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HomeMy WebLinkAboutMiscellaneous - 15 WINDKIST FARM ROAD 4/30/2018 (2)91 r s LOT & STREET LQ ( i W I n d,. MAP/PARCEL CONSTRUCTION APPROVAL HAS PLAN REVIEW FEE BEEN PAID? YE NO PLAN APPROVAL: DATE / 319 l APP. BY . a l/b DESIGNER: PLAN DATEAZ CONDITIONS WATER SUPPLY: Qz:tiTOWN WELL WELL RMIT DRILLER WELL TESTS: CHEMICAL DATE APPROVED BACTERIA I DATE APPROVED CTERIA II DATE APPROVED PLUMBING SIGNOFF WIRING SIGNOFF COMMENTS: FORM U APPROVAL: APPROVAL TO ISSUE YES NO DATE ISSUED fi- BY CONDITIONS: FINAL APPROVAL: ALL PERMITS PAID YE NO WELL CONSTRUCTION APPROVAL YES NO SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO OTHER YES NO ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: 3 % BY:� SEPTIC SYSTEM INSTALLATION IS THE INSTALLER LICENSED? CYE NO TYPE OF CONSTRUCTION: (IjE ) REPAIR NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW YE NO CONDITIONS OF APPROVAL YES NO (FROM FORM U) ISSUANCE OF DWC PERMIT DWC PERMIT PAID? DWC PERMIT NO. /,Jz BEGIN INSPECTION YES NO: EXCAVATION INSPECTION: NEEDED: YES NO CiY NO INSTALLER : cls/�Z PASSED 7S 9 7 BY t�---� CONSTRUCTION INSPECTION: NEEDED: kA1 AS BUILT PLAN SATISFACTORY: YES: APPROVAL TO BACKFILL: DATE: BY AJ -J v FINAL GRADING APPROVAL: DATE % D Z¢ 0 � BY FINAL CONSTRUCTION APPROVAL: DATE: /D Z BY D 7 /J� n NORTH J L ' 3 a Town of North Andover ' ' ''• ' HEALTH DEPARTMENT cNust� CHECK #: iL,J l l DATE: LA - LOCATION: / H/ O NAME: t CONTRACTOR NAME: T_yRe 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 tems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ Title 5 Report $ . A J - U ❑ Other. (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer i I Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. — ILA 410 Commonwealth of Massachusetts 3mr, & ©�F �WA Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary A. sme is f 15 Windkist Farm Road } I5� Property Address 1 Ira Houchins Owner's Name North Andover MA 01845 04/16/2015 Cityrrown 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. A. General Information 1. Inspector: RECEIVED MAY 1 1 2015 Warren Pearce Jr TOWN OF NORTH ANDOVER Name of Inspector HEALTH DEPARTMENT Pearce Construction Company Name 196 Park Street Company Address North Reading City/Town 978-664-5264 Telephone Number B. Certification MA State SI1959 License Number 01864 Zip Code 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 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 3/13 Tale 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. k a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Windkist Farm Road Property Address Ira Houchins Owner's Name North Andover MA 01845 04/16/2015 Cityfrown 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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 ► t Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Windkist Farm Road Property Address Ira Houchins Owner's Name North Andover MA 01845 04/16/2015 CitylTown 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 obstruction is removed distribution box is leveled or replaced ❑ Y ❑ Y ❑ Y ❑ N ❑ N ❑ N ❑ ❑ ❑ ND (Explain below): ND (Explain below): ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Commonwealth of Massachusetts vz Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Windkist Farm Road Property Address Ira Houchins Owner Owner's Name information is required for North Andover MA 01845 04/16/2015 every page. Citylrown 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 Y2 day flow t5ins - 3113 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 15 Windkist Farm Road Property Address Ira Houchins Owner Owner's Name riforma equine fo d for tiis requireNorth Andover MA 01845 04/16/2015 every page. Cityrrown 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 ❑ i 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 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 o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Windkist Farm Road Property Address Ira Houchins Owner Owner's Name information is required for North Andover MA 01845 04/16/2015 every page. Citylrown 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 t5ins - 3113 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 �M 15 Windkist Farm Road Property Address Yes ❑ No ❑ Ira Houchins ❑ No ❑ Yes Owner Owner's Name No information is required for North Andover MA 01845 04/16/2015 every page. City/Town 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)): Detail: Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) ❑ Yes ® No Current Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 15 Windkist Farm Road D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Date 04/16/2015 Date of Inspection Pumped 3 years ago per owner gallons Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Yes ® No ❑ Overflow cesspool ❑ Privy ❑ f �% 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 Property Address Ira Houchins Owner Owner's Name information is required for North Andover MA 01845 every page. Cityfrown State Zip Code D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Date 04/16/2015 Date of Inspection Pumped 3 years ago per owner gallons Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Yes ® No ❑ Overflow cesspool ❑ Privy ❑ f �% 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 1 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Windkist Farm Road Property Address Ira Houchins Owner Owner's Name information is required for North Andover MA 01845 04/16/2015 every page. Cityrrown D. System Information (cont.) State Zip Code Date of Inspection Approximate age of all components, date installed (if known) and source of information: Installed in1997 per as built by Merrimack engineering dated August 5, 1997. Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: 30" feet feet Comments (on condition of joints, venting, evidence of leakage, etc.): All appears OK inside house. Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 22" feet ❑ 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: 10'6" x 68" x 5' deep Sludge depth: 4" t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 15 Windkist Farm Road Property Address Ira Houchins Owner Owner's Name information is required for North Andover every page. Cityrrown D. System Information (cont.) MA 01845 04/16/2015 State Zip Code Date of Inspection Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 35" 1" 3„ 14" How were dimensions determined? 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.): Tees are in place; Liquid is at proper level; Outlet tee is high; Tank appears in good shape; No evidence of laekaoe. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): 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: t5ins • 3/13 Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 t Owner information is required for every page. t5ins • 3/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Windkist Farm Road Property Address Ira Houchins Owner's Name North Andover MA 01845 04/16/2015 Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels 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: Design Flow: Alarm present: Alarm level: gallons gallons per day ❑ Yes ❑ No Alarm in working order: Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ❑ Yes ❑ No * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Commonwealth of Massachusetts H Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 15 Windkist Farm Road Property Address Ira Houchins Owner information is required for every page. Owner's Name North Andover Cityrrown D. System Information (cont.) AAA 01845 Zip Code Distribution Box (if present must be opened) (locate on site plan) 04/16/2015 Date of Inspection Depth of liquid level above outlet invert 1/4" - pipes settled 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 is level, distribution is equal; Header pipes are settled some; Trenches are OK; D -Box appears OK: Minimal solids in D -box. 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 4a2 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Windkist Farm Road Property Address Ira Houchins Owner Owner's Name information is required for North Andover MA 01845 04/16/2015 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: (2), 68 ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No surface sign of problems; No sign in D -box of back up. Camera check of trenches found no ponding in the trenches. 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 ° 3f13 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 wM ° 15 Windkist Farm Road Property Address Ira Houchins Owner owner's Name information is required for North Andover MA 01845 04/16/2015 every page. City/Town 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 _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Windkist Farm Road Property Address Ira Houchins Owner Owner's Name information is required for North Andover MA 01845 04/16/2015 every page. Cityrrown State Zip Code Date of Inspection t5ins • 3113 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 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Windkist Farm Road Property Address Ira Houchins Owner's Name North Andover MA 01845 04/16/2015 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: 2 feet Please indicate all methods used to determine the high ground water elevation: // 0 /1 Obtained from system design plans on record If checked date of des" I d' 1/20/1997 revised 2/10/1997 Ign pan reviewe . Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: Review files ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Test hole data from design plan dated 1/20/97, revised 2/10/97 byMerrimack Engineering. Site was built up for proper separation to ground water. Dry basement, no sump pump. 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 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Windkist Farm Road E. Report Completeness Checklist 04/16/2015 Date of Inspection ® 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 Property Address Ira Houchins Owner Owner's Name information is required for North Andover MA 01845 every page. Cityfrown State Zip Code E. Report Completeness Checklist 04/16/2015 Date of Inspection ® 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 �� .IVE T vA-nouS � BcoG. = 149•Io �t r �� .IVE T vA-nouS � BcoG. = 149•Io 1u s•r =198.07 ovr s -T = 198 • So 11.1 D -BOK 149•oCo ov(' D-8cx = 197.90 lilt. T2•w l =14'.08 tuL.Tit»2 =07.84 END T¢+-1 = 197•.52 EuD T12KZ 147. SZ Lo -r I '13.5,60 s. F. Seer e- TAu4 BLDG Ti E c 0o- t�l G Srr�.H.(e,M) ZI.$'— D-Box s� ( 95, Lo -r I '13.5,60 s. F. Seer e- TAu4 BLDG Ti E c ScDG , Co12 A 8" G Srr�.H.(e,M) ZI.$'— D-Box ( — 77.3' Sy -3' a,6 TV�Z .: _ Sy•o' 1 GSo' m 137. iV-" f30STo �j RoAp AS BUILT PLAN Z OF SUBSURFACE DISPOSAL SYSTEM LOCATED IN NoM'i+ ANDOVER, Mk AS PREPARED FOR CoLo tJ (AL Vi LL.AGE DEvELo PM F-W7r Co�P• .. �,r " DATE: AUGUST 5, IR97 SCALE: 1 W' . —Lo -Cl WiwNr-(gT FARM 2D_ MERRIMACK ENGINEERING SERVICES 66 PARK STREET - ANDOVER, MASSACHUSETTS 01810 t O v a w R w i w Z Z Z y i o L 3 JK O a w R w w Z Z Z LO o L 3 3 m r. 0 w 0 N o� m CL O a w R Z Z Z LO o L 3 W LD o ,O O c0 0o a t F- i a a (1) a E N ch0 40. O IC vi ., o E m y d a C d M E E a� a LL 0 0 a, y 0 rn O J a O Z Z Z U c� C7 d E i-° CO) U` m 'c H a� m w 0 N o� m CL O a LO R Z Z Z LO o L 3 W LD o ,O O F- N = LL a N ch0 O vi ., o E m y d a C d M E LL LL 0 U a O c� C7 i-° CO) U` w 0 N o� m CL � M F: • • L9 • Town of North Andover HEALTH DEPARTMENT ,Ss�CMUStI CHECK #: DATE: D� LOCATION: H/O NAME: /l CONTRACTOR NAME:4/� / .-e_w 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 In _ector /' $ Ulffitll-e-5'Report $ ❑ Other: (Indicate) $ IId. Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. rab return Commonwealth of Wassachusetts 'f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessment 15 Windkist Farm Road Property Address Ralph Desimone Owner's Name No Andover City/Town MA 01845 State Zip Code 1/22/08 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 1. Inspector: Benjamin C. Osgood Jr. Name of Inspector New England Engineering Services, Inc. Company Name 1600 Osgood Street Suite 2-64 Company Address No. Andover City/Town 978-686-1768 Telephone Number B. Certification MA State License Number 01845 Zip Code 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: U- asses ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority r-- 6? � I - 23 -08 L�fnspecto s Signature Date The system inspectors I submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Windkist Farm Road Property Address Ralph Desimone Owner's Name No Andover MA 01845 1/22/08 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) Syste asses: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If "not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed TITLE 5 FORM 2007.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 15 - Commonwealth of Massachusetts iLL Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a Jap 15 Windkist Farm Road Property Address Ralph Desimone Owner Owner's Name information is required for No Andover MA 01845 1/22/08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: 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 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. TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Windkist Farm Road Property Address Ralph Desimone Owner's Name No Andover MA 01845 1/22/08 City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ 2,,- 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 ❑ 0', Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow ❑ D Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ 2" 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. TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Windkist Farm Road Property Address Ralph Desimone Owner's Name No Andover MA 01845 City/Town State Zip Code B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No 1/22/08 Date of Inspection ❑ [V Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ E!( 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.] ❑ [a'. The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ E],_ 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 ❑ 19 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 ❑ EI / 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. TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 15 The size and location of the Soil Absorption System (SAS) on the site has been determined based on: N//El 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)] TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 15 Commonwealth of Massachusetts -0 Title 5 Official Inspection Form R' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Windkist Farm Road Property Address Ralph Desimone Owner information is Owner's Name required for No Andover MA 01845 1/22/08 every 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 ❑ D Pumping information was provided by the owner, occupant, or Board of Health ❑ 2/ Were any of the system components pumped out in the previous two weeks? [2/ ❑ 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? EK ❑ Were as built plans of the system obtained and examined? (If they were not ^/ available note as N/A) L� ❑ 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? Lid' ❑ 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? E4X ❑ 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: N//El 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)] TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 15 Commonwealth of Massachusetts ._ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments „ . 15 Windkist Farm Road Property Address Ralph Desimone Owner Owner's Name information is required for No Andover MA 01845 1/22/08 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): l' Number of bedrooms (actual) DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required] Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Last date of occupancy/use: Other (describe): Gallons per day (gpd) Date El Yes Lp No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes[ No ❑ Yes V No 21 r+t v y Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Windkist Farm Road Property Address Ralph Desimone Owner's Name No Andover MA City/Town State D. System Information (cont.) Pumping Records: Source of information: 01845 1/22/08 Zip Code Date of Inspection General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: d)O a -e -W eA:> o V�- k'1,A0 LN (r- F.,a ti PO t2c�p gallons Type of System: [� Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Yes ;W No ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): Approximate age of all components, date installed (if known) and source of information: C( `I C.2 8 O k fz c --o 2� 5 Were sewage odors detected when arriving at the site? ❑ Yes DQ No TITLE 5 FORM 2007.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form 1 I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Windkist Farm Road Property Address Ralph Desimone Owner's Name No Andover City/Town D. System Information (cont.) 1/22/08 State Zip Code Date of Inspection Building Sewer (locate on site plan): Depth below grade: Material of construction: ❑ cast iron ❑ 40 PVC ❑ other (explain): Distance from private water su I well or suction line' 1 Z feet pp y feet " Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 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: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle 1S�o� fes! c.L 5 L 1 Distance from bottom of scum to bottom of outlet tee or baffle y f How were dimensions determined? i►4 1, TITLE 5 FORM 2007.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Windkist Farm Road Property Address Ralph Desimone Owner's Name No Andover MA 01845 1/22/08 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.): Tj},1� K I ,J -Qf% Owl S C H U o PcJ C Ci3 t N v c7 �� Ca„JP,7n z ti0 Foivc,-c,C: or 10141,r4GC- - 1,u v2. 0--k-) 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 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): TITLE 5 FORM 2007.DOC • 08/06 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System • Page 10 of 15 Commonwealth of Massachusetts _w Title 5 Official Inspection Form 1=I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Windkist Farm Road Owner information is required for every page. Property Address Ralph Desimone Owner's Name No Andover City/Town D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: Design Flow: Alarm present: Alarm level: State Zip Code gallons 1/22/08 Date of Inspection gallons per day ❑ Yes ❑ No 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 Distribution Box (if present must be opened) (locate on site plan): r Depth of liquid level above outlet invert D 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.): 9D X t N "C7 r> 9 •'tl 0' N a ey k D CAA t 0F:� L-& l4' 4 64 t. I A-) G �- Yes ❑ No os&a a Lf. t�ts:2� 3yi1� N Ear <tc . Pump Chamber (locate on site plan): Pumps in working order: Alarms in working order: ❑ Yes ❑ No ❑ Yes ❑ No TITLE 5 FORM 2007.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 15 Commonwealth of Massachusetts -ft; Title 5 Official Inspection Form j,l Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Windkist Farm Road Property Address Ralph Desimone Owner Owner's Name information is required for No Andover MA 01845 1/22/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: El leaching pits leaching chambers leaching galleries leaching trenches leaching fields overflow cesspool innovative/alternative system Type/name of technology: number: number: number: number, length: number, dimensions: number: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): " n+ vf -,: LSH—,Y2EaLKES S"%Ja, --- GaJ C&e. > TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 15 Commonwealth of Massachusetts Fi Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Windkist Farm Road Property Address Ralph Desimone Owner Owner's Name information is required for No Andover MA 01845 1/22/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 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.): TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 15 y Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Windkist Farm Road MA State 01845 1/22/08 Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 4;0 i�—� 4 N t�- V, r� I TITLE 5 FORM 2007.DOC • 08/06 of 15 Property Address Ralph Desimone Owner Owner's Name information is No Andover required for every page. City/Town MA State 01845 1/22/08 Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 4;0 i�—� 4 N t�- V, r� I TITLE 5 FORM 2007.DOC • 08/06 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Windkist Farm Road Property Address Ralph Desimone Owner's Name No Andover MA 01845 1/22/08 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 ground water: feet Please indicate all methods used to determine the high ground water elevation: R1 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: k2dz,?t�7 � ie ✓✓> > SNa c v� eJL e— +a e)+ R ►4tS c%C�> (� 0-0>'/7tnj C'sa,,+o TITLE 5 FORM 2007.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 15 I N\/rZr ELEVATi o W S d K06. = l q4 . l Q Ill S -T- = 195.&7 STrt.N -(cn) ZI_, 8' i3.7' ov-- S -T' = t q0 .!5,0 D -Box -- 3S, S' Ill D -Box = i9S.a4, T-Z'v ( -- 77.3' Sy, 3' ovZ- D - Box = 19 7, `?o 'EuD TV- ""_ i eq - o' 6 57' 0 ` IUG. T2 = 197, 015 W4'. E►�D ?1Z�1 = 1°t7•S2 ENS TFZ'PZ 117, 572 I rl Z li3, 5'60 S. F. SEP -i c TAu4 137, 8v-" M05olliftinagg, AS BUILT PLAN Z OF SUBSURFACE DISPOSAL LOCATED IN NoZT�t A N DDVER , M A . AS PREPARED FOR GoLoNigL VILLAGE DEVEI.APME�-T' DATE: AuGusT 5, i947 SCALE: i"= Zo' Lo -r I L.litinKiST FARM M. MERRIMACK ENGINEERING 66 PARK STREET ANDOVER, MASSACHUSETTS 01810 VENT SYSTEM SERVICES d 1/ _ W-\ dr: �1. EVATi o tit 9, e- QGDU, ( gq•lo I u s.T = 190.&7 ou-r S•r = 198 -.6,0 iu D -Box _ IgB.o4 Our p - Qox = 19'7. -qD I UL. T2 It I 19'7 , 08 Nit, TTZ*Z = N7.89 END -MO-1 IF" b T2 *2 I R7. SZ I I SQ4. T► ,, rG STM.H•(cre� ZI.B' l3.7' — -Box -- 3S',S' �R3' Ej4b TSZ. Z 137, iW {3o STo r`i Ro R D AS BUILT PLAN � OF SUBSURFACE DISPOSAL SYSTEM LOCATED IN NoRT�{ A N DoYElZ , f, -,IA. AS PREPARED FOR GoLo r,1 (AL Yi L(,AG E DEVE1.o PM EI,iT DATE: AuGusT 5, 1947 SCALE: i"= zo' LST I I.JItink(sT FARM M. MERRIMA CK ENGINEERING 66 PARK STREET r ANDOVER, MASSACHUSETTS 01810 r 7- - e-oep.. W-6 SERVICES FORM 11 - SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot i4o. �YmL'Im' (_07' I On-site Review Sv S�N`f Deep Hole Number *S.+_: Date:..:.5.1Z 1 I7 L Time:.. � .1. Weather %v Location (identify on site plan) Land Use Slope Surface Stones r—Cw Vegetation W kQ f�, �orN uryK ASK L::. ►"ols" I ul Landform ... .....::. Position on- landscape (sketch on the back) . Distances from: Open Water Body feet Drainage way ; . feet Possible Wet Area Z -00.i.+ feet Property Line 3>O feet Drinking Water Well feet Other A DEP APPROVED FORbt - 12107/95 DEEP OBSERVATION HOLE _OG* Soil Texture (USDA) Soil Color (Munsell) Soil Mottling Other (Structure, Stones.G avlel�rs, Consistency, Depth from Surface (Inches) Soil Horizon {SSL 10Lfvt,z(2- u - PN (o -21Z I„! SSL .1 SIS�(o 4KSIL/C1=lur�gc S� 03 ZZ �4' Ct SSL 7'V514 Iogvu�li; M LfJ Mvl1slV4-,t=11?�t I%✓ r i r:� 14#st_4 P-Ew itioal3 �Z� (o G di, Ria C Z Standing Water High Ground Water: r— Lit u I (WZ � J C,IC.r,-jam �'� 5-14- r nvWSS t U� — r o o S �- Depthto8edrock: Weeping from Pit Face: ? Parent Material (geologic) Depth to Groundwater. Estimated Seasonal in the Hole: _ DEP APPROVED FORbt - 12107/95 I` Location Address or Lot No. p� uM , (,vim 1 ■ FORM 11 - SOIL EVALUATOR e 0o M On-site Review 3 3 5'L �� to Time:. Weather s uNAIk qQp Deep Hole Number Date:.:..:.:.:�. Location (identify on site plan ...................:... . ... ( QQ'0S.:. Slope (%) 3 Surface Stones Land Use mow.._ �ocui✓� U w IC t�SFi.f .. o o is cw lull .......... . Vegetation WN.f:I� ht ¢.1.... � L... Landform .... �J. itiV1�1 . : Position on* landscape (sketch on the back) Distances from: feet Ofee; Drainage way pen Water Body Possible Wet Area 2,�7U_.+ fest Property Line feet 3� Drinking Water Well feet Other ...::.....:......... DEEP OBSERVATION HOLE -00. Other Soil Depth from Soil Horizon Soil Texture Soil Color (Munsell) Mottling (Structure, Stones. BouldGraveers, Consistency, Surface (Inches) S L I u� ►2z(Z M A-44 I U/,, V f K f f=vLt 144lri o-16 Avo F- M�4NH M001S Vj Lj ('S (. /v1040 U/1-1 F4U14 t _ L sL 5�+('/3 Mi+sS1VCj Fiim (A' 1041`z46 I="+gLk owe _ M ZIJ U r4a1r5 S 7- Cz G �5 2 �s� ��4- 1kJ95SI U�- t.ovSt �K.4*461C rzAA� u� Tl LL OepthtoBedrock: Parent Material (geologic) G Weeping from Pit Face: Depth to Groundwater: Standing Water in the Hole: Estimated Seasonal High Ground Water: t pgp pppROVED FORM- 12107195 W I-) I" I, -_I--7 / -3: 1 ""''1 r KUM "M MAKKr I I "UMtS 5�125btS�G.3y / 08/14/97 INV U2:54 FAX 5049575599 bisfP' ON A9PULT -.*- — _ GA rcaRlrs � S. �y �� Efl1i cif S�� 7S�!��MW Ito 1�� 0o 6C snr an cur ZC irw MRs: _ 318` hashed Gravel SloeE� C =59 1-0/31/96 5 0 s r SOF MATERIAL m-02 T!I]WG=XL - ec: �Z?.96e4 I QIUAIr Y GOM11ML ` T IS _ GRAIN . SIZE DISTR.IBUM03N rmmv Ro.1 f i 4 APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PE R1VII'I' 719097 DATE: 7'11- F7 CURRENT INSTALLER'S LICENSE#. LOCATION: 6 r* % LICENSED INSTALLER: I%r Ili SIGNATURE: CHECK ONE: h%7:\ t;i� TELEPHONE# &S -- NEW 5 -- NEW CONSTRUCTION: IF,NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. Administrative Use Only $75.00 Fee Attached? Yes No Foundation_ As -Built. Yes No Approval ,� �/I� Date: %l� I r FORM U - VERIFICATION 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. ****************Applicant fills out this section***************** APPLICANT: APPLICANT: S Phone d '� LOCATION: Assessor's Map Number 1019 Subdivision Street Parcel • Lot (s) f St. Number SGD ************** *********Official �se Only************************ RECOMMI;NDAT ONS F AGENTS: Date Approved SPA/ Conservation Administrator Date Rejected Comments Date Approved Town Planner Date_Rejected Comments Food Inspector -Health ter. §4_ -p -tic I spector-Health Comments Date Approved Date Rejected Date Approved Date Rejected Public Works - sewer/water connections ( -�% 3L) ,57 - driveway permit T_ % ���,� A) Fire Department �4 (ZS F Received by Building Inspector Date TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System. ) constructed; ( ) repaired; by %�� / Cf G�2- /` ✓ /wry! located at Zo T— / was installed in conformance with the North Andover Board of Health approved plan, System Design Permit # % dated 2/Z g ? with an approved design flow of 40Yy gallons per day. The materials used were in conformance with those specified on the approved plan; the system was installed in accordance with the provisions of 310 CMR 15.000, Title 5 and - - local regulations, and the final grading agrees substantially with the approved plan. All work is -accurately represented on the As -built which has been submitted to the Board of Health. Installer. Design .01 Lic. #: Date: Engineer: Date: /6 t Town of North AndokALTH , Massachusetts BOARD OF Oct. 24 CERTIFICATE OF COMPLIANCE Form No. 4 19 97 This is to certify that the Individual Soil Absorption Sewage Disposal System constructed ( X) or repaired ( ) by Bill Sawyer INSTALLER at _ Lot 1 Windkist Farms SITE LOCATION has been installed in accordance with Board of Health Regulations as described in the Design Approval Site System Permit No. 893 dated Feb. 2 19 97 The issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. BOARD OF HEALTH Town of North Andover, Massachusetts Form No. 2 NORI'h BOARD OF HEALTH a- 19 O L N � F 0 r�o,,.,• DESIGN APPROVAL FOR CNusEt� SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant �I �f�-?�, ( Test No. Site Location 1-1yr 1 IAJ,�i✓�� Reference Plans and Specs. ENGINEER Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. S Ni Fee C AIRMAN, BOARD OF HEALTH Site System Permit No. -k� Town of North Andover, Massachusetts Form No. 3 pORTh BOARD OF HEALTH 1 3:.�... -P- 1997 o ti p DISPOSAL WORKS CONSTRUCTION PERMIT ,SSACHUSES Applicant _010E -C 2 NAME /' ADDRESS TELEPHONE Site LocationG� % 60W Permission is hereby granted to Construct (4-ror 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. 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