repair (�(an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CHAIRMAN,BOARD OF HEALTH Fee D.W.C. No. 01/21/1999 13:43 978-688-9575 N ANDOVER DWTP PAGE 01 North Andover Water Treatment Plant 420 Great Pond Road North Andover,MA 01845 Nb& } TP r W.- 1-z January 21, 1999 Mr.Robert Dowling 1.424 Salem Street North Andover,Ma 01845 Dear Mr.Dowling: The following are the results of the private well sample collected at 1,424 Salem Street on January 20, 1999: 7.24 pl., 0.12 mg/1 phosphate 0 color uiiizts 2.4 mg/l nitrate ONUS to b"dity uait� 0.000 mg/i iron 6d s.0. : ;' ,.,:. 0.020 mg/l manganese 194 mg/Las:CaCO3 Total hardness Comore't The well is free from bacteria, and all the parameters are excellent for a well. The results of these analyses meet the required federal and state standards for drinking water. The water is also on the borderline of being considered hard,with the range of anything above 200 mg/l as CaCO3 being an indicator of hard water. The nitrate level is well below the standard of 10 mg/l: The maximum level for well water turbidity is 1,0 turbidity units and for color 15 color units but naturally the lower the number the better. If you have any further questions please call us at 688-9574 Sincerely, Kelly Long Senior Water Analyst North Andover Water Treatment Plant Mass Cert.#for Bacteria-MA 21054 et. sY sr�P�. t �i � �.,i"J ;t, 4 �, 4 y44 R •y7.: M1� i�rid���., 1 g ..'.l: d'� rr�v"Y, 4 'k 7�„ � t�'r't. X£' �„�'AT�„ '�_7 yx'f u y,�.'}`>'„p,t#et�}"�-•,'per v><y�#t,.'ri-4:`. J..F.y rE lM[•. # + ti •.1 I.. d. 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Auto,P4 "age,sIIlaw mob UM, II41 W—M tIImaw IK S 4� T, mug OR ITO mm, mom."IIIIIitIIIf "A WNW Ipprov PiN I"Ewa a sIJoao A",II'at a.? IIs �,N jit nq sIr y§.efir IIIIYP rt nen cze f HA,n r _0 jp,p 0,,M,@ 'Its, m tIN jqodq� In Ile Is i qq Ih4 ng�IITells r Ipig mil Moto an IItIall N pp I Boom I F I6W IlIIIITQ n IIIIslim IIIIIIisIs I,Isi itisIIIIERA iI0 IRMO II-WIN rc ac ..........low I IiM I )I _,rni IisIzi, "RON NO itIIgi IitIIIisI �S DATE Sheet of BOARD OF HEALTH TOWN OF NORTH ANDOVER j� SUBSURFACE DISPOSAL DESIGN REVIEW FEE �"� y PERMIT # DATE RECEIVED 2011 � APPLICANT 0 B' R/a ) ASSESSOR'S MAP ADDRESSlLf Sr�L�il #L# / Z ENGINEER STREET . �� �S�opp�� ADDRESS PLAN DATE REVISION DATE CONDITIONS OF APPROVAL: APPROVED DISAPPROVED -7'_W40 Dv TZ,&r T 6' ,'5V5 Pv/11�0 `4' I N49-i 6 /:7 2 - I �I /2 PLAN REVIEW CHECKLIST ADDRESS ENGINEER GENERAL / 3 COPIES �� STAMPy/ LOCUS NORTH ARROW SCALE CONTOURS t/ PROFILE SECTION ✓ BENCHMARK �� SOIL & PERCS l/ ELEVATIONS WETS. DISCLAIMER WELLS & WETS WATERSHED?6 DRIVEWAY WATER LINE/ FDN DRAIN — SCH40 TESTS CURRENT? SOIL EVAL SEPTIC TANK MIN 1500G C60 . 17 INVERT DROP G(RB. f-(+200% EDF) 25 ' TO CELLAR MANHOLE ELEV GW # COMPS. D-BOX SIZE # LINES ~T FIRST 2 ' LEVEL STATEMENT 7 INLET - OUTLET = (2" OR . 17 FT) TEE REQ'D? LEACHING MIN 660 GPD? '11b RESERVE AREAI'Q`� 4 ' FROM PRIMARY? -- 2% SLOPE 100 ' TO WETLANDS e—' 100 ' TO WELLS L--' 4 ' TO S .H.GW3 (5 ' >2M/IN) 35 ' TO FND & INTRCPTR DRAINS 325 ' TO SURFACE H2O SUPP 4 ' PERM. SOIL BELOW FACILITY ✓ MIN 12" COVER ✓ FILL? S (-2-5-' if above natural elev; 10 ' if below) BREAKOUT MET? TRENCHES MIN 660 gpd SLOPE (min . 005 or 6"/1001 ) SIDEWALL DIST. 3X EFF. W OR D (MIN 6 ' ) RESERVE BETWEEN TRENCHES? IN FILL? MUST BE 10 ' MIN'. 4" PEA STONE? VENT? (>3 ' COVER; LINES >501 ) BOT + SIDE X LDNG = TOT (L x W x #) (DxLx2x#) (G/ft2) Copyright 0 1995 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 BOT + SIDE X LOAD = TOTAL (L x W x ,#) (2 x (L+W) xD x #) (G/ft2) FIELDS 1j��lp MIN 660 GPD 900 ft2 BED GW MIN 4 ' BELOW BOTTOM OF FIELD .a ' PIPE ENDS JOINED?_ < 4" PEA STONE? i/ DIST LINE SLOPE . 005? C---- >3 'COVER-VENT SCH 40 6/ MIN 12" COVER RATE /1� LDG -` X 660 = I ��� X - ZLI'= TOTAL ��lo G/ft2 REQ'D (ft2) LXW DOSING TANKS AND PUMPS DIMENSIONS X X = PUMP CAPACITY Spm � L W D Vol. DISCHARGE SIZE DISCHARGE RATE DISCHARGE TIME 9Pm i MANHOLES TO 6RADE41,L--- ALARM SEP. CIRC. c--�GW (Min. 1 ' below inlet) HWL LWL CHECK VALVE 'BLEEDER HOLE ` MANUAL OP. SWITCH i Copyright m 1995 by S.L.Starr' i NEW ENGLAND ENGINEERING SERVICES IN t S�Q September 22, 1995 Sandy Starr North Andover Board of Health Town Hall Annex North Andover,Ma.01845 Re: 1424 Salem Street Dear Mr. Sandy: Enclosed are three copies of the completed design plans for 1424 Salem Street in North Andover.This plan requires some variances including the use of a clay barrier in lieu of a concrete wall so that the slope requirement may be relaxed. According to Mr.Dave Ferris at the D.E.P.the clay barrier is an acceptable alternative to a concrete wall as long as the specifications in the clay barrier detail are met. The owner is anxious to get this work done,so any time you could give to reviewing this plan quickly would be greatly appreciated. If you need me to be present at your board meeting next week please do not hesitate to call. i Yours Truly i Benjamin C.Osgood Jr. 33 WALKER RD. - SUITE 22 - NORTH ANDOVER, MA 01845 (508) 686-1768 TOWN OF NORTH ANDOi/ER%� BOARD OF€EALTH FFr B16 IMi UVCOMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENviRoNMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDY CORE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A _ CERTIFICATION Property Address: 1 H a Sa.) ► S Name of Owner ►rye i(`h Q e-l U' 6 f*,r-n I Yl 1 A D 1 Zs N 5 Addrass of Owner: 50- n c. Data of Inspection: I a 1- acl Name of lnspeetor:,(Plsase Paint!S11rl S SbLLCA f I am a DEP approved system inspector pursuant o Section 15.340 of Title 5(310 CMR 15.000) Company Name: Mailing Address: 19sb Li J i n Si- n tie b Yrl/{ C i e-24 Tdephone Number'� CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of 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 rther Eval tion By the Local Approving Authority Fails Inspectors Signature: Date: do I � The System Inspector shal ubmit a co of this spaction report to the Approving Authority(Board of Health or DEP)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. I NOTES AND COMMENTS I I i I I I I revised 9/2/98 Page 1of11 I i t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1'-1 a 4 30.1 art St•_ N v i-11 A rid U J 4'r, M A (�'i g H 5 Owner: lY1 i c h 0.2 ► D' er,, P+1 Date of Itupecticn: (— aa-aq INSPECTION SUMMARY: Check A, B, C, o/ A A. _ SYSTEM PASSES: V I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: i i B. SYSTEM CONDITIONALLY PASSES: One ormore 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. 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,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank, whether or not metal,is 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 complying septic tank as approved by the Board of Health. 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 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 revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1'-1 S 00 em S+. N. A n ci p J e r , m A p 18 N S Owner: Date of Inspection: I- a a-Ac( C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditlons 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. 11 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: I Cesspool or privy is within 50 feet of 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 ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS 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. Method used to determine distance (approximation not valid). 3) OTHER I I � revised 9/2/98 Page 3of11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1 H 3 L( S C..11,m St. Owner: Y�i G1�0.f✓1 D P>r Date of 4rspwdon: 1 - a a- 410t D. SYSTEM FAILS: You must indicate either "Yes" or"No" to each of the following: I have determined that one or more of the following failure conditions exist as described 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. Yes No 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. 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: 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: i I The system serves a facility with a design flow of 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: j j 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 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. I ' j revised 9t`"2 98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property address: I g a u Sal exn S*- (V. R n dk 0 J e-r I M A o m- 5 Owner: . M i ch eLe l D' Data of Inspection: i- a a-R Check if the following have been done:You must indicate either"Yes"or "No" as to each of the following: y2No L/ Pumping information was provided by the owner,occupant,or 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. — The facility or dwelling was inspected for signs of sewage back-up. — The system does not receive non-sanitary or industrial waste flow. — The 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 tees,material of construction, dimensions,depth of liquid,depth of sludge,depth of scum. 'The size and location of the Soil Absorption System on the site has been determined based on: — Existing information. For example, Plan at B.O.H. — Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) 11 5,30213)(b)l The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5ottt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: I H AH SC`i CXn St. M. 4,U-),GI 0,;Cr 117\f j G 1 T'-I Owner: m i Gh a e 1 V, e`;(� Date of Inspection: 1- a a-q(k FLOW CONDITIONS RESIDENTIAL- Design flow�M9.p.d./bedro m. Number of bedrooms(� n): Number of bedrooms(actual): Total DESIGN flow Number of current residents: n Garbage grinder lyes or no): ees t��puQO' DV Laundry(separate System) ( r o):_; If yes, separate inspection required Laundry system inspected s or t� Seasonal use(yes'or no)-_z / ,f Water meter readings,if available(last two year's usage(gpd): T—W9 aito Sump Pump lyes or no):170 Last date of occupancy: ' Qi2 ✓r' I COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gpd ( Based on 15.203) Basis of design flow Grease trap present:(yes or no)_ Industrial Waste Holding Tank present:lyes 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)i, . ast date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of infor ation: IM21 System pumped As pa of ins pection: es r no) If yes, volume p mped: C�D t� gal s Reason for pumping:' wr TYPE 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components,date installed(if known)and source of information: qs- Sewage odors detected when arriving at the site:(yes or i l I revised 9/2`/98 Page 6of11 i i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: )H:Z H Sci Pan S+, N, H nd D o e rt M iq D t g l 5 Owner: r")i Ch 0-e-1 D r i f r1 Date of Inspection: I- a a— q q BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construc on:—cast iron—40 PVC—other(explain) Distance from,private water supply well or suction line Diameter if // Comments:(condition of joints,venting, evidence of leakage,etc.) SEPTIC TANK- (locate on site plan) Depth below grade: Material of construction:Zconcrete metal Fiberglass —Polyethylene—other(explain) If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: Sludge depth:_ q 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: r� Distance from bottom of scum to bottom of outlet tee or baffler How dimensions were determined: )M1Acoe QL 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.) i GREASE TRAP: (locate on site plan) Depth below graded:_ Material of construction:—concrete—metal—Fiberglass —Polyethylene—other(explain) I 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: (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.) i revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 11-4 ay S a I�rn S+, N.f��1ci J u t M A 6)i S L I S Owner: V-n('0-h&e-A 6)' e ci 1 Date of Inspection: I-aa1-c q TIGHT OR HOLDING TANK-4(Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions: Capacity: I gallons Design flow: gallons/day Alarm present " Alarm level: Alarm in working order:Yes No_ Date of previous pumping: Comments: (condition of inlet,tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: (locate on site plan) lepth 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, etc.) PUMP CHAMBER: (locate on site plan),. Pumps in working aider:(f)or No) 4 Alarms in working order(f!i r No) Comments: ( (note condition of pump chamber,condition of pumps and appurtenances,etc.) i revised 9/2%98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1'i"ot LI SW cm SF. N. A n ck o J e cl Owner: Y7l i('baa-10 c 6r;e n Date of Inspection: I- a a-q-^( SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: Type: leaching pits,number:_ leaching chambers,number:_ leaching galleries,number:_ leaching trenches,number,length: leaching fields,number,dimensions: ' overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition of soil,signs of hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.) CESSPOOLS: (locate on site pla 1 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:.1 W (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.) i revised 9/2'/98 Page 9of11 I� I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) eroparty address: 1'� S 0.1 f m S N. A et d o v e.r, 1'1r1 R U 1 1— t Owner: Date of Inspection-, 1- a a- Q^� SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all'wells within 100' (Locate where public water supply comes into house) I i I i a,i' x X15' Leach Ile-4 • New 6Lwage, Pu-mp H FEYistinq ebbe Gal . -Tank � A -0 - A 3 - A = 14,3 .D- C = --2?f 2'' Rilsting Pbme - C = 13: W revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(coed wed) ft""Address. 114 a N S�I�m S�. �. A 0 CC o O� Owner: mi Qe 1 D' MA p �� 13ricq Inspac0on• NRCS Report name Soil Type'; Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater Feet Please' dicate all the methods used to determine High Groundwater Elevation: Obtained from Desi gn Plans on record Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data" Describe how yo establ' h the High Groundwater Elevation. (Must be c ompleted) revised 9/2/98 Page 11 of 11 � ,'..��lr+(�7��{vhf., r •� 't tv` i r. 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