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HomeMy WebLinkAboutMiscellaneous - 147 JOHNNY CAKE STREET 4/30/2018 147 JOHNNY CAKE STREET ire e t .210/1-07-A-018& 0000_0 } Y t t di SEPTIC SYSTEM INSTALLATION IS THE INSTALLER LICENSED? G >-.,, NO TYPE OF CONSTRUCTION: NEW - EEPAI NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW YES CONDITIONS OF APPROVAL YES NO (FROM FORM U) ISSUANCE OF DWC PERMIT NO DWC PERMIT PAID? YES NO DWC PERMIT NO. INSTALLER:,/�C Gam/ BEGIN INSPECTION YES NO: EXCAVATION INSPECTION: NEEDED: PASSED- BY CONSTRUCTION INSPECTION: NEEDED: AS BUILT PLAN SATISFACTORY: YES : APPROVAL TO BACKFILL: DATE: �Zl� t� BY FINAL GRADING APPROVAL: DATE z�g4 BY ZJIJ FINAL CONSTRUCTION APPROVAL: DATE: BY r_A.•yf ..r` y u1t.d� Tr Es LIMMA Y o tJvears 4V1 10' t. (3,w , 410, 49 Pt's. .95 ' e l % 54'' — Aa two?. 43' r r2 't tot o � L B� i FI -FOWN OF NJR AN 0 R/ BOA HEALTH I �. M AY 241996 ' Pee-cxKr 3 �I��! crt s �o, � �� �Ati uew O Cys, Z v;: ._..ION woY � A ISE QoA 0 AS BUILT PLAN OF SUBSURFACE DISPOSALSYSTEMLOCATEDIN AS PREPARED FOR DATE: IAA'Y 7-1, 19 9(p SCALE: fo ' JofiPOYC)9X6 MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS 0 LAND SURVEYORS • PLANNERS " PARK STREET • ANDOVER, MASSACHUSETTS 01810 O TEL 1617► 473-3553, 3MS7?1 I Commonwealth of Massachusetts City/Town of /(/. �4ndo v�y- System Pumping Record ;M Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information r_ /r ~ Important:When filling out forms 1. System Location: on the computer, t ! ZU» , use only the tab key to move your A re cursor-do not i1010 ye,- ' use the return !1t^S� key. CitylTown .y. State Y Zip Code 2. System O ner: r Name 2rmn Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: frons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes �] No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pump �— ��2�5 Name Vehicle License Number Stewart's Septic Service Company 7. Loc tion where contents were disposed: S art's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 i ature of Hauler Date natur f Receivin Facility Date t5form4.doc•03/0 System Pumping Record•Page 1 of 1 11 i; ' COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS P d DEPARTMENT OF ENVIRONMENTAL PROTECTION A F WW< V� �'•M Sv TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:_147 Johnny Cake Street _North Andover_ Owner's Name:_June LeFave Owner's Address:_147 Johnny Cake Street North Andover,Ma.01845_ Date of Inspection:_8/3/2001_ f u t Name of Inspector:Neil J.Bateson_ M Company Name:`Bateson Enterprises Inc._ Mailing Address:_111 Argilla Road_ _Andover,Ma.01810_ Telephone Number:_(978)475-0786_ 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 ems.I am a DEP � � approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000 The system: _X Passes Conditionally Passes Needs F er Evaluation by the Local Approving Authority F i1 Inspector's Signature: Date: 8/3/2001 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 DER 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. E Page 2 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:_147 Tohnny Cake Street_ _North Andover — Owner: LeFave Date of Inspection: 8/3/2001 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N;ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent:System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: pag e 3 of 1 l OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 147 Johnny Cake Street_ _North Andover— Owner: LeFave Date of Inspection: 8/3/2001 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 15.30�(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 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. Thetem 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: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_147 Johnny Cake Street _North Andover— Owner: LeFave Date of Inspection:_8/3/2001_ D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _No_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool No Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _No_ Liquid depth in cesspool is less than 6"below invert or available volume is less than''/s day flow _No_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _No Any portion of the SAS,cesspool or privy is below high ground water elevation. _No Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ _No Any portion of a cesspool or privy is within a Zone 1 of a public well. No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _No_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] —No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either`yes"or to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply Y ary g PP Y the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:_147 Johnny Cake Street_ _North Andover— Owner: LeFave Date of Inspection:_8/3/2001 Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes No Yes_ _ Pumping information was provided by the owner,occupant,or Board of Health No Were any of the system components pumped out in the previous two weeks? Yes _ Has the system received normal flows in the previous two week period? i _No Have large volumes of water been introduced to the system recently or as part of this inspection? Yes _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) Yes_ _ Was the facility or dwelling inspected for signs of sewage back up? Yes _ Was the site inspected for signs of break out? _Yes_ Were all system components,excluding the SAS,located on site? _Yes_ _ 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? _Yes_ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? i i The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no Yes Existing information.For example,a plan at the Board of Health. No Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] i I Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:_147 Johnny Cake Street _North Andover — Owner: LeFave Date of Inspection: 8/3/2001_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_4_ Number of bedrooms(actual):_4_ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):_440_ Number of current residents:_4 Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no):_ —No_ Water meter readings: Juty 99 to July 01 =55,000 Ft3 x 7.5=412,500 Gals./730 Days=565 GalsJDay_ Sump pump(yes or no):_No cY' P _ Last date of occupancy- No COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgketc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):— Water meter readings,if available: Last date of occupancy/use: I OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:_Pumped two years ago,owner_ Was system pumped as part of the inspection(yes or no): Yes_ If yes,volume pumped:_1500_gallons—How was quantity pumped determined? Measured tank_ Reason for pumping:_Inspect tank&tees._ TYPE OF SYSTEM X 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 components,date installed(if known)and source of information:_Tank original,D-Boz& Trenches was replaced 5/24/19%. As built plan._ Were sewage odors detected when arriving at the site(yes or no):_No Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_147 Johnny Cake Street_ _North Andover– Owner: LeFave Date of Inspection: 8/3/2001 BUILDING SEWER(locate on site plan)X Depth below grade: 20" Materials of construction:–X–cast iron -X_40 PVC—other(explain): Distance from private water supply well or suction lime: Comments(on condition of joints,venting,evidence of leakage,etc.):–4"Cast iron thru wall.3"PVC in house. No leaks. SEPTIC TANK:X locate on site plan) Depth below grade: 8" Material of construction: X concrete metal_fiberglass—polyethylene I —other(explain) If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions:_10'x 5'x 4' Sludge depth: b" Distance from top of sludge to bottom of outlet tee or baffle: 21" Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle:—8" Distance from bottom of scum to bottom of outlet tee or baffle:_13" How were dimensions determined:_Subtract scum&sludge depth to tee length._ Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Pumped septic tank.Inlet&outlet tees ok.Depth of liquid at outlet invert.No evidence of leakage._ I I GREASE TRAP:_(locate on site plan) Depth below grade:— Material of construction:—concrete— —fiberglass fiberglass___polyethylene—other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_147 Johnny Cake Street North Andover— Owner: LeFarve Date of Inspection: 8/32001 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:_0 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 level&distribution equal.D-Boz cover broken,replaced same. Evidence of carryover,pumped d-box to clean.No evidence of leakage._ PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORINT PART C SYSTEM INFORMATION(continued) Property Address:_147 Johnny Cake Street- -North treet__North Andover — Owner:_LeFave_ _ Date of Inspection:_8/3/2001 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: X leaching trenches,number,length: 3 trenches 571 long_ leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.):_Soil ok.Vegetation ok.No sign of ponding to surface._ CESSPOOLS:^(cesspool must be pumped as part of inspectionxlocate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): I f Page 10 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_147 Johnny Cake Street- -North treet_North Andover— Owner: LeFave Date of Inspection: 8/3/2001_ SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. Driveway BWater Meter House A C D- Boz Septic A to Tank=1518" Tank A to D-Boz=4317" 57' ® B to D-Boz=4616" C to Tank=2114" Page 11 of 11 OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 147 Johnny Cake Street- -North Andover— Owner: UFave Date of Inspection: 8/3/2001_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water— 4 feet j Please indicate(check)all methods used to determine the high ground water elevation: X Obtained from system design plans on record-If checked,date of design plan reviewed:_4/5/1996_ Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: As per design plan._ I Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 147 Johnny Cake Street _North Andover_ Owner:_LeFave Date of Inspection: 8/3/2001 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 4 feet Please indicate(check)all methods used to determine the high ground water elevation: X Obtained from system design plans on record-If checked,date of design plan reviewed:_4/5/1996_ Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: As per design plan._ « Tel: (978) 475-4786 Fax: (978) 475-5451 B ATE S ON ENTERPRISES, INC. Excavating-Water.& Sewer Lues-Septic Systems&Pumping Service 111 Argilla Road Andover,Mass. 01810 Title 5 Inspection Report Property Address: 147 Johnny Cake Street, North Andover Owner: Lefave Date of Inspection: 8/3/2001 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system i Neil J.B eson Bateson Enterprises,Inc. I i NEW ENGLAND ENGINEERING SERVICES INC F SEC 16 December 14, 2002 North Andover Board of Health Town Hall Annex 27 Charles Street North Andover, MA 01845 RE: TITLE V REPORT: 147 Johnnycake Street,North Andover, MA Dear Sirs: . Enclosed is a copy of the Title V report for the above referenced property. The system PASSED our inspection. If there are any questions please call me at my office, 686-1768. Sincerely Benjamin C. Osgood, r. 60 BEECHWOOD DRIVE-NORTH ANDOVER, MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 t COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 111 -7 �/�Nr1 nycl�KG si AI,) A 77-( t'c Pcv C-R., M{� Owner's Name: Ar a►��� 0'*!S v -L I AN Owner's Address: i wz <i^v j4 qNj C p.k e. sT. Q1)RTlt A-N ao C2 m1 Date of Inspection: f. z�—Zj o s Name of Inspector:(please print) 13 6-0 o D a - Company Name: l)Cvy um cr,-r}A�u CN Ut,v E`2.1 As Cr Mailing Address: (o o Q, D tZ i v N a Rift{ Abv.b ojj�-- A-A Telephone Number:q Z p,• _ �G 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 toSection 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: C Date: 2- z o2 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. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: / 7 Jo t-f"Aj a MkC ST�L'e V0 277-1 /- �DOc)4 2 M/q Owner: P W-r 2 LCiA, fes`5V c--w v FW Date of Inspection: i A 12/0 7- Inspection Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: have not found any information which indicates that any of the failure criteria described in 310 CMR i 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. r The system,upon completion of the replacement or repair,as approved by the Board of Heal 11 pass. Answer yes,n or not determined(Y,N,ND)in the for the following.statements.If' determined"please explain. The septic tank' metal and over 20 years old*or the septic tank(wh metal or not)is structurally unsound,exhibits substan'al infiltration or exfiltration or tank failure is' ent.System will pass inspection if the existing tank is replaced wi a complying septic tank as approved by d of Health. *A metal septic tank will pass spection if it is structurally sound, leaking and if a Certificate of Compliance indicating that the tank is less 0 years old is available. ND explain: Observation of sewage backup or br o high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled o even distribution box.System will pass inspection if(with approval of Board of Health): br en pipe(s%ar ,replaced coon is removed distribution box is leveled or replaced ND explain: The syst required pumping more than 4 times a year due`toy broken of obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): \� broken pipe(s)are replaced obstruction is removed ND explain: ` Page 3 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: /,�/ �V o 2T { &A)o0,)Qt AAA Owner: Date of Inspection: z Ick z. C. Further Evaluation is Required by the Board of Health: itions exist which require fiuther evaluation by the Board of Health in order to determine if the system is failing to pr public health,safety or the environment. 1. System will p unless Board of Health determines in accordance with 310 C 15.303(l)(b)that the system is not ctioning in a manner which will protect public health,safe and the environment: Cesspool or prf +is within 50 feet of a surface water Cesspool or privyls within 50 feet of a bordering vegetated wet d or a salt marsh 2. System will fail unless the Board ofcalth(an blic Water Supplier,if any)determines that the system is functioning in a manner that protects a public health,safety and environment: _ The system has a septic tank and so' absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a ce Ovate\Supply. The system has a septic and SAS and the S"is within a Zone 1 of a public water supply. _ The system has a sep ' tank and SAS and the SAS 4,w`ithin 50 feet of a private water supply well. The system has septic tank and SAS and the SAS is les than 100 feet but 50 feet or more from a private water sup well".Method used to determine distance ':. "This cyst 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 frim pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less th5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: /11 -1 i- VO9:11( C-VJDOUJ✓L MA Owner:_ P A-TiRtC it, 0.50(AA0 AA1 Date of Inspection: t 2 ) ?-to 2- D. System Failure Criteria applicable to all systems: You mast indicate"yes"or`no"to each of the following for all inspections: Yes No ✓ Backup of sewage into Facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than%z day flow ' Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped i/ 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. _V Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic 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.] Af 0 (YesJNo)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 ('pd. You must 'tate either'yes"or`no"to each of the following: (The following feria apply to large systems in addition to the criteria above) yes no �\\ _ — the system is within 400 feet of a surface drinking water s _ the system is within 200 feet`of a triizutary �ce drinking water supply the system is located in a nitrog sensitive`areaInterim Wellhead Protection Area-IWPA)or a mapped Zone II of a public watef'supply well If you have e7ed"yes"to any question in Section E the system is con ' ered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator o large system considered a significant threat under Section E or failed under Section D shall upgrade the syste accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department..._ s Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENT'S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: _�11�2T1-( Win!�Oc/L✓1- ��" Owner: PA? 61 J, Date of Inspection:_/ 2 z o Z- Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No _%z'� 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?(Ifthey 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: Yes no Yes , Existing information.For example,a plan at the Board of Health. -"-Determined in in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: /q'7 Join y si v ft-TF( jZo e7uFd- mA � 7 Owner: A-L2l cid u"—►v Al Date of Inspection: - t Z z> 2 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: rl Does residence have a garbage grinder(yes or no):ba� Is laundry on a separate sewage system(yes or no):ko [if yes separate inspection required] Laundry system inspected(yes or no):— Seasonal use:(yes or no):_W Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): !Ua Last date of occupancy: c.-.✓r r e hr COMMERCIAIJINDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Pnd Basis of design flow(seats/Persans/sg8,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):— Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pc D /?2« Zo,D/ Was system pumped as part of the inspection(yes or no): i1 jp If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: 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 components,date installed(if known)and source of information: C3� til f 9-I(, QeJL A s I Were sewage odors detected when arriving at the site(yes or no): &LO Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_ /,91 -i-MV y c_414CF sT JUO RD-4 /4.v D D%JL/Z A414 Owner: Roi-atuti O'S v w I Q 0j Ad Date of Inspection: t 0 Z BUILDING SEWER(locate on site plan) Deptk below grade: l Materials of construction:yst iron 40 PVC other(explain): Distance from private water supply well or suction line: — Comments(on condition of joints,venting,evidence of leakage,etc.): ►? I PE tLodKs CVD i .y F1SL�EvT SEPTIC TANK:—(locate on site plan) Depth below grade: 3 Material of construction: ,/concrete_metal fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: J5b b UAL 4 M S Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Z g" Scum thickness: Zia Distance from top of scum to top of outlet tee or baffle:_ Distance from bottom of scum to bottom of outlet tee or baffle: /,6 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.): 14 o O C.,,✓ .1 ✓1, C 0 Al C t`^ " �t1 6-60.0 'A N e� AQ n r f C � N Di"1 GREASE TRAP:1L(locate on site plan) Depth below grade:_ Material of construction: concrete metal fiberglass___polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping; Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: / 7 SIJ O ATN 8NA2 00- �.,t�•9 Owner: P"2iC K Date of Inspection: [Z117+07- or z1 z(0zor HOLDING TANK: q A (tank must be pumped at time of inspectionxlocate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity:- gallons Design Flow: PAlons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 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.): _ 91:-k / AJ Tam C-->til a ,c1 r,n AD -'i QiI.- 410 ENCC or Saf i,�S C�}2(2y ay'2 PUMP CHAMBER:] ✓}'(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): I Page 9 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1I1-7 C-6-AU VO(VfN A;.v Do.)t2 .4u4 Owner: PA-7-0-101, p`S.v�t a✓:4 v Date of Inspection: E z! ,210 7— SOIL SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: c/leaching trenches,number,length: --�, 5-7' Ire"EKE$ leaching fields,number,dimensions: overflow cesspool,number: innovativetalternative system Typetname of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): aiLfh vF s,3 Tr-iyt i-o o,<.s C:-Dad> 1L)'> E (v C vr r�OAJ 01NC,- Dig-me DA-me ��r�, O� yiyySvr4L tlEbC�)�>lU. CESSPOOLS:/04-(cesspool must be pumped as part of mspectionxlocate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:/ll (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): I Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:-J.9? ✓mac XloAl.yCgKt S j -Al )Z-)Y A-ND ooiFlz A44 i Owner:_ FAVM10% Date of Inspection: y z- SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. . y Hb ' �R �L �3 -7' 5' Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /'/1 J�HNN Ncai�e si _LIfOYLIH ftit/DOtic2 ,"fl Owner:- 2/CA Q`S t1 t Ju HN Date of Inspection: I l i2/ 0,- SITE EXAM Slope Surface water ivo�c Check cellar Shallow wells NoNC li Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: L/"-Obtained from system design plans on record-If checked,date of design plan reviewed: ?l'6 Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: SVS AByI/C 1a0JV9 w&_j 67A (N i E-EIVED TOWN FRTH ANDOVEP, DA 11 SYSTE P MPZNQ RECORD OCT 0 5 2004 !l TOWN OF NORTH ANDOVER SYST M OWNER& ADDRESS HEALTH DEPARTMENT SYSTEM.LOCATION DATE OF PUWgNQ: E:.SS AOOL: NQ YES __.__._._..._ 5m trc TYES NATUREOF SERVICE: ROU'CINl:�. EMERUENCY r . 013SERVATIONS: GOOD CONDITION ^ FULL'I'O COVEp, HEAVY OREASE BAFFLES IN PI<ACE ROOTS _ LEACHFIELD RUNBACK BXCESS1VE SOLIDS_ FLOODED SOLID CARRYOVER'—OTHER EXPLAIN ucm COMMENTS: (__ / "FKANSFERRED 1'U qw C;UN'TIrN'1'S, Sd f77�%C S C0iitlhoNillepllil of NIONSlidlitsellli Massachusetts --Sy-eiciii Lcic"aiioil / I �n Dote of 1'uliiplrng Cesspool: '��� ,� Ve �.J Ct+hl{r' 'rftiii ���+ a Yet System Pullilted by: ----r 0� Llctns2 �t Conlcnts Iro�lsleiteJ ir: � I ` S ' D of Unle Illsheclot Pp I i Town of North Andover, Massachusetts Form No.2 NORTl� BOARD OF HEALTH O ,,,,.o ,•7� F w p i M •+,��'--'—*-• ' DESIGN APPROVAL FOR SSACHUSf< SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM • Applicant. ,J611k C� �'6 Test No. Site Location 1 7 JO �ftiti Reference Plans and Specs. «< • ENGINEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. . G,/�%/'Com/ • CHAIR AN,BOARD OF HEALTH LFF * Site System Permit No. f F. i Form No.4 Town of North Andover, Massachusetts BOARD OF HEALTH May 30 , 19 96 CERTIFICATE OF COMPLIANCE This is to certify that - the Individual Soil Absorption Sewage Disposal System constructed ( ) or repaired (X ) by Mike Reilly INSTALLER at 147 Johnnycake Street North Andover, MA 01845 SITE LOCATION has been installed in accordance with Board of Health Regulations as described in the Design Approval Site System Permit No. 818 dated Mayes, 19" 96 The issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. BOARD OF HEALTH li Jd#oVvycg,�.6 � X38 s�3n]qb 1. Cone ionw alth of Massachusetts ". assachusetts System Pumping Record System Owner System Location Date of Pumping: l�� `'l — Quantity Pumped: gallons U� Cesspool: No (7 Yes �_� Septic Tank: No �_� Yes 'tT System Pumped by: Fare4ort .5o&n""aa License# Contents transferrred to : Greater Lawrence Sanitary District Date: _ Inspector: I I UILPI ES ulriMAW of WVBRTS to� y e.toT►�1, 1��.�o ''. xm i Y liv, 10' — 2 ' ►��� 1b to .) a 01 1 V IANY 2 41996` E 8a 8e P1LE"EXk,T 3 IJ�k1 uE�l O Lo-r 17:7 ° oa 'Il` _104 WO Y. CA" �LoAo AS BUILT PLAN OF SUBSURFACE DISPOSAL. SYSTEM LOCATEDIN IJ��T>a D�N�Ov�l2 • AS PREPARED FOR . 0 gEapETTE G., Ig�� i DATE: IAAY M, 199(p SCALE: E MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS " PARK STREET • ANDOVER. MASSACHUSETTS 01810 TEL (617) 475-3553. 373-3721 � f ( 41�� ofHFA.j i-( I.or )3-A JowNY-<4u,' NoI�TH Atil�vEl�, �'t,4. �4PP�� CSN i �ti���sp (tiJQTG-r� SV Pr-nt -� rbWrJ ❑ WEI.(_ �P oyCD�(6 5S StPTIC SyS TEM -PL---Sl6A /PIT"OviN6 Aurtyol?iTly R�4SoNS = D� St�--Ic SYSTEM 1,�5`IiOI�,,Q7'�o,U EYG()WJT(o/J 1tiSPt6iiO&j U/JrC 6- S-Y, IfFRASS ❑ F41t- FINAL 1 u5P6—�-rloA) %PPROVED Q/3TC 6_Zy_�� AP1-2IQ7v(^)G AUTHOI?pry DtSAPP�UvEi� D,a rC Fk4L APPI;�pvaL 7-10APPRa 1VJ6 ,Health i .... .�.udover,Kasa r SUBSURFACE DISPOSAL DESIGN CHECK LIST LOT APPROM DATE S-)q-P5 DISAPPROVED DATE Provided: Reasons: rifle V FAIL CK h Reg 2.5 `y The submitted plan must show as a minimums a) the lot to be served-area,dimensions lot Cabutters Ib location and log deep observation hoes- detance to ties d c location and results percolation tests-d• .stance to ties d design calculations & calculations showl, g required leaching area (e) location and dimensions of system-includ ng reserve area f) existing and proposed contours (g) location any wet areas within 1001 o'O ser age disposal system or disclaimer-check wetlands mapping (h) surface and subsurface drains within ,100 t of sewage disposal system or disclaimer (i) location,any drainage easements within 3001 of sewage disposal system or disclaimer-Planning' Board files (3) known sources of water supply within 2001 of sewage disposal o system or disclaimer { (k) location of any proposed well to serve lot-1001 from leaching facility , (1) location of water lines on property-101 from leaching facility (m) location of benchmark' (n) driveways (o) garbage disposals (p) no PVC to be used in construction (q) profile of system-elevationa'of basement, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and other elevations (r) maximum ground water elevation in area, s-wage disposal system (s) plan must be prepared by a Professional z ngineer or other professional authorized by law to prepay. such plans Reg 6 Septic Tanks (a) capacities-150% of flow, water table, te, s, depth of tees, access, pumping (b) cleanout (c) 101 from cellar wall or inground swimming p of (d) 251 from subsurface drains deg 10.2 Distribution Boxes (a) slope greater 0.08 teg 10.4 b) scamp Town of North Andover, Massachusetts Form No.3 NORTH BOARD OF HEALTH a O0L 9 U DISPOSAL WORKS CONSTRUCTION PERMIT .- ,SSACHUSEt Applicant NAME ADDRESS -�" TELEPHONE Site Location : Permission is hereby granted to Construct ( ) or Repair (4,4,a'n' Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. ; moi,BOARD OF HEALTH Fee �O b. % D.W.C. No. ��� �' r �� � X12 PLAN REVIEW CHECKLIST ADDRESS !/� �d>��ViyyC.9IC�� ENGINEER GENERAL 3 COPIES ✓ STAMPy LOCUS NORTH ARROW SCALE ' CONTOURS L/ PROFILE SECTION BENCHMARK `' � SOIL & PERCS ELEVATIONS WETS. DISCLAIMER WELLS & WETS WATERSHED?//YO DRIVEWAY (Elev) WATER LINE. ---- FDN DRAIN SCH40 ✓ TESTS CURRENT? `�/ SOIL EVAL SEPTIC TANK MIN 150OG . 17 INVERT DROP .ARB. GRI R 0% EDF) 25 ' TO CELLAR MANHOLE ELEV GW ## COMPS . D-BOX SIZE ## LINES FIRST 2 ' LEVEL STATEMENT " INLET IG �- OUTLET/to M _ /7 (2-- OR .17 FT) TEE REQ'D9 / ) LEACHING 1,p � � �` L---LL MIN 660 GPD? RESERVE AREA . 4 FROM PRIMARY? 20 SLOPE 100 ' TO WETLANDS 100 ' TO WELLS 4 ' TO S.H.GW (5 ' >2M/IN) 35 ' TO FND & INTRCPTR DRAINS 325 ' TO SURFACE H2O SUPP 4 ' PERM. SOIL BELOW FACILITY MIN 12" COVER v' FILL? (25 ' if above natural elev; 10 ' if below) BREAKOUT MET? TRENCHES gp ' SLOPE (min .005 or 6"/100 ' ) �ISIDEWALL DIST. 3X EFF. W OR D (MIN 61 RESERVE BETWE �N FILL? ��` MUST BE 10 ' MIN.J29 4" PEA STONE? � NT? 3 ' COVER; LINES >50 ' BOT 323 + SIDE 0180 X LDNG /3 = TOT (L x W x ##) (DxLx2x#) (G/ft2) Copyright © 1995 by S.L. Starr ,( rCi+ �/ G 1 CL Q �� ,v �`v 41z /V Z> V -)v 7� 4" NAV 5 2403 14 1�� .. wU)�5 Ir�VI r�li�y ,,��,4;�,/ �rl��i�)`I�i•'I'��v `7l� rti`r,,�,�(r)/`�l�:� ,I �' 'r'; r,i }.{:)�v k}/.lill j}i}I�kr;.l,'ti, '• , " 3 n� I,. . ..• r s ysT� I �� > t'zM U.wN R & hUOIZCS S 'SYSTC M JI c�, r t , • — i • I p 1i f's ' Vi y,? CR:Y.I.CC; ✓ ROUTInC. Cr: ER� ':: ,�'UU0 C�I'j',U1 i IQI'� ..•� hUl,� TU CU / : ,SQA IUy C'"R,4Y�R �ml ^t X ,I,' r .11) h1.'(y�1�, Ylt 11 r1 ti� r / .r)''j yt,le (I, t S �l• - ._ wPUM�('CO`OY. . ... r I i"I 'ii,h Iju C'V NI ryI cyi I, ,�� ; I �� 11� 1 ii�r�5��l�1����0 ,1 u • Cov�j. altCommonweh of Massachusetts Executive Office of Environmental Affairs ®apartment off OVER/ Environmental Proteeti- NO Wllllam F.Weld TFudy Coxe Gaemor X (� S",airy Argeo Paul Celluccl „- .vld . S.L. U.Governor c5 mm,as ser SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC.. OWN FEAR PART A f�, CERTIFICATION ss: Property Addrey J U kr\r\ c`\L e,•• �"� r.. 0- G $ IJP•( Address of Owne .. Date of Inspection: — 9' ►'n,, (If different) Name.of Inspector. Q t `, � Company Name,Address and Telephone Number. BATESON ENTERPRISES, INC. TEL:1508)1-5.1.41-4 Excaating Water&Swer Lines-Septic Systes&Puinq FAX:15081-473-3-15 1 L47,9— t78 Service CERTIFICATION STATEMENT 1 1 1 ArgiNa Road . Andover,Mass.0 18 10 I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of sewage disposal systems. The system: Passes ,« , Conditionally Passes Nems Further Evaluation By the Local.Approving Authority. F ails Date:Ins Inspector's Signature: _ 9— The System Inspector shall 4tay patioy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. It the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. ,. , INSPECTION SUMMARY: Check A, B, C, or D. AJ SYSTEM PASSES: I have not found any information which indicates that the system violate,any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: i i One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yea, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) _ The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if•the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 One Winter Street a Boston,Massachusetts 02108 i FAX(817)SWI049 a Telephone(817)292.5500 ei i J Pnnted on Recycled Paper L SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM '• " PART A } CERTIFICATION (continued) IPV@P* ty Address: I I '_'�Qknh C V� Y } Owner. d� �� r Date of Inspection: B] SYSTEM CONDITIONALLY PASSES )continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken. settled or uneven distribution box. The system will pass inspection:a(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is,levelled or replaced • a The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ! broken pipes)ari replaced obstruction is removed 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 the public health, safety and the environment. 1). SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONINGi IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: , Cesspool or privy is withih 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE-SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that thb well is free from pollution from that facility and the presenck of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 3) OTHER , (revised 11/03/95) 2 ,.:: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _SA Owner. ° � Date of Inepeotion v\ v ! , fj � r! 1 _r. D) SYSTEM F �11111 determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for . this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. p Ll 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 invertor available volume is leas than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. E Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. 3 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 it private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitro B� Po gen and nitrate iiitrogeti.' El LARGE SYSTEM FAILS: The following criteria apply to large syatems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply I the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00.and 6.00. Please consult the local regional office of the Department for further information. (revised 11/03/95) 3 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 14 1 �Y� �Lc� S 1 j i Owner. Date of Inspection: Check if=umping ve been done: formationwas ivqupstod of tho bwnee, oosupant, and Board of Health, VNone of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates �t period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _As built plans have been obtained and examined. Note if they are not available with N/A. I ty or dwelling was inspected for signs of sewage back-up. does not receive non-sanitary or industrial waste flow��,��he:m as inspected for "signs of breakout, components, excluding the SoilAbsorption Syateni,°have been located orithe site.`s •, The septic tank manholes were uncovered opened, and the interior of the septic tank was inspected for condition of baffles or tees terial of construction, dimensions,depth of liquidi depth of sludge,depth of scum. _�sizeocation of the Soil Absorption System on the site has been determinedbased on existing information or by non-intrusive methods.; a. r u•,-,.,, 4 _The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub. Surface Disposal System. y t r, . _R .,t _ •ti ,t r�' .✓aa?. fit... _,Y"•F3 tr. (revised 11/03/95) 4 r. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: I y��aD Y\V\ Owner. ��/� A 1� .•. F tY a Date of Inspection: dv\11� FLOW CONDITIONS RESIDENTIAL € }, Designfl— ow:440 ¢allons i Number of bedrooms: —14 N c�. umber of current residents: Garbage grinder es or n Laundry conaftud w system (yes or no—yes Seasonal use(yes no): Nil 6 ®v ��3 5 C, �) / `] Water meter readings, if available: t r S a - Last date of occupancy: CUcc x COMM ERC IAL/INDUSTRIAL Type of establishment: Design flow.---. gallons/day ? „ Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yei or no)_ s f Non-sanitary waste discharged to the Title B evetem: lyes or ho)_ ' Water meter readings, if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: t v 144A e)^ System plumped as part of inspection: (yes or no) 2S If yea, volume pumped l O� rr r z, Reason for pumping: TYPE OF STEM Septic talWdistribution box/soil absorption rp on ayetetN Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records, It any) Other(explain) APPROXIMATE AGE of all components, date installed(if known)and source of information: O �S Sewage odors detected when arriving at the site: (yes or no) � (revised 11/03/95) 6 r> SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ,, A 19 Owner. r\(-. r. Date of Inspection: SEPTIC TANK (locate on site plan) r If Depth below grade: Material of construction:_'%oncrete_metal_FRP—other(explain) t Dimensions: Sludge depth:_ .� Distance from top of sludge to bottom of outlet tee or baffle: 1 Scum thickness: 3 �� Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pum condition inlet and utlet s or es,�dept of liq 'd level in relation to tlet ' v rt, etru integrity, deuce of e © .)�1 V, 1 VtQ, © � t�V pU t rti r o v GRtASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete_metal_FRP_other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: ° (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage, etc.) (revised 11/03/95) g s f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property ndareas: 1- Gt,�c� Owner. 1 �Uv\V\ 9.4,\caUn r , Date of Inspection: TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: Material of construction: _concrete_metal_FRP—other(explain) Dimensions Capacity: gallons x Design flow: gallonslday Alarm level: E Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX_v (locate on site plan) "J s k Depth of liquid level above outlet invert: Comments: "wl (note ' level d ri tion ' equal, evidence of soli�Earrov r,evidence of le ge ' too 1 pu of bo Ott.) V f II g UQ- PUMP CHAMBER:_ �� (locate on site plan) V Pumps in working order:(yes or no) Comments: I (note condition of pump chamber, condition of pumps and appurtenances,etc.) (revised 11/03/95) I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C N 1 a 'SYSTEM INFORMA TION (continued) Property Address • Owner. Date of Inspection SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) , If not determined to be present, explain: Type leaching pits, number;_ leaching chambers, number:_ leaching galleries, number: � Or t leaching trenches, number,length: _ 5 leaching Gelds, number, dimensions: overflow cesspool, number: Comments: (note con ' 'on of soil, signs of hvdraulic failure. leve f ponding, dition of vegetati tc. �\t V e _ M �� o CESSPOOLS:-^D\^2 .. . (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: �.. : Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: , Indication of groundwater: . inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) r r PRIVY: (locate on site plan) Materials of construction Dimensions: Depth of solids: Comments: (note condition of soil, sign of hydraulic failure, level of ponding,condition of Yegetatioa,eic.). (revised 11/03/95) g I I e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (o�on`tinn ed) Property Address: (Lf , 1��1/�. 'JC% '`� • A '"�"�' Owner. Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate.all wells within 100' << w - , 53 ` 8 q0' So Q S3 = a� DEPTH TO GROUNDWATER groan Uf7W Depth to dwater: l feet method of determination or approximation: Q C `1J�j �'CAti ------------ (revised 11/03/95) 9 a I • i .a,•wv�Y4�Is.W,gyi�.YiwliNww»w.. _ __•_- . I.ri�R�n..,.»`--�.. E 1 ! i I I I - r 1 ' LOT 13 14, A i I ! r I I { s i I3— � � 9 c I r TNOIV,,".S I SO I t 1 / I � VA- 1 A K o vil i--r I t a _ bl sT s ax /Wzr-rIt D Or` -1 e14 i E y Commonwealth of Massachusetts City/Town of NORTH ANDOVERMAS ���® SAC RECEIVED - System Pumping Record 2006 Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. The System Pumping Record mu,4 be submitted to the local Board of Health or other approving authority, A. Facility Information - Important: When'filling out 1. System Location: forms on the computer, use only the tab key Address—to move your - cursor-do not _--___ ___,___,—_� Cit /Town _----- use the return y � State - ----------------- key. Zip Code 2. System Owner: . Name ___---- ----_--.^.-- - - - --__.. _ - ---- ------_..._.. 1q7 ahnn« Address(if different from location) - -- ... . C ttya,wn State Zip Code - I Telephone Number B. Pumping Record 1, Date of Pumping 2. Quantity Date t Y — - Gallons 3.. Type of system: ❑ I Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): --- _— ... _ _-------------.._ ---.._ - -- --- -- 4. Effluent Tee Filterresent? p ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: / 6. Sy em Pumped By: Name —�-- ---------..---..-.._._...__,-----------.. .------ 6f vehicle License Number a rte% «. Company - --- 7. Location where contents were disposed: Si ature of Hau ---- -- http://www.mass.gov/dep/water/ proyals/t5forms.htm#inspect Date t5form4.doc•06/03 System Pumping Record •Page ' of tyS/�iJ_`, I �1 •.�,;�i�'���::t>')jr11y�•. t ..� .. .l' t. .�,. ,�schus:efts 3: ;� Q. >~ ORTH ANDOVER MASSACHUSE `r ;uMo. `Record C�:�I1�;�;ti��1�"�,;\.Y•ti�C.i� {�yly!�'+1L'(t�i:l.'r.���•• .., •.'!Cla+.yyr.¢+ G l„ r 1.'X.lip :4:.t.. ., , A•.J'"•Y':'tr;' . ri1C;b i��1''i:t lZjYt.<,L'1 .Ir'.; a I DEP,has prdvlded thla form for use bye locaj goards'of Hea th. The System Pumping be subinitted to the.local•Soard of Health or other app thorl P g Record must A. '. . . A Facility Inforr4tlon .p - LIZ UL_ �,ortlmt.' ;r »'. •' TOWN OF NORTH A,IDO'VER ,?.YVhel1'(�lllll�OUt' :�.. System Location;` HEALTH DEPARTMENT _Z 44A 17V L40 6�7 only the tab key Address ill `-' to move your:; carrot•do `use the.btum< ' Stat a Zl Code. $ystemjOwner r . D �� Nam Addrm(I different from bcaIn Code uon) ,Y ClbrlTovm; State' Telephone Number `'� umping , ewfd, r'• .I. ', a4 '�rtt,i1,•t t �'�.lrt; ��IG.IV,{���.r•f i�I� .: ,-•� 1 1;J Date of Pumping L syz> 6 'Date 2' Quantl Pumped: l ty P Gallons -T+' a ♦.f s ste Y P m; P. Y Cess .❑, 0 1 • os �. ;.. P � ) Septic Tank ❑ Tight Tank [�f Other(describe) E., (fluent Tee Fliter resen ,,..., R ......, ; •.❑ Yes, No If yes, was itcleaned? ❑ Yes N • ';,�.:::. :���'S.��'�Co�ditlon`ofS� ' ' � , 5..:....,.. c, ::w ' ' )Y i,',�Fi'�ji'�l�i�•'tp Ya�9l.±�%�' r7Y�� "' ',d'I _/� �) ,� rw •,:.::a'�Y: .' !' ,£{`i X, ------------ P i;.'I:.a': - ;n�;:y;'; "T:,c�a jar,}� i •� !4 i r K!d ' 'V�'�'�+ '''.' ;1•q.!�'gil'�cY.;;'wP:S'rb:� 'I�;r••r 4'r•l�lt•'1.1''''ti..,, �J Pumped By;'' :''�..• •'��:.!:i :.`'fi�':i;:%•' •ami:j'�:�•,�p�l��i r��'' i lY '' �r �,_: ' tri ,.. '#. �, : � �" a+J;..•.. w�. Vehi cen4eNumber Ina :✓7:.t`:•; �.;.. S t. At I f�1 ".7^'y,lji u��p,�,1,r`xL{1�t!�'•.. I�lLlllT+:rt'�vj,+:•J�":: ::Y� � ' •'Yy,'1 1 ty�., `e.'i�'JHrli.11 7k'�w •.r•:¢I;l'r'{Y"t1���1,tiv\• ''' 1 '. •'.'�;,,,' .:+:7i'' Locatlon.where Contents yuere d( posed: :••r : n. "t:.';:: ter., '•r.....; r,; ' ':9" moi.:r:;t•', - .r '�.hl:�i.'..'.. ,il..,,.:''1:''r•1'`;{•'�:yr" .:,{1• • „S•.,.'••:,i L'.�:$j.a,51 �.rlY FV ';t'!'�;.f,�. ''>, �•Y ,+' , /� • 1 , +Yi:@ + -•t:.•,: Date :httpJiwww mass gOWdep%wafer/approvaJs/t5forms,htm#Inspect i5rorm4.doa'oaros `' Sy:tem Pumping Record Page I of I t J . , ��Yrafi o tt t 1 u ✓� �f� {MIS y,���'+ �✓f 4,st�',��,yN+, `rub,, t,., tt �4'rMM0.hN � ,Qf M asachusetts t MASSACHUSETTS �:aCitylown of'NORTH ANDOVER, a: Syst Trp,pq Record, Form 4 DEP has provided this form for use by local Boards of Health. The System PumpJpg Record must be submitted to the local Board of Health or other approving a thor f, k Facility Information N0`J 1 U 2011 VAwOr,o,ui 1. System Location, ',)DV) nQ forms on the / f/ TOWN OF NORTH ANDOVE cornptrter,use 1� ' 2 ENT only the tab key Address to move your cursor•do W:. CRyfrstate Zip Code own use the refto _ key..... 2. System Owner. - .. OolUg� Na""I Lf'7 0c)h n.n CA Address(If differen from location) ,yam CmiRown- state Zip Code Telephone Number M Pumping Record We ) �.( 2. Quantity Pumped: Date of Pumping 3. Type of system. [] Cesspools) Septic Tank ❑ Tight Tank ❑ Other(describe), 4. Effluent Tae Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No 5.' Condition of System: Vehicle Uoense Number 7. Lmtlon� re contents were disposed: T rnt ( �fto n�a 3lprwtun of Date hdpjtwww.mass.gov/deptwater,lapprovwsttSforms.htm#lnspect t5form4.doc,08103 system Pumping Record•Page 1 of t