HomeMy WebLinkAboutMiscellaneous - 148 STONECLEAVE ROAD 4/30/2018 (2) MgTONECLEAVEROAD .)ad
2101104.B-0127-0^0'0.0` --
NORiq
` 6668
F _ 9
Town of North Andover
HEALTH DEPARTMENT
,SSACHUSEt
CHECK#:(J� 9 DAT :� 3
LOCATION kV
H/O NAME:
CONTRACTOR NAME: So I C t L�x
Type of Permit or License:(Check box)
❑ Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service-Type: $
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal(Septic)Hauler $
❑ Recreational Camp $
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ Trash/Solid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
Title 5 Report
❑ Other. (Indicate) $
1�
Health Agent Initials
White-Applicant Yellow-Health Pink-Treasurer
Commonwealth of Massachusetts
Title 5 Official Inspection Form �3
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
' J2
148 Stonecleave Road
Property Address
John Grant
Owner Owner's Name
information is
required for every North Andover MA 01854 11/20/13
page. Citylrown 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: DEC 0 2 2013
key to move your
cursor-do not John J. Soucy T
use the return OWN OF NGR'i�-i ANDOVER
key. Name of Inspector HEALTH DEPARTMENT
Soucy's Sewer Service, Inc.
Company Name
78 North Broadway
Company Address
Salem NH 03079
Citylrown State Zip Code
603-898-9339 13397
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ e ds urther Evaluation by the Local Approving Authority
11/20/13
Insp tor's Signature
The system inspector shall sub /acopy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner ._
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
r
Commonwealth of Massachusetts
HWee= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
148 Stonecleave Road
Property Address
John Grant
Owner Owner's Name
information is
required for every North Andover MA 01854 11/20/13
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 Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
148 Stonecleave Road
Property Address
John Grant
Owner Owner's Name
information is
required for every North Andover MA 01854 11/20/13
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):
❑ 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 b the Board of Health:
) q Y
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
148 Stonecleave Road
Property Address
John Grant
Owner Owner's Name
information is
required for every North Andover MA 01854 11/20/13
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
k Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
148 Stonecleave Road
Property Address
John Grant
Owner Owner's Name
information is
required for every North Andover MA 01854 11/20/13
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
H Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
148 Stonecleave Road
Property Address
John Grant
Owner Owner's Name
information is
required for every North Andover MA 01854 11/20/13
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
148 Stonecleave Road
Property Address
John Grant
Owner Owner's Name
information is
required for every North Andover MA 01854 11/20/13
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage (gpd)): well
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
= Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
GSM , 148 Stonecleave Road
Property Address
John Grant
Owner Owner's Name
information is
required for every North Andover MA 01854 11/20/13
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: current
Date
Other(describe below):
General Information
Pumping Records:
Source of information: Soucy's Sewer Service
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1000
gallons
How was quantity pumped determined? gauge on truck
Reason for pumping: Maintenance and Inspection
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
v
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 148 Stonecleave Road
Property Address
John Grant
Owner Owner's Name
information is
required for every North Andover MA 01854 11/20/13
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
1978
Were sewage odors detected when arriving at the site? ElYes ® No
Building Sewer(locate on site plan):
Depth below grade: 20feet
Material of construction:
® cast iron ❑ 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 100'
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 10"feet
Material of construction:
concrete metal fiberglasspolyethylene other ex Iain
® ❑ ❑ 9 ❑ ❑ (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
N v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 148 Stonecleave Road
Property Address
John Grant
Owner Owner's Name
information is
required for every North Andover MA 01854 11/20/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
40"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
7"
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? Tape and sludge tool
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pump tank annually
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
a
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 148 Stonecleave Road
Property Address
John Grant
Owner Owner's Name
information is
required for every North Andover MA 01854 11/20/13
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.):
Static level good, structurally sound, baffels good.
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•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
,^M 148 Stonecleave Road
Property Address
John Grant
Owner Owner's Name
information is
required for every North Andover MA 01854 11/20/13
page. Cityfrown 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.):
"D: box replaced and inspected prior to Title 5 inspection, see permit.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins.3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 12 of 17
a
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 148 Stonecleave Road
Property Address
John Grant
Owner Owner's Name
information is
required for every North Andover MA 01854 11/20/13
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:
20'X45' (900W)
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
No signs of hydraulic failure.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-3(13 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 Stonecleave Road
Property Address
John Grant
Owner Owner's Name
information is
required for every North Andover MA 01854 11/20/13
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 148 Stonecleave Road
Property Address
John Grant
Owner Owner's Name
information is
required for every North Andover MA 01854 11/20/13
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 -
_ I
�sEPti BA,ef,ZAC—A//a
_SeorT /�'foV�kT/ S._
WEST b✓AR D C•/R--CCF_ c r - -•.3S C E%V TE.P S_f,_____..._..._
e•�PEA.�/.v� /yJAss• _ _ �r,e�?.LiNf ri.ni`�L+S_5___.
S /N GRauND P2A1Y
R 7- �c�
Cl)ty NuT Z.cAfe
I
t
:rc_SEVTIt .TAN/l
s` 1 O l��aSO Q S
ti,� •-,.�,x, Exi.$j�t:,7E.•/f//JCr v� � _ v„ , �s��s�H�rssvr''o `�`".
p Pip
o
ELSV 9T/o NS
Nit 5- /35.0
?AA/A/ Qz-CT 134�G
aur l. y ice:
I
c TO,njc C'/a f
15ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
c
Commonwealth of Massachusetts
z Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
148 Stonecleave Road
Property Address
John Grant
Owner Owner's Name
information is
required for every North Andover MA 01854 11/20/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: 6'feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Dug hole with auger in low drop off area, behind bed, no water at 5'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
x = v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
;M 148 Stonecleave Road
Property Address
John Grant
Owner Owner's Name
information is
required for every North Andover MA 01854 11/20/13
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
i
DATE OF SERVIC COMPLETE SEWER-SEPTIC SERVICE INVOICE
///a f &3 78 N. Broadway(Rt. 28), Salem, NH 03079 -/
CUSTOMER NAME - Serving MA & NH
BILLING ADDRESS elf
CTYSTATE ZIP PHONE: 800-541 -9379
V,6'4'
17f Come visit us at
JOB ADDRESS IF DIFFERENT THAN BILLING ADDRESS
ADDRESS STATE ZIP www.soucysewer.com
DESCRIPTION OF WORK
VACUUM PUMP
❑ SEPTIC TANK GALS. ❑ CESSPOOL ❑ OVERALL SYSTEM
❑ DRYWELL ❑ BASEMENT ❑ FAILED SYSTEM
COMMENTS
TERMS OF PAYMENT TYPE OF SERVICE TAX EXEMPT
CASH ❑ RES/COMM ❑ TAX
INDUSTRIAL❑
CHECK ❑ CHARGE ❑ PLUMBING ❑ TOTAL $ �oU,
JOB COMPLETION
This is to acknowledge completion of the above work which has been done to my satisfaction.We will assume no responsibility for any damage
made to sprinkler, lawn, bush, driveway, curb or walkway.Any form of payment provided by the customer constitutes a binding signature of this
invoice and assumes all responsibility for payment in full,along with any collection or reasonable attorney fees on outstanding balances.
DATE CUSTOMER SIGNATURE SERVICEMAN'S NAME
i
0 -
�
• ��r
��RATEDA44`
PUBLIC HEALTH DEPARTMENT
Town of North Andover
Community Development Division
CERTIFICATE OF.
COMPLIANCE
As of: 11/19/13
This is to certify that the individual subsurface disposal system received a
SATISFACTORY INSPECTION of the:
D-Box
By: John Soucy
At:
148 Stonedeave Road
Map 104•B Lot 0127
f North Andover, MA 01845
Tkfli ssuance of this c r�'tificate s%1l not be construed as a guarantee that the system will function satisfactorily.
Michele Grant
Public Health Agent
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
• S�,TTLEb)syc .
North Andover Health Department
Community Development Division
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATIONINF RMATION
ADDRE S: \O, MAP: �(� .� LOT:
INSTALLER:
DESIGNER:
PLAN DATE:
BOH APPROVAL DATE ON PLAN:
INSPECTIONS ` Y S C-�
TANK INSPECTION:
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
❑ Contractor reports any changes to design plan
❑ Existing septic tank properly abandoned
❑ Internal plumbing all to one building sewer
❑ Topography not appreciably altered
Comments:
SEPTIC TANK
❑ Building sewer in continuous grade, on
compacted firm base
❑ Cleanouts per plan
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ 1500 gallon tank has been installed
H-10 loading
❑ Monolithic tank construction
❑ Water tightness of tank has been achieved by
visual testing
❑ Inlet tee installed, centered under access port
❑ Outlet tee installed, centered under access port
(gas baffle/effluent filter)
❑ inch cover to within 6" of finish grade
installed over one access port
❑ Hydraulic cement around inlet & outlet
Comments:
PUMP CHAMBER
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ 1500 gallon Pump Chamber installed
❑ H-10 loading
❑ Monolithic tank construction
❑ Inlet tee installed, centered under access port
❑ Pump(s) installed on stable base
❑ Alarm float working
❑ Pump On/Off floats working
❑ Separate on/off floats
❑ Drain hole in pressure line
❑ cover at final grade installed over pump
access port
❑ Water tightness of tank has been achieved by
testing
ElHydraulic 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)
Comments: �� ��
{ m y �� �'�"s'•�.»v��* *"y r a. 1�...� r Pte. � �. � r�'�
r h A
�" f.1t ,•:��,3r'�., !.fin
ty r
{f �
.Z
r^per 7`�
a
f i
a g$
A • i
1
'�• � � � t r yah.
y J'
• I/
�c
. _ s
Abovt;PV4
�l•' 4-
' -� l� _ •z � '�•n�" fir;
At t � a
3 F
_.! s r it �� �:k �� ' , ➢i, { �i� {� , {
t , �;.# 4-110 It t:
4` k 1a l
)o{
Aij11! F
+ S '` Vt
a 5
Tj
s '
f
4 �
If
r
�� *V
A
>
(r� r
y
{ k
r�
1 ... at.rbc e � .. •z.. -o-:;."1 .yy{ - �` .:.
Blackburn, Lisa
From: Sawyer, Susan
Sent: Friday, November 15, 2013 10:06 AM
To: Blackburn, Lisa; Grant, Michele
Subject: d box 148 Stonecleve
John Soucy called.The D-box at 148 Stonecleve is done.
There is plywood over it, so there is no safety issue.
The inspection can be done Monday or Tues. if we are busy today...which we are.
Told John we would call him when it is done.
S
a
Susan Sawyer 2
Public Health Director
Town of North Andover ; V✓✓
1600 Osgood Street �L
Suite 2035
North Andover,MA 01845
Phone 978.688.9540
Fax 978.688.8476
Email mailto:ssawyer@townofnorthandover.com
Web www.TownofNorthAndover.com
Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records. For more information please refer to:
hftp://www.sec.state.ma.us/pre/preidx.htm.
Please consider the environment before printing this email.
1
_ ► I►� I �
Commonwealth of Massachusetts Map-Block-Lot
• 104.B0127
BOARD OF HEALTH Permit No
BHP-2013-1030
North Andover
P.I. FEE
F.I. $125.00
-----------------------
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted John Soucy
---------------------------------------------------------------------------------------------
_..� to(Repair)an Individual Sewage Disposal System. lb—fty,
at No 148 STONECLEAVE ROAD
as shown on the application for Disposal Works Construction Permit N:�e
HP-2013-103 ated..------ emb r
�' 12 91
2013
Issued On:Nov-12-2013 BOARD OF HEALTH
HORTp
A 6639
0
•�ria :.
Town of North Andover
:o HEALTH DEPARTMENT
S�CNUSt
CHECK#• DATE: 1111r7-q1-!!2
LOCATION:
H/O NAME:
CONTRACTOR NAME: QY
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 Yo Septic Disposal Works Construction(DWC) $1�
❑�, Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
❑ Title 5 Report $
❑ Other. (Indicate) $
Health Agent Initials
White-Applicant Yellow-Health Pink-Treasurer
• "��' . Commonwealth of Massachusetts Map-Block-Lot
a -- 104.B0127
BOARD OF HEALTH
----------------
Permit No
North Andover BHP-2013-1030-----------------------
FEE
HP-2o1s-1o3oFEE
$125.00
-----------------------
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted JOhn-SOWY---------------------------------------------------------------------------------------------
to(Repair)an Individual Sewage Disposal System. x
at No 148 STONECLEAVE ROAD
----------------------------------------------------------------------------------------------------------------------------------------------------------
as shown on the application for Disposal Works Construction Permit No. BHP-2013-103 Dated November 12,2013
---------------------
Issued On:Nov-12-2013
--------------------------------------- FILBOARD 0 �XALTH
MOR7
6669
e. Of w• �h0 d
w
Town of North Andover '
HEALTH DEPARTMENT
CHECK#: J DATE: I
LOCATION:
H/O NAME:
CONTRACTOR NAME: a.os
Type of Permit or License:(Check box)
❑ Animal $
S
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service-Type: $
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal(Septic)Hauler $
❑ Recreational Camp $
r
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ Trash/Solid Waste Hauler $
❑ Well Construction $
is
SEPTIC Systems:
❑ Septic-Soil Testing $
❑ Septic-Design Approval
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
a
}
N°R1116.,N Application for Septic Disposal System c
-` Construction Permit - TOWN OF ToY ATE
^e .'
$250.00—
Full Repair
3••o- y ORTH ANDOVER, MA 01845
"Ssa���SEs, $125.00-Component
Important ApOication is hereby made fora permit to:
tones on the ut Construct a new onsite sewage disposal system*
computer,use VRepair
epair or replace an existing on-site sewage disposal system*
only the tab key �l
to move your or replace an existing system component—What? /L 20 n 60k—
cursor-do not
use the return A. Facility information
key.
r Address or LotAle
t# /� /�
14 KI�1/.I[C V9A
City/Town
2.-*TYPE OF SEPTIC SYSTEM*-
❑ Pump Gravity(choose one)
J**If pump system,attach copy of electrical permit to application***
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)(Attach Draft Maintenance Agreement)
❑Pressure Dosed(D-Box Present)S.A.S.
2. Owner Information
r� �
Name
Address(if different from above)
City/town state.
Zip Code
Telephone Number
3. Installer Information
Name 9 Name of Comp y
Address
City/Town State i rk• C9�U'7
^� Zip Code 7
Telephone Number(Cell Phone#IF possible p/ase)
a. Des! ner 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
Z c 9r%l w,
°STM Application for Septic Disposal System
�j ooL
T6PAY,g DATE
. = AConstruction Permit - TOWN OF
ORTH $250.00-Full Repair
p.,. 4y ANDOVER MA 01845
�4SS�cwu5E4 $125.00-Component
PAGE 2OF2
s
A. Facility Informationcontinued...
5. Type of Building: esidential Dwelling or[]Comma-;-'
B. Agreement. �bed
The and gned agnr
on-site sewage wage dispo.
Environ ta/Code, _ _ win Of
North d ver,and n -----Ice has
lee ss d by this nc 1
ame
Applica' n Approve. j m /j r S
_-
Na �
Appli tion Did
ppro di, f
r/9 71..'a-,s—
For
SlFor Office Use Only:
L Fee Attached. -- f
Z. Project Manager Obligation Form Ai,----
3. Pump 3 stemP If so,Attach cony ofl
4. Foundation As Built. (hew const-.u I._
(Same scale as approved plan)
.5 Floor Plans?(hew construction oniyi
i
Application for Disposal System Construction Permit•Page 2 of 2
of N�T� Application for Septic Disposal System 111,h?
.' oc DATE
. = ..• AConstruction Permit - TOWN OF
MA 01845 25o.00—Full Repair
ORTH ANDOVER
�,SSA�N�s�g�h $125.00-Component
PAGE 2OF2
A. Facility Information jeontinued....
5. Tyne of Building: esidential Dwelling or[]Commercial
B.. Agreement
The undersigned agrees to ensure the construction and maintenance of the afore-described
on-site sewage disposal system in accordance with the provisions of Title 5 of the
Environ tat Code,as well as the Local Subsurface Disposal Regulations for the Town of
North d ver,and not to lace the system in operation un7,-/c
e 'icate of Compliance has
be ss� d by this Boar f Health.
+9 vG l
ame Date
Applicati n Approve y: (Board of Health Representative)
�//,
Na� Date
Appli tion D pproVdforhe following reasons:
For Office Use Only:
1. Fee Attached.; i` Yes�� No .
2. Project Manager Obligation Form Attached.; s No
3. Pump S sv tem? Ifso,Attach copy ofElectrical Permit Yes No
4. Foundation As Built?(new constnuction ronly): Yes No
(Same scale as approved plan)
.5 Floor Plans?(hew construction only). YeoNo
Application for Disposal System Construction Permit•Page 2 of 2
TO: NORTH ANDOVER, MASS -7 l 19 7 (T
BOARD OF HEALTH
FROM: DESIGN ENGINEER Re: Soil Absorption Sewage
System Inspection
This is to certify that I have inspected the construction of the said disposal system at
�57-01YefCZver, Mass.
SITE LOCATION \,,4SUNO/S.0
The grades and construction are as specified in my pl Pe • s dated
t9V "IN
19 �, o�w�tlaa�e
J' H 3S0( ?�
g. Pr ?��/. S nitarian
!/✓_�_T tNA D C/��L� _ -�S..C,�/Y Tom' ��.�__...._.____....._....
S �N GRauiv L `7LI7
t
` o r 9
C� N NuT Lac�7'�
G . 121. 00-
a�,o�ss3�o�d �
Ap , oK
}
7 W A/ dZ-(T t 3�J,44
s
I
NORTH ANDOVER BOARD OF HEALTH
INSTALLATION CHECK LIST
APPROVED DATE DISAPPROVn DATE 44XCAVATION. OK
REASONS•
"1
FAIL OK
Wetlands
Drains
Well
Water Line Location
3. No PVC Pipe �.
4. eptic Tank
Tees - Length & To Clean Out Coverst', •�
Cement Pipe to Tank - On Both Sides of Tank tf,
5. Diribution Box
Cover & Box - No Cracks
All Lines Flowing Equal Amounts 0,4. tv
No Back Flow
h. Leach field or Trench 711
�mensions a�4
6ne Depth '
ed Ends
n Double Washed Stone �j
7. Leach Pits -��-'`�I�`"�' )
Dimensions
Stone Depth
Splash PadsM
Tees r
Cement Pipe to Pit - Both Sides
Clean Double Washed Stone
No Garage Disposal
Fina GradinInspection �,. 7_1 z
10. Barrac adin Covered System
j(11 . As- - Built fitted
ocation
Dimensions of System
Location with Regard to Perc Test
Elevations
Water Table
f
TOWN OF NORTH ANDOVE; ,
UA rk SYS78M PUMPINQ MCOKU
S ST M OWNER dt ADDRESS
SYSTEM IOCATIQIJ
4"
eP. o
DATE QA Pl �#Q; �J _QUA N'MTY PUMPED:-
� .... .... . .
�'�:�SAOUL: NO, YES
.. 5npuc 1'cnk: NU
Es
NA fUKU ON seRYtCE: gou'fiNk...._ (AF����:
JUN 0 3 2005
00OD CONDITION � PULL 'M (. vER [HEALTHIvU"N OF
�AYY Q ry~�'a�h�+,ER
SA E$ IN Pt,A(;f DEPAFiTME^dT
ROCrt'S w ._, LEACKKUD RUNBACK
OXCE381VE SOLIDS ._... FLOODED
SOLrDCARRYOYLR OTHER EXP LAiN -
VVMMENTS,
t'uN!'EN'!'� f1tAN�P�K�iD 1'l!
i
�L\ Commonwealth of Massachusetts
P. = City/Town of NORTH AND MAS Cl1S
System Pumping Record E�'
Form 4 MAY 19 2008
DEP has provided this form for use by local Boards of Heal t . The System Pum Record must
be submitted to the local Board of Health or other,approving"M_w 10RTH AND vE
H HLTi'DEPARTMENT
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer,use N + �s1 a �' 4 s f✓ �= t! �'b
only the tab key dyes.
to move your , . C.t �s
cursor-do not City/Town state Zip Code
use the return
key. 2. System Owner:
vow
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ~ tet-` '� 2. Quantity Pumped:
Date GaU s
I Type of system: ❑ Cesspoof(s) � Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
C�—CC =a
6. System Pumped By:
Name
4`` Vehicle License Number
w4 1 sC J�•t v 31 P<.� �?+ j 'i c '
Company
7. Location where contents were disposed:
Signature of Hauler Date
httP://www.mass.gov/dep/Water/approvals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
R -- ACGE•SS M/A VY0e.E'S TO F �.� BEcow 6,egDE �¢/�/• OR LE55�
¢n
B' \
4 /O'• � E DE rA/L S S�4owwLurH
LEVEL OA! THis PLAN SNEEr
o e A,,CE TYPICAL DE7,4/L S
C,4Sr I,eo.,/ TEE a
OFA CE,2TA/�/ /t�1AN-
'• ¢"�CAST I,PON TEE u " UFRC T�/e0�2 . �Q U/✓A -
3'�4'. LE'wr �,PO0c/C7-S Ma✓
4
BF Su.Bsri ru rFp
Qt/e- Y W17- Ttif=
0
�lP.o.20(/,4L O,G' 0 TN
• � 4„ THE e�.a�� o�- NEALru
n 4"
a
AA/� THE DES/G.VE,e_
12 /YI/til. EL SUB-,6,4-56 - = /Z
cSEPr/C TANk c.S'ECT/O�l/ 4-A 5 ��
,c./or rO sco1e-E BSEP 7-1,-- TANK — cSEG r/O Az 8-.S
AAn7- To csCAL E
B'- a
e
0T%
.41 -
p z.,
77 7
��--. 1 I ► _2 z 2
h � a
GRAV4:5 '
�•a ' G�eAvEL Sua-B•GIS� Tie/81.1r/O/C/
' •• -err--, '_S�/B-,8�1 S E
3 'Box
,.
D/57-R/8Ur/6N D
BOX SET/DA./.S PLA ti!
SCA e-
cSEPT/C T,QNK PLAN
A107- TO cSCAG E
DETA/Ls FoR /000 6i,4e . CoAlc. SEPT/,f 7A-A11< n,,VC. D/Sr'R1Sar-10A1 BoxoF-
)04
��
_a..
". • ' •. -, , , ' . - - - ' '- . : _ • • . . _ - . . '. . - : . - tae EQU/vvGE,vTJ
' •• - - - s CAPPED ENDS
Z_�" C> S'-p" Z'- �1oE,eA2%eATED 5/7.-Fla.P/PE
�oe Ec?c//vACENr)
v
PA,2T/AL BED EA�ID SECT'!o KJ %
A,e
SCALE �2 _� D ��
�A ` 900s � N
(FORSPEC/F/CAT/Oit/S — SEE SECT/OA/ Ar LOWt-- e RA/ ;AIT)
D1sre 18LJT/OA/ &X v
,'F/,Q.ST LE,C/gTN OC-
0,
FO.005 P V 'C• PAPE cS�f-YA L- L
BIT. F/B. PIPE, -5°.OdS
AB.so/e PT1o/v ,BEo PL.A N
A.107- To cS�-.4LE
aSE[.EGT _
SE4L ED _
Oror,vr,
�CKFlLL �'
IA/ sue-J'o0.42
�/, � d f / � �f � i f �7- -•• - •� - - •. C,eUSNC'O STO.vee' . •• -
r r�► G �", ¢.,�PE�,�oeATED !} .
✓4Z 467A./7-
1Z I n G -f- - 3/¢' TO /�Z WASHED O
G,QUSNEL� STONE O N
� � �voUBLE NJASf/ED
ED
ro MEET A-.4.
^� ? '� _�..�!�:.�.'_-.��r _f� �1� 7`'••�'C.;r,��.r�1t'e'. 1IV SPEC. T'-//-Go•)
r s 7 x}N C,� � /�:o X .r o•a ,_ H BSD, P 7'/O N BE1� cS�EC T/O/tJ .
kYWZ7. � ' �.eDF/L E �Iti/� ;f iBS�.ePT�oN BEL) /SLA v Ati/A sEC T/O NS SHEE 7- oJAC
' AIL
��