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HomeMy WebLinkAboutMiscellaneous - 148 CROSSBOW LANE 4/30/2018 -,� 148 CROSSBOW LgNE 210/1 pg1�-0000.0 � =� - - - - - - -- ---__- 1 -.- J �� .10PTN 7253 ct r° .=r n Vp Town of North Andover HEALTH DEPARTMENT �ss�cNust4 CHECK#: DATE: 9 JJSJ I LOCATION: H/O NAME: c 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 $ ❑ TrashlSolid Waste Hauler $ ❑ Well Construction $ SEPTICSystems : ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ Title 5 Report $ U ❑ Other:(Indicate) $ Health Agent Initials i White-Applicant Yellow-Health Pink-Treasurer J'' 1 ,j 72E3 MORTM Town of North Andover HEALTH DEPARTMENT ,ss^CH�Stt. CHECK#: 41-P DATE: 9 LOCATION: H/O NAME: CONTRACTOR NAME:,Ii 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 $ V ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ > Title 5 Report $, ❑ Other. (Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer 3 Commonwealth of Massachusetts b �jIaE iCEI D Title 5 Official Inspection Form JUL 15 2015 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments TOWN OF NORTH AND wM 148 Cross Bow lane HEALTH DEPART / Property Address VL� Chris Mclaughlin eF Owner Owner's Name information is North Andover MA 01886 June 23,2015 required for 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:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not John DiVincenzo use the return Name of Inspector key. Stewarts Septic Serive � Company Name 58 South Kimball street Company Address Bradford MA 01835 City/Town State Zip Code 978-372-7471 S113386 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 , 4 ector's Signature Date he system inspectoshall sub it a copy of this inspection report to the Approving Authority (Board of Health or DEP)wi i ys of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 148 Cross Bow lane Property Address Chris Mclaughlin Owner Owner's Name information is required for every North Andover MA 01886 June 23 2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 2 of 17 ' Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 148 Cross Bow lane Property Address Chris Mclaughlin Owner Owner's Name information is required for every North Andover MA 01886 June 23 2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ® broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): needs outlet baffle and pipe leaching around outlet. ❑ 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 ' Commonwealth of Massachusetts u W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 148 Cross Bow lane Property Address Chris Mclaughlin Owner Owner's Name information is required for every North Andover MA 01886 June 23,2015 page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y day flow , t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 148 Cross Bow lane Property Address Chris Mclaughlin Owner Owner's Name information is required for every North Andover MA 01886 June 23 2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or ❑ ® tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 148 Cross Bow lane Property Address Chris Mclaughlin Owner Owner's Name information is required for every North Andover MA 01886 June 23,2015 page. City/Town 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): 600 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 ' Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 148 Cross Bow lane Property Address Chris Mclaughlin Owner Owner's Name information is required for every North Andover MA 01886 June 23,2015 page. City/Town State Zip Code Date of Inspection D. System Information j Description: Number of current residents: 2 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No i i Last date of occupancy: I Commercial/Industrial Flow Conditions: Type of Establishment: occupied Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 148 Cross Bow lane Property Address Chris Mclau9 hlin Owner Owner's Name information is required for eve North Andover MA 01886 June 23,2015 4 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): I General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No 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) Y) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w, 148 Cross Bow lane Property Address Chris Mclaughlin Owner Owner's Name information is required for every North Andover MA 01886 June 23 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 6/10/81 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 26" Depth below grade: Leet 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.): Septic Tank(locate on site plan): , Depth below grade: 14"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 148 Cross Bow lane Property Address Chris Mclaughlin Owner Owner's Name information is required for every North Andover MA 01886 June 23,2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 39" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Sludge judge &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.): Outlet T in place needs to be lowered liquid level low leakaing around tank. Outlet invert baffle good. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 5 148 Cross Bow lane Property Address Chris Mclaughlin Owner Owner's Name information is required for every North Andover MA 01886 June 23 2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): I Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 ' Commonwealth of Massachusetts _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w, 148 Cross Bow lane Property Address Chris Mclaughlin Owner Owner's Name information is required for every North Andover MA 01886 June 23,2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 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.): Equal dist no solids carryover no leakage. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 148 Cross Bow lane Property Address Chris Mclaughlin Owner Owner's Name information is required for every North Andover MA 01886 June 23,2015 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: 1-30x49 ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: i Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No hydraulic failure no ponding no damp soils. I Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert i Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection 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 148 Cross Bow lane Property Address Chris Mclaughlin Owner Owner's Name information is required for every North Andover MA 01886 June 23,2015 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 ' Commonwealth of Massachusetts -W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 148 Cross Bow lane Property Address Chris Mclaughlin Owner Owner's Name information is required for every North Andover MA 01886 June 23,2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 148 Cross Bow lane Property Address Chris Mclaughlin Owner Owner's Name information is required for every North Andover MA 01886 June 23,2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 7'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: 9/8/78 5/18/77Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Pulled file ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Taken from design plans on record water at elevation 106.50 bottom of bed at elevation 111.00 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 148 Cross Bow lane Property Address Chris Mclaughlin Owner Owner's Name information is required for every North Andover MA 01886 June 23,2015 page. Cityfrown 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 ;SUBSURFACE DISPOSAL SYSTEM AS - BUILT t LOT 12 , CROSSBO l' LANE ,\ ; 'DRTkJ ANLDOVER ' MA . DATE: 6- 10-81 i r - FL YAW5S0C. P. C. r PLAISTOW, NEVV Hf,.MPSH! I RE 03€ 65 p0 BOX 569 ,��-�` � •;ass b't�pF /S'T F�S/ONAL PROFILE SCALE : VERT : ("- 4 � ( DESIGN ELE.) (2 3.8 2 1 ( 117.17(! 17,10) 116.72(1)6.60) / 116.63 (116.40) (15,52 I (6.32 (116.17) i (SAME)117'80 11517(SAt,lE) ( II 7.30)117.27; II PLAN SCALE: -1 = 40' / i N.:jYE' SrE SURc:URFACE SYSTEM ;y DESIGN FOR LOT DINIENS O ?.IS ; AND COR'i`)URS. / i LOT 12 `. a % ,% i� � i -� �� / `\ i �; �i � 6-- ��;-' � rte; '. � ;� �,,. �4 �-�; `' �n �, � . \� ',�i � � � a � ;, M ;' i � %�' ��� � , I �.- 9N1�-� � Ma / ,. X1,5 I¢ . / �i �. • � ''.1 j ii ��� I 1 ,; • StisTt�u-yam, . ' FILE COPY PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 7/27/15 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Repair of line from tank to D-box and new baffle By: John DiVincenzo At: 148 Crossbow Lane Map106.B Lot 0117 North Andover, MA 01845 The Issuance of this cerhtf`cate shall iRot ,e construed as a guarantee that the system will function satisfactorily. Michele Grant ��j Public Health Agent 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com S ICEIY`j G North Andover Health Department Community and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 148 Crossbow Lane MAP: 106.B LOT: 0117 INSTALLER: John DiVincenzo DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: I INSPECTIONS Line from tank to D-box and new baffle INSPECTION: 7/24/15 DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ xisting septic tank_properly_abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION-BOX ❑ Installed on stable stone base ❑ H-20 D-Box ❑ Inlet tee (if pumped or >0.08'/foot) ❑ Hydraulic cement around inlet & outlets ❑ Observed even distribution ❑.,/ Speed levelers provided (not required) [vJ Schedule 40 PVC Pipe Comments: ) •' Commonwealth of Massachusetts Map-Block-Lot '. 106.80117 BOARD OF HEALTH Permit No North Andover -BHP-2015-0311---------------- ------ FEE $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted John D1Vincenzo to(Repair)an Individual Sewage Disposal System. at No 148-CROSSBOW-LANE __w -&----------------- as shown on the application for Disposal Works Construction Permit No. BHP-2015-031 Dated July 15,2015 ---------------------- ----------------------------- -------------- Issued On:Jul-15-2015 --------- PA ) OPTY A 7252 R: Of AAORTH _ 9 Town of North Andover HEALTH DEPARTMENT s�cNus CHECK#: DATE: LOCATION: H/O NAME: f AAt. khhk , CONTRACTOR NAME:, w v 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)-x $ ❑ Septic Disposal Works Installers(DWI) $ ❑ 'Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other:(Indicate) $ lf2 Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer i _ • Application for Septic Disposal System DATE Construction Permit — TOWN OF TODAY'S M—Full Repair NORTH ANDOVER, MA 01845 $2(115.0o Component Important: Application is hereby made for a permit to: When filling out ❑Construct a new on-site sewage disposal system* forms on the computer,use Repair or replace an existing on-site sewage disposal system* only the tab key to move your Repair or replace an existing system component—What? t j&e 7p h cursor-do not use the return A. Facilitv Inforion key 7p� "oz"g. Jl U 44.,) Address or Lot# ua Ne , City/Town 2.-*TYPE OF SE IC SYSTEM*: ➢ ❑ Pump Gravity(choose one) ***If pump fystem, attach copy of electrical permit to application*** ➢ M Conventional System (pipe and stone system) ➢ ❑ Infiltrator or Biodiffuser(Gravel-Less)(Attach a copy of your certification to install this type of system.) ➢ ❑ Pressure Distribution S.A.S.(No D-Box) ➢ ❑ Pressure Dosed(D-Box Present)S.A.S. ➢ ❑ Does the system require an effluent filter? Yes No If yes, does plan specify make and model of filter? YES =(no further info. needed) NO=(installer must specify brand of filter before DWC issuance) What is the Make? What is the Model. 2. Owner Inf rmation w ,� �✓ N me /fig' ✓b�s big t� Address(if different fro ab � ov ) � City/Town State Zip Code Email address Telephone Number 3. Innss�talle Information IN —L,91l11itJ�w'2_!� ��Gts/�G(�T.S ?�'l� Name Name of Company Jr Addre �/=,'!� City/Town State Zip Code Telephone Number(Cell Phone#if possible please) 4. Designer Information Name Name of Company Address City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit-Page 1 of 2 o w Application for Septic Disposal System TODAY'S DATE Construction Permit — TOWN OF $250.00—Full Repair NORTH ANDOVER, MA 01845- $125.00 -Component PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: ❑Residential Dwelling or❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sew ge disposal system in accordance with the provisions of Title 5 of the Enviro ntal Code, as well as the Local Subsurface Disposal Regulations for the Town of North ov r. I nderst d that until a final Certificate of Compliance has been issued by this o rd H h, th nstalled system is not approved. me Date ' App ion Appr By: (Bo d ealth Representativ h 4s] )�D Name / Date Application Disapproved for the following reasons: For Office Use Only: L Fee Attached? Yes No 2. Project Manager Obligation Form Attached. Yes No 3. Pump S sy tem? If so,Attach copy of Electrical Permit Yes No Applicant received copy of "Electrical Inspection Notes for Septic Systems" Yes No Handout? 4. Reviewed approval letter, all paperwork received? Yes No i Missing: 5. Foundation As-Built?(new construction only): Yes No (Same scale as approved plan) 6. Floor Plans?(new construction only): Yes No Application for Disposal System Construction Permit•Pae 2 of 2 pp p Y 9 SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: (Address of septic system) For plans by (Engineer) Relative to the application of IT(VA) (Installer's name) And dated (Originalate Dated 115 o ay s ate With revisions dated (Last revised date) I understand the following obligations for management of this project: 1. As the installer,I am obligated to obtain all permits and Board of Health approved plansrp for to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer,I must call for any and all inspections. If homeowner,contractor,project manager,or any other person not associated with my company schedules an inspection and the system is not ready,then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. 1 understand that requesting an inspection,without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a$50.00 fine being levied against me and/or my company. a. Bottom of Bed—Generally,this is the first (V5 inspection unless there is a retaining wall,which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection—Engineer must first do their inspection for elevations,ties, etc. As-built of verbal OK (or e-mail to: healthdept@townofnorthandover.com) from the engineer must be submitted to the Board of Health,after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system,all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade—Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer,I understand that only I may perform the work (other than simple excavation)and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible. 5. As the installer,I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the.sand and stone to be used. c. Final inspection by Board of Health staff or consultant. d. Installation of tank, D-Box,pipes, stone, vent,pump chamber, retaining wall and other components. 6. As the installer.I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner,general contractor,or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: � (To y's te) / ( ame—Print) ( e—Signed) �L\ Commonwealth of Massachusetts C� E. City/Town of No Andover System Pumping Recon Form 4 i9WN U►'t r ,,n ,: 'p LTN pit=., DEP has provided this form for use by local Boards of Health. Ot_erfirrnsTfnay 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. Aa Facility Intorrnation Important:When filling out fomes 1, System Location, on the computer, use only the tab 148 Crossbow Lane key to move your Address --�-�-�-,�-_-.—._--..-T---- -_--�-. cursor,do not No AndoverMA use the return key. City/Town State Zip Code 2. System Owner: - Mclughlin Name mNm Address(if different from location) City/Town State Zip lode 7 o t7P 28` Telephone Number B. Pumping Record 1. Date of Pumping --- l 2. Quantity Pumped: Date �,/ Gallons 3. Type of system: Q Cesspool(s) Septic Tank [ Tight Tank (� Grease Trap ❑ Other(describe): -V \ 4. Effluent Tee Filter present? El Yes o If yes, was it cleaned? Yes ❑ No 5. Condition of Sysiet is d 6. Syst�e Pumped By: Name vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart' Pre-treatment Plant, 20 Mill Bradford, Ma 01835 Sign ur o u er Date g tore of Receiving Facility Date t5form4.doc•03/06 System Pumping Record Page 1 of 1 RECEIVED &\ Commonwealth of Massachusetts JUL o 20 City/Town of No Andover ` 13 System Pumping Record TO HEALTH DWN OF EPARTMENT NT HEALTH DEPARTMENT u,p OVER 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 Important:When filling out forms 1. System Location: on the computer, u I�n use only the tab � / � �l/OS key to move your Address j cursor-do not No andover use the return City/Town Ma key. State Zip Code 2. System Owner: C Name nes Address(if different from location) City/Town State Zip Code Telephone Number R. Pumping Record 1. Date of Pumping pate 2• Quantity Pumped: Gallons 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 Pumped By: Name Vehicle License Number -- Stewart's Septic Service Company 7. Location where contents were disposed: SteW. -treatment Plant, 20 So. Mill Bradford Ma 01835 Date Signature f Receiving Facility t5form4.doc•03/06 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of No.Andover } W° 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 !an Important: j V �� U U11 When filling out 1. System Location: forms on theC TOWN OF NORTH ANDOVER computer, use DEPARTMENI only the tab key Address to move your No.Andover Ma 01810 cursor-do not use the return City/Town State Zip Code key. 2. System Owner: tab Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping / /� 2. Quantity Pumped: �� L- Da to Gallons 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. S s m Pumped By: Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stpvjo Q Pre-treatment ant, 20 So. Mill Bradford, Ma 01835 1Wn1Ao(HaffeAV V Date� Signature of Re iving Facility Date y. t5form4.doc•03/06 System Pumping Record•Page 1 of 1 TOWN OF NORTH ANDOVER SYSTEM PUMPLNG RECORD DATE: S1 STEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) Z?Ac,k DATE OF PUMPING: QUANTITY PUMPED GALLONS CLSSI OOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY 013SERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTE:'11 PUMPED BY: CONIMENTS: CONTENTS TRANSFERRED TO: i FORM U - LOT RELEASE FORM ' INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from fs; Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. **II*,_****�******APPLICANT FILLSOUT THIS SECTION ******* APPLICANT C !VI✓1�1 I✓I y /e � I I PHONE .j k6" 7�,-I, LOCATION: Assessor's Map Number /0(g a PARCEL 17 SUBDIVISION---TklAa11 (,vv 1,S i � LOT(S) STREET r0 SS 6 0W La VI -e_ ST. NUMBER— ***** OFFICIAL USE ONLY 4NSERECMMENDATIONS .TOW AGENTS: RVATION ADMINIS TOR DATE APPROVED b DATE REJECTED COMMENTS—fio (11PiT1 andsn�6 6 _�,�. ��_W �c�� 10 Z}/ TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS--------- ------ ----- -- FOOD INSPECTO H TK..._ DATE APPROVED DATE REJECTED L�l�— `�SEPTIC INSPECTOR-HEALTH DATE APPROVED _ DATE REJECTED__ COMMENTS GLV PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT — RECEIVED BY BUILDING INSPECTOR _— — DATE_ Revised 9197 jm r 1 t ,vt•7>`((9,�Lt'/l�rlr�''.rl'ftj,`rrV�l•:.,.; .. .. ����, •r.� lu;; �•�r,4tr ,wpr,: 't� � ',r i1'r' '•'v:Pq'.y,1.b r 0R( A111D0VE, � Mqg t SACHUSETTS I�Vy1Cecord. . :,'�,v,y;V. '� '.SrO.'iS�, .Y�Y, �'w�l'���t��•,(ly�,�{�y(�/]� �1J�11r1,`++,;,,,•, r• „ •:I•. :'!1rlr.r, Vit 1'J.r'' 1�5 al��;�r,rq,:^: n.nYi1J' Y.',r: • r.l>,�1,,,li tij�„+ l ,,l.,rl'r;'vF. .''ly6n1.1�v•r,1�('ar.�i:.','' DEF,.has provided jhla form for use by local Boards o be aubml�ad to t.he.local'Board o/ t stem Pu Health or other a P rovl 8,uthorl y p1�9 tyInform'a lon Lm RQr J+,r Wh4n(Ult/1�OUtSystem Locatlon: Only the tab koy Ad '103) amore you.. �i��• lX.�/�Gy�-lJ2/ — alnor r do'I1w1Y, " .Cl /T1wnQ J TP I WW m'4?•`'i t• ,;`��,+,� 1'''r.rn) rr,+,'.,:,r , .;'.. .I. ' `�''{' �Y+ jl 1i t\ , J / .. •11. ," ,, '1 -,• , Coe �.SY318M Owner • •1'.'•`?{rr.� ��,\�)G. ((''iri��,ri,f�'ti.J srr• r ,•��i 1,+; •1•,�w�+, '1l�r nt,,t.,. .... . . t. J'.:�,.y y'f_(1:',v'••„w�.:,..•, i' li;,i• � ////}}}} , irT11 4..'. — 7777. reti(I(dtNerrnt rom bcsUon) Slat�j _ //p Cone —_ Tolophone Number '-- — :•;: 6x-Pumplg'R�'``e�ord J, � , ,1 r fiya�tl�frr I/7rt�,li,lPiLrr�'}fl�l.i,f'•y� ' j '%•''•, '7t l�lj'i J;;�;'•''�•'% Q of Pumpinq+ 2, Quant) cv Dole ry Pumped: 0 Cesspool($) eptic Tank:'�•�' TI9ht Tank ;.Q�.0ther(d03'O'dbafit/1 ' •�"';'�ijrl\II;\�/j7�./yr,..y,l ri'r.;,.. ,' r.S• �•1 .'i's :,/•' ;4rV''.Efflut3ri� Tee Fllta(' resent?..❑ Yes bllo cleaned? Q [� ;,�, ,.' ". ;;';,�.�rJ:, �, , :.,. P,.• �/ Yes Np IV(,l;':Y�;r �11�l,CGnd��1Gn.Q.( y; 'm,,�,t.',' . ... :y.^�,tyg:;• ljv vht ltn',Y�r'J'/(:iJ.IIJ,i7 I 'lL,�li.4,1{J`,i/:•�,'" -------------- Od ,�. �.f,'r 'rb 1�I'�tlJ'JJ''J'¢•!'f�'!.'���d':.4<i„�i. ••Y' I _ � "'"_'i ., .••.,,,�• •!fir,;,7r,+�l t~��./;-jil"::+f�i,' ',:Pt+J.11'(•(,1�•�'i, L . ;�•:.?• �••' ,'r;�':j��e4,J:.`rY,>i+,�,; �1� ',��, � ,d,�,t 4j,Jh.`�''+1��',�':: .,^1 � V9hIC�6 �1 +9 NulTlb6r `�r:� •j.Y++�-'�>.,�;`r,?'yY�';/�'ti� ,1U�• .�7;�t'•� �'i�c� '.i' JT. �n ' ..t�:,.� ,•.'r„(�r(�.i i i�;l.�,\�Yaf�f�� r�i��,.,,��tr, 'j�+���.+1`�{%1��,,.1�1 �,':Y;�,' �-. ,�' �.�•, o whey@ i� 1.;,T:�,,;�; :�,�' :. . (.r:�,.;r•'' ::,:,7, LoCB n. conl�nts'w e',disposed; ,�. � (i':,I'.: �,;...I•, •'.c','(.'.1i--.lr--Jf��� `�I1DD..N i�'i<1' :��;,t)' ,� • 7. �.,._ ,,; ,�. ,^.L•• :. :S'j: ;, . .I,:• 'div � ": , :•,• ',`. .,F,',11`.i3i'1`;:��,. 1r:•V.�'�'r't',' ',(+•/.4,h',��,t:�:J^�t,1'.l!�d'Y.�.4:f•'�•:''. .: ��, / t I wnrd;!1 JI' ;`:•i:',1`�j;':��•:'�)3,,(�, �.r•S'tQ/11�U1/OI H1Ute(��`�ilf�;'t,.y..:;.,•'' l)ol ', ' :nt>�:/hvww,mass,BoV%dep!vreler/apprCvaJs/t6(orms,hfm#Inspect � fcrrr kdoa O�QJ „ . SMOrn Pumping ROWM P ;a . �6 a 1 Nei ;,...� t*'7.1•+pl�!}Mii 1`t..�•,L v! s� � .'. I ':. 80 46,A M USE T-T ; TOWN OF 1,1,4' y NOR TH ANDOVER (, r' i fi�''I(1, HEALTH DEPARTMENT- 1;4P, D S P,h ori Pt Idld lhl+ lolls Iol " :vrnl119d Io 0i Ioc+l B ,r '/ o.;ul BoerC+ 0/ p/ CIIIOr rA?rOrrn '.. ^V $� I:a.�i A' FaClll ty C I .Inprlry In(orm��lon ' I: �`J'il.r!'\.fl,/r„',, '' ''1(+'�iOwr�' I'� I �''• , iii ':--- ,1 •ISyria '1• + . ', :'��%'i '•14.����'Yi��r�>'i:,Y�J',.i.m�Ojwnlor,.;.���.�,., • `� 1 1I,J V'1,� i' v' 'S x,1,•1'.,• .,'1•' V Irini Iwn IouU9n) IT -PIumP�nB'�egord ly�,''`� 1. Oele of PvmDinp� ' ,�A '. , J. • 'rY9� of �y��lvm,�;,• � Co>>�ool(�l g� r • er �I: a� 1904 r ' ,�Q�OlhoJ�(deacrtbe•� '� 'sal l a . Y a," E erj(I rr� �III�� rr1 flrir,, .% Y8). O'911IC:080dp� 1 PWd10M`q •I %'• •l,y�.,'1'S';r''yiy7 r"'',�'ii i5�';I�',1n , ! GG 1 G �� � ri� • ,�• ,I,/1 :, ,y,lr�"' rll�rl�`'�� ir`i J' ''I r� 1' , � .. I �f�l'1 � ' I' f �►�I ' .r• •',,��J^JI,"�;11y�, ff'!„)` , i ..1, �''t�J,l'�''I•r'` «�,)+1 �111i115v1(r�,Jll ��I"�Jj�l,� ����!!I;', / ooa ron�wher�,00plb�la' ''' 1 .. •. -1. '',': :'�„J,,,y�i, '��",.J,.v Ib�s�I,t ,I�,oio ohposo/a: ,� �.porldeA 'aieilaD�roYtl�lblorm�.r,,maln�o'ocl �lil � F COMMONWEALTH OF MASSACHUSETTS t EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTEC „`� ONE WINTER STREET. BOSTON. MA 02108 617-292-550 (99 r` � 3 FQ� WILLIAM F.WELD T COXE Govemo: Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A ! CERTIFICATION/6kjoo Y4-1 Property Address: / � SS /J 0W Address.of Owner: Date of Inspection: U s (If different) Name of Inspector: ��✓✓ 1 am a DEP approved system inspector pursuaqt to Section 1 .340 of Title 5X310 CMR 15.000) Company Name: Pita J>``�` C� 7-I C� 4 Afp 6 vY✓ j.r/1 r - Mailing Address: 1.�^� J9& F-419D 3T` 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site s age disposal systems. The system: Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: " Date: ,,1�' . 7 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. 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. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (reviaad 04/25/97) Page 1 of 10 DEP on the World Wide Web: httpllwww.magnet.state,ma.us/dep Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A /'� CERTIFICATION (continued) �•JProperty Address: � e �j 4 v� eW � �U Owner: as a"oj/ Date of Inspection: 61 SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or.obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: f rj Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER •� WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE{ ENVIRONMENT: _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility,andrthe_ presence_ .of ammonia nitrogen and nitrate nitrogen-.is equal to or less than ppm.`Meihod used to determine distance (approximation not valid). 3) OTHER l (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) iF Property Address: Owner: Date of Inspection: D] SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded'or-dogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water,analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: 14 You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems 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: Yes . No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area-IWPA) or a mapped Zone II of a public water supply well) 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 04/25/97) Page 3 of 10. r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Date of Inspection: . aS Check if the following have been done: You must indicate either "Yes" or"No" as to each of the following: Yes No _ Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. f` As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. e/ The size and location of the Soil Absorption System on the site has been determined based on: The facility owner land occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)J (revised 04/2S/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C YSTEM INFORMA/�TI N}� ,. Property Address: j t.�/�i-d �� 'fit ` f��� � � f"T Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: g.p /bedroom for S.A.S. Number of bedrooms: Number of current residents: Garbage gnr:der (yes or no):-77� Laundry connected to system (yes or no):—`°' Seasonal use (yes or no):—­1"0 Water meter readings, if available (last two (2)year usage (gpd): Sump Pump (yes or no): ( Last date of occupancy: ,U f -P �L ') COMMERC I AUI N D USTRIAL• Type of establishment: Design flow: gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (,yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last,date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no) �S If yes, volume pumped: f 0 4 gallons Reason for pumping TYPE OSTEM Septic tank/distribution box/soil absorption system Single cesspool, Overflow cesspool Privy Shared s stem (yes or no) (if es, attach previous ins Y Y p inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) (revised 04/25/97) Page 5 of 20 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner:/ Date of Inspection: BUILDING SEWER: (Locate on site plan) „ Depth below grade: Material of construction: t/cast iron _40 PVC _other (explain) Distance from private water supply well or suction Irnf Q(i r•- fo ' Diameter C r� Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: ,PS (locate on site plan) p rr Depth below grade: _b Material of construction: — oncrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: /d rif f S� 7( .S Sludge depth: 1JI n Distance from top of sludge to bottom of outlet tee or baffle:3/ Y Scum thickness: 1,41 Distance from top of scum to top of outlet tee or baffle: 6 a Distance from bottom of scum to bottom of outlet tee or baffle:__ 4 How dimensions were determined: ©N SrT"-k 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.) —r F. G,r"� 4,v o n C o Tro rw/ - Al d L„eAR S — S U a GREASE TRAP: ,> (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)f Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revived 04/2S/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: f Owner: /J�� � 6 Date of Inspection. TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions: Capacity: gallons Design flow: gallons/day ( r Alarm level: Alarm in working order_Yes; _ No Date of previous.pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: �� (locate on site plan) Depth of liquid level above outlet invert: ' Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER:_ (locate on site plan) Pumps in working order: (Yes'or No)- Alarms o)Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/]5/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: f -5-7- X/ Date of Inspection: �_ Q SOIL ABSORPTION SYSTEM (SAS):-.'V^ (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: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil; signs of hydraulic failure, level of ponding, condition of vegetation, etc.) _ /4 U 1? eI+F" cs'1>�r e•cs CESSPOOLS: _ ! f ',4 (locate on site plan). r 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) a PRIVY:__ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,.etc.) (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4 Owner: Date of Inspection: q SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) •'+ , � ., CIA r rao _ ..._ r� Ap t (zaviaad 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ��1° l0//v sz 61 w Owner: Date of Inspection: )FO z Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health .. Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) 0(/l 4 ct ; F3 0 41 �► �e r c� JAI jrU �-rY rL- d � S�✓ � G G'� (rvimed 04/25/97) Page 10 of 10 Address Title of Fi:ie Page — of Date File Open: --_ Date FIe closed: Doc ------ Document/Action Title Date of action �oitu to other Purpose of 60"" e"tJAction and notes; Num. Document{ doeurruent/ Action De artment ------------ Board of Appeads — Board of Heal h Plannung Board _ Co nseruatiion commission -Boildin Department ,_____ _ UUpy L,U r UU111 •Ult\ .7 SUtSURFACE DISPOSAL SYSTEM CHECK LIST j NORTH ANDOVER BOARD OF .HEALTHC leo S-5 do Uj APPROVED DATE PROVIDED DISAPPROVED DATE TIME REASON Title 5 Reg. 2. 5 Fail OK The submitted plan must show as a minumum: e lot to be served (area,dimensions ,lot //,abutters) (Planning Board files) location and log of deep observation holes-distance to ties location and results of percolation tests-distance to ties design calculations & calculations showing required leaching area location and dimensions of system (including reserve area) - existing and proposed contours location of any wet areas within 100' of the sewage disposal system or- disclaimer (check wetlands mapping) surface and subsurface drains within 100' of sewage C disposal system or- disclaimer ; location of any drainage easements within 100' of sewage disposal system or disclaimer (planning board f files) known sources of water supply within 200' of sewage 1 disposal system or disclaimer location of any proposed well to serve the lot .(100' from leaching facility) j location of water lines on property (10' from leaching facilities) location of benchmark n driveways _ garbage disposers p no PVC is to be used in construction a profile of the system (elevations of basement , plumbers pipe septic tank, distribution box inlets and outlets, distribution field piping and any other elevations) aximum ground water elevation in area of sewage disposal system (s) plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans i Septic Tanks, Y Reg. 6 V(bCleanout ties -. 150% of flow, water table , tees, depth s, access, pumping, om cellar wall or inground swimming pool om subsurface drains -North Andover Subsurface disposal system check list - Page 2 Fail OK Distribution Boxes Reg.10.2 Slope greater than 0.08 Reg.10.4jo�b Sump Leaching Pits Leaching pits are preferred where the installation is possible Reg.11 .2 (a) Calculations of leaching area (minimum 500 S.F. ) Reg.11 .4 (b) Spacing Reg.11 .1 (c Surface drainage 2% Reg.11 .11 d Cover SSmaterial 411 Leachin Fields 3) Reg.15.1 (a) reater than 20 minutes/inch Reg.15.1 (b Area (minimum 900 S.F. ) Reg.15.4 Construction of field Reg.15.8 d Surface drainage 2% Reg. 3.7 (e 20' from- cellar wall or inground swimming pool Leaching Trenches Reg.14.1 (a) Calculations of leaching area (min. 500 S.F.) Reg.14.3 (b) Spacing (4 ft. min. 6 ft. with reserve between) Reg.14.4 (c Dimensions 14.5 Reg.14.6 (d Construction Reg.14.7 (e� Stone Reg.14.1 (f) Surface drainage 2% Dow .hill Slope fb ) Slope y/x = (to be shown) ) y/x X 150 = (to be shown) Pumpe i Reg. 9.1 (a Approval i Reg. 9.6 (b Stand-by power s f 1 i , i SOIL PROFILE & PERCOLATION TEST DATA Town/City o_ A JJ p, No.&Street LAC,p N YA C.(Q(_L_E Lot No. 10 Loc./Subdiv. 10 Gj LI-S cG5tky.,)P1 an Owner Investigator-,-T7 F>A-f?(3 (AG-A.L.L_n ObserverZE SOIL PROFILES-DATE t-/ !j 9 -n 1' Elev. �' Elev. 3' Elev. f 4.Elev. 0 1 0 `1 0 0 1 b.t2 i 1 1 1A-TA _ ��8e 2 2 2 2 3 3 3 3 4 4 4 4 Z t l Boer 4 a. Loi' Vo 5 5 �tLL 5 5 L �o 0 v �2S Q oc � v 6 6 6 6 7 o e 7 7 7 8 8 8 8 ' 9 9 9 9 10 1 10 10 10 Benchmark Location Elevation Datum Percolation Tests-Date�� Pit Number 1 2 3 4 5 Start Saturation Soak-Mins. Start Test-Time Dr.o ,of 3"-Time Drop '..of 6"-Time Min's.lst 3"Drop z Mins.2nd 3"Dro Notes & Sketches on Back Frank C. Gelinas & Associates, North And. Board ° Aealth North , SKPTIC SYSTEM V INST!lML TION CMK LIST LCT � I?_ DAT$ b- Ft?ff�7ED �AVkifdt+l - OK FAIL J sortsi �ra FAIL OK 1. Distance Tot a. Wetlands b. Drains c. Well 2. Dater Line Location 3• .No PVC Pipe 4: Septic Tank a. Tees --Length & To Clean flat Covers b. Cement Pipe to Tank - On Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Lines Flowing Equal Amounts c. No Back Flow 6. Leach Field or Trench a. Dimensions b. Stone Depth c. Capped Lads d. Clean Double Washed Stone f 7. Leach Pits a. ons b. S a Depth ---- c. lash Pads d Tees . Cent Pipe to Pit - Both Sides f. Clean Double Washed Stone 8. No Garbage Disposal � 9. .Final Grading Inspection 10. Barricading Covered System 11. As Built Submitted a. Lot Location b. Dimensions of System c. Location vith Regard-to Pere Test d. Elevations e: Water Table Commonwealth of Massachusetts Q Uo City/Town of NORTH ANDOVER MASSACHUSE S System Pumping_ Record Form 41 DEP has provided this form for use by local Boards of Health. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Location: C ��`�` fonts on the .���.� `M J computer,use only the tab key Address ,/''� +� move your c r^� cursor-return not ret use the City/rown State Zip Code key.,.. 2. System Owner. oLan I r n Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record l 1. Date of Pumping Date 0 2. Quantity Pumped: 161 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 of System: 6. 9ystern Pumped By: t-rGnK-- gop'M2 ame Vehicle License Number mpany 7. Locatio where contents were dispose ac) tJ Signature of Hauler Date http:/twww.mass. ov/de /water/a rovalstt5forms.htm#ins ect 9 P pp p t5fonn4.doc•06/03 System Pumping Record•Page 1 of 1