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HomeMy WebLinkAboutMiscellaneous - 143 GRANVILLE LANE 4/30/2018 (2) 143 GRANVILLE LANE le 21-0/1.06.0 D059-0000.0 J L Cunningham Lindsey U.S.,Inc. (� P.O.Box 703689 Cunnin �l.am Dallas,TX 75370-3689 Cunning lne,�Telephone(888)738-8714 Facsimile(214)488-6766 1J CLCAT@CL-NA.COM ***********************AUTO**3-DIGIT 018 764 T3 P1 95000058954 Building Commissioner or Inspector of Buildings 120 MAIN STREET NANDOVER,MA 01845 Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS Ch. 139, Sec 3B Claim Number: 2658369 Policy Number: 2658369 02 Company Name: MERRIMACK MUTUAL FIRE INS co Cause of Loss: ICE DAM Lo Date of Loss: 2/9/2015 Insured: RICHARD & MARY FOWLER o Property Location: 143 GRANVILLE LN � II Claim has been made involving loss, damage, or destruction of the above captioned property, which may either exceed $1,000 or cause Massachusetts General Laws, Chapter 143, Section 6, to be applicable. If any notice under Massachusetts General Law, Chapter 139, Section 313 is appropriate, please direct it to the attention of the writer. Kindly include a reference to the captioned insured, location, date of loss and claim number. Section 3B. No insurer shall pay any claims (1) covering the loss, damage, or destructio.ns.to.a building or other structure, amounting to the one thousand dollars or more, or (2) covering any loss,damage or destruction of any amount, which causes the condition of a building or other structure to render section six of chapter one hundred and forty-three applicable, without having at least ten days previously given written notice to the building commissioner or inspector of buildings appointed pursuant to the state building code,to the fire department or arson squad of the city or town and to the board of health or board of selectmen of the city or town in which the same is located. If at any time prior to the payment the said city or town notifies the insurer by certified mail of its intent to initiate proceedings designed to perfect a lien pursuant to section three A, or to section nine of chapter one hundred and forty-three, or section one hundred and twenty-seven B of chapter one hundred and eleven,the said payment shall not be made while the said.proceedings are pending; provided, however, that said proceedings are initiated within thirty days of receipt of such notification. Any lien perfected pursuant to section three A, or to section nine of chapter one hundred and forty-three or section one hundred and twenty-seven B of chapter one hundred and eleven, shall extend to and may be enforced by the city or town against any casualty insurance policy or policies covering any loss, damage, or destruction pursuant to which the proceedings to perfect the lien were initiated. No insurer shall be liable to any insured owner, mortgagee, assignee, city or town, or other interested party for amounts disbursed to a city or town under the provisions of this section, or for amounts not disbursed to a city or town under the provisions of this section. On this date, I caused copies of this Notice to be sent to the persons named above at the addresses indicated above by First Class Mail. Cunningham Lindsey Catastrophe Department cicat@cl-na.com 800-867-3885 Ct NO RTN 1N :A / 6 2 t 3r'� •cot" b _ 2 • Town of North Andover �a'•';;; .:`�` HEALTH DEPARTMENT �f CHU`+�S CHECK#: ZV D E: �� LOCATION: H/O NAME: CONTRACTOR NAME: Type of Permit or License:(Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ Z"Title itlIRnspector $5 eport $ ❑ Other. (Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer l FILE# N A nd Saa I Q R90,31v w0 1/ MAY J yU ?Qi TOWN OF NORTH ANDOVER \ J T= V INSPE,i..r+no HEALTH DEPARTMENT f .�.1�1 11 Dean G. Luscomb H& Sons P.O.Box 135 _r- Middleton, MA 01949 -- 978-774-4065 Licensed Plumber#20285 J y\ SUBSURFACE SEWAGE DISPOSAL SYSTEM INPSECTION FORM 7 PROPERTY OWNERS NAME G u a r rh e r Q PROPERTY ADDREss 143 G r(2 r)yc.I I e- L an e `f N- A r,)(I(-)ver MA ADDRESS OF OWNER(if different) ------DATE OF INSPECTION NAME OF INSPECTOR nP U. f� -(--) LU C Q W b QUALITY IS NUMBER ONE TO US. a � t i Commonwealth of Massachusetts - Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 143 Granville Lane Property Address Guarnera Owner Owners Name information is required for North Andover MA May 22, 2012 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Dean G. Luscomb II cursor-do not Name of Inspector use the return key. Dean G. Luscomb II &Sons Company Name P.O. Box 135 Company Address Middleton MA 01949 X60/ Cityrrown State Zip Code 978-774-4065 S1848 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Ag��) x V"J�— May 22, 2012 Insp ctor's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****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•11/10 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 w 143 Granville Lane Property Address Guarnera _ Owner Owner's Name information is North Andover MA May 22, 2012 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Checo,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 13) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•11/10 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 143 Granville Lane Property Address Guarnera Owner Owner's Name information is North Andover MA May 22, 2012 required for Y every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 {{ll pass inspection if(with approval of Board of Health): �v ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed El Y F1 N 0 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 143 Granville Lane Property Address Guarnera Owner Owner's Name information is North Andover MA May 22, 2012 required for _ Y every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water Y P 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: V 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 N ❑ ® 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 143 Granville Lane Property Address Guarnera Owner Owner's Name information is North Andover MA May 22, 2012 required for every 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 sign flow of 10,000 gpd to 15,000 gpd. For large stems, you must indicate either"yes" or"no"to each of the following, in additi0fi= e 'Vquestions in ion D. Yes No ❑ ❑ the system ithin 400 feet of a surface dr' ng water supply ❑ ❑ the system is within 20 et of utary to a surface drinking water supply ❑ ❑ the system is located in ' rog ensitive area(Interim Wellhead Protection Area—IWPA)or a ped Zone II o ublic water supply well If you have answered"yes"to any stion in Section E the system i nsidered a significant threat, or answered"yes" in Section D ove the large system has failed. The o or operator of any large system considered a signif nt threat under Section E or failed under Section all upgrade the system in accordance ' 310 CMR 15.304. The system owner should contact the ropriate regional office of t epartment. t5ins•11/10 > Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 J r'' r ' Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 143 Granville Lane Property Address Guarnera Owner Owner's Name information is North Andover MA May 22 2012 required for y every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® 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? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information 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 gpd t5ins-11/10 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 143 Granville Lane Property Address Guarnera Owner Owner's Name information is required for North Andover MA May 22, 2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Owner and previous title v 511/1Z010 Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d town water _ 9 ( Y 9 (gP ))� Detail: Sump pump? ® Yes ❑ No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of blishment: Design flow(base 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/per s /sq.ft., etc.): — Grease trap present? ❑ Yes ❑ No Industrial waste holding tank pres ❑ Yes ❑ No Non-sanitary wasted arged to the Title 5 system? ❑ Yes ❑ No Water r readings, if available: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- e 7 of 17 Commonwealth of Massachusetts ¢ - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a`wM 143 Granville Lane Property Address Guarnera Owner Owner's Name information is required for North Andover MA May 22, 2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Lasmo a of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Last pumped approx 6-8 months ago and has been pumped on average every 1-2 years. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: No need at this time 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-11/10 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 143 Granville Lane Property Address Guarnera Owner Owner's Name information is North Andover MA May 22, 2012 required for every page. City/Town State Zip Code Date ofinspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: House and system are 36 years old -previous title v Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): j 18t Depth below grade: feet Material of construction: ® cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4"cast iron in good shape with no signs of any problems. Septic Tank(locate on site plan): / Depth below grade: 1311 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) Precast rectangular concrete 1000 gallons If tan is mea, is al Is111age con1.firmed by a Certificate of Compliance?(attach a ��ea ate) es o Dimensions: 5' D x 5'W x 8' L 1040 _ Sludge depth: 1 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts 4 - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 143 Granville Lane Property Address Guarnera Owner Owner's Name information is North Andover MA May 22, 2012 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) � Distance from top of sludge to bottom of outlet tee or baffle 35" 1" Scum thickness 6" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? sticks and tape measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The septic tank and baffles are in very good condition. The solids in the tank are very light. The liquid in the tank is running at it's correct working heigth. The tank does not require pumping at this time. G" se Trap(locate on site plan): Depth below de: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyOhyfene ❑ other(explain): Dimensions: Scum thickness Distance from top o um to top of outlet tee or baffle Distance nom bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments f ,M 143 Granville Lane Property Address Guarnera Owner Owner's Name information is North Andover MA May 22, 2012 required for Y every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comme n pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as ed to outlet invert, evidence of leakage, etc.): -� Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan) Dept elow grade: Material of nstruction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene p other(explain): Dimensions: Capacity: gallons Design Flow: gallo eper day Alarm present: Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Dai Comments (condition of alarm anZoatitches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 ge,\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 143 Granville Lane Property Address Guarnera Owner Owner's Name information is North Andover MA May 22, 2012 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) — Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Zero" in both d-boxes 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 1 is 3" below grade, 16"x 16"squrare. D-box 2 is 14" below grade and is 20"x 20"square. Both d-boxes are in good shape both structually and working. The soil in this area are clean and dry with no signs of any problems. Chamber(locate on site plan): �u Pumps in workin er: El Pyl�10 Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamb dition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: S.A.S. was located b d-box and level area of and and previous title v. Y _� t5ins•11/10 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 143 Granville Lane Property Address Guarnera Owner Owner's Name information is required for North Andover MA May 22, 2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1 -20'x40' ❑ 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.): The S.A.S. is in very good condition with no signs of any problems. The soil in this area is clean with no signs of ponding or breakout. This area is covered with well maintained green grass. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number a configuration Depth—top of liquid et invert Depth of solids layer Depth of scum layer " Dimensions of ce of Materials-o construction Indication of groundwater inflow ❑ Yes lio t5ins-11110 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 a • c I • Commonwealth of Massachusetts 4 Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 143 Granville Lane Property Address Guarnera Owner Owner's Name information is North Andover MA May 22, 2012 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Co nts(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): (locate on site plan): Materials of co ction: Dimensions Depth of solids Comments(note condition of soil, signs o raulic re, level of ponding, condition of vegetation, etc.): `` t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 143 Granville Lane Property Address Guamera _ Owner Owner's Name In Ion Is required for North Andover MA May 22, 2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) G raf.v1x`L ux,� 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 3 F,,3 A PEA y4P�a /113 G'wh L.Its ta,u, JODI A � Lew 9 w A ID DZ a 10q'G 4, t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M. "t 143 Granville Lane Property Address Guarnera Owner Owner's Name information is North Andover MA May 22, 2012 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope G ra.ol u A ® Surface water No+� ® Check cellar S--'P PUMP ® Shallow wells No -- Estimated depth to high ground water: 6' below grade 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: Previous title v's on file. ❑ Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: Topsfield 1 You must describe how you established the high ground water elevation: The bottom of the sump hole is 6' below the grade of the back yard with no water in it at this time. The sump was dry at the time of the last inspection also. The bottom of the SAS is approximately 2' below grade as the d-box is 14" below grade. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 r #' Commonwealth of Massachusetts 4 - Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments f 143 Granville Lane Property Address Guarnera Owner Owner's Name information is required for North Andover MA May 22, 2012 every 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 k f DelleChiaie, Pamela From: DelleChiaie, Pamela Sent: Monday, August 15, 2011 3:56 PM To: 'Imagid516@yahoo.com' Subject: FW: I.R. - 143 Granville Lane, North Andover, MA Attachments: 20110815132350332 Importance: High Trying this again.........please confirm that you have received it. Thank you. Slat,Riganala, Pamela DelleChiaie Departmental Assistant I Community Development I Health Department Town of North Andover 1600 Osgood Street I Bldg 20 I Suite 2-36 North Andover,MA o1845 S Office-978-688-9540 2 Fax-978-688-8476 0 Email-pdellechiaie(@townofnorthandover.com -6 Website http://www.townofnorthandover.com/Pages/index "We can never see the path of our life if we are too busy focusing on the pebbles under our feet."--Anonymous From: DelleChiaie, Pamela Sent: Monday, August 15, 2011 1:42 PM To: 'almagid516@yahoo.com' Cc: Sawyer, Susan Subject: I.R. - 143 Granville Lane, North Andover, MA Importance: High Dear Mr. Magid, Attached is a copy of what was in your Health Dept.file. I will have Susan Sawyer,call you regarding your other Title 5 question. Have a nice day. &a Re9444, Pamela DelleChiaie Departmental Assistant I Community Development I Health Department Town of North Andover 1600 Osgood Street I Bldg 20 1 Suite 2-36 North Andover,MA o1845 2 Office-978-688-9540 0 Fax-978-688-8476 O Email-pdellechiaiePtownofnorthandover.com -2 Website http://www.townofnorthandover.com/Pages/index "We can never see the path of our life if we are too busy focusing on the pebbles under our feet."--Anonymous If you are happy with the customer service you have received from town departments,please let us know...feel free to complete the general Comment Form (link below): http://www.townofnorthandover.com/Pages/NAndoverMA WebDocs/contact I 1 i 4 ` � by � �ef�'ii '".�ir 1 N♦- v nvsa� cTTorrs vtu Deana Laic &sons MAY 1 P.O.Box 135 ' Middleton,MA 01949 10Y�IN:4�N " 478-774 4065 011?." L Y I.icepsedPlumber#20283 ' ''� � �^ 3UB3I1RFAbB 3Es'9VFilPB DT3P08AL 3Y318MINP�B PROPERTY OWNmNAMB - �r vt � ADDRESS OF OWSI$}t(telt) j DATE OF INSPSC IgON NAME OFINSPHCTOR2�fll Al >? QUALITYLSNUMS%I4Qffi�OJ:�3 ���- � - r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assess nts 143 Granville Lane TONNN NOfliti pt10 M tt Property Address Leonard Guamere owner Ownefs Name infxnastton Is fequbed for North Andover MA May 4,2010 p every page. Ctlyrrown State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered In any way.Please see completeness checklist at the end of the form. who, O, A.General Information forms on the ✓` i� r computer,use 1. Inspector: ti only the tab key to move your Dean G.Luscomb 11 cursor-donot IJamaot use the return Inspector key. Dean G.Luscomb It&Sons WQCompany ea P.O.Box 13 135 Middleton MA 01949 am Cayrrown state Zip Code _ 978-774.4065 S1848 Telephone Number License Number B.Certification I certify that I have personalty 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.l am a DEP approved system Inspector pursuant to Section 15.340 of Title 5((310 CMR 16.000).The system: ® passes ❑ Conditionally Passes ❑ Faits ❑ Needs Further Evaluation by the Local Approving Authority 4&Inspector's Mre" ?f.7lYLL e.2MAX In ft 6 ,20/0 Date 0 The system inspector shall submit a co of this Inspection report to the ApprovingAuthorityBoard of Health or DEP)within 30 days of completing this Inspection.If the systis a hared sstem 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. W--Owe TAb5OMftea0K&nF ma&bMt"swag MMOWsy M•Pogo1 art? r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 143 Granville Lane Property Address Leonard Guamera owner Owners Name ref� I' required for North Andover MA May 4,2010 every page. Cityrrown State Zip Code Date of Inspection B.Certification(cont.) Inspection Summary.Check(/ B,C,D or E/always complete all of Section D A) System Passes: Pf 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 extst.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 j 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 exfiltrafion 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): abu•osoa Tiso601fidd- xd-n Fa &ftud 0e8mW0hpmd8ydam•Pap2cr1T Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 143 Granville Lane Pmp&*Address Leonard Guamera owner owners Noma Infa""s"a"is required for North Andover MA May 4,2010 every pogo. City/Town Stets Zip Cade Date of Inspection B.Certification(cont.) B) System Conditionally Passes(cont.).- Observation 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 pips(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 pips(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): .l0 ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation Is Required by#ie Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health In order to determine if the system Is falling to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR \� 16.303(1)(b)that the system Is not functioning In a manner which will protect public health, safety and the environment: ❑ Cesspool or pfivy Is within 60 feet of a surface water ❑ Cesspool or privy Is within 60 feet of a bordering vegetated wetland or a salt marsh .aaaB M OOMY MperHonFaeca�bsvBotamup.abpmd er�em'Pps 80117 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 143 Granville Lane Pro"AMM Leonard Guarnera Owner owtwe Name Infonnation d fo m required for North Andover MA May 4,2010 every page. Cig7fown State Zip Code Date of Inapsoon 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: O ❑ The system has a septic tank and soil absorption system(SAS)and the SAS Is within l 100 feet of a surface water supply or tributary to a surface water supply. N/ ❑ 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 60 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 indicates absent and the presence of ammonia nitrogen and nitrate nitrogen Is equal to or less than 6 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be 1 attached to this form. l I� 3. Other: D) System Failure criteria Applicable to All Systems: You fit 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 fes' dogged SAS or cesspool 11 due 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 dogged SAS or cesspool ❑ Liquid depth in cesspool is less than S"below invert or available volume is less than%day flow C8M•09Y6B TaM60151dW1 pa, Fm 8ubmimSoapo VhPNlSysam•Ppe4arrr Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 143 Grenville Lane Property Add Leonard Guarnere Owner Owners Name Wormrequired re regwred forNorth Andover MA May 4,2010 every page. Ciyrrown Slate Zlp Code Date of Irrepedion 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. PU ElAny portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ,�,I Any portion of a cesspool or privy Is within 60 feet of a private water supply well. ❑ Any portion of a cesspool or privy Is less than 100 feet but greater than 60 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 S 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 20009pd- 10,000gpd. ❑ all The system alis.l have determined that one or more of the above failure F� criteria exist as described in 310 CMR 16.303,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 21 n flow of 10,000 gpd to 15,000 gpd. For large sy s,you must indicate either"yes'or'no"to each of the following.fn-addtilon to the questions in Sect Yes No ❑ ❑ the system is w 4 et of a surface drinking water supply ❑ ❑ the syate ' within 200 fe f a tributary to a surface drinking water supply ❑ ❑ system Is located in a nitrogen sitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of blit water supply well If you. a answered"yes'to any question in Section E the system nekiered a significant threat, or an "Yee in Section D above the targe system has felled.The o or operator of any large system considered a significant threat under Section E or failed under Section hall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department tbYu•Oa09 M5Ordd iMpxialFa eaa1emeawaa,MwoW8ydnm.Papa5d17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 143 Granville Lane Property Addrees Leonard Guamera owner Information h Owner's Name required for North Andover- MA May 4,2010 every pegs. Otiy/rownstale Zip Code Data or leepedw„ C.Checklist Check If the following have been done.You must Indicate"year or"no'as to each of the following: Yes No LI ❑ Pumping Information was provided by the owner,occupant,or Board of Health ❑ if Were any of the system components pumped out In the previous two weeks? d ❑ 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? E ❑ Were as built plans of the system obtained and examined?(if they were not available note as N/A) i� ❑ Was the facility or dwelling inspected for signs of sewage back up? U✓ ❑ Was the site Inspected for signs of break out? L�I/ ❑ Were all system components,excluding the SAS,located on site? Ill ❑ Were the septic tank manholes uncovered,opened,and the Interior of the tank Inspected for the condition of the baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge and depth of scum? ❑ Was the fadlity,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 Sol[Absorption System(SAS)on the site has �/ been determined based on: I� ❑ Existing information.For example,a plan at the Board of Health. �, ❑ Determined in the Held(if any of the failure criteria related to Part C Is at Issue approximation of distance Is unacceptable)1310 CMR 15.302(5)) D.System Information Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example:110 gpd x#of bedrooms): 16h '0 nmsomddkW.WW Fan<amem—ft~ouW�,+systm.pope d I? Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 143 Granville Lane Property Address Leonard Guarnem Owner owners Name rMormatlon Is uiredfor North Andover MA May 4,2010 _ e very page. cKyrro" Sfete Z(p Code Date of Inepecdon D.System Information Description: I I�WtK.( UiILG(�� SCM+ Number of current residents: �/� Does residence have a garbage grinder? Lvi Yes ❑ No Is laundry on a separate sewage system?[If yes separate Inspection required] ❑ Yes ['No Laundry system Inspected? ❑ Yes E�'No Seasonaluse? ❑ Yes 93'No Water meter readings,if available(last 2 years usage(gpd)): Detail: Sump pump? [ Yes ❑ No (;crr�rf� Last date of occupancy: Date Commerclallindustrial Flow Conditions: Type f hmertt Design flow(based on 31 15.203): oago r day(god) Basis of design flow(seats/pemons/sq.ft, Grease trap present? ❑ Yes ❑ No Industriel waste holding tank nt? ❑ Yes ❑ No Non�anitery was charged to the Title 6 system? L_Yes.❑ No W r readings,if avallable: t9ro•09VB TftSoWd MPxA FmrcWMOu SMIWDaPOWarum-P".7d17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal system Form-Not for Voluntary Assessments 143 Granville Lane Prope*Address Leonard Guamere Owner Owners Name for requ etbn b North Andover MA May 4,2010 required every page. Ctty/rown State ZIP Code Date of Ineloodlon D.System information(cont.) Last date of oocupancyluse: Data Other(describe below General Information Pumping Records: a Source of Information: Qw�Fon Ao¢�G Eur-�r- Was system pumped as part of the inspection? ❑ Yes 0 No If yes,volume pumped: U gallons How was quantity pumped determined? I Reason for pumping: 00 Type of System: Septic tank,distribution box,soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)Of yes,attach previous inspection records,If any) ❑ Innovative/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)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): ibtrr•once rrsomssroxemr�,e6,bw.lomeaxoDeoifpoael bydem•Pepsedl7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 143 Granville Lane Pm"Addraa� Leonard Guamera Owner owners Meme Information Is rewired for North Andover MA May 4,2010 every page. chyrrown state ZIP code Date of Inspection D.System Information(cont.) Approximate age of all components,date Installed(If known)and source of information: r a � Were sewage odors detected when arriving at the site? ❑ Yea te' No Building Sewer(locate on site plan): Depth below grade: fast Material of constriction: g!r.' st Iron ❑40 PVC ❑other(explain): Distance from private water supply well or auction fine: feet Comments(on condition of joints,venting,evidence/of leakage,etc.): �u Cash �rort („J�Po!Lf oT O!qh�pltl��MS Septic Tank(locate on site plan): Depth below grade: feet 134 Material of construction: G(iwncrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain) If tank Is metal,list age: yam y a Certificate of Compliance?(attach a copy of certificate) ] No Dimensions: /Owpal. 5atdoxSr0ee4?x**'Lo7.. 'n Sludge depth: < arns•oave Title oewe k.P.5.Fin 8,6.0—8e0 MV dOrd-•Pageegt7 rCommonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 143 Granville Lane Prop dyAddroas Leonard Guamera owner Owwre Name mtb qukedfor North Andover MA May 4,2010 eMY p fovery page. CIW?own Slate Zip Code Date of Inspecflan D.System Information(cont.) r Septic Tank(cont) n Distance from top of sludge to bottom of outlet tee or baffle 3 s < Scum thickness Iu 1 Distance from top of scum to top of outlet tee or baffle 6, I�h Distance from bottom of scum to bottom of outlet tee or baffle ZN l ;pLecki a^J T,en,eara�e How were dimensions determined? Comments(on pumping recommendations,Inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7F,,- Sr i Ta-.k an,( 4e.96 are- ye-cy good sl apf-, K,&u-t ,r, tie, tank is f-w),7)hg at A-S Correct- working �it.i It�-i. �re. ctfL, no S�nfq o� a�K brrrb�Ctrc �ii Sa���f' 42rv-, a.et do -A CeW/rcTm„(n$ aL IS 4Ime. U Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑metal berglass polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top scum to top of outlet tee or battle Distance from/bottom of scum to bottom of outlet tee or baffle Date of last pumping: Deb an-am rmseomes,evemmFa Sb.0-9-.oempwsarab.•ve9e,odr7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 143 Grenville Lane PmPenY Addrese Leonard Guamera Owmr Owners Name Inforrequfr eaIs North Andover MA Mev 4 2010 every very pP for r gts Zrp Code Date of Urepeclbn every City/fovm _ D.System Information(cont.) Comments jon pumping recommendations,Inlet and outlet tee or baffle condition,atructurej integrity, liquid levels amoral d to outlet Invert,evidence of leakage,etc.): Tight or Holding Tank(tank must be pumped at time of Inspection)(locate on site plan): Depth below grade: N/ Materiacnscton: ❑ oreeo ❑ metal ❑fiberglass ❑polyethylene other(explain): Dimensions: Capacity: gagone Design Flow: ga perday Alarm present: Yes ❑ No Alarm level: Alarm i rking order. ❑ Yes ❑ No Date of last pumping: Dare Comments(condition of alarmf/ff-twitches,etc.): i r' •Attach copy of current pumping contract(required).is copy attached? ❑ Yes ❑ No tWu•ONG Tftsoftld'- c6m FpoesWa�rem8e+re90 Oirpaalarilem•Paao rtg9 \ Commonwealth of Massachusetts kvTitle 5 Official Inspection Form Subsurface Sswags Dlaposat system Form-Not for Voluntary Assessments 143 Granville Lane PropenyAddress Leonard Guarnera Owner Own Wo Nemo Infommtion Is required ror North Andover MA May 4,2010 every page. Cltyrt'ovm state Zip Code Dete of hrepeefbn D.System Information(cont.) 2'X Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet Invert Zero w in RO1f, V 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-fdox Z is 1#11yado.2.4c 2"'LZor'sg�crare Q- O s atm'" ceod 54w0e T_ Sal( 2r� ase areasiSClean &A 0( No r'SnJ a7' ft��t >7ro6��mS Pump Chamber(locate on sits plan): 1� Pumps in workir a er: ❑ ❑ No I" Alarms In working order: ❑ Yes ❑ No Comments(note condition of pump chamber, on of pumps and appurtenances,etc.): I Soil Absorption System(SAS)(locate on site plan,excavation not required): If SAS not located,explain why: 4X tt le f-- 12/'/�Of/ W-0808 TW606"r KSGn Fro &ftXfeos8rsapanepesy 67nlem•Pap.12d17 Commonwealth of Massachusetta Title 5 Official Inspection Form Subsurface Sewage Disposal System Fonm-Not for Voluntary Assessments 143 Granville Lane PR"Ny Address Leonard Guarnera Owner owners Nems information is North Andover regvlred for MA May 4,2010 every page. Cpy/rownState Zlp Code Date of Irwpedbn D.System Information(cont.) Type: ❑ leaching pits number. ❑ leaching chambers number. ❑ leaching galleries number. ❑ leaching trenches number,length: ai( leaching fields — number,dimensions: ❑ overflow cesspool number: W-41��`P^$r ❑ 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.): / 1l N Sf2.< !s irl V tt qoo cn�r(y'o>, Sarin Aig area, !S Clect.n ct"Adr14 w/A.)* S1Gnl of a.+�nrn), „tet �eb QrYLf 6S C"IertQdc.�,� Gl J+ia/n7(i41ne� �—SS N� Cesspo:qufd I must be pumped as part of inspection)(locate on site plan): / Number urat Depth— liquid to Inlet invert Depth oferDepth oferDimensiospool Materialsuction Indication of groundwater inflow ❑ Yes ❑ No unr•aamme _ rm.s omr hp.rm,ra�am.rowa..�m�+sruam•vro.maa+7 commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 143 Granville Lane Pmpedy Addtese Owner Leonard Guarnera information b ownees Name Inrorm required for North Andover MA May 4,2010 every page. Cnyrrown Stets Zip Code Date of hrepedlon 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 gns of hydraulic failure, 1 of ponding,condition of vegetation, etc.): Who.0106 71Ma OekN Mpecem nonce&-ft-8 wapstaepoa%dwn•rape 140(77 Commonwealth of Massachusetts Title 5 Official Inspection-Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 143 Granville Lane PmperlyAddress Leonard Guamera Owner owner's Name required for North Andover MA May 4,2010 required for wary pop- cttyfr— state Zip Code Dale of Inapecgon D.System Information(cont.) 6ranvillc t Sketch Of Sewage Disposal Sy m:Provi e a view of the sewage disposal system,including lies to at least two permanent referen landma or benchmarks.Locate all wells within 100 feet.Locate where public water supply ente the buildl g.Check one of the boxes below., han&sketch In the area bel p ❑ drawing attached separate From 4 �u1ti12 3 A "VA /,13 G'.W1G�ctne Al.A wlolx/ P n aa.•+� 8 �Lk Q6T =s01 Afoul 97�p., 131-4 p Zf,4,"6 bOoX - -- T li D w+•aaea rmssomaa Fa Sub>I,r o.a &DhPmdsrxan•vwsrsarr Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 143 Granville Lane Properly Address Leonard Guamera Owner Intortnalion Is Owner's Name required for North Andover MA May 4.2010 every page. Clwrrown State Zlp Code Date of Impaction D.System Information(cont.) Site Exam: (Check Slope CrmcQ"A1 WSurface water Note. ErCheckcellar S(4?-jp pw-.p (Shallow wells fJahC 6' Estimated depth to high groundwater: feat 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/observall n hole within 150 feet of SAS) Q� Checked with local)Board of Health-explain: Pre.UIC�S fICIL.,� I�toorbS ❑ Checked with local excavators,installers-(attach documentation) (� Accessed USGS database-explain: 7ops�iel6Q 1 You must describe how you established the high ground water elevation: p 7T 6"&M -f AI— &-m o mb A-4 Z, 6 r Rse&aw hack smrd cJ/A,o aka c i n ib a6#a r T-r' 4 t/.t., S As-is a p .a a r u++J Tiny, c c & P-13cyc is /fl�" r �uuSFaer`E Before filing this Inspection Report,please see Report Completeness Checklist on next page. •�� T06ee6" Fam ame.r.o.awnu.rnc WM syaan•rage 10011 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 143 Granville Lane PropertyAdd Leonard Guamere Owner Owner's Name infmmeson leNath Andover "ked for MA Mev 4,2010 every page. crtyfrown Stele Zip Code Date of Irmpedbn E.U/ R_eport Completeness Checklist pQ Inspection Summary:A,B,C,D,or E checked 93'Inspection Summary D(System Failure Criteria Applicable to All Systems)completed Ik System Information—Estimated depth to high groundwater M(Sketch of Sewage Disposal System either drawn on page 16 or attached In separate file two•e9MG Tib6eaddYnpereq,Fw, &&-fpm BeapDinwW ayrtan•Ppe 77M 17 f-\ Commonwealth of Massachusetts City/Town of '" 1e D System Pumping Record Form 4 OCT 3 TO 22009 DEP has provided this form for use by local Boards of «irprtsa "ER used,bu e Information must be.substantially the same as that pr id Bef6Fe u ng th s form,ch Ith r local Board of Health tQ determine the form they use.The System Pumping Record must be submi the local Board of Health motWr approving authority. A.Facility Information 1. System Loc L Left side of house,Right side of house,Left front of house,Right front of house, Laft4evro—fhou!5DRight rear of house.Left rear of building.Right rear of buil in , A GAddress cityfrown State -- Zip Code 2. System Owner �L)CR/TCVk Name Address IN different From location) Gly?own state Zlp Code & a-1 3:3 Telephone Number B.Pumping Record 1. Date of Pumping oats 2.Quantity Pumped: gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): — 4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes❑ No 5. Condi' nofSystem* U ~vvv1 6. System d By: Neil Bateson F5821 Name vehicle License Number Bateson Enterprises Inc company 7. Location where contents were disposed: lci tv Lowell Waste Water Sigiretue of Hauler t5Fomt4.dooa 08M System Pumping Record•Page r of 7 TOWN OF SYSTEM PUMPI G RECOIZI 1Q DATE: ��g�O 1 SYSTEM OWNER&ADDRESS SYSTEM LOCATION (--PIC:left fi—t of hou-) t � t DATE OF PUMPING: QUANTITY PUMPED: ('0'0 GALLO CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises,Inc. COMMENTS: CONTENTS TRANSFERRED To: G.LS.02 Lowell Waste Conn tones Itlth Off Massachusetts &�Massacltusells system Pumping Record System Owner System Location LI-3 6 fcrl ,1 l,� �t Date of Pumping: —?--C,r- '.Lem ()uahtity Pumped: r-2�0'gallons Cesspool: No 14-' Yes Septic Tank: No ❑ Yes System Pumped by: FdWer6 5 410w-" License# Contents traosferrred to: Greater Lawrence Sanitary District Date: Inspector: .t 11nnn otnvr 1111 of h1AUN41A1aelip Le• �YAlonitlwnei^�-�„ ___._.__--.----Nyrf1pn11•uaelli,il — ------- LCA, �} 1tna11111y 14uut1ed: j�'�Bnllulu I�A10 fit 1111111111110,to ( --9 {'pAgnloll: Nn KIS �'e� I I bepllo Ipnk: Nn I.I Yes 1 I Ilyllplll(4111111011 py1 �'A�AAn �NIVyk4/J�Aa 1•1ee11ep k__...__..-___ 4'untaule IIA11e11<ma111n: NIAAIri-I�dlttUlY1-UuItkHY-UIIYUI►_ --- IaAlp%_._._..._.-'---•--...........-------•--------._.•IAepeelul: Commonwealth of Massachusetts I .Massachusetts System Pumping Record f_ System Owner System Location �p L)OAAP,�CL fj�;L, ui We Lit Date of Pumping:.a —9 C, Quantity Pumped: lows-lions Cesspool: Nc�W Yes U Septic Tank: No ❑ Yje9UD System Pumped by: $'c Wont hot tCaCd License# Contents transferrred to: Greater Lawrence Sanitary Vistrlct Date: Inspector: r I VOWN OF NORTH ANDWrR NORTH ANDOVER BOARD OF HEALTH ! REPORT OF PFRO TEST ADUPJ= OF SYSTEM fid✓ G .G+GLn� �C.n /�_ DA7IC 6 NAME OF PROFES/SSI��ONAL WGIHM OR SWTAKIAN CONDUCTING TESTS NAME OF LOT OWNER ADDRESS pia/C,-, Cl 1 SHOW APPROXIMATE TIIOV OF PITS ON SKETCH 01 REAR OF THIS SIMT e�0 'e'� '�70 72� I,�' GI✓C��L pcs C ra a c a� C�c.�D�IC;f✓otal Soil Logs �� soil Subsoil _ D the & Tomes ater Level Pit D th (J 9'• L.9". Igoe i 0-)c aA ;;,6 Time to Time to Pero Tests Depth Saturation Time Drop 12" - 9" Drop 911 6" Other Considerations:��'!��00'>�/ jam/ ✓r E'er/ a'� / �G y� Recotimnenda ons ✓ / %Cl�7 ✓ 7/0 46C Q PK r X z a�7/ Signature ( L"Ph 3 /3ARaAG•N[1.0 G t•M• ASso c/ATOS 1 I VA/Est WARD C rR/ E /a (• AIL ROAD AVE, i e i (" P, LUY �• i S.F. �r►Q / iU V" FM i „1"1` �� ! y 1 1( ,/�/� UUU/�D 1_p,�eVVV ��✓ ( V �� n'1GALLO H yG�f R o.464 no. i 5•F•QE ` � YYY 4W A �o,_• �Dir�ySGlSTfcR�`'\Q� S/ONAI�;;� V � a, iC -/oo CCL TANK rJ i r a i I I I i I I ( PLAN �sNOtt/iNc I' PA?OPOSED SUBSU,eFAGE ,.SewAce DJSpas4c. .c�STEM � PROPdSEO LOT CTRAd/NG + -/ / AGE '�u-�• DATE : 7aZ- Z7 /976 ZiC �joe,4 // V ALLE ZAI/y E OW,VE,e: !�.L,/L1 ASSOC/.4TE5 /Z RA/L,240A.D AVE. Ci ' LOCAr/oN: LOT //, �2Ac/l//LLE LiIN6 a i /,-iS tom/ '� /Uo, A.voo✓E/z., MASS, l ' - ws :555 OF EIASS: e j ( / >4 rT2)6CAY cT. 4ARBA4•.4GL0, �9 Of V d 1 I WE3TL(/ARh C/BCGs nnaanrn;,•� Y^B 4, — /Vr„ Ira o. CeAWAA* , MAss. 1 \ TEL., rvlo¢^.4983 \�`��7oFin�••�;''/. DIES/GAA DATA - 1 TYPE OF 861/GO/A/4-- ¢ 66D,4?OdM DWEGG/Al4-; - QARAC,E 0 CEL44A', PGUMB/NG FAG/G/T/ES: NU.t/E i �Z peop• 3ELUAGE FCAW EsT/MATE: ¢OCJ G•f?D. 00 f�A�•I Iva 4 URM. ' ��; SEPT/G TANfC /000 !a<IGLD c1 ANEL• X72 ABSaFPT/ON AREA: 900 tSF, ABSoeP//o v BEp i � OPERto[Ario,v 7s57s �/ I 1 4AL' ' DATE 7-•22.7G `g K r % Ttlp ELEI/AT/oN G G.9 f. � o ,BOTl79h/ELEYAT N G Z•9 S4r41o.eAT/ON /5 M/n/. /Z"ro 9" DROP 7 M-1- 0 IN.9"' " OR 9 M14• \ 00' geeeo4Ar/o v RATE 3 M./,A/• ¢5000�. ' DATE /Dd o g N TDP ELE4AT/DA! 66.9 I0 0�1 24 /omnia k ,�SUB60K- 41,.T 3p' SO/G TYPESe .3c^.Scar y GS O•.,. -ZO'. ANO S gAI4 '/SID WATee TA@GE /2"et.nY LOC140A . .i/oµ/nrEK fL3un tBo N/A �OrroM'EIsUATW `� 6�F 1 i - TESTS llaK/DklGTEG' BY Jtt�N J, BAl2BA4AGa6 ,,es, 7E&Ts a%irNF55Ed BY: A112, AlvoovErz f/ aTsi Dir. %230. '70 r—,C IA 70 - . _ CRPVEL) ENDS 9d• '.. Gj O . o �. 4VPE.2F21leA P.IIC. P/PE CON ECtU/YALENT,) p IAF BED Ch/ 0h1 n n A&E-A', 90o T. FOR SPEC/F/CAT/ON 4 ..4EE SECT/D.1/:-.4T'LQWER'RMH7-) D.ts 4181jrl v Box t ¢�CRSTSPOV S- 0/ - _/ODO 9AL.CONCRETE SEP7YC TANK I ¢'"��'OL/D P.!/.C.,SEALED TO/.1/TS,5°•OOS .. 1 ., - AB.SORPT/DN OE-0 iPLAit/ 7q ` AA/ r 7o cSCA4E -� 45 \ F,i.Uen i E o o `sE c 7- PROP, - N ao/.vr, 4L Z n.a^�i'd o.e_�I�o�/ �� .. � rb•;// [MASHED `. s ` j it_ le C,eUSHBD STO.V6 m1 N R//v�EP Iff-1 PE�Q° EGO[l/✓AGENT MO � . � � REMO✓E .ALC LOi4M� ' ?E?GAGE. W/7N. Q�1NK _.r Aa3V G!4AV- TO IELaV6GZQ•`. .. GOT"'�IIh'.2A.VY/LGE L/1NE, ,Vo.AR/DOI/EXZ BEz> PLAN" ANS SECT/oNS cSHEET OFZ / FILE#tN[ Tnu V INSPECTIONS r.a Dean G.Luscomb II& Sons MAY 10, 2010 P.O.Box 135 Middleton,MA 01949 TOWN OF NIM ANDOVER 978-774-4065 METH DEPAR7MEN7 Licensed Plumber#20285 �a SUBSURFACE SEWAGE DISPOSAL SYSTEM INPSECTION FORM y PROPERTY OWNERS NAME Le0rlQ.rd Cj uQrn2TQ ' PROPERTY ADDRESS P-43 ('-)ra nyT I I e _ Q n Q ADDRESS OF OWNER if different DATE OF INSPECTION ©� - T NAME OF INSPECTOR 1)e<<.n_G LtSC J0 M b QUALITY IS NUIVMER ONE TO US. t Commonwealth of Massachusetts Title 5 Official Inspection FormQN Ay � Subsurface Sewage Disposal System Form -Not for Voluntary Assess M 143 Granville Lane yw 09,pAAAWNG' � Property Address Leonard Guarnera Owner Owner's Name information is required forNorth Andover MA May 4 2010 every page. Cltylrown y State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altere in any way. Please see completeness checklist at the end of the form. bI t Important: When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your Dean G. Luscomb II cursor-do not use the return Name of Inspector key. Dean G. Luscomb II &Sons Company Name %- P.O. Box 135 Company Address Middleton MA 01949 Cityfrown State Zip Code 978-7744065 S1848 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: VPasses ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority a / � 02-0/0 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts G Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 143 Granville Lane Property Address Leonard Guarnera Owner Owner's Name information is North Andover required for MA May 4, 2010 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check(;�B,C,D or E/always complete all of Section D A) System Passes: i [7f 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or components mores stem as described in the"Conditional Pass"section need to be Y ID 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•09108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 143 Granville Lane Property Address Leonard Guarnera Owner Owner's Name information is North Andover MA May 4 2010 required for Y every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 p� 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): U ❑ 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-09108 Title 5 official Inspection Forth:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 143 Granville Lane Property Address Leonard Guarnera Owner owner's Name information is North Andover MA May 4 required for , 2010 every page. Ci yrrown 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 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: Y pp Y 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 A r gg d S S o 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 Y day flow t5ins•09108 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System-Page 4 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 143 Granville Lane Property Address Leonard Guarnera Owner Owner's Name information is North Andover required for MA own May 4 2010 ylT every page. City ' 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. ❑ PV 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.) ❑ �J 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 J� 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 ign flow of 10,000 gpd to 15,000 gpd. For large sys s, you must indicate either"yes"or"no"to each of the following,,in-addition to the questions in Sectio Yes No ❑ ❑ the system is wi ' 4 et of a surface drinking water supply ❑ ❑ the syste ' within 200 fe f a tributary to a surface drinking water supply ❑ ❑ system is located in a nitrogen sitive area(Interim Wellhead Protection Area—IWPA)ora mapped Zone II of a blic water supply well If you- ve answered"yes"to any question in Section E the system I nsidered a significant threat, or answered"yes" in Section D above the large system has failed. The o 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•09/08 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts UTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 143 Granville Lane Property Address Leonard Guarnera Owner information is Owner's Name required for North Andover MA every page. CitylTown May 4, 2010 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? ❑ Ef 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? I� ❑ Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has �/ been determined based on: Ly ❑ 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): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins•09!06 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 143 Granville Lane Property Address Leonard Guarnera Owner Owner's Name information is North Andover MA May 4 2010 required for Y every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: r Owe pmoviols�\14 Number of current residents: Does residence have a garbage grinder? [ Yes ❑ No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes 2"'No Laundry system inspected? ❑ Yes E�_No Seasonal use? ❑ Yes [/ No Water meter readings, if available(last 2 years usage(gpd)): t Detail: Sump pump? [ryes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type ofblishment: Design flow(based 3, OW, 15.203): Gallo r day(gpd) Basis of design flow(seats/persons/sq.ete. � Grease trap present? El Yes ❑ No Industrial waste holding tank p nt? ❑ Yes ❑ No Non-sanitary wast scharged to the Title 5 system? 0. Yes ❑ No Water er readings, if available: t5ins•09108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 143 Granville Lane Property Address Leonard Guarnera Owner Owner's Name information is North Andover MA May 4 required for , 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): ---—� General Information Pumping Records: Source of information: Last P is G VlXarCwc�S d� Q-,c(on AcAei� E�- r- Was system pumped as part of the inspection? ❑ Yes 2 No If yes, volume pumped: 0 gallons How was quantity pumped determined? Reason for pumping: Type of System: R( 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•09108 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 143 Granville Lane Property Address Leonard Guarnera Owner Owner's Name information is North Andover required for MA May 4, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Oow ,ono 1;4 ar 3� Pret/i oct`5 >L'{ I �V Were sewage odors detected when arriving at the site? ❑ Yes OeNo Building Sewer(locate on site plan): Depth below grade: r g N feet Material of construction: [cast iron ❑40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Ca Jr0V1 /,JZA)1) ai rd M-f at �3n� p4�n,S Septic Tank(locate on site plan): Depth below grade: feet/3" Material of construction: [concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) co 11 C r)clk If tank is metal, list age: years y a Certificate of Compliance?(attach a copy of certificate) ---E" -YesT�] No Dimensions: s r® X `Vag < � u Sludge depth: t5ins•09!08 Tittle 5 Official Inspection Forth:Subsurface nsped Sewage Disposal System•Page 9 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Foran-Not for Voluntary Assessments M 143 Granville Lane Property Address Leonard Guarnera Owner owner's Name information is North Andover MA May 4 2010 required for , every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) A. ` r Septic Tank(cont.) /1 Distance from top of sludge to bottom of outlet tee or baffle `�S � I g �a 4 IScum thickness G' I gv VVV ; Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): ��^; Er , e)k- If (' p)r2l, �v' Er t S correct- t�JY X11 arm n® S!' "Ir ci f= a K PrAl e rgi r 7;L sa l Grease Trap(locate on site plan): 0 - Depth below grade: feet Material of construction: ❑ concrete ❑ metal berglass polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from t�p-of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•0908 Title 5 official tnspecfion Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 "^ 143 Granville Lane Property Address Leonard Guarnera Owner Owner's Name information is required for North Andover MA May 4, 2010 every 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 at-re#atpd to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: MateriaL. f construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene other(explain): Dimensions: " Capacity: gallons m€ Design Flow: gaudnsper day Alarm present: Yes ❑ No Alarm level: ` '. Alarm i orking order: ❑ Yes ❑ No Date of last pumping: Date \ \ Comments(condition of alarm andfloat switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09108 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 M 143 Granville Lane Property Address Leonard Guarnera Owner ' information is Owners Name required for North Andover MA May 4, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) �.,X Distribution Box(if present must be opened) (locate on site plan): S Depth of liquid level above outlet invert 7,-,ro u in R6R-1 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.): (30 y- I s 3" /4111adoto 2A Zv i eJ Pump Chamber(locate on site plan): (� Pumps in workin der. ►"/ 0-Yes—'❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, on of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): Y-1 If SAS not located, explain why: 02AY01 t5ins•09/08 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 143 Granville Lane Property Address Leonard Guarnera Owner Owner's Name information is required for North Andover MA May 4, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑/ leaching trenches number, length: LM leaching fields - number, dimensions: /'� / ❑ overflow cesspool number: -����" -�g=� �� ❑ 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.): 7C.e SAS i's r'n utfrq goo 'ti's aDWe , iS CO&tt e✓/ AGI rnalh-�4)11e--1 �r-rss , l® Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configurati Depth-top of liquid to inlet invert Depth of solids layer Depth of scum layer , Dimensions of cesspool Materials. nstruction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 . Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 143 Granville Lane Property Address Leonard Guarnera Owner Owner's Name information is required for North Andover MA May 4, 2010 every 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 etc.): s A, igns of hydraulic failure, el of ponding, condition of vegetation, t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 143 Granville Lane Property Address Leonard Guarnera Owner Owner's Name information� required for North Andover MA May 4 2010 every page. City- y ' State Zip Code Date of Inspection D. System Information (cont.) Sre.n 01C, i4,. Sketch Of Sewage Disposal Sy em: ProviFview the sewage disposal system, including ties to at least two permanent referen landmarkarks. Locate all wells within 100 feet. Locate where public water supply enter the buildine of the boxes below: [�hand-sketch in the area bel w o r ❑ drawing attached separatel37b Fran t Rc� ' 3 raveI kL /113 bre."Ae- � e /V, Rnc(owr Q Gk 13 �v T' = �l� /011 971 rl v aux ^t1 R /P t5ins•09/08 Title 5 Official In spectio 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 143 Granville Lane Property Address Leonard Guarnera Owner Owner's Name information is required for North Andover MA every page. Clty/Town May 4, 2010 State Zip Code Date of Inspection D. System Information (cont.) Site Exam: 02"Check Slope Gm—f ,--J [Surface water WoYW, (Check cellar SL4b1•, Ly Shallow wells Pam � l Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) [r Checked with local Board of Health -explain: —Pre—y`tyS f►rte-.. . or+s ❑ Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: hack gard 4,/ Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Massachusetts System Pumping Record System Owner System Location OA v-tu Lit, Date of Pumping: . ! C, Quantity Pumped: /OZ)gallons Cesspool: No� Yes ❑ Septic Tank: No ❑ Ye r System Pumped by: 9!4&,J ct 460&tided License# Contents transferrred to : Greater Lawrence Sanitary District Date: Inspector: t�ItlllllltllilY�pllll�r h�ll�Ap4�lltat:111 i�yNl�tl! fltvttet � _ _ __----------_--__— -8y�lcttt I•ucttlittit Le 7�s L(A � 061ftr10 -q 9e, t��t�t�iltY runt,►t:� l �g�uattt �yltiatq�tttt�ti,Ft, ,,y, �'�C�p�►ri �nla4��� l.Ictalee �!__ - -------- -- t'uuiattl� Itnttsl tttttl to : tmw Wiwi ti lwl►1t-mit, --_— . I Cone ionw alth of Massachusetts PAA-.-, , Massachusetts System Pumpinu Record System Owner System Location C L-(3 LIVU Date of Pumping: Quantity Pumped: gallons Cesspool: No (. Yes L) Septic Tank: No U Yes System Pumped by: vctrwart 51&,�wjw License# Contents transferrred to : Greater Lawrence Sanitary District Date: Inspector: Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 143 Granville Lane I Property Address Leonard Guarnera Owner Owner's Name information is North Andover required for MA May 4, 2010 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist U Inspection Summary:A, B, C, D, or E checked [Inspection Summary D (System Failure Criteria Applicable to All Systems)completed [j?/System Information—Estimated depth to high groundwater UeSketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official Inspeckon Forth:Subsurface Sewage System•Page 17 of 17 i �LN Commonwealth of Massachusetts City/Town of M "'. DEQ System Pumping Record Form 4 OCT 3 0 2009 �M DEP has provided this form for use by local Boards of F e'th,(��t�F e o t�ilsl nay b used, bu e information must be,substantially the same as that pra ide .I ore using this form, chec ith y, r local Board of Health tQ determine the form they use. The System Pumping Record must be subml the local Board of Health or.otlaer approving authority. A. Facility Information 1. System Locafi=Left side of house, Right side of house, Left front of house, Right front of house, L r of hou e,- ight rear of house. Left rear of building. Right rear of buil in� + A Address Cityrrown State �- Zip Code 2. System Owner: Name Address(if different from location) Cityrrown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition ofSystem: �-�/ 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: L.S Lowell Waste Water Signature of Hauler Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 A TOWN OF �+ SYSTEM PUMPI G RECORD . l OCT 1 9 2004 DATE: s� U � 1 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example:left front of house) 6v at&-� N DATE OF PUMPING: QUANTITY PUMPED : L®"0 D GALLO CESSPOOL: NO YES EPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G-L.S.D2 Lowell Waste TUM OF NORTH ANDOVER NORTH ANDOVER BOARD OF HEALTH REPCRT OF PERC TEST ADIRRESS OF SYS ��-�� �J Ile /.� e ,C,n .// DATE a9 74 NAME OF PROFESSICNAL EtJGINMU CR SANITARIAN CONDUCTING TESTS CY NAME OF LOT OWNER ADDRESS SHOW APPROMIATE LOCA OF PITS ON SKETCH ON REAR OF THIS SHEET C,,a P✓ -no UUJ'oG7 U 4rA / A GToG �D tal Soil Log: //12T soil Subsoil _ Depths & Types Water Level Pit Depth /ton f/ 71 -)01-)c Time to Time to Perc Tests Depth Saturation Time Drop 12+l - 911 _ Drop 9" _- 6" 4419 P, see Other Considerations: `:' ' G! 'Z/ —nf a Ix—e. zz' hn 00- r� e/ _n - Recommendations: ✓-C /Cc1U� Pf 7� j f 741- oz— Signature — °� 7t> /83 15op 0?113 � 1 33 el -2.5Z �✓ n'r�° 1 �� --7 LOA/ � pec On � 1 1 • ^1��� S!GLV ER `��-� � 'j • ,. �'oS�'pn�r �3 /�- R 13,4 G-��w a G' � • M� Ass � ciA7� S to RAlLAoAlJ AVE 0-1i z I 4,r vv o S.F . �✓ ��% ���/ JL 0 V � F / A o `" lllsss U f BARBAGALLO rp ) ` �i'p p S•f l3 E L .o P No. 464 O h E /oo & L TANK ' I I — r6 4� 11� i i s I I I t I f I PeDPOSE� SUBSU,e FgGE S.CWAc,6 DISPOs4e- cSYs m*r P,eO Po,SEa Lor 6TRAI 1A1C7 ] w 13e ZA /�,/� cS'CALE �„-�D I�qT� J'UL Y � 7 /y 7� 01rv/vE,e� �j. Z , M fl ss o c 1,4 TEs AVE. N1416 /A/ rREE• I I ,l �/,DO 1/E/Z2, ti1A5�. 41 L0CA7-/oAJ: GOT /I� �Rsi,t/d/GL E ZAA/E 1 /(,f0, e.) MA MASS. ale, W� -,s 7 `s OF M4, A, JosEPH cT BAeBAGALG- o ' /, N/E.STu/A/2l� C!/QCLE �`e jc ,,J /PEAp/NG MAss. ?'Z ZAG5 Cv Al D A TA = TYPE Or BU/L D/it/f7: 4 BEDA2490 M p vv 67Z-L /Ad1, 7 4 GARAGE Ce"&, PLUMB/A/G A4C/G/T/ES= /L/O/, E Q p�pp, tl Q SEllJAGE FLOW EST/MATE SEPT/G TAtilk : /©a O D roL Q - L�NEL. (� ��Z• �' ABSD.FPT/ON AREA 9�0 S� 496oA2,0T10A-1 BEI, o tPERCOLAT/ort/ 7ES7:5 - b c3AL, ` DATE 7- TDP E4E4/47-/0N 4;(. 7Z '` .B47'TOry ELE✓q T/dN G 2•9 \ SW 7-Zl 'A T-/DA/ 15 M,,-,/. CIO �\ /2"ro 9" DROP 7 Mi-V• 9., ro 6” DR-OP 5 M,A/, \ N 30' PE�PGOC.AT/oN RAre 3 M.//"/, TEST PITS G8 --o&/ ,rrZ3 ¢ ,;Z6, 660 1 ° kh g oA rE 7-z2-� �.1ku a TDP ELEI/ATIDN �G,9 � g`Sut35o,t.. _ _ SD/C 'TYPES 3G"S/G T Y �� _ - O' ~ZO'• � AND sHNv WA MR TABLE iZ` tcAY LOCAT/ON Alo VV-4rSP- � Et. GZ•/y BOTTOM &.6VAr10A1j G o . 5 1 6TESTS coAlDacT&;o BY /,7D.0 TESTS W/TNESSED BY - /vb. A.voavc�z /E�Lrfi fir. J ---- 170 PCAA.f e '406SMW C/e/TEi2/A c5'HEE / of 2 1 Coe EGA[!/!/AGE/V7 r ! - • p 6 • p p • . • e O e p O• • CAPPED ��t/OS C7 o" o s'o" 2'-�" 1OE.erOeATE4 P. l C• P/PE Coe E4c//vA4E1V7") ZDV IDART/AL BED Eti/D SECTIO til c SCALE - A,e EA - (Fok 5PEC/FICAT/0A/S - SEE SECT/D Al A7- LOWE2 R/4a147-) DoreIBU7-10AJ Box h f �v 4" CAST I,&V, S=.O/ /DDO 6141-. COMG2ETE SEPT/C TANK ' a ¢"QSS'oG/� �//.C.,<SEALED TO/NTS5=.ODS PT/OAJ .BES IE�G A AJ ?4 /UoT To cScQLE- 76 PROP, \ r114-1. EAL ED cSEL EG T pWEL. i GPfI / TO 4,V7 EiAGK�lLL _ - soc/o N N. let _g1C15 OR (JQA //8"TO j/8WA " SHED o e • •o a •• � t aF - \ `' ��,` 5 ` 10 0 •po a .:1• •o a e`b� C�USHED 6, STONE o e•S�4'9' e e ¢'•�PECORArGD d• e . o e R l/•C. P/PE 46,Qo e o o e N EOc//bl 41-ENT Q o O O 76) /�,. WASHED 0 N x q 1i d G�USNED STONE � O � It �DOC/BGE !f/ASL/ED OSPEG'EEr A A��.O. O v i L o n .4,65o/ep7-/o A.1 BEle cYECT/OA/ E16601e- JAI .B EZ� �tREfE• sCAG E � =� O "jI h REGGAGE W/TH BSFnIIC QUA/ 61 QAVEL. 7-0 V. 6G.ZO. # �ieOF/G E �T' 1I �'�2/i�/t//G L E ZA4/e, /vo. AP,14ot1EQ- c_aG'ALE f-70.2. l��-�O f�E,2����- �i20F/LE AND fiBS�.2PT/on/ BE1� Al-A&I ANIS SECT/On/S �HEE T of � �� 4 { r U� r � lf�j' . �, t �� ,, Air TO: NORTH ANDOVER, MASS 19 BOARD OF HEALTH FROM: DESIGN ENGINEER Re: Soil Absorption Sewage System I nspection This is to certify that I have inspected the construction of the said disposal system at GRANVIZZe 1/4f✓Z-- North Andover, Mass. SITE LOCATION The grades and construction are as specified in my plans and specifications dated -)L7 19 76. jN OF M4ss90 o JOSEP ti Rtarian �pF T F-- INV A NAL SP`���P 5 0 1 0 y ' O Town of North Andover HEALTH DEPARTMENT SACNUS! CHECK F#: G1� DAT LOCATION: j H/O NAME: CONTRACTOR " E: Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ _ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ` ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ Rport $ 3�• ❑ Other:(Indicate) $ F Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer PLA A-1 sli GtWIti/U PeOPO.SEb SC/6SueF4GE SEWAOCS b15R OSQ_, SYsrEM AJ Z07- aTR-4,b1A _ �••�� // ,� / ' / / / p`' DR Ara.! DATA Y OW AISe 14 �� � G� LOGAT/OA/: C07- II �,2�iti/d/GL E L `I//E 920 dolej C,I.. 49OW7 00000' DC=7_5 / G % `� Q�Q�' j � e-7 lg tTOSEPR cT &ARBAUALL o , /QS• I , l / / We.STu/AR b C',(RCGP 000, 4V -C h D j C, Q G C `� \ G!% � /t/o . 14?EA b1A1e, , AIA s5. 1. W GIJt/C.•-ec/ G • l•IEs,G AJ DA rA� C'.ar.�/c/ v�� /� c-c �► ���'� �� T Y,046OF BUic a/wG: p w"5L L /Ayc ' , S I ,4 -` CARAfE CELLAR PLUMB/NU FAG/G/T/ES �. C�•t/E ^v \ ��� SEGUAhE FLOW EST/ME'AT : c' <aA2• v 4 a 2M ► � � SEPric rAA/k ` y flBsoePT/oN AREA : y0o S,r AG',5o�/�T/oma/ �3Ej� 0 t Z PERGOCAT/opt/ TESTS 4= , t DATE' 7-ZZ-7( 77,P E4E1/A7-10N ` a ,G3OTTDitJ ESE✓A T/dt/ G 2 9 SATU.CAT/OA/ i 5 Al �v /Z"ro 9" DROP 7 Mi1 ra G" DROP > m PE,4ee04AT/OA/ RATE ' o TEST PITS _eL-/ '"Z A�3 #¢ 3 �5 DDD N DA rE 7-Z2-7� �� ► Q TOP ELEtIAT/DA./ $suds� c_ -y WArek TABLE /Z" CeAY LocA 7-/O A/ ,Jo w..---,P \ N A55u,4gEU v/A BOTTOM ELE1/A7/0N p , ��r= TESTS CaV&ICTED BY vD1_6;Z2,y f BA.tBAI�AL�v ,f.S. 7'657s W/7-A1_lSSED BY �t/o . An,-oa,�� ��EtlLTf L�E.t7T• / --- _0 7o` / 1 JOG'.,4Al e -DES/,-,V ��e/rE�e/A cS'HEET / OF 2 <SEALED c-701AIr, 5oL/D PICC. P/PE I� - o i• e • 6 • e • • . • r e e e e CAPPED �lvDS COR EQU/vA1-ENr.) 2D' IF PA,27-/,4L_ BED E/vD SECT/D til h ti sSCALE (Fo,2 5PEC/F/C47-1I - S'EE SECT/D it/ 4T zowE,2 JDo S. D51- l sarlDA/ Box I ! -/DDD 4�lL. CONG.2ETE SEPT/C TANK P(/.C. <5EA1-E.D TO/NT - o 5 5 -,0 5 j I 4'� PERF. P.liC. S=.OUS- , A j 74- AZO7- To c5'CALE 1 - 70 � X20,? � � � ¢"� • • ' •. . . • . : - _ - • SEALED TO/NT, CS'EC EGT r , (D(o ! (05 DI, ! • oho e �1 .g s e � b C,eUSNED STONE c:� ee e • e •o a .•oe� j C6 iVV EQtI/�/i9LENT 1 M in � � � A� c� � <C7 7-0 d 3�eUSNEXZ,.S onlEED !' �voUBCE H/AS/,�ED TO MEET A.4.S.14.O. U X91 i h! �I a� �I� .� •'•i,BSD�P7"/O/t,/ BEl� cS�ECT/p/C,/ lL/n/ G-2A:/EL TO EGE✓ �G, zd. �.eOF/G E Zoo- '11 ��'/2/f�ll1//GCE Lfi�/E, �o. A&,,,00v6v woe. /'LAO PE,2 . � - '73i20F/L E AI 4s-,5 SEC TIO NS f/EE T o� Z i - ���� / `` � K _. � �; r � � e ;,��.� •9� r. ' �� ..�. ♦. � � }� <°'�t ��«k 1I,�ii. f �+f � •#i� Q � � � ` ,r ., , '•a rN.� � ', ,'` �y 1,Y i � 7 t�r ��ti �� � � � v'+ , r �" � I �� .^' ,�1 \. � , V � r FILE# d)L0gOgA ® . O ; + �TIT�,LE V INSPECTIONS ' , �,��® k Dean G. Luscomb II & 5ons DEC 0 $ 2Zok R P.OBox-1'3 5 PN��VE Middleton, MA 01949 �om �V °A0 cMEN� z. `1 978-774-4065 LEN-SED PLUMBER #20285 t1. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i PROPERTY OWNERS NAME: Le OhCp Fol G a ro erd T ii=7-1L ' 22 L PROPERTY ADDRESS: 1 -�ra r)VC I I�_Lr-L _�-ALidQv4�_MA ADDRESS OF OWNER: _S_0-me______ (if different) DATE OF INSPECTION: �Cn NAME OF INSPECTOR: . Q.C-L-bZ_61.1-u SC,-Q m b_�______-___ QUALITY IS NUM.B.E.R. ON.E TO- US t COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION it DEAN G. LUSCOMB II & SONS P.O. BOX 135 MIDDLETON, MA 01949 1-978-774-4065 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:,/$/3 6r7anv)/1e RECEIVED Owner's Name: r_rHP_tA/.caDEC 0 8 2004 Owner's Address: OF NORTH ANDOER S� Date of Inspection: ce Q4� Zoo TOWN HEALLTH DEPA TM NT Name of Inspector:(please print)-Dean G. Luscomb II Company Name:Dean G. Luscomb II & Sons Mailing Address:p_o_ Box 135 Middleton, MA 01949 Telephone Number: 97s-774-4o65 CERTIFICATION STATEMENT I certify that 1 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 Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: &jWM1,k- Date: r_,G zGn�_ 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. 1 Page 2 of 11 Middleton, MA 01949 1 -978-774-4065 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) i Property Address: /'V3 Gr-cp A /y, Ancloyer Owner: G-q a,r-ri er-C,_ Date of Inspection: L Z 4o Inspection Summary: ChecaB,C,D or E/ALWAYS complete all of Section D A.. System Passes: V 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. IJ 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: JJ 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 Jexplain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 r Page 3 of 11 e.u. tsox 1X) Middleton, MA 01949 1-978-774-4065 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 619 Owner: Date of Inspection: 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(l)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: N Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if 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 I of a public water supply. N The system has aseptic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform 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:� 3 i Page 4 of I I Middleton, MA 01949 1-978-774-4065 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) . E Property Address: 10 6 rarl V t lie- ane— Owner. ne— Owner: me Date of Inspection: 2, O D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No JBackup 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 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool j Liquid depth in cesspool is less than 6"below invert or available volume is less than_day flow J Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped J 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. AL Any portion of a cesspool or privy is within 50 feet of a private water supply well. AJ 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 ,� ,n are triggered.A copy of the analysis must be attached to this form.] �V (Yes vo 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: T8'b"astt;sidered a large system the system must serve a facility with a design flow of 10,000 gp ,000 gpd• You must indicate eithe "or"no"to each of the following: (The following criteria apply toa tems in addition to the criteria a yes no the system is within 400 feet of a surfs inking upply _ the system is within 2 eet of a tributary to a surface drinking water pp]y the s is located in a nitrogen sensitive area(Interim Wellhead Protection Area—I or a mapped ne 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. 4 Page 5 of 1 I Middleton, MA 01949 1-978-774-4065 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: �T owner: za,r-n e?rz;�- Date of Inspection: '2 zo Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No jz_ 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? _l/ Have large volumes ofwater been introduced to the system recently or as part of this inspection'? — Were as built plans of the system obtained and examined?(If they w re not available note as N/A) VwoS �e Repo r+ � m 10 A310 Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? V1— Were all system components,excluding the SAS,located on site? Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no V"'/_ Existing information.For example,a plan at the Board of Health. V — 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)J i 5 F Page 6 of 11 Middleton, MA 01949 1-978-774-4065 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:.. Zan-, Owner. Guar7,7er, Date of Inspection: •Z OW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMjt 15.203(for example: 110 gpd x#of bedrooms):J6("44"/.'Vel-I we / Number of current residents: zilw Does residence have a garbage grindere�. r no): Is laundry on a separate sewage system(Yes o�' D [if yes separate inspection required] ] Laundry system inspected(yes oK66�NO Seasonal use:(yes or(Q:Lop Water meter readings,if available(last 2 years usage(gpd)):)caw n W 6:6e-r Sump pump(GDor no):)�S Last date of occupancy: Ct.4 r:,qAt COMMERCIALANDUSTRIAL Ty a of establishment: Design (based on 310 CMR 15.203): gpd Basis of design seats/persons/sgft,etc.): Grease trap present(yes o :_ Industrial waste holding tank pr es or n _ Non-sanitary waste discharged to the stem(yes or no):_ Water meter readings,'if av ' e: Last date of occu use: OTHER(describe): GENERAL INFORMATION Pumping Records / �,,� t/Aar. Source of information: .� Pal.,4.',-a 2 i'I'Ieh f'4S ASO �c�l v�7 Ccs✓ Was system pumped as part of the inspection(yes obi ): Nd If yes,volume pumped:/M gallons-Ho was g tity pumped determined? Ecz u. ^Vul1 -,r Reason for pumping: ni�+� 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/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank —Attach a copy of the DEP approval —Other(describe): Approximate age of all components,date installed(if known)and source of inf rmation. TRZ /�u.� rd s�� czr� d2& ,-s c>/ � -� - frCr�1'es T�l-e, Were sewage odors detected when arriving at the site(yesno P-6 it 6 i Page 7 of 11 Middleton, MA 01949 1-978-774-4065 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: G�'^V'1L Owner: �stitcfn��a Date of Inspection: BUILDING SEWER(locate on site plan) �» Depth below grade: Materials of construction: cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leak Ye,etc.): �'/l ��ron o✓/No si�.�s o ar,r ,n mob( r SEPTIC TANK:,(locate on site plan) Depth below grade: X? Material of construction: (/con rete metal_fiberglass___polyethylene _other(explain) f r2Ca,S r' r l GUO ( If tank is metal list age: Is age confirmed dy a Certificate of Compliance(yes or no):4(attach a copy of certificate) _ r ,. Dimensions: F'�ivt 3 X h lam AC rNrWe /0��, Sludge depth: OU s�, Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 0`' Is' L1 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: .I Z" How were dimensions determined: Pg S41c_ks gzyo`pT.- mews" Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): I of are in 'y oo� Comet,, is w tJo si�nS of rd 6 iem S k Lyrs �Ki L1Ci�Gt 1� �.e �n kcoc�S /IC 1—a'pt'i'rL GREASE TRAP:t(locate on site plan) Depth below grade:_ Material of construction: concrete metal fiberglass_polyethylene_other (explain): ..._,� — Dimensions: Scum thickness: Distance from tofo op of out e r b Distance from boto bottom et baffle:Date of last pumComments(on pmendations,inlet and outlet tee or ba e structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): �,,, 7 Page 8 of 11 Middleton,VMA 01949 ^ 1-978-774-4065 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: GrZZAV 1 16 Owner: rn r� Date of Inspection: TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth be o e: Material of construc i concrete metal fiberglass_polyethyl other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): '� ""•�-., j�y Alarm level: Alarm i r 'ng order(yes or no): Date of last pumping: ' Comments(con ' ' n of alarm and float switches,etc.): DISTRIBUTION BOX: Y*-�(if present must be opened)(locate on site plan) 7ZZr- D-8,ok, is Depth of liquid level above outlet invert: .Zero 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.): 71Z 3-8o to V OO S ccs b S nS o a^ r'vG/ /nS. !wi ox. i9 Yi! �Cs1�f .S4h�n i S�.��CY.� PUMP CHAMBER: (locate on site plan) — Pumps in working order(yes or no): Alarms in worki r no : _y en (note condition of pump chamber,conditionmps anda~ p�pVttenances etc.): -T-)-3ok *2— / &./o, grac& 7rw-Z--Rmx is D-!3o x 43 61 ?doo( 00"'bo-' , �u Ja w,p (-S Cleall r Z)-pox l see cz�e no ,S)�•,t< o �t�y Prddt��s'. v-Box '40-S /-lh/w anwe-a'we�s. 8 Page 9 of I I Middleton, MA 01949 1-978-774-4065 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Ilk'—? G r<jn V r 1l /tJ. /�l"1caC�U�p r Owner: rne-r Date of Inspection: Q SOIL ABSORPTION SYSTEM(SAS):Mks(locate on site plan,excavation not required) If SAS not located explain why: �y Rrnly os rro'm 1612 3�p( Type / leaching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimension ,,�Se/Q//��z�G vGc overflow cesspool,number: e innovative/alternative system Type/name of technology: ®,�.A/p Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): _ // S-1,1, sod i h $ /SCa, iS C Case CESSPOOLS:tJU(cesspool must be pumped as part of inspection)(locate on site plan) Number an uration: Depth—top of liquid ' invert: Depth of solids layer: Depth of scum layer: " L Dimensions of cesspool:. Materials of construction: Indication of groundwate w(yes or no): ,, Comments(not rtion of soil,signs of hydraulic failure, level of ponding,condition..of vegetation,etc.): PRIVY: (locate on site Materials of construction: " Dimensions: Depth of solids: ''" Comments(no rtion of soil,signs of hydraulic failure,level of pondi condition of vegetation,etc.): 4 J e Page 10 of 11 Middleton, MA 01949 1-978-774=4065 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM SYSTEM INFORMATION(continued) Property Address: 0 Owner: Guc�.r oe-r'c- Date of Inspection: [Z O SKETCH OF SEWAGESPOSAL YSTEM Provide a sketch of the sew a disposal ystem including ties to at least two permanent reference landmarks or benchmarks.Locate all well within 100 feet.Locate where public water supply enters the building. r E,}r ckra-►w 1y13 6nmWl[e-141w- tA EG 13 , 7— LO M7 7n 13h> DFrTl' ��,DZ=/09 G �' D1' t � 11, 0 1-0 Page l l of l l Middleton, MA 01949 1-978-774-4065 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) '/ I Property Address: A( 3 bun vi 0-g- AA t9za over M7, Owner: Guarner- Date of Inspection: SITE EXAM lope Surface water No-a- ✓Check cellar ✓Shallow wells N n � � I Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: ��)ained from system design plans on record-If checked,date of design plan reviewed: t� Observed site(abutting property/observation hole within 150 feet of SAS Checked with local Board of Health-explain: il�r�evGaS 7 -Le 1Z' 40,.x, I C) 3�0 Checked with local excavators,installers-(attach documentation) =Accessed USGS database-explain: 'I.51_s4'bfdl i You must describe how you established the high ground water elevation: Tkz /3oti{rii.. ni -TSL Su..,r tot .. 1,110 . d-r 6 f- to G✓ l� n�IQC�G o C wI No wo't ew-- [h i �zt- SIAMP PiA.M;P ha,s o7 l . 4e,07 u;d a coups o� /' vim �2tzjhS a/�ie!i �aGvfte C.T Q Lal- 07'r 25.40ZU On �akn r>a Dce«- Aa l 11 w , 4-7 Y�J FILE #/VA /U a 3 o 1 4.3 s= , TITLE.V INSPECTIONS FV Dean G. Luseomb II & $ons P.O. Box 135 F � t 619262001 ,�i+tl:iddletan, MA 01949 ? p y- , 1-978-774-4065 -� LICENSED PLUMBER #20285 Cz ` . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM lJ PROPERTY OWNERS NAME: gQrr!_e.l_t .eon and Ga ua.rn erQ PROPERTY ADDRESS: 3 (3ra n �_ll Al__A-n OBD UPJ' /"A ADDRESS OF OWNER: (if different) DATE OF INSPECTION. NAME OF INSPECTOR: -e—Q-Q_-__ L u S C O m ID - - ----------------------- QUALITY IS NUMBER ONE TO US COMMONWEALTH OF MASSACHUSETTS _► TTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS r DEPARTMENT OF ENVIRONMENTAL PROTECTION Y �t DEAN G. LUSCOMB II -P.O. BOX 135 MIDDLETON, MA 01949 1-978-774-4065 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:J/ J n � n 0V Owner's Name: GtAA MAr Owner's Address: Sa r�•e_ Date of Inspection: Oerl•, 23 �'�DO) Name of Inspector: (please print)Paan G_ T.nGr omb II Company Name: ppa„ r_ i.usc om_ -11—L Sons Mailing Address: Middi-etnn- MSO Telephone 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 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 Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: ° Date: Qcl ?j?, 24�)l The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 vean u. buscumu 11 (x JV11J `Page 2 of 11 P. O. Box 135 Middleton, MA 01949 1-978-774-4065 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: P13 Gral)L /le laoe lV� fin �VGr ►'1'IQ., ' Owner: 1 ;ri3er a_ Date of Inspection: /OIZZ 1 Inspection Summary: Check A�,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. 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: 0Observation 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 pipes)are replaced obstruction is removed distribution box is leveled or replaced ND explain: K) The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Dean G. Luscomb II & Sons Page 3 of l l P . O . Box 135 Middleton, MA 01949 1-978-774-4065 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: /4-3 Grctr, �i Ile lane 1V I An ao✓e,r- Owner: UO r- era, Date of Inspection: O 123e6 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. I. 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,safetyand the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier,if 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. N The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. N 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: 3 Dean G. Luscomb II & Sons Page 4ofII P. O . Box, 135 ' Middleton, MA 01949 1-978-774-4065 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Al Gran 1/f ll2 Lc xr— N, R17do yPr Owner: &ygLrnercL Date of Inspection: 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 IU Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool N Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow JJ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped lU 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. JJ Any portion of a cesspool or privy is within a Zone I of a public well. N Any portion of a cesspool or privy is within 50 feet of a private water supply well. J Any portion of a cesspool or privy is less than 100 feet but P P �'Y eater than 50 feet from m aP rivate 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.] (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. Large Systems: To be *dered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate eithe "or"no"to each of the following: (The following criteria apply to systems in addition to the criteria above) yes no — the system is within 400 feet of a surf�drlwater supply the system is w2edin fe a tributary to a surface drinki ater supply the system� is�1.9 nitrogen sensitive area(Interim Wellhead Protec Area—IWPA)or a mapped Zone II ofdpublic water supply well If you hanswered"yes"to any question in Section E the system is considered a significant threat,or wered "ye ' in Section D above the large system has failed. The owner or operator of any large system considered a gnificant 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. 1 4 Dean G. Luscomb II & Sons Page5of11 P . O . Box 135 Middleton, MA 01949 1-978-774-4065 OFFICLA.L INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: I�3 •ny (.c�,�� IJ. tan o ver— Owner: Q r er, Date of Inspection: 10 ,1231,01 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: 3� No Pumping information was provided by the owner, occupant, or Board and 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? jj—/� Were as built plans of the system obtained and examined?(If they were not available note as N/A) V _ 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? i/ _ Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition of tthhe baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? V — 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: Yep. no �7 _ Existing information. For example, a plan at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part.0 is at approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] 5 L C U 11 V. L U J 1-U let U i.L lY J V 11 a Page 6 of 11 P. O . Box 135 Middleton, MA 01949 1-978-774-4065 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Z�13 Gran t II e �ane- iJ, A ndover Owner: Guar era Date of Inspection: /0Z3 W FLOW CONDITIONS RESIDENTIAL Number.of bedrooms(design):-IL Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): r-�'A Number of current residents: A Does residence have a garbage grinder abr no): Is laundry on a separate sewage system(yes or jo t NU[if yes separate inspection required) Laundry system inspected(yes or<Q�o Nd Seasonal use: (yes or &-20 Water meterge ings, if available(last 2 years usage(gpd)): Tw h l Sump pumpor no):-&S Last date of occupancy: rren-� OMMERCIAL/INDUSTRIAL Typ tabIishment: Design flow on 310 CMR 15.203): gpd Basis of design flow(s ersons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present _ Non-sanitary waste disch t e Title 5 sys es or no):_ Water meter re ' s,if available: Last d occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Iq s k Ap'-p- ll / a^Q y/0*1 Was system pumped as part of the insp ction(yes or a: No If yes,volume pumped:lz>00 gallons--How was quantity pumped determined? Slicks o Tpe l�casu� Reason for pumping:N_ o Pe.&yl Pti•Hp�s �� lc;s Ci m,- 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) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all cojonents,date installed(if known)and source of' fformation: 1410evoe r) Were sewage odors detected when arriving at the site(yes or(q): IVa 6 Lean u. Luscomo 11 bons Page 7 of 11 P. O . Box 135 Middleton, MA 01949 1-978-774-4065 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 143 Gran vi 1(p nL N, �lndov r Owner: Cruarner0L Date of Inspection:—1012-s'101, BUILDING SEWER(locate on site plan)/eS 144Depth below grade: /jJ� Materials of construction: cast iron _40 PVC_other explain): Distance from private water supply well or suction line: /U N Commentts'(on condition of joints, venting, evidence of leakage,etc. Tion WZ A-)Q S t'q6 gan,# to rd &.g SEPTIC TANK:IeS(locate on site plan) Depth below grader Material of construction:_✓oncrete_metal_fiberglass_polyethylene —other(explain) t-!1-91 s Rye u10-e-Cor, A00 . ./ If tank is metal list age: 4A Is age confirmed by a Certificate of Compli e(yes or no):NA(attach a copy of certificate) Dimensions:w, IZOQr Z, 6_6c/J4,(� � Sludge depth: _ /" Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: < /ii Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee of baffle: /2 How were dimensions determined:_ $u -'4"Ck and Comments(on pumping recommendatio s, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet inv vidence of leakage, etc* / / Jahr' �l/G�r �f /i w o X ih,C 9,)Gs 174,4pt?Cu!'/L� �D{/"r'7 -e-1- 6'rne-. REASE TRAP�JVQV(locate on site plan) Depth below _ Material of constructs concrete_metal_fiberglass`polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of o ee or baffle: Distance from bottom of sc ottom of outlet tee or baffle: "Date of last pumpin Comments(o mping recommendations,inlet and outlet tee or baffle condition, aural integrity, liquid levels I s relat o outlet invert,evidence of leakage,etc.): 7 Lean u . Luscomo 11 & 5ons Page 8ofll P. O . Box 135 Middleton, MA 01949 1-978-774-4065 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 rnvi �a►tie, Ol.). Rn over' Owner: G ar- Date of Inspection: D Z3 P 1 T GHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below Material of constructio concrete metal fiberglass_polyethylene otherkepain); Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm ing order(yes or no): Date of last pump�m Comments kcentfition of alarm and float switches,etc.): r DISTRIBUTION BOX:YG� (if present must be opened)(locate on site plan) :D—`f3oyL j s I(,tiC f `� SSuart� � 3"fie%aw J raa/. Depth of liquid level above outlet invert: Grp 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- K i5 '0 ✓-ru 17 ool a s o cz rdz�v><1' U- J (S level CYea %c i o- ' r wis -3oX ha's /--ihlej- Qnel / P QIP CHAMBER:AA (locate on site plan) Pumps in working order(yes or no . Alarms in working order(yes or no); Comments(note condition of pump chaono pumps an a $nances, etc.): -3ox #Z a / /vw Gra.(yC Sax is 20"kZO" S,50Crr— Ikep l C�" 1�cttc� above ou�� Inocre 4 fro" 7L 2) (�a tj' in very c! Slr� _ /3o#r SAruC{urLc�l/ and Gc�/if r'r1� _7e - Si/ /k, �� area TS C164h a,,9W Dry W106 Sr�l�� Gf �tvt'� /�r0d/PSS �l.�d X 1 S 15-W-717P 1.5 e 8 Lean U. Luscomb 11 & 5ons Page 9 of 11 P. O . Box 135 Middleton, MA 01949 1-978-774-4065 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1/3 &MnVI ll I-a r12, _ l), /Clnalav Owner: ct r Date of Inspection: 3 Q J SOIL ABSORPTION SYSTEM (SAS):1ES (locate on site plan,excavation not required) If SAS not located explain why: (/y sh C4 G iCf w a ���I�Sd1�lZ` r a Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: - G ,'nWz U�ol�� G -' lOr4$1 ,Uq overflow cesspool,number: //i7eS- 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.): iresaac;✓ror>� �o,) cc lo ] 4-4 if <a rna . C POOLS: 1 (cesspool must be pumped as part of inspection)(locate on site plan) Number and configura Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materi�constructIndicatow(yes or no): Cooil, signs of hydraulic failure, level of ponding, condition of vegetate etc.): IVY:I`'� (locate on site plan) Materials of construction: Dimensions: -- Depth of solids: Comments(note conditi of,signs of hydraulic failure, level of p di g;c'bnd-ition.,_of vegetation, etc.): - s ` 9 Dean G. Luscomb II & Sons Page 10 of 11 P. O . Box 135 Middleton, MA 01949 1-978-774-4065 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C Gralw /le Ia n<, SYSTEM INFORMATION(continued) Property Aldress: 143 �r,' r LI)V l Ile, Layl-e— I K)A /gnolover , Owner: ern— Date of Inspection: /Ozz'z 161 SKETCH C F SEWAGE DISP SAL SYSTEM Provide a sk tch of the sewage d' posal system including ties to at least two permanent reference landmarks or benc Locate all wells wit in 100 feet. Locate where public water supply enters the building, g 3 d ' > /fa use �v. 14 Add►�ti- "y I /6'/D �eGK i3 f-d r = 85'�a nk AtoDL =/Oq��pi! 13fo z = 7�16„ a-ion s - D'1 �2 X 10 Page I 1 of 11 P. O . Box 135 , Middleton, MA 01949 1-978-774-4065 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 3 Gru vi Ile L."�e_ !V lana over- IYI�z� Owner: rot,. Date of Inspection: D . OI SITE EXAM /Slope Grdaa l V Surface water 06(w- ✓Check cellar 1)rLI w/Ski, pU.K-,,p /Shallow wells tic ria, Estimated depth to ground water �1 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: V' 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) J/Accessed USGS database-explain: You must describe how you established the high ground water elevation: p�lln� o� i� C��, e-lowd �cri e? �r dti Dwn�r SQ�'a� a Alv ,Orr-w has CQu eve , s � :r i f��vy �airs �e is are 7U 8,#11 �� # Jif i��� /� /7Q E-Qpelr✓ vl .2-/ �.�–lo L,' L7 r-a -C,. ' 11