The URL can be used to link to this page

Home My WebLink AboutMiscellaneous - 15 SULLIVAN STREET 4/30/2018 (2) 15'SULLIVAN STREET _ 1011 G7.B-GUS'-GGGG.G �7�- MAP # LOT #_ PARCEL # STREET___._._....._................. CONSTRUCTION APPROVAL HAS PLAN REVIEW FEE DEEN PAID? YES NO PLAN APPROVAL: DATEIq�! APP. BY..... C ._...... DESIGNER: �� //_�� PLAN DATE;___- 1o? CI CONDITIONS WATER SUPPLY: TOW WELL WELL PERMIT DRILLER WELL TESTS: CHEMICAL DALE faf-`PROVED_.6f,.,7/`�,.Z.__ BACTERIA I DA1 E f1F•hRUVED g/1/s'Z._. BACTERIA II DAZE APPROVED COMMENTS: FORM U APPROVAL: APPROVAL TO ISSUE �S NO DATE ISSUED CONDITIONS: FINAL APPROVAL: . ALL PERMITS PAID YES NO WELL CONSTRUCTION APPROVAL YEc NO SEPTIC SYSTEM CONSTRUCTION APPROVAL Edi NO OTHER YES NO ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DATE:. _.,... BY : _ i i SEPTLG _Y_9IEM__ZNS..T..9.4.L.A.Z�_QN. IS THE INSTALLER LICENSED? YES NO TYPE. OF CONSTRUCTION: NL-"W REPAIR NEW CONSTRUCTION: CERTIFIED PLOT Pl._nN REVIEW l S 110 CONDITIONS OF APPROVAL YES NO (FROM FORM U) ISSUANCE OF DWC PERMIT YES NO DWC PERMIT NO. �� INSTALLER: %/M /f&lZ_//,'y ;BEGIN .INSPECTION < � NO: _------------------ EXCAVATION . INSPECTION: NEEDED: PASSED /�Z//C/� BY _ —----- — _--------- CONSTRUCTION INSPECTION: NEEDED: AS BUILT PLAN SATISFACTORY: APPROVAL TO BACKFILL: DATE: 27 BY—__� 1 -'._._____.______..___—__ FINAL GRADING APPROVAL: DATE / / BY FINAL CONSTRUCTION APPROVAL: DATE: BY_`_._______�.____ Now - ., m �1yy�_....ro,.` +' :,°"+ ',..!.•. .... 'r 'x'!',eq" a. k, .. `ver y' t •,,{p a gl�,T `T '. 2 :r — ,,tM�'�'`�4C -f •S jr ..,.•A .,., "'F`?P"{"1{' A `e: q';+L i"s+' :n+!•.A�.J,,.�,. 1:.:er•.'7 �w,y eyp� e .:.,• �a.�`� eaZ �r7". e.+q'•.. M .�;t �. a� ,' o:' 4` ,?�4 a .r; a 1�':' -��y+p:^ �a t� er}.' .`., 2u"2?.. r�.,+'�'fY�kt. ,> .rr ,r. '� s 'f t r,. F1 .',�T• .�k� F, ....x �° �t � t3ALEN 7-U R 1KE 0 I 2 . . r . M � D7 U ILI Al r i �i AS-BUILT CHECK LIST and FINAL INSPECTION Proposed Elevations As-Built Elevation House / `7� C� j 769 %76 , off% Tank IN Q C. Tank OUT / 79. 81 / 7_ _ y D-box IN 173.97 72, 90 D-box OUT 773.7 7 7`�` 7� Trench Inverts Line 1 %73 S� 773^ / 3 J 73.73- - 173,3 Line 2 Line 3 Line 4 Bottom of Exc. / 70,,3 Stone OK? D-box checked? Pipes cemented? i TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: °y SYSTEM OWNER & ADDRESS SYSTEM LOCATION i (example: left front of house) DATE OF PUMPING: 'a�' �- QUANTITY PUMPED 1 GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE I>< EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PLTMPE.D BYE COMMENTS: CONTENTS TRANSFERRED TO: FORM U - LOT RELEASE FORM �--� 1ST t c ,--macapprovals/permits li I., i nl,CTION.,:. This form is used to verify that all ne,,, ssary from- Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. FILLS OUT THIS -SFCTICNI—1.. APPLICANT PHONE LOCATION: r+sZesS&s Vao dumber PAFcE_ UO't 7 SI JEDIVISION LOT (S) STREET DO x-L I Q q \1�'ST. NUMEER OFr=1ClAL USE ONLY RECO NDA T IONS OF TOWN AGENTS: /lo �� y -- o PEN rJ�c Ic �i�2 0� Sy-2 ucicn-t- CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS i) >,1 dh A-Q Q d1�(quo Ul ,d u CE`l cn {2I / c (/�( 1.r M2. TOWN PL4NNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS PUELIC WORKS -SENERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DE°AR71NIENT REC-EiVED EY EUILDiNG iNSPECTCR DATE Revised c;c^im . OS%LOiW OU:,13 lab!( iju out)z w zw { Lor I L_ 0T � .L. 0 7 .� �vb`,,o �1�r P !� to G A Pia A v� l .-1 Liz vj l IV 7 ,1) P T NOTES: ALL TIES SUBJECT TO WHAT AN ACCURATE INSTRUMENT p I n T I-)I AN CSF I AND MANNING NNAL r n a avr� ym-- r rrrrr•rr. .. . . . .�.. - - - C ��n '��® ver Town of o O n No• 0 4rrryka a �� , DRIVEWAY ENTRY PERAJ I y No An�d6Ver Mass.,- cam•.r.iHtwn n ,yy , ;. BOARD OF HEALTH PERM 1 LD THIS CERTIFIES THAT.. -11f .,�1atetekee-N—A.••XN•41 ......"......' •••• BUILDING INSPECTOR has permission to erect afj&OW.04fuildings ........ .... ••• Roug ,14441/ �/ i n y to be occupied as.J 9*V"/* A o s..• �#9AP� final hm e 04 ft provided that the person accepting this permit shall in every respect conform to the terms of the application on file in U I G 1 SPE TOR this office,and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration anNstct strnsuctiionn offC o R na Buildings in the Town of North Andover. Final VIOLATION of the Zoning or Building Regulations Voids this Permit. ��, PERMIT EXPIRES IN 6 M 0 NPA92-ib-)2 .0,M11111,40- dc) ELECTRICAL INSPECTOR d.r J".0-CS O.-ep 0 Rough UNLESS CONSTRUCTION . STARTS • Service (� T ........ PERM FOR FRAMUBUILDING Final DATE:4.:i&— .FEE PAID _ 0 •• •• •• •BUILDING INSPECTOR GAS INSPECTOR Rough Occupancy Permit Required to Occupy Building Final Display in a Conspicuous Place on the Premises FIRE DEPT. Do Not Remove Burner �`� )E:,A-`�� No Lathing to Be Done Until Inspected and Approved by Smoke Det. I,#lj,7j Building Inspector LOT 2 SULLIVAN ROAD SUBSURFACE DISPOSAL SYSTE M ASBUILT :: •7 IN NORTH ANDOVER, MA PREPARED FOR : HITE BIRCH CONST. CO. INC 380 ESSEX ST. SUITE I LAWRENCE MA. 01841 DATE MAY 22, 1993 SCALE . NTS. PREPARED 9Y : E NVIRONEERS, INC. 1 P 0. BOX 516 NO, ANDOVER, MA. 01645 tNVEkTS EL(�EVATIONS DWELLII&G OUTLET 178026 TANK INLET 176.21 ,( � 175.94 , l \, TANK OUT LET D BOX INLET 17390 D BOX - OUTLET 173075 ✓/ END OFPIPE 173038 .,hal �' 1 � - • f 1 � J I NOTE: FOR PROPERTY DESCRIPTION SEE ' N. E. R. D. # 12101 , 1 }}`£, i DejQtrnent of Environmental Management/ i $ �y4 x s r� ATER WELL CO MPLET WELL LjQC GEOGR HIC ESCRIPTION Ad Iress ! — N S��W of (leer) Tc,rcle) City/Town gYl✓_� Rd- (road) Well owner A ress 2 Pe N S E OVT of Im1.i tenths/ (circle) Board of Health permit: yes r4 o Ej intersect. Iroad) WELL USE WELL DATA Domestic Public❑ Industrial ❑ Total well depth �d0 ft. Monitoring❑ Other Depth to bedrock_ft. _ Water-bearing iocklunconsolidated material: Method drille i Gate drilled Description Water-bearin nes: CASING 1) From To Type IT 2) From To Length ft. DiaI.I.D.) m. 3) From To Length into bedrock-2 —f t. Gravel pack well: dia. l Protective/well seal: Screen: dia. Grout-[3 Other Slot' lengthL--from—t STATIC WATER LEVEL Static water level below land surface ft. Date �. WELL TEST i Drawdown ft. after pumping �, hr. min,at C , gpm Hosea red Recoveryft. after—hr.—min. I LOG of FORMATIONS C MME TS f 2 _01aterials rom To �1�/� Driller 62+.G U.GFf/✓l.,r�/t CZZ 'd Mass. Regi N t' n Firm 1 Addre ' City/Town Si nard're 6W4ArriWdregis(erya dr!ll r Plsasr print tirm/y BOARD OF HEALTH COPY .�. :ALTH BOARD OF }{I Mown of North Andover ,Mass . Q O trmit # APPLICATION FOR WELL & PUMP PERMI )plication . is hereby made for permit to drill a well . Application is ide to install (_) a pump system. Lot It - )cation: Address - � Address 3 d Tel . - Z////_ -7`7G oner _ c � Acldres :11 ontrae1�0�'��'..�aaq �m Contractor Address OJ ,Q0`f�eI P 7-LL CONTRACTOR (To be completed at time of pump test ) 1pe of Well Well used for iameter of Well c� Size of Casing Depth casing into Bed Rock epth of Bed Rock as Seal Tested? Yes No (_) Date. of Testing of Wc -1 — Well Ended in Wha.t. Material epth epth to Water_ De Gals . Per Hin . for 4 hours rawdown �l� feet after pumping _hours' at ate of Completion Signature actor � � ., .. .. .. .. .;�:., ..:Y:::':-' :'tip: c�r:. .. .. .. .. .. .. .. ..:. .. .. .. .. .. .. .. .. .. .. .:•;;;. ,. ,. ., .. „ ,. ,. ,. .. .. .. ., r UMP INSTALLER (To be' filled in- be Lore insta].l.ation ) i ze & Name Pump__ /.4 • Pump Type Used�lf/ f/ 'ater Pump Delivers / GPM Size of yank _� 0✓) 'ipe Material Used in Well : Cast Iron (_) Gnlvnnized (_) Plastic (C-� Jell Pit (_) or Pitless •Adapter (LIr 'r e or Name Well Seal �' :14— las sleeve used to protect pipe . Yes (_) _ Yp ate Q• 2 ' . r��t�lri�c�4�1r�1r�k►4�'r►F�4�M�1r�1r�4�M�4�4ti4�4�lri't�kt'tt4�r4t�Y�4�'t�t�Mr4�M�4�V►�i'tti'r�'t�'rti't5`r;;:';'.:.;;;;�,;,r,:,;,�..,. .�;:". ." , )at'e Water analysis repor-t •submitted to Board of health_ Date release given to owner of record & Bldg . lnsp }lealth Inspector Dr,jsarunenl of Environmental Management/Division of Water Resources WATER WELL COMPLETION REPORT WELL C GEOGRAPHIC DESCRIPTION Address N S E W of iferr) Iclrclel City/Town i r,narn Well owner Ar Iress �4 N S E W of pn1,in fe,,Ihsl Iclrclel intersect. W/ Board of Ilealth permit: yes no El (roadl WELL USE WELL DATA Q / Domestic Public❑ Industrial ❑ Total well depth_—� ft. Or Monitoring❑ Other Depth to ft. bedrock_ — Waley-beating Tock/unconsotidaled material: Method drilled /` Description Date drilled Water-bearin nes: CASING 1) From�—To Type LL ,, 2) From To Length [Lft• Dia(.I.D.)/in• 31 From To �7 ,, ft. Length into bedrock woe--- Gravel pack well: dia, Protective well seal: Screen: dia. Grout-E] Other Slot" length from_to STATIC WATER LEVEL Static water level below land surface I� G ft. Date r WELL TEST c� Drawdowny,2-f-ft• after pumping hr. min.at gpin Ho ea �dovery,,– it. after—hr.—min. 0 LOG of FORMATIONS C E �C aterials From To /S% � Driller. /^ 7 Mass. Regi t tib Firm n Addre J r City/Town nae e u rw /see drllf r Please print firmly DRILLER COPY . :a .!7houte-view 47aaeatv2�y ' Pita :`::'.66 UTTLETON ROAD WESTFORD. MA 018$6 ~ (508) 692.8395 FAX (50$) 6920023 1-800.649-TEST: . ` Report Number: C^6284 . Report Date'' JuJy 24,1992 li Cent: l_ Sample'Taken'At: iris. Roger Skillings .White 'Biz•ch Construction 'r Skillings and Sons Lox?, -Sullivan Rd. 369 Proctor Hill Rd �I.Andover,Mass '. �.., Hollis NH 03049 Sample Taken By:. SKS Staff On: July 23, 1992 CERTIPICATE OF ANALYSIS .� a,.; sir+�f'ure?;e .. -:tie;M,�- ,.'+a•Y?'`ri.'�';,--'- -��ti.. _ TEST PATER a EPA Max RESULTS UNITS r Notal Colaform�(P) r `r� =� .ts p - 0 ;Calcium Eimit;} r�_22.4. /I;r�;;: _ "~` �•-r='. �,, CO 'OIC "` `�•:s:"."•• gig/ rt er v 1 •y��. i.y <> a:ii.'1•. � �4 , h (. :0 1 �, <<. :Manganese (s} ,'� '��; .� •.7�0 415 :", .��`.0:03.5. <�r'' N:'�v=•.�,-8��-- --: i � "� ��i Sodium _ <. -`_• 3 r Potassium (S) No .LImit � 1 � Alkalinity ( ) No'Limat ; 76--;,cam:,, `5 Ammoniaa3 /L J4 ChlorideMg �. 7r r. Chlorine .(total)- , „7 Color S` rr, Conductivity; rJ NO 'Llmlt t. » �711mhOS/CIA'r w,`.�' ;'� ""f~• Hardness :< k.-: .� .• . .: , No Limit- '.-.: b9• ':,-: -mg/L -.� Nitrates(as N)(P) > �• i0 <O.Q1. r Nit=ites(as N) r 1: �, ' <0.01 ,,.. pH: (S) X A SU...., ` •�h. x •- _ . ..,�.. �( .) .. . c�_1 z.:ti':�".-z: •.� �...�Ov;t:,;��c,x.��,ra�.�.4x 3� Sulphates (S) 250 _ 12.2 Turbidity �r 5r"' . 0.3 tS Sediment , C POs/Ile$ J .:g^c; , {�C+(,:_ d a NT= 'ot Tested, 9 .Value.`ExceedsPALSTI3, '�iVTC-Too .�t'umerous ,- n t0 Cotl t : u - ground>Bacteria Noted; EPA Advisor Liin�t Exceeds EPA•Advisor - (P.)=Primary `EPA .Staridard,::(S) Secondary EPA. Standard. (Iaay;affect aestheLics;.of drznki,nS;water a e. :taste, color;=.etc:);.,.', .This water .sam le' :as.t - p r ested, meets or, exc'eeds� EPA: hdalth-s�taiidards it t 4, bjY :the'.parameters i seed above f,,,'1'he"quallt'y,`o .:tli st�TBtQr `ls.. •.. ` accepted as POTABLE according tdl$PAtandarcg + 1 lassaah s=St �tifi'ed' Pa tzsett ate Cer _ M�c1': carlson-,.- dor.'~ { Testing;Laboratory ��MA04$; % Thorstens e"r Laboratory;`Inc. '>�, l � !M 9ti f,k51• i. t ij 7 ' '�'�. `�j, � :��„ •• :-. ------------------------------------------- - j FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. __ � _ Z ****************Applicant fills out this section***************** APPLICANT• ��✓n C-€' i F�'�Ji �r 1 ti'< I',L7-- Phone LOCATION: Assessor' s Map Number Parcel Subdivision f� .. Lot(s) Street 5: �_�_; s� r / �'r;� i r. c`, St. Number ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Date Approved Conservation Administrator Date Rejected Comments 1 Date Approved Town Planner Date Rejected Comments Date Approved �--� Health Agent Date Rejected Comments _ 2 Public Works - sewer/water connection ivv 7 driveway Pe. rmit A Fire _ Department VPReceived by Building Inspector Date Town of North Andover, Massachusetts Form No.3 • NORT!{ BOARD OF HEALTH • Ott« o 4,, IL 19 Q3 DISPOSAL WORKS CONSTRUCTION PERMIT 'SSACHUSEt Applicant NAME ADDRESS TELEPHONE Site Location Permission is hereby granted to Construct k/) or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CHAIRMAN, BOARD OF HEALTH Fee D.W.C. No. Ca�S iso r 'i. 4 = y y sk Town of North Andover, Massachusetts Form N0. 2 w k BOARD OF HEALTH t ��•��•�O it �• � � t .: Y, r t. ♦ .:� k 7 's DESIGN APPROVAL FOR , -SOIL ABSORPTION SEWAGE DISPOSAL,SYSTEM yApplicant A�4t15 � / C'or'd Test No Site'tiocation � -V f A J & �r w v, k. i k�' tr'�.r Y.i� r',as✓F' .• ME �5:�Fi + ? a .ry Ns �'} Reference Plans and Specs �— DATE zjr ENGINEER ,: i, DESIGN + �uR � e' . ra;•i k r-•• ? {` -'... ! �? t `Permission Is granted for an Individual soil absorption sewage disposal system to be Installed 4Am accordance with regulations of Board of HFealth j ry x,° ✓t,�aAt' s'z' i+`34crI'M t � S�'q� c.''44''PP$ i vs} i� fkr ^�. R.. r }°a6� i t`q 7 r • F3' � i ��+`X e��ix 2 � t�,i..{ ¢��rn'r n{' �4y s`t * " ,7 �*+ Y � � CHAIRMAN BOARD OF HEALTH baa, ., Ir• +�:a +i �� ryoo-�a'•�y;y,,,�y� 4«��r i �i >.!"7fq 41,1V ��:x{ r y/f.� •.,F 's. 'nh » �":i�vEi� �t�4� `�i� t.. 561_ Site System Perrlllt No �� }r. rryr5.��4rd r NUMBER FEE THE COMMONWEALTH OF MASSACHUSETTS $25 . 00 ,3141 ........................... ...MOWN...... of ........... This is to Certify that -------Skilli-ag-s....&...Sons-------------------------------------------------------------------- NAME 269 Proctor Hill Road, Hollis, N.H.... ............................................... ................................................................................................................. ...... ADDRESS IS HEREBY GRANTED A LICENSE Well Drillin — Lot #2 Sullivan Road ...��f�rmit.....................w.............................................................. For ......................................................g ........... ............................................................................................................................................................................ ....................................................................................................... ..................................................................... ............................................................................................................................................................................ This license is granted in conformity with the Statutes and ordinances relating thereto, and December 31 , 1992 - ess sooners s ndedN rev expires------------------------------------------------------------------- .... .............. .. ..................................... ------- --------------- ------- ---- .... .. ..................... .........July-1-0..........................19....-92 ..... ................. .......... .... ..... --------------- .. ............ ------ 0 .... ............... A,:" FORM 433 HOBBS & WARREN. INC. A PLAN REVIEW CHECKLIST ADDRESS ENGINEER � GENERAL 3 COPIES STAMP LOCUS SCALE N CONTOURS E PROFILE SECTION BENCHMARK ELEVATIONS SOIL & PERC INFO ✓ WETS. DISCLAIMER WELLS & WETLANDS WATERSHED DISTRICT DRIVEWAY WATER LINEZ,-' DRAINS� RESERVE AREA f/ SCH40 ,Y SLOPE SEPTIC TANK MIN 1500G. LIZ . 17 INVERT DROP GARB. GRINDER(+200% EDF) 25' TO CELLAR MANHOLE TO GRADE ✓ ELEV 04 GW �K D-BOX - Q�t # OUTLETS ?/ FIRST 2' LEVEL STATEMENT INLET/73. �/ - OUTLET 173.V= Z6 (20' OR . 17 FT) LEACHING / /'� 100' TO WETLANDS C/ 100' TO WELLSI/ 325' TO SURFACE H2O SUPP 35' TO FND & INTRCPTR DRAINS 6, 4' TO S.H.GW "V 2% SLOPE 4' PERM. SOIL BELOW FACILITY MIN 12" COVER FILL? (25' if above natural elevation 10' "f below) TRENCHES MIN 660 FT ' SLOPE (min . 005 or 6"/1001 ) >3 ' COVER? - VENT SIDEWALL D,IST.T. 2X EFF. W. ORD (MIN 6' ) j� IS RESERVE BETWEEN TRENCHES? �/ IN FILL? V/ MUST BE 10' MIN. (�'� BOT 596 X LDNG 1%0 + SIDE X LDNG 4q = TOT 7a -��0 2) (L x W x #) (G/ft (DxLx2x#) •' 1 DATE 4A Z Sheet of BOARD OF HEALTH TOWN OF NORTH ANDOVER / SUBSURFACE DISPOSAL DESIGN REVIEW FEE_ 6 PERMIT # 0,3 DATE RECEIVED` Z �� APPLICANT ASSESSOR'S MAP ADDRESS PARCEL # LOT # ENGINEER // p�� STREET ADDRESS / PLAN DATE _ C� / ��9� REVISION DATE CONDITIONS OF APPROVAL: 11,5E APPROVED DISAPPROVED ,l IIS Sadlivan Moadl .1Jefeg CasWdflo Worth Andover, M&01045 Owmer zewase HNSPe n orsftsm UDWRM910M McPGWQ IrIltme v IH3cIDa�11 ®� I$It��Il�4s C�®Il�� I Zen-vice Pumping & IIraum Co., Inc. (617) Z45-7576 P.O. myon A690 (WO) 7541-9925 Wafteffieldq Ma 01=0 IF= (617) U6-C7937 William F. Weld Commonwealth of Massachusetts Governor Executive Office of Environmental Affairs Trudy Coxe Secretary Department of Environmental Protection David B. Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Owner: Jeffrey Castaldo Property Address: 15 Sullivan Road, N.Andover Address of Owner Date of Inspection: April 21, 1997 (if different) Name of Inspector: John B. Nicholas Company: Service Pumping & Drain Co. , Inc. P.O. Box 498 Wakefield Ma 01880 (617)245-7576 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 roper function and maintenance of on-site sewage disposal systems. The system: X Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: 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 SUbfidARY Check A, B C, or D: A] SYSTEM PASSES: x 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. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. 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 cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11/03/95) One Winter Street o Boston, Mass. 02108 o Fax (617)556-1049 o Phone (617)292-5500 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Droparty Addraoo: 15 Sullivan Road, No. Andover Owner: Jeffrey Castaldo Date of Inspection: April 21, 1997 B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health) : broken pipe(s) are replaced obstruction is removed distribution box is leveled 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) : C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF 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 and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 3) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 15 Sullivan Road, No. Andover Owner. Jeffrey Castaldo Date of Inspection: April 21, 1997 D] SYSTEM FAILS: 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. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static Liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid Depth in Cesspool is Less than 6" below invert or available volume is less than 'i 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 _ Y Pp Y 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. II� E] LARGE SYSTEM FAILS: 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: the system is within 400 feet of a surface drinking water supply. the system is within 200 feet of 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) I The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00 Please consult the local regional office of the Department for further information. (revised 11/03/95) 3 4 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM I PART B i CHECKLIST Property Address: 15 Sullivan Road, No. Andover I Owner: Jeffrey Castaldo ` Date of Inspection: April 21, 1997 Check if the following have been done: X Pumping information was requested of the owner, occupant, and Board of Health. X None of the system components have been pumped for at least twoweeks and the j 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. I N/A As built plans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. X All system components, excluding the Soil Absorption System, have been located on the site. X 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. X The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. X The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Subsurface Disposal System. e r �F I (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 15 Sullivan Road, No. Andover Owner: Jeffrey Castaldo Date of Inspection: April 21, 1997 FLOW CONDITIONS RESIDENTIAL: Design flow: gallons Number of Bedrooms: 3 j Number of current residents: 4 Garbage grinder (yes or no) :no Laundry connected to system (yes or no) : eyes Seasonal use (yes or no) :no Water meter readings, if available: Private well Last date of occupancy: Occupied COMMERCIAL/INDUSTRIAL- 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: GEAIERAL INFORMATION PUMPING RECORDS and source of information: system never dumped System pumped as part of .inspection: (yes or no) Y If yes, volume pumped: 1500 gallons Reason for pumping: maintenance TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system Single Cesspool Overflow Cesspool Privy n Shared system (yes or no) (if yes, attached previous inspection records, if any) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: 4 years per owner Sewage odors detected when arriving at the site: (yes or no) n (revised 11/03/95) I 1 i 5 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 15 Sullivan Road, No. Andover Owner: Jeffrey Castaldo Date of Inspection: April 21,1997 SEPTIC TANK: X (locate on sirte-plan) II! Depth below grade: 27" built up to 6" below grade Material of construction: x concrete metal _FRP _other (explain) Dimensions: 10' x 5' x 5' Sludge depth: 3" Distance fromto�udge to bottom of outlet tee or baffle: greater 18" Scum thickness: 8" Distance from top of scum to top of outlet tee or baffle: 5" Distance from bottom of scum to bottom of outlet tee or baffle: 18" 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.) All okay. Tank should be pumped every two years. GREASE TRAP: N (locate on site plan) Depth below grade: Material of construction: concrete metal _FRP _other (explain) Dimensions: Scum Thickness Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc. ) I i i I (revised 11/03/95) 6 i i ! SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM j PART C SYSTEM INFORMATION (continued) Property Address: 15 Sullivan Road, No. Andover Owner: Jeffrey Castaldo Date of Inspection: April 21, 1997 TIGHT OR HOLDING TANK: N f (locate on site plan) Depth below grade: Material of construction: concrete metal _FRP other (explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc. ) DISTRIBUTION BOX: Y (locate on site plan) Depth of liquid level above outlet invert: 0 Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.D -box never used. All okay. No visible signs of failure. Box was never hooked to tank. PUMP CHAMBER- N (locate on site plan) Pumps in working order: (yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc. ) s i (revised 11/03/95) 7 I • I I E E I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) jProperty Address: 15 Sullivan Road, No. Andover Owner: Jeffrey Castaldo Date of Inspection: April 21, 1997 SOIL ABSORPTION SYSTEM (SAS) : Y (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: I I i Type: leaching pits, number: leaching chambers, numFe-'r. leaching galleries, number: leaching trenches, number, length: 2@ 40' leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc. ) Field brand new. Tank was never hooked to D-box. CESSPOOLS: N (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: j Inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc. ) PRIVY: N (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 11/03/95) 1 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 15 Sullivan Road, No. Andover Owner: Jeffrey Castaldo Date of Inspection: April 21, 1997 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100` 1 i 4 I DEPTH TO GROUNDWATER Depth to groundwater: 4 feet method of determination or approximation: observation hole (revised 11/03/95) i A SUBSURFACE SEWAGE DISOSAL SYS:kI4 11VSrr:i,ll�,v ulv . ADDENDUM 1 Property Address: Owner: Date of Inspection: (No comments) ? 1CO o D s7 0 ,� G °.;vice Fumping s Drain Co. , Inc. has been retained by the owner to provide an inspection of the on site sewage disposal system as defined by 310 CMR 15.303. D.E.P. guidance instructs the inspector to make an evaluation of the systems performance on the day of the insprection. The Title 5 Inspection in not designed to provids information to 3emon�trato that the system will adequately serve the use to be placed upon it by the new over as stared in 15. 302. This inspection is not a warranty or guarantee of the systems future performance, and does not either express or imply that. v�seci ! 1/03/95, 10 7 t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ADDENDUM 1 Property Address: 15 Sullivan Road, No. Andover Owner: Jeffrey Castaldo Date of Inspection: April 21, 1997 Distribution box and leach trenches are new and unused. Septic tank was never hooked up to distribution box or leach field Initial Service Pumping & Drain Co. , Inc. has been retained by the owner to provide an inspection of the on site sewage disposal system as defined by 310 CMR 15.303. D.E.P. guidance instructs the inspector to make an evaluation of the systems performance on the day of the inspection. The Title 5 Inspection is not designed to provide information to demonstrate that the system will adequately serve the use to be placed upon it by the new owner as stated in 15.302. This inspection is not a warranty or guarantee of the systems future performance, and does not either express or imply that.