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HomeMy WebLinkAboutMiscellaneous - 1504 SALEM STREET 4/30/2018 (2) 1504 SALEM STREET --- -- -/ - 210/106.A-0037-0000.0 r Commonwealth of Massachusetts _- RRIMN I= - City/Town of Tewksbury System Pumping Record N �,� j� Form 4 TOWN OF NORTH ANDOVER DEP has provided this form for use by local Boards of Health. Other f it -- .. I .I NXI Ae"IT he information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: 1. System Location: When filling out y forms on the computer, use only the tab key Address to move your n /0 l- IV/)—.:z �:ursor-do not —/�/ — – ---- use the return City/Town State Zip Code key. 2. System Owner:, f�fame �ienan Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of PumpingD 2. Quantity Pumped: O Gallons ----- 3. Type of system: ❑ Cesspool(s) ©Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): --- ---- 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: VLi �- 7226NaVehicle cense Number Company 7. Location where contents were disposed: Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record •Page 1 of 1 NORTH TOWN OF NORTH ANDOVER 00 p PERMIT FOR WIRING SSACMUSEt This certifies that � ti rl2 G..................... :e has permission to perform .......... .................................................... wiring in the building of................... ..... ............................................. S SE S .....................n... ,North Andover,Mass. Fee... Y... ... Lic.No...�/-Z?......... ... ....... ELEcmicAL INSPECTOR ,Check # r 9363 r � Commonwealth of Massachusetts Official Use Only t Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date:_ City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number)1` Owner or Tenant ar Arp/ Telephone No. Owners Address Is this permit in conjunction with a building permit? Yes No Purpose of Building sem' ❑ (Check Appropriate Box) Utility Authorization No. Existing Servic02lJ6 Amps /a VoltsOverhead Und rd ❑ No,of Meters New Service Amps / _Volts Overhead ❑ Undgrd ❑ No.of Meters Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: Com letion of the ollowin table mqy be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total No.of Luminaire Outlets No.of Hot Tubs Transformers KVA Generators KVA ` No.of Luminaires Swimming pool Above ❑ In- o..o mergency ig g d• rid. 0 Batte Units No.of Receptacle Outlets c;2- No.of Oil Burners FIRE ALARMS No.o.Zone.- No.of Switches No.of Gas Burners No.of Detection and No,of Ranges No.of Air Cond. Total Initiatin Devices No,of Waste Disposers Tons No.of Alerting Devices KW Heat Pump Number Tons .___............ No.of Self-Contained No.of Dishwashers Detection/AlertingDevices Space/Area Heating KWLocal❑ Municipal Connection ❑ Other No.of Dryers Heating Appliances KW Security Systems:* No.of WaterNo.of Devices or E uivalent Heaters KW No.of o.of Si s Ballasts . Data Wiring' No.Hydromassage Bathtubs No.of Motors No.of Devices or Equivalent Total HP Telecommunications Wiring: OTHER: No.of Devices or E uivalent Estimated Value of Electrical Work: Attach additional detail if desired,or as required by the Inspector of Wires. � Work to Stark (When required by municipal policy.) Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived b the the licensee C Y owner,no permit for the performance of electrical w provides roof of liability ark ui issue unless P ty insurance including � y undersignedg completed operation coverage or its substantial equivalent. The certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND [3 OTHER [I (Specify:) . I certify,under the pains and enalties of perjury, that the information on this application is true and complete. FIRM NAME: Licensee: � LIC.NO.: j"Q S/7 ►mo��,rep Signature (Ifapplicable, entente license number line.) LIC.NO.: Address: �e4 .4Jo1 GCc /3/�Bi Bus.Tel.No.:lo I *Per M.G.L c 147,s 57-61,security work r es Lty Alt.Tel.No.: OWNER'S INSURANCE WAIVER: I am aware that Department Licens a does not have the liability Lic.No. required by law. B m signature y q h'insurance coverage normally By y gnature below,I hereby waive this requirement. I am the(check one) ❑owner ❑ owner's anent. Signature Telephone No. P ERMIT FEE: S _ � � 1��. P �W�. � �=S �. � ����. �� � f �. a The Commonwealth of Massachusetts Department of Industrial Accidents Office of investigations 600 Washington Street Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):_ /,J' GJ h/7 Address: 2(/p 06 4 S / City/State/Zip: /--L )ZTX�,O Phone#: 2 21-2� Are you an employer?Check the appropriate box: 1.ElI am a employer with 4. ❑ I am a general contractor and I Type of project(required): employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2. I am a sole proprietor or partner- listed on the attached sheet. 1 7• E]Remodeling �Z ship and have no employees These sub-contractors have 8. []Demolition working for me in any capacity. workers'comp.insurance. [No workers comp. insurance 5. 9• ❑Building addition ' p ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11-[1 Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.] t employees. [No workers' comp.insurance required.] 13.❑Other Any applicant that checks box rl must also fill out the section belov!Showing their Workers'compensation policy t o Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractois that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: TD//7 Policy#or Self-ins. Lic.#: Ae7_e!�7�y�/ t� Expiration Date:_,f-&— Job Site Address: l�l/ ,!57q �Lo fyj City/State/Zip: A j�o��C_ Attach a co of the a workers compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of i• Investigations of the DIA for insurance coverage verification. Ido hereby certify under the at and penalties of perjury that the information provided above is true and correct. Si ature: Date: Phone#: 7 Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: t Information and Instructions Massachusetts General.Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." . An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or.license is being requested,not the Department of y 'Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a'valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. 1 i The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-72.7-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dna I COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS v' DEPARTMENT OF ENVIRONMENTAL PROTECTION i r i TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION a Property Address: V SO Owner's Name: /J- Owner's Address: _ Date of Inspection: Name of Inspector: (please print) C'hgr�eS TR o ux WSJ 3 26 Company Name:77--w s 6tz" S'P,,,r„ Cos fre- „- Mailing Address: a13 Ak+FrN Rd Telephone Number: 7 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the'proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: /Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails I Inspector's Signature• — Date: 7— / 0 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments I I ****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. i Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: /.Szrg� Sra�. Yt Owner: Date of Inspection: Inspection Summary: Check A.B.C.D or E/ALWAYS complete all of Section D A. Svstem 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: r B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section ed to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by a Board of Health, will pass. Answer yes,no or not determined(Y.N,ND)in the for the followine temenu. If"not determined" please explain. The septic tank is metal and over 20 years old* or the sept tank(whether in or not) is structurally unsound. exhibits substantial infiltration or exfiltration or tank �llure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as app ved b} the Board of Health. `A metal septic tank will pass inspection if it is structural! sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is avail. e. ND explain: i Observation of sewage backup or bre -out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settle r uneven distribution box. System will pass inspection if(with approval of Board of Health): ren pipe(s)are replaced uction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: _�$US/ �� (`,ovt '� Owner: Date of Inspection: C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of th 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 ' accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a mannXaace otect public health,safety and the environment: i Cesspool or privy is within 50 feter Cesspool or privy is within 50 fevegetated 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 enviro�thinl nt: _ The system has a septic tank and soil absorption system(SAS)and the SAS is00 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 Zo 1 of a public water supply. The system has a septic tank and SAS and the SAS is wi 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS less than 100 feet but 50 feet or more from a private water supply well". Method useZ,performed distance "This system passes if the well water anat a DEP certified laboratory, for coliform bacteria and volatile organic com ounds he well is free fro P mollution from that facility ry and the presence of ammonia nitrogen and rtrate 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: I 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: L5-0 Owner: Date of Inspection: 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 day flow Z 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. 1"Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 1 Any portion of a cesspool or privy is within a Zone l 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 eater than 50 feet from a private water � supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that tbi well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] (�(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as j described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of I 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 tgn flow of 10,000 gpd to 15,000 gpd. You must indicate either'yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the c ' ria above) yes no — the system is within 400 feet of a surface g water supply the system is within 200 feet of a tribu to a surface drinking water supply the system is located in a nitrogen ensitive area(Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water suppl 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: /S-09' �-�- Owner: Date of Inspection: Check if the following have been done. You must indicate`yes"or"no"as to each of the followinz: Yes No .e""_ Pumping information was provided by the owner, occupant,or Board of Health Were any of the system components pumped out in the previous— P p p t>s two weeks . — p — 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) P40n o.ti� 1— Was the facility or dwelling inspected for signs of sewage back up? — Was the site inspected for signs of break out? 1 — 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 g 1 stems . P , The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no — Existing information. For example,a plan at the Board of Health. �— Determined in the field(if any of the failure criteria related to Part.0 is at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] � I 5 Page 6 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: j s—O !( Sit l//x. S+ Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual):_ 1 DESIGN flow based on 310 CMR 15.203 (for example: 11,0 gpd x;;of bedrooms):q_o c>i0�ir3$S�'wt e� Number of current residents: 3 _ / Does residence have a garbage grinder(yes or no): A/ Is laundry on a separate sewage system (yes or no):*✓ [if yes separate inspection required] Laundry system inspected (ye or no): /I Seasonal use: (yes or no): / Water meter readings, if available(last 2 years usage(gpd)): s C .t Sump pump(yes or no): c Last date of occupancy: COMMER CIAL/INDL STRIAE Type of establishment: Design flow(based on 310 CMR 15.203): d Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): _ Industrial waste holding tank present(y or no): Non-sanitary waste discharged to the rtle 5 system(yes or no):_ Water meter readings. if availabl Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection( or o): If yes, volume pumped: . �V gallons-- �jow was 4uanti pumped determined? Reason for pumping: L (�-yYtoitx l�r� -tvt� t.9a3,&xp TYPE OF SYSTEM Septic tank, distribution box, soil absorption system _ Single cesspool _Overflow cesspool _Privy Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner —Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components, date installed(if known)and source of in ormation: Were sewage odors detected when arriving at the site(yes or no): Al 6 Page 7 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propern Address: _/ . S-�- Owner: Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: I,e Materials of construction:_cast iron — 40 PVC_other(explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage,etc.): 0 6ser✓t- SEPTIC TANK: (locate on site plan) Depth below grade: -2, 1,- Material of construction: ./concrete_metal_fiberglass polyethylene _other(explain) If tank is metal list age:_ is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: , L, Distance from top of scum to'top of outlet tee or baffle: Distance from bottom of scum to bottom,of outlet tee or baffle: p How were dimensions determined: A-'C1 , , " Comments(on pumping recommendations, ' let and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakaee,etc.): VL)" CC ✓— � Vt e GREASE TRAP:_(locate on site plan) Depth below grade:7— Material of construction:_concrete_metal_fiberglass�o thylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffl . Distance from bottom of scum to bottom of outlet a or baffle: Date of last pumping: Comments(on pumping recommendations, et and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of le ge, etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /S'p S(S & �S . Owner: Date of Inspection: TIGHT or HOLDING TANK: (tank must be pumped at time of inspect' (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working der(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: / (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 1a Y Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, anv evidence of leakage into or out bo etc.): " /�,� + C R P�D'Jt ow vex— ��w k D � U V-i�c.�,T 1 i aue S 1ti:j ej4[h' I PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber, dition of pumps and appurtenances, etc.): i . I 8 Page 9 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): /(locate on site plan,excavation not required) If SAS not located explain why: a Type leaching pits,number:_ leaching chambers,number: leaching galleries,number:. --leaching trenches,number, length: ' <2 leaching fields,number,dimensions: overflow cesspool,number: innovativeialternative system Typeiname of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): s4u,Ls to 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 laver: Depth of scum laver: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hvdrauli ailure, 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 hydraulicfa* e, level of ponding, condition of vegetation, etc.): 9 Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: /SU y S11- Owner: Date of Inspection: 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. i 3q. p ICK. N 33' jai 10 Page I I of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /�lU�/ �}— Owner: Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water�—feet Please indicate (check)all methods used to determine the high ground water elevation: -'Obtained from systemdesign plans on record-If checked, date of design plan reviewed: 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: 11 Li all D eN o1!3 f rec :-;o(minanis A r p fi 41 cfj c ICTOSCA-4 Act' mTesl pdfiip fOtAbok ccloW3 Z, x t -�7 dit Temi"rial WATER BILLING HISTORY 31?009()-DES1H()tqc, JIM & SHAROHNETER #1 ',3170096 .!ep.su - 1: - 1.504 SALEM ST wt;lcadnd! 7d U CYCLE SERVICE PRIOR CURRENT USE WATER SEWER FEES TOTAL 1 2000-13 1e/01/1999 1098 5 J4 cJ 2 2000-23 ol/es/2 147.42 0.00 00 147-42 lrltzrr - _0(1,,, 11r,2 lise) 34 2.82 0.Oki 0.fjo 3 2000-:33 04/03/2003 1186 1210 92-82 20.90-43 (16/161-?jig 0 24 165.52 0.00 0.00 65.52 r,42 1227 17 4f,.41 00 0.00 45.41 5. 2001-13 21101-13 10/03/7_00[i 1227 1260 33 90.09 0.00 11-08 1101 09 6 2001-23 12/29120 1260 '1296 26 79.98 0.410 11 .0B 1 2001-33 04/113 81.'98 60.14 12001 1286 11304 8 49.14 0.00 11.00 8 2001-43 136/1812 001 1304 1332 20 76 0.00 11-00 87.44 ') 2002--13 09/14/2001 1332 1362 10 95.90 0-00 -5.5s; 75 OWN 10 2002-23 01117120112 1:362 1392 20 49.40 0-00 5 90.85 11 2002-33 04/18/20(12 1382 1422 121 .20 0.00 5.5.s 126'54-95 12 2002-43 06/24/2002 1422 1441 19 46.93 0.00 5.5r 52 148 Expi Oukk13 2903-13 09/19/2002 1441 1-473 32 93.20 0.00 5.97 99.17 114 2003-23 12117120 1473 1510 37 112.20 090 5 mp.1 15 2003-33 03/12/2003 1537 27 74.20 . .97 1113.17 asolt0.00 1.97 8 0.17 o(d 2903--43 06/11/2003 1537 1580 43 13S.00 0-00 5.97 Netw Neighb( REUIEW CHOICE 1t ar <EHTER> MORE HISTORY: Q CD 777777- stwt T Inet- hibox - Tvi tz,mvRs i 1V1 V R S m 1A s P OP-51N DATA C ALCULAT101.IS.: -�, ;�; SDILOBSERVATIONS B C t W1 TNESS 1�12.� •. r . PAW r ' �. pERCpLaT1oN TesT Qo.74 DATE } T o P- ELEVATION I CoL . c� I Co�j.cam ; ;BOTT ELE�/artolJ AT ORATION i2 � �.. D2oP- r�llNs 2-2-2 2� � ;.pERC (ZATE - ►✓11N.�INC:N IC� '� "� ", � t", z•� 3 4 5< � SOIL PRoFiLLc_ DEEP i�r No. 2 , [� DAr E £� Its-0:>A .: >, ` ro P-E LE VAT 10 n1 Cvlv:.c' +TOPSOIL- c9'2 Z7 C71C r1 c7 ` SUBSOIL PARE N T :SO ILI� COP fly I s; wAT1=2 TABLE y NED CRUS HE D ,STONE y': 79��� Gj�-c7�' " ; a; Gj12AV E L F r +HED ciZUSµE'D STONE V�/ATER TABLE LEVATION , J2 ul F3:or roM.:ELE.vArro� � `3` I3UiLDINC� TYPE ,B. R., pP- x —I r-2c2 C�.AL. /Urvlr = �pc7c� PD Flow w�7c7 SPD FLo v /x 200 0= 12�7c� C,PD USE I �jc�c� G?`� SEPTIC 7;-,NK xr ' J TIZENcHES : St0EWALLARE,q 2 SF/L FX I . cwCTRL$ rsF.. — c ./L�Nf G,AT. F3 orro M AQEA �-� 2 5 G�LF x C4AL./LAN FT (� To'TAL TREI-ICH GaF>Ac I T`( _ ---- GAL. LIN 'FT — COc7c� GPD FLowF. TRENc - __ .__ _ I .� ✓. A ,�T I NLS REQ D. USE I-G. I .F. 1 i, - 1 " 'S Xk € - c'''.c�rS�� �)r,�*�'•t.Y����4j'� r:t�1�°��J *" '��,$� a� �'�7.�+{ 's 1:" ' 44 •A s�! =:�'. �/ w • j �� ,t ld1 N 3 ��r..v. fa 'x��,.F�`�i�0.7� x :}.;1, yr i.Ma.F$r `.€�- •xit:3£`�v,-t _� � � � �'-' 'fir asx� � _ � _ � > r� + 4�,a � x x aw�`+�^+li`�'� �, .�fi�@ x •�, � t tis r.ir fi�' da s r 4xai� y 3 v r 7�fns`` rt�r IN it z �� ���.#°'y'S.•k�t ��e I •�• �• ' � .r,�At���,- S' �," r ��x xy` .Y.-M �.,� � �x�... . '.'`''.c.� �1 u x..;+u.� ,7y �t ,a��� x'`'°'1)� f��,� .,Y k•�' Kf�4� 4'�'�F�'`������� '� ,��"�x`. a. 'Y.,•�4 � r • � �� .. � �x 7w4 rT X.• ? - - 7 '�' t .,s� a *. y �' � 1'.�;`'S. `ti+aT+tl c Of'`�,'� � kl ��•yy�� t # %e�a� I ,�' . Y � � �. . I � as, s � y..,, t '� �: +•' �#fy t� � � G •�r,I �C� Y/'- �"�'L�r ^5t< �+ �. K& K� �,Kr ,,_ �krx, �m`�� ✓""",t '� ys•�k �"{ �M��`�'� '' �e � x:� �: ,�L x.``�,�'� y 3 M�� mr xs'g. 4�� -:.'`i . low Z,,ff. , ix �F�', ^ .� ��" � ��'� I •.� • �'/'� /���' `�' _ - �d� .:7r ^s"�•v.TT�, yc�•,,,Y�k �5�5 4 �r_`v���'?f�2ry�€Q . 'kkx" tcti, J C/ �I _ 'v •r.*.i 1 wW yO} 8 '�`S'�3 x1m a �'4�+e: vs 7X•�` 'y } $ k a \�:a�* ]� n '„�.., t�;�h.,.a�i�., .. x 93+ ., � -As�xpv+,� ��."+” ��t"z•�ts.ur{'1ry .� �",?`§a ��y 4_ c�``.`�++f' _`, u y ea LOT,. G sT�>:E T PREPARED �OSZ It J y �.6�-g w I f �ikr �Ys!i V L dMItiJSK I I&S,SOCI4TES INC.. �;� !. I yy=' ENCjI NEERS ;. .AQct-IIrEG TS f! - t 451 ANDOvEfZ 5.7'-rL£ET . 4!''N,/ G.�.•ti�� DAT�� CSG � I� �� W4OUR . ¢a r D.:E51 DAA CALCUL torl,S I_O6SERVATfoNS B (51 Wt > Y i r_t�,�C•. 'tit :s R :rtS .z, ,rx. '�f s - -- T P E RcpL_AT i o N TEST X10. 4- 5 a , nfi r •`DATE e.>-0,4 2� ioP- E�EVATIotJ - rs co�•v go-rrorn- ELEVArlorJ z4 a 5AT JRATlorj - MINS Fah (2' --,, 9 's�,�4 9 —► (v DROP COINS.. �� G PERI RATE - t✓1'In1.�INGN ICS SOIL PKOF►LE- DEEP Rr Yjo 2 j 3 4 5 T �� , .%a, 1. I n,� bt o P-E LE VAT i T o� TI I I 11 r r r :So I L r2AvE1L ,�+ �Ys (CSI �A � �'�'�" Al W Avg`+ n ; c x 1 WaTER T�,BL LEt/RTroNr�', . l ���'"...ga�.. j .a.�' ..n�#"Y= :��.§tT��3 L:T [ .::3[ ELENA T�o►.t,�°� ..::a+t�•,:i,Yo»�. �izsaswsx,� ..�'e...v�`,'��Y � .I.��:� c� �)'>%7�.'L7� .Y;, f ., • # 1�� �n t " "gG�&,a Rdh�.n�+.,�.� ��}'r.,q,� j��yl� ��'fi .�.� �', �.3�� 1• .-. "(f�E4 HS` y ow r _ +�� �,�.} �Ot7C7 ��P.D�FLAVV x .Z00� = 12�7c� CPD USE ( ' c7�� G z t t 3rr� st �EwAG,� 2 S F L�K I ��cy .aL - 2.�7c� S S F (: AI./L�N.FT.~ 3� TT'OztY1A4;2tA 2 SGILFx - �� Ca ALS/SF = I - Ic7 ClAL./LIN . FT, -.{ ��14}+� n � y. ��♦�f' .yFri vJ 4 L' C .t4�'1„a ms`s. c,♦1'} 4 FT �� }-T� � F CA PAC I T`( AL./ L.I N. FT.. k t7t w AL.. LIN.F T.=I9 F. Tp-E N C N a " µ CPD 1✓i.ow� '� i�7� '' L. ES REQ o. U S.E moi - L.F. NO P1,14 On4 ti gam_ .�F .wb+ � � � �x•vr rL t wx�1T'�' � r r'`� Y�F �2ar � ,� k d' i�'" L 5 xr �S ti At s J,-2er2 170 �} r�'�9-as,�� :�' *e.��•;"��A..Sa a�w�' a'�C.� c¢ At°S3 J 17�J Er��a 2 w } to , '}�� � /�C /n( �C/1 I� I" li I coca. C ``t' t ' r03�T11�pY'ftv¢irL'A T I'D nz A O�6 rnrrresfi r Q 4Vl L1\EVIL\TV L'[LL LLL VL' LY nTCL�,.L/.v OZ.L LW EXECUTIVE OFFICE OF ENVIRONMENTAL T.AL A FA T)IVPARTM ,NT OF FNVTRONMFNTAT,PROTFC"TTON ONE WLKTER STREET,I104TONT,AIA 02103 617-292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A C>I*aRT I=fTCATIION PROPERTY ADDRESS; 1504 SAI.E�_vI�STREET NORTH ANDOVER,NILA Oa845 DATE OF TNSPF,(TION: &26-97 A.DD>IRE18!5 0-Irt OM'1NE R: NiTANIE OF I:ISPEC TOR: .1'�CYS '"�G T„I (IF T ukA':,R', I AM A DEF APPRe.' ED SYSTEM DDi i,SPECTOK PURSUANT''TO SEC ION 15.340 OF rrru 5(3io a&IR j5.4w) j COMPANY NAME: ACTION-KING ENTERP>IIT;•MS TNS". ?�1A ENG r' ]E�>€IES$. 16 LIV>IPiGSTON STREET LoWFL 'L i11R52 TELEPHONE NUMBER:— 15033 452-7,'50 FAQ.° i'503g 45:-13770 CERTIFICATION STATEMENT --.i I CTRTId'Y'.1'.L'IAT ILTA_VE PER80YALLYUTRPECTEED THE 51-WACE DIMPO3-AL*`•'4TEN AT=v ADDRESS AND THAT THE INFORMATION REPORTED BELOW IS TILE,ACCURATE AND COI. 'Lrsii: AS OF THE INSPECTIONE OF INSPECTION. THE INSPECTION WAS PERFORMED BASED ON MY TRAEN+ G A,NsD F.XPFRW,KC F A'N'N TRW,PROPFR FUNCTION ANSA VATNTFNANC'F,OF ON-STTF SFWAOF; TDTSPOSAT, SYS S F%l ls. Twv ISYSTEM. X PASSES CONDI-(TONALLY PASSES NrF D8 VtTRTAFR FVATJTATfON.RY TIRW LO CAT,APPROVTNO ATTI'aORTTV FAus R($PECTOR'SIGATIiIi ..� DATE; 8-25-3' I=.SYSTEM LY!OPECT0-R SMALL SUB I'A COPY OF, TM.R INSPECTION IIEPOLTIT T:)TUE A PPARON'2N'G AITT11101RITY WITHIN THIRTY(39)DAYS OF COMPLETING THIS INSPECTION. IF THE SYSTEM IS A SHARE,D SYSTEM OR HAS A DESIGN FLOW OF 10,000 GPD OR GREATER,THE INSPECTOR AND THE SYSTEM OWNER SHALL SUBMU 7iUE REPORT TO TRF APPROPRTATI;RFGTONAT,OFFTC'F°OF TRF:DVPARTMFNT OF VNVTRONMF'NTAT,PROTFfC"70N. �'IDRICINAL SI.IOxTLD IIE SENT To THE SYSTEM C?WNTEIR ANID COPM, TO=, 13> yE,R,Its A_PPLICAD>LE AND IRE APPROVING AUTHORITY. TNSPFC.TTOV SITMMARYr C'AFC K A,11,C',,OR I1 A} SYSTEM PASSES: X d"AVE NOT;I<`OILTND ANY INFOIRN tAT'ION 4'i'Mr-rl VDfCATE8 AT TTS SY, TEI42 E SOT.A`t!:!3 ANY OF THE FAILURE CRITERIA AS DEFINED IN 310 CMR 15.303. ANY FAILURE CRITERIA NOT EVALUATED ARE INDICATED BELOW. COMMENTS- B) I SYSTEM CON DFI10 iALLIT PASSES: N/A ONF,OR MOTIF gVSTFM COMPONFNT,4 WWI)TO nr RF°PT,AC VD OR RFP:ATR_VD. TTTF S'1'STEM €por."C`OI�'IPLIJTIO14T or, TIM Z"EPL.A.GEtNIE c?Iii.RE,PA—,1"AS4; ! LNTq'!'I;.1.�0�_° INDICATE YES,OR NO,.OR NOT DETERMINED(Y,n,OR NED). DESCRIBE BASIS OF DETERMUNA a FON ue1 ALL TNSTANCES. IF"NOT DFTFRMMT)IF;XPT,ATN W TTY NOT. 'NFMTRATYON OR EXFELTRATION,OR TANK FAMUTRE IS IN 17vir-,-E Ti, TIIE S ST,EhT Wa�.L PA:3s" �SPECTION THE EXISTING SEPTIC TANK IS REPLACED YVITRi A CONFOIC�imii.NG %RPTIC TANK AS APPOROWD TSV TAF'BOARD OF TTFAT,TW ACTION-ICING ENTEaRPRISES,INC. ST RE V.T LOW ELI.,SIA 018:52 TEL: (505)452-7750 FAX:(508)459-0770 PROPERTY ADDRESS: 1504 SALE U STREET :NVQ HAI DG V ER.,KA Lfl3TJ OWNER;GF-RRV AUGER DATE OF ViSPECTI€7N: 8-26-97 ACTION KIl'RTG ENTE1tI'RIgES,LNC:".IIAR 1BEE,017 RE,TAl1NED BY THE C OWNER TO PRONIDL�ANO L"T,- r 'TK�N O '1�T'=r�,ON- SITE SEWERAGE DISPOSAL SYSTEM AS DEFT;D BY 310 COIR 15.303.D.E.P.GLIDAINCE LNS I FACTS THE INSPECTOR TO MAKE AN EVAiLUATIOiN Or THE SYSTEMS PERFORMANCE ON THE DAY OF 117HE INT SPEC TION. TRF TM F 4 FKSPF("TTON T4 NOT DFSIC'WD TO PROVMF INFORMATION TO T)lPMONSTRATF,THAT TRF SVgTFM W ML-ADEQVATELY!S.ERNT, TLE U,SE TO BE PLA Cri,n- U,ro-N*T DST im NrW C?NVIN'TjR Al R- STATED N. 15.304", TM.3 V SPECTION IS NOT Ai:'t:Ra'V�'!iEE OR GUARANTEE OF THE SYSTEM FUTIU.E i E:tFO&'-,'Al' C;E,AND DOES NOT EITHER EXPRESS OR IMPLY IT. I PAGF 1-A AC TIQN-l0gG rLNqERr_"TES,LNC.. SUBSURFACE SEWAGE DISPOSAL SYSTEM MpEr-14-)N FORM PART A CTRTWICATION (CONllTnyjlED) PROPERTY ADDRESS: _0048 AMEM STREET NORTHANDOVER.Ie k 0184:.* R OWNERt GERRV ATJGF --- JDATE OF 0"SPE,M. -ON- 8-26-97 8) SYSTEM CONDITIONALLY PASSES (CONTINUED) NZA SE""Ar-ri•BAICYtTl'ORBRE,jtKO17 OR MC HISTATIC NVATE,R LEf VE L 0-PSE R1Tll LIN,'1117RE DISTRIBUT1011,1TBOX 15 DUE TO BROKEN OR OBSTRUCTED PIPE(51 OR DUE TO A BROKEN SETTLED OR UNEVEN Db4TRIBUTION B02L THE SYSTEM WILL pASS INSPECTION IF(WITH APPROVAL OF THF ROARD OF RFALTR). —BROKE N P]rE,(18)AXIME REPLACE D D ----..-DISTRIBUTION BOX 19 LEVELED OR REPLACED Tm, SYSTEM RE QILMIE,D PITINfru9c INIORE MAN In-UR MI-1 IES A YEAR DUE TO BROKEN OR OBSTRUCTED PIFE(S). THE SYSTEM WELL PASS INSPECTION IF 041TH APPROl"AL OF THE BOARD OF HEALTH). RROXFN PTPF(q, )ARF RV-PUACET) —OBSTRUCTION IS REM O'VT(D Q FURTHER EVALUATION IS REOUIRED BY THE BOARD OF HEALTH: N/A —CONDITIO-IN'S EXJSTM'lHC_ff REQtr[RE IN ORDER TO DETERINMI TE EF THE SYSTEM Vil FAILING To PR,,' HE SAFETY AND THE ENVIRONMENT. SYSTEM%V-ff,L!'A 8 8 IWL-E,8,.q BOARD OF"E.A L T-11 DE TE,R M_M' T_,'g s FUNCTIONING INA NULNNER WHICH WILL PROTECT THE PZIBLIC HFALT-111ANDS',iffE,1`47 AND THE ENVIRONMENT: CFS.SPOOIr.OR PRTVV N WrMYN"M41 VT OF A STTRFA(I ,V WATPR CESSPOOL Olt PRI"jS Wrj ,0 F ORAS ALT TrVIARSH. 5EET OF A DORDERP�C VE GET.-f-Ep SVSTFM WIT,Y,FATT.TrNT,FSS TWF ROARED OF TWALTU(AND PTTRTf(-WATFR STTPPT,TFR, W APPROPRIATE)DE,TIER140N.E.S TE AT THE( SYSIT,M IT FUNC rflO-Nr�"G, LN A!:UNTINTER TnAT PROTECT THE PUBLIC HEALTH ANDS'AFETY AND THE EINTiVIR-ONTMENT. TRVSV8TFM RAS ASFPTTC TANK AND ?(DIT,ARSORPTION WSTEMANT)TLR wrVRW 100 117-1 F T TO A S 1URFA C E,WATER S t TPL Y CDR TROUTARY To A siva i_;rCE,wA Tr,R SUPPLY. THE SYSTEM HAS A SEPTIC TANK AND SOIL ABSORPTION SYSTEM AND IS WffHpj A ZONF,I OF A PTiTRF,T(-WATF.RSUPPLY WFI,T,. TIM, S'V,5TE,�NfUASAS]r'MC -TA-N]K-4-NTD,'30ELABSoRPTfO-N,-Y- iO FEET'OF A PRIVATE WATER SUPPLY WELL THE SYSTEM HAS A SEPTICTANK AND SOIL ABSORpTl()N SVS!17ErVi Arq-lj IS LES" TITAN 104 W.FT RUT%FFFT OR PVTORF FROM A PRIVATT,WATFR-.gTTPPI;.,V wVT I.- UNLESS A -Aillp. VOL rr r ORG-'NTIC CO"�QOr-_7*,T8 IN-DICATESTHA T-1- LS ram EvrL FROM THAT FACILITY AND THE PRESENCE OF AMMONIA NITROGE4.,L14-D NlprRATVNMor�F,NvTSF,QTf4l,ToORT,'FSSTRF,-';PPM. NWTIROIDfT%lVTITODJWTFRVr,,j,-, DISTANCE, ("ppR 0--y-BLATIONNOT VALLD)T- PA AC`TTONXING FNTT;RPRISFS,INC''., D) SYSTEM TAILS: NIA _ I RAW,DVTF.RMTW D TRAT TIIT;SVSTFM VTOT,ATFS ONF OR MORF,OF TFIF FOT.I,OWING FAIL-tME'CRITERIA Aha DEM ID LN 3MO C MR 15.303. THE DAS_IS TOR TUBS DETr-! ti'ILNIA.Tz'DN IS IDENTIFIED BELOW. THE BOARD OF HEALTH SHOULD BE CONTACTED TO DETEIUMPQ—,l WHAT WILL BE NECESSARY TO CORRECT THE FAILURE. YES NO BACKUP OF SEWAGE INTO FACILITY OR SYSTEM C034FONEN T. DUE TO AN OVERLOADED OR CLOGGED SAS OR CESSPOOL. iDISrHARCM,OR PONDING OF T;M TTFNT TO TRF SITRFAC F OF TTTF GROITNO OR SLTRF,ACE�'%'ATERS DUI!.TO AN 0VERLOAIDED OR CU)GCED SAS OR cE Stir0OIL- STATIC LIQUID LEVEL IN THE DISTRIEL'TI€iN BOX AL:A' ;:;- R T I;LL T:: AN OVERLOADED OR CLOGGED SAS OR CESSPOOL. I,TQITM TDF,PTH IN C YSSPOOT,IS I FSS THAN PM RFLOW INVERT OR A.VAIrLARTY, Vd_DI,TTME TR LESS TIIAN 112?DaY FLOIK REQUIRED PUiVIPING MORE THAN 411MES IN THE LAST YEAR NOT DUE TO CLOGGED OR OBSTRUCTED PIPE(S). NiTMRF,R OF TIMES PITMPFTD ANY PORTION OF THE, Serb ABSORPTION SYSTEm; c-r-s-s°oo ,mR r*rrwy IS mull-xv THE HIGH GROUNDWATER ELEVATION. ANY POR TJLOIv OF A CESSPOOL OR PRIVY 1S Wfl—Il v i 0 0 FEE OF A SUiIi,ACE WATER STTPPT,V CDR TRMTTTARV TCD A STTRFArIF WATFR STTPPT,V, AN"YPORTfON OF A CE($SrOOL OR PItIN'Y IS WTTILIN A ZONTE I OF A PUBLIC WELL, ANY PORTION OF A CESSPOOL OR PRIVY 0 WITTuu 50 FEET O A::tI:TATE WATER SUPPLY WELL. ANV PORTION OF A CESSPOOL OR PRTVV IS T,FSS TITAN 100 FF-TT RITT G'.RF.ATF.R TITAN 50 FEET FROM A PRWATEE%J'ATa R SUPPLY WELL WIT'.'7 NO A!-'` �.I",r;, WATER QUALITY ANALYSIS. IF THE WELL HAS BEEN ANALYZED TO BE ACCEPTABLE, ATTACH COPY OF WELL WATER AXALYSiS FOR COLIFORM BACTERIA,VOLATITF ORGANIC" C'OMPOTWIDS,AMMONIA NTTRO(-,.VN ANID NITRATE NITROGEN. E) LARGE SYSTEM FAILS: THE FOLLOWING CRITERIA APPLY TO LARGE SYSTEMS LN APjlr-rrcD!kT.M"M :BC:."E. N/A, TRF DFISIGN FLOW OF SVSTF,M TS II►,000 GPD OR GRF.ATF.R(LARD..SVS'T'F.Xl) ANTI TRV SYSTEM IS A SIGN�'ICA,NTT THREAT TO PUBLIC IIEALTII AND SAFETY A.WLI`THE ENrVTRONMlGNT BECAUSE ONE OR MORE OF THE FOLLOWING CO2NDITIONS EST: VFS NO TIIE SYSTEM ISWTrIIIN 400 FI~r'T Or<A SITrtrACE tDB—n G NVAT R sicTrLY THE SYSTEM Is WIT'HI 200 FEET OF A TRIBUTARYTO A.9URl AIC-L LRviK-oG WATER SUPPLY. TRF SVSTFM IS T,OrATF.ID IN A NTTROGFN SFNSITTVF ARRA (INTT'RTM WFUT,ITFAID PROTECT-19- !%f AREA(WPA) OR A MAT'T'ED ZO'NT Ti OF A PITDL,IC~II A'rml SI'pPLY WELL. I TUR,OWNER OR OPF,RATOR OF ANV SITC FF14VSTFNI SRALL RR1NG TIO;SVSWM AND FAC"IT,ITV TNTO W1.1, COMPLIANCE WITiI TU< G RO UNDWATE,R TRE AT!kfENT PRO GR-ALM REQ1MR-ENI ENTS,OF 314 C�NM 5:Qo A N!I A.I?f�, PLEASE CONSULT THE LOCAL REGIONAL OFFICE OF THE DEPARTi` MN"T FOTO FURTHER UNT,ORNUkTIO . rAGE ACnON=NTNG EN. TE'RPRjlQ ;rvc. PART B CHECKLL13T PROPERTY ADDRESS: 004 SALEM STREET[' NTOP.TH ANDOVE "AlA 42345 OWNFR- GFRRV ATSQrF,R BATE OF LNTSPECTIO`r:L&16-9',7 CHEC'IK ff T"IIE r'O-Y LONIVINC IIA%TL BEEN DONE. YES NO X PITO PING TNFORMATFON WAR RFQTTFRTF,TD QTF TRF,OWNER;{TrrlrTPA`TT,.A-,%,o R04RID OF �'ALTM X _ 'NONE OF Tt'J'E( SYSTEM COMPONENTS H.4T/E BEEN PUMPED F014 AT LEAST TWO WEats ti'T:� THF,RY'�TF,1%4 HA%RF,F..N RIFCFYVrNC.NORMAT,FT,OW RATVS DTTRP,VG TTT.AT PV,RTOTD. T,ARrr,, VOLITIMES OF M ATER ILAVE NOT BEEN TIIL SYST,",,qs%(,E.NT'L.�'[},T As PART OF THIS INSPEC-ITON. NlA AS RIM T PLANS TT.AW,,RFFN ORTAMT)AND FXAMTNVI). NOTE TT'TFWV ARV NOT AVAD.A.RLE W_TT'I_T N;/A. __-- TFE FACILITY OR DW ELLDiG WAS pjSpECTED FOR SIGNS OF SEWAGE BACK_up. x T''IIE SYSTEM Dore 5 NOT RECEIVE Nt N_SA!�TrARY OR rvDTrS�RL%L.�'VApTr z{.OW, x THE SITE WAS INSPECTED FOR SIGNS OF BREAKOUT. x ALL SVSTf EXI C0—-Nf ONr,-NlN,,J.X I.,+I+DLIrj 1 H SOIL.ADS011�.l XO ,%-y' li y ..w�L. I � LOCATED ON THE SITE. X TTTF,R1F PITC TANK MANHOINS WVRV UNCOVERED,OPFNFTD,AND TTTV+,TNTVRTnR OF'T'RF. 'E'P ITC TANK WAS!WSPECTT ED I'�R CONDMO.N OI!1<Z + , ES c:R T^L'�s EIIL4I It, CONSTRUCTION,DMIENSIONS,D1,PTH OF!JQLID,DEPTH OF SLUDGE,DE:z _ TWk R177 AND LOCATTON OF THF,ROTI.ARSORPTTON RVaTFM ON IDETE,PMLtir_pp THF RTTfi.T AR RP.FN ARTn OP'�Ee�� T�'ieTf:L'�'I'Y_DR!3LAT ITON OR_.i_PPROjy�LA�:T 1�V METHODS. x_ F.XTSTING INFORMATION. F.X. PLAN AT R,O.R. x --- DETERi�'dI'ii TED IN,,TRE FIELD OF A,'!'Y OF THE$AILI1��P.T�A�4w � r- r APPROkLMATLOAi OF DISSTAiNCE IS UNACCEPTABLE ii5."s4�i(3)(u)� � LAVED TO�;P.1 C Ls�,T �S�TE. PAGE 4 A.CrLON-lMiG ENHIEi PRISES,INC. SURSURFAC V,SF.WAGF,IDTSPOSAT,TNSPFC'TTCEN FORM PART C QETQTL":a.! T �DAai A TSlIAT U L*.7 L ul L M 1U tATITOIN PROPERTY ADDII.ET-q: f�4,8AL FM ST'I E'T' NORI H AND04TIt IVA 01945 OWNEES: GERRY AUGER DATE OF INSPECTION: 8-26-97 RFSTIDF.NTTAT,: - DESIGN FLOW; 4_40__ �.p-d-/DEiDI TONS MR S.A.S. NUMBER OF BEDROOMS:- 4 NUMBER OF CURRENT RESIDENTS: 2 GARRAGF.GRTNT)F,R(YES OR NO)_ NO SEASONAL USE(YES OR Nth) NC WATER METER READEPiGS,W, A,AILkBLE. CLAS T IlV2 i a��Al- LTStJGE �i� aiic RF SUPUMP(YES OR NO) YES r,ATT1V1DT+tTi'C'c)I�NFx'TF illFt`TF n To SYSTEM;VFS LAST'DATE OF OCCUPANCY: OCCUPIED C0M N I RCI AL/ENDUST�ItWX IN LA TYPE i?R i+"START,TSW-W-KT! DESIGN FLOW; ^GALl,LONR/D-4Y GREASE TRAP PRESEN;,(YES OR No) INDUSTRIAL WASTE HOLDING TANK PRESENT: NES ES OR NO') _ NON-SANTTARV WASTE DTSCTTARCM D TO TTS TM,F S SVSTFM- (VF,S OR NC!} WATER AfETE,R RE,ADrgC,,R,IP AVAILABLE; LASE`DAY OF OCCU PA.NCY: OTTIER; (I_DESCEPJ'Brl LAST DAY OF OCCUPANCY: GFNRRAT.MORMATI )N PUMPl G RECORDS AND SOURCE OF 174TFOR,'�L,&TION. Ot�TOBETi-995 SVSTF,M PTjN PFD AS PART OF TNSPV TlOK(VES OR NOVVS .IJ l YES,VOLVAIE PU'AlPE1D 1500 GALLONS. REASON FOR PTvTh. POIG E SP4CT[0N OF TANK&ND BAFFLES TVYT;OF SVSTFM A SEPTIC rANKI DY'-iTR nITTIOr;DOXI501 -A-880R OAT 8YSTEjt1 SINGLE CESSPOOL __-- OVERFLOW CESSPOOL PRTV V SHARE,D SY,91MM(YLS OR NTO)a YES,ATTACRT PREt'I0I'S�TSI'L'CT IOR'RECrDIWR;IT��T!') LA TECHNOLOGY ETC, COPY OF UP TO DATE CONTRAL-a OTtHi,ER;, APrR0X, A'-"E, aGE. OF AL,C0 1't'(??9TF�`NdTSf DATT EVRTAi•LT`D fid$C_N�TW; T = Q N)AID SOF,RCE€TI?M,OEt31s_1 gr SFWAGV,ODORS DF.TF:C'TFI D WTTF N ARRTMG AT TrrV SITE. (VES OR NO) NO PAGE 5 ACTION%ISG ENT E R P R 11,11 E'Ill,1JUK%C. PART C S,V,STV,M WFORMATTON(CONTTNTIFn) PROPERTY ADDRFS8, 1504 SALEM. sTREFT NORTIT ANDOVER, MA 01445 OM1114M,R; DERRY AUGE R DATE OF INSPECTION.8:216-97 RTTVT,IDTNG SFWFR- (LOCATE ONSITEPLAN) DF,PTFF RFJOW GRATA': N/A INLATERIAL OF CONK,.*.4�!R jTCTlQ!.l----AST lRON 4n PVC' —OTIMIR (EXIPLAEN� DISTANCE FROM PRIVATE WATER --- DYAMVTFR--- SUPPLY WELI,OR SUCTION LINE--__ CoAf ME NTS(CONDITION*Onforn- ITS; VE,INTING,ENin-ENw-E OF LZA.-KAGE,ET C) SVPTIC TANK- (LOCATE ON SITE, PLAIN) DEPTH BELOW GRADE: 30" MATERIAL OF CONSTRUCTION-:-X CO-NCRETE—ME(TAL—FIBERGLASS -POLVETIFfLE.-NE OTELE R (VXPTATNL� IF TIAINK ISAME,TAL,LIST ACE IS AGE COINIIMTYIfEID LRY CEIRT-MCA-11 Or, COMPLIAINICE DMIENSIONS: '01 x�l x 61 SLUDGE DEPTH: V DISTANCE FROM TOP OF STTTDGF TO ROTTOM OF OT-JTfVT TVV OR RA jftf• ScUm TMCKNE,98: A S." - DISTANCE FROM TOP OF SCUTINI TO TOP OF OUTLET TEE OR RAFFLE: DISTANCE FROM BOTTOM OF SCUM TO BOTTOM OF OUTLET TEE OR BAFFLE ROW T)MVIVSTON4;WVRV j)rrFRMTWT)- TAPE WA,%TTRWMVNT C'OMMENT'S: (RECOMMENDATION FOR P6MPIfqG,CONDF.-IlOrq OF NLE T AND OUTLET TEES OR BAri FLES,DEPTI-1 OF LIQUID LEVEL TN RFLATTON TO OTJTT,VT TNWRT, STRUCTURAL TNTEX-MM,FVMWNrF,(IF LFAKAGW,VTr,)_ LOOKED GO"D-NO SIGNS Or PRE of 10 i BACKL-'. FFLE 1`1 ',CE _11A 5 IJN -- GRIFAW TRAP- (LOCATEONSITE PL-A!O, DEPTH BELOW GRADE: .MATFRTAT,OFCON94TRiT(-7'v—ON7CONCR F 'TIF "TA 1,—F1#WRC:1,A9S--pt3yVVTWVT,FNt;-OTRFR(F7s'PT,A DLKENSIONS: SCUM THICKNESS: DYSTANC "('p Off'FROM" Off'Si�7TTNIF TO TOP OTJTT,JPT TFF OR 14AMF,- DISTANCE FRO"'$'BOM"Nf OF SCT-711f TO BOTTOM or ormra TEE OR.n, -r-TL_ DATE OF LAST PU;4IPING. romw,m". .. (PX'C-01MAIENDATIONFOR PUMPE NC-CONDITION Or PLE T AND 01-FLET TF rN,0!.� mI r,x Ir LEVEL IlliRE'l-ATION TO OUTLET LN'-VERT,STRUCITTRAL INTEGRITY, EVIDENCE Off,11'LEA KAGE. ----------- ACTION-KMG VNTFRPRTSFS,TNI''. SYLTD811tFACE.SEWAGE,DISPOSAL SYSTEEIINI POWN-i PART C SYSTEM INFORMATION(CONTINUED) PRP,Pr(RTX-4DDRE,R,R. I'-SR04SAI.f!tjlRTRFT.T NOR— OWNER. GERRllAK6:ER DATE OF INSPECTION; 8-26-97 TT('-NTORFFOT,9U';GTAKKt K/A (TANK MUST BE PIMPED PRIOR-TO ORATTPV,AOF TNSIvrTp (LOCATE ON lqT-r pykm) DEPTH BELOW GRADE: MATERTA L OF CONSTRUCTION: (lONirRVTV.—MV.TAT. FMRRr-TASS—POT,.W,,TRWF.NV,----OTYM.R (EXPLAIN) DAM NSIONS; CAPACr[Y.- GALLONS DESIGN FLOW. —GALLONS/DAV ATARM TVVFT, VIOTT! DATE, OF PIRE __iT COTIVIMENTS: (CONDITION OF INLET TEE,CONDITION OF ALARM AND FLOAT SWITCHES,ETC.) DISTRIBUTION BOX: x "LOCATE ON SITE FjN)— F)FPTTF OF Tjol TM)T,VVFy 1 AROVIF O"TXT TNW.RT-- a COINOZINTS: (NOTE IF LEVEL AND DISTRIBUTION IS EOUAL,EVIDENCE OF SOLIDS CARRYE E CE vH)I? OF LEA 'E V , N lCk E wro OR OTTT OF Box, 0 G ETC. --- NO SIGNS OF SOIpS CARgyjNG OW (LOCATE, ON SITEPLAN) P"M IN TN WORKMG ORT)YR ,W8 OR ALAR-MrS IN WO-RIONC. ORDER(111 S OR_voi CO&RUETNTS: (NOTE COND110K OF PUMP CHAAMER.CONDITION OF PUrv!PS AND APPU-jK7jENApiCES.E-fc� ACT-1n►N-KLYC ENTIIE�rRTISES,rgCr PROPVRTV ADDRVAS.- 1504 SAIRM STRFFT NORTH ANPQ�VFR,M OWNE It:V-9.BRY AUGE R DATE OF—LLq5PEC—..o-- SOW ARSORPTIONSYSTrm(SA.%)- (LOCATE, ONSITE PLAIN,IT,POSS-Mir- E'X'rAVAMl',T NOT REQU-MX1,D;BUT-,%IAY Pl'APPROX"MI.A-.11"n In" MTRUSIVE INIETHODS). IF NOT TYPTIFRXIMFM TO RV PRF8F-XT.,'FXPT,A TK- TVPV,- T r OL lr-�G T4 JJui IL%l 'T LEACHING CHAMBERS,NUMBER. LVA CFrtKr.GAT-JYRTF.9,NTJNMVR,--- LE ACHPgG T--RXNC=iS;N X .jT .0ji:,RiENr,TJ9.- (4) XV LEACHING FIELDS,INUMER4 DUVIENSIONiT.- OVERFLOW CESSPOOL-NUMBE& AT,TFRNATYW SVSTFTvT! IN-AAlE OF TECILNOLOGy CoMhENTS- (NOTE CO-N-1)1-HONGFSOU.,SIGNS OFt-i-VDRAUiUC.FAFLURE,LEVEL OF P0NDPiG.00-NDl-110N CF W,C-FTATTON, ETC. -CPSISPOOT's.. N/A GOOD (Ie(Tf to ON NUMBER AND CON1,TGURATION; iiF DF'yM-TCDD M TOTNV�,RT- DElYM OF SOLI DIS LAYER: DEPTH OF SCUM LAyE&- DRdENSIONS OF CESSPOOL. NFATFRTATA OF CONSTRTJ(-iT-07W----- LN- DIC ATION Or, GROUNDWATEE R.,-- AfTUST-liE�.Lllv!�PED I AR-1�01q ImN.-F.E.C-..-0 Ti co r '13 Or' llYDRATTLIC flABLUIRE,LEVE I,Or, sit VEGETATION,ETC.) TOF PRINrY. —N/A (LOCATE ON SITE PLAN) MATERIALS Or, C.ONSTRUc-_ ff O_N. DEPTH OF SOLIDS: %iE!NT S ICY tv COMMENTS: (No NDITION OF SOIL,VlFGf"TATION, SIGNS OF H"RAULIC FAILURE,LEVEL OF POINDLNG,C0.NDjjrjoN ol., PAGF.9 ACTTON-TCMG VNITUPRTSIPS,Mr. SUBSURFACE SEWAGE OzaposAL&Y&TEM rilispEctlol'i FoRm VANI,ti NIAL T TON f r C)NT"I INT, 4VARN M-9,42NICATTON(MNTU%VTRl)) PROPERTY ADDRESS: 1:504 SALE,MiSTREut NORTH ANDOVER,rvuoims OVVW,IR- GVRlRV AUG MR PA TIE 0-P EVSPE ICTION. 3-26-97 SKETCH OF SEWAGE DISPOSAL SYSTEM: ENCLIT TPE TIES TO AT T,FAST TWO IT41LIVIAINIENT RrEfT,.RrE-?VCE.!4 LAN DM- OR pLrLNlCTRt ARXIS COAT ALL WELLS Wjj—.N 11bum, SALETNISTREET PAGV9 Y ACTION-KING EMl'TEP.PRISES,Edo. 26 L V GSTON STREET LOWELL,MA 01457, TEL; (508)452-7750 FAX: (503)452-•0770 PR.OPEl` 7111 Arrnmrms- 1504 8ALEM STIREFET NORTH ANDOVER.ltd, 01845 OWNER;GERRY AUGER DATE OF INSPECTION: 6-26-97 DEPTH TO GROLT-41D'4VA a E R,. PLEASE TTS ICATF AIX,TTIF MfTTTODS TJSFD TO RVlT-•RM-TNF 3UGIT f,'.1ROTTND A.TFTt VV Y-VATTON.. ODiTLial`eiLs�o4 a RViYt.bet�..iS7IG LL."UN' f 01 l�rsa�.ery,/ItV/ 7t_0RSVRVATT0N OF STTF.(ARTT"I NG PROPFRTV,0RSFRVATT0N 90IN,RASRMFNT slump FTS.) X IDETE&MINE IT FROM LOCAL CONDITIONS —CHECK WfftF T,OC`AY,BOARD OTS TTFAT TTT i CHECK FEMA MAPS �`4'TI&.0 K PTTMPTNG REVORM CFE 4K LOCALE CA:'ATOD'w,aSTA:LERu __TJSV TTSOS DATA DESCRIBE IN YOU OWN WORDS HOW YOU ESTABLISHED Tim HIGH GROUNDWATER ELEVATION. (MUST RF.COMPT VTFD) .DED VTSUAL INSPECTION OF SURROUNDING AREAS I PAGE it) .._.._ .._ ®ppRD OF HEAD OVER/ Commonwealth of Massachusetts 1995 Executive Office of Environmental Affairs OCT i Q Department ® _ .. Environmental Protection Wllllam F.Weld Gammor Trudy Coxe Secrotnry,ECF1 David B.Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 15' G5 Y `��3 rz ►t S'4• IV o 4 i#` ��� Address of Owner: Date of Inspection; 5 �� S >� (If different) Name of Inspector: 3--to 0,(;-o o(�) a n.. Company Name, Address and Telephone Number: IV r-u, L KG L4,1 p 1� H Gi tv���'^�' ���v'c e 3 3 lS✓a L. IC,:, Q(4) > c e t�� iq­10V e< , r�1 � C, : CERTIFICATION STATEMENT S D-' (p`' - )-2�� I certify that I have personally inspected the se%age disposal system at this address and that the information reponed below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site se%vage disposal systems. The system: ✓ Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fa{Is Inspector's Signature: Date: The S,,stem Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this in:oection. If the systern is a shared system or has a design floe of,10,000 gpd or greater, the inspector and the system owner shall submit report to the appropriate regional office of the Department of Environmental Protection. 71"ir orivinal shouid ue sett iC sysletr, o%' net and copies sen; to the bLlyer_if app!_able and the approi Ing author!, INSPECTION SUMMARY: Check AD B, C, or D A] SYSTEM,PASSES; y, 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. 1 One Winter Street • Boston, Massachusetts 02108 ® FAX(617) 556-1049 C Telephone (617)292-6500 b %Jt Pnnied on Rmy_lI d Pepe, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner:' Date of Inspection: B; SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed -� pipe;$,, 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(5) are replaced obstruction is removed distribution box is levelled or replaced he $vs;em required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass �— nr, c .? ;fin, if iw!!'i dpprova! of th(: Board of Health). broen pipes; are replaced --- obstruction is removed C] z'•JF:TEJER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist wh,ch require funher evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environrnent. t) 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: Ccss000! or p,i'. $ within 50 feet of a surface water �^ Cessocol or w'thln 50) tee! o?'a bordering vegetated wetland or a salt marsh. SYSTEM Vti'ILL FAIL UNLESS THE Bo-ARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE), DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MA, NER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE EN'VtRO OiENT: a Se'D(iC tan an() Soo absorption sy5te- arid r> vrinin i Uv lket lv a qui dCt odic �uPP;Y v iril uiary iv u .� sUrface %%ate,, 5U )i1' The �;en, ha, a septic tangy; and soil absorption system and is within a Zone I of a public water supply ��ell. The system has septic tank and soil absorption system and is within 50 feet of a private water supply well. Tile sv;; n ha: a sen; c tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water suppl,' +ell, 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. 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 ce5spooi. .ase,; 6 .5/95+ 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1 S0Ll SIq LNOef1, Owner: v+4yvi, r;:c`A4R S Date of Inspection: DJ SYSTEM FAILS (continued): 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 1/2 day flow. Required purnping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Arr, portion of the Soil Absorption System, cesspooi or privy is below the high groundwater elevation. Any pon on of a cesspool or privy is within 100 feet of asurface water supply or tributary to a surface water supply Any portion of a cesspool or privy is within a.Zone I of a public well. _ Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water.supply well with no acceptable Fater 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. EJ LARGE SYSTEM FAILS: The fo!lov.:n1 criter!a to large in addition to the criteria above The desigr fiov. of system is 10.000 gpd or greater (Large System' and the.sysiem 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 40Q feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply T the system in a m:ragen sensitive area (interim iVe!Ihead Protection Area (11VP.4) or a mapped Zone II of a p,jbiuC ••ate The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program regiiirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information, ra✓.scd B/15/9Si 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST y* tips �•�, !`aK�ovQ�, rvl �. c, ��w� Property Address: t ©`f ' " 2' Owner: 0,1,F R c a C S Date of Inspection: ; SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: l `� , 144 JA,>.,e V. , Vyl� . � I F v i Owner: T'P, y r%1 Date of Inspection: `� 1 u• 4 (`+ 5l FLOW CONDITIONS gESIDF.NTIAL.: Design flow: f;al!ons Number of bedrooms: Number of current resident :T Garbage grinder (,yes or no): A? Laundry connected to system (yes or note 5 Seasonal use (yes or no; _L 1Vater meter readings. if available:_ IV 1 A,/4,'44•a1-rz Last date of oceupane�'. COMMERCI AUINDUSTRIAL: Type of establishment: _ Design flow: '(j ^ " y Grease trap present: (yes or not^ Industrial Waste.Holding lank 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' ast date of occupanc)'. GENERAL INFORMATION PUMPING RECORDS and source of information /-pa io Ye,94-5 S'—Cc.e Ne .�Hn1�AtZ I�e'e.h�xo .� System pumped as par, of inspection: (yes or no)411 If yes;volume pomhr' S Q_o gallons Reason for pumping. T' .I, r Pe e TYPE AF SYSTEM Septic.tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: l d �}/B445 e Sewage odors detected when arriving at the site: (yes or no) o ;revised Bi,S/95; S i 75 r� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) ' l Property Address: y Owner: Date of Inspection: SEPTIC TANK: (locate on site plan) Depth below grade: 30 Material of construction; -concrete metal —FRP —other(explain) Dimensions: /5,00 Cr 4 L Sludge depth: 3 " Distance from top of sludge to bottom, of outlet tee or baffle. .'. Scum thickness: U Disia,,,ce from top of scum to top of outlet tee or baffle: y i,Dance from bottom of scum to bottom of outlet tee or baffle: Z. Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural me rity, evidence of leakage, etc.' Y Q 42 ry� a W 7C s /3 4'Fl r s 7�^�C �G'd G o o O C<.dt�s G Z r✓B I i I RFASE TRAP; :,IoCa e on c;te plat,: i�tr,. • be�c;.: grade'___ Malfl'(;al o' conslnicnion concrP •' metal __-_FR.P _othertexplain) Distance from top of scup, to top of outlet tee or baffle;_ ^tic ;� rFs frn^^ bOt?Or., c c�tm itc�`tnn. ni o6it!- len o, bart't, r`orc,me n!5. . irecr)mme,ndation for pumping, condn on of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural nte5trity e,idence of le waE2c, el( rr_• :sed E. ,`_iSSP 6 r 7S" -3 y°.. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: �q vow .t°'G h Deb S Date of.Inspection: TIGHT OR HOLDING TANK:— (locate on site plan) Depth below grade: Material of construction. concrete _metal FRP ^other(explain) Dimensions Capac t}: gallons Design flow: eal!ons da Ala-:n I .el: i Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX,. o,-xate on site plan,, Depth of liquid level above outiet inven. Cornrnwits / If IC',-e! :"d d. n. p, (nnra ri <r de Cd•1(,.v?r eviclenre of leakage into or out of boy, etc t e-14"��/ Wil es D - (3 "'i "Cyt,-f/–f 15,01 ko .4.0'7 40 7u l e ti /'l AL o 4S go,'< Y gjt ,' L01. J`xci rK�r`� '�H T., Yo =tet � �rTnG/�dS XN a GA EL /t>a -17i6vey2 l/• S.'Ga .v/".CaeByOGc(e i PUMP CHAMBER: (locate on site plar� Pumps in working order.(yes or no? Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) i re•:;se� 6!i5iy 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) ;Udv✓ � rKi ; g4.> Property Address: / S i ^ Owner:.. —T f1 ji, Date.of Inspection: SOIL ABSORPTION SYSTEM (SAS):^ (locate on site pian, if possible; excavation not required, but may be approximated -by non•intrusive methodsr - - If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number. leaching trenches, number,length: leaching fields, number, dimensions: overlow cesspool, number, ;omn,ents: (note condition of soil, signs of hydraulic failure, level of ponding, conditi'on of vegetation,etc.) *7 CESSPOOLS: ;locate on site piani. Kumber and configurator' Depth-top of liquid to inlet even: Depth of solids layer, Depth of scum layer ( mens:ons of cesspool 'tatenal< of construct on, e; groun0',�:;te: inflow icesspool must be pumped.as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: 0ocate on site plan) Materials of construe ion Dimensions Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) _.zssc 8!i5i357 8 f ri t"yTr n r�, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: I Sv 4 14 �tz >r J 7 �%U2�h ��t c�G v ti � (rYl W Owner: Y n ii (c' it+I as Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties.to at least two permanent references landmarks or benchmarks locate all wells within 100' I e I GA L I 1 ,II DEPTN'TO GROUNDWATER Depth to groundwater: Za _8 feet method of determination or approximation: lam:S��.n� iZ J��(o.w So eou.e p!p G Pto to a b',.5 (rev.sgd 8/15/95 9 12/09/00 Action King Enterprises,Inc. Disposal Report November 2000 Date Source Name Qty DISNOANDOVER DISNAND/LOW 11/03/2000 1504 SALEM DESIMONE 1,500.00 11/09/2000 350 HOLT RD"111CRUSADER PAPER 3,000.00 11/15/2000 1615 OSGOOD ST;MARILYN MOTORS 1,000.00 11/20/2000 DALE STREE 500.00 11/29/2000 350 HOLT RD CRUSADER PAPER 4,000.00 Total DISNAND/LOW Total DISNOANDOVER DEC 3 Page 18 of 29 �----� FORM U - LOT RELEASE FORM ..i INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relievej. the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICAiVT ffLLS OUT THIS SECTION APPLICANT--"�w��s V1�VC),A) PHONE G 3 0XV5 LOCATION: Assess&s Map Number PARCEL SUBDIVISION 1 LOT (S) STREET �� t1 I�-��1 ST. NUMBER_,L�)y USE RECOMMENDATIONS OF TOWN AGENTS: a €3 ` p f Nk �b e C (C ONS ERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS ✓ '�� ���°��( l lyi`� I. ��- �. ( L' '� . z ` /G t`� 1 . (i I TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INS,P CTOR-HEALTH DATE APPROVED �-� DATE REJECTED �SEfSTIC�4tSPECTOR-HEALTH DATE APPROVED 3 9 DATE REJECTED ` COMMENTS t__ �- / / 4-1i PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING 4NSPECTOR DATE Revised 9197 jm SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: , 'peµh }� l c�o✓Lt UYl Owner: ���' n i 4r'.,�r Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' .. ... ------------- iI i I 1 _ 4ovsi i � �; ISoo _ �'AL '7 TkNIC I/ II DEPTH TO GROUNDWATER Depth to groundwater: Z, -8 feet method of determination or approximation:_ Soeov i p%4 oeto orC�+'a5 ise::sed 8/t5;95: 9 Board of Health SEPTIC STSTEH Bt� /W� North Andoverix"19- - INSTA.A.ATICK CHBC$ LISP LOT` _)YP OVED+ DATE DI SUPSCIVED X AVATICHI. OK r�IL _ eaiunst i FAIL OK 1. Distance Tot . .� OFF ---._ 7 � a. wetlands ?r,C ow /1Vr;V(d__A6 b. . Drains 7'(�fW< c.. Well a5O �^�s CA-W JFJ. (S . 2. Water Line Location I w 3. No PPC Pipe 4. Septic Tank a. Tees -_Length & To Clean Out Covers b. Cement Pipe to Tank an Both Sides of Tank 5. Distribution Box a. Covers-k Box - No Cracks b. All Lines Flowing Equal Amounts c. No Back Flow Leach Field or Trench M a. Dimensions b. Stone Depth c. Capped Ends d. Clean Double Washed Stone 7. Leach Pits a. Divansions b. Stone Depth c. Splash Pads d. Tees e. Cwt Pipe to Pit - Both Sides f. Clean Double.Washed Stone 8. No Garbage Ili spo sal 9. final Grading Inspection 10. Barricading Covered System 11. As Built Snbmitted a. Lot Location b. Dimensions of System c. Location with Regard-to Pere Test d. Elevations e. Water Table Board of Health tier;J: :�ndoversMass SUBSURFACE DISPOSAL DESIGN CHWK LIST LCT #_6- 541,EM, �i APPROVID DATE I ZZ--21N - DISAPPkOM DATE_,,, _ Provided: Reasons: (.9 Title V. FAIL CK Reg 205 The .submitted plan must show as a minimum! a) the lot to be�served-area,dimensions lot #sabatters blocation and.; su log deep ,observation hoes-distance to ties fil' "design location and relts pereo�tiori tests-distance to ties calculations &' ''calculations showing required leaching area (e) location,and dimensions, of system-including reserve area M existing and prc`posed 'contours (g) location any,wet areas within 1001 of sewage disposal system or disclaimer-check wetlands mapping J(h) surface avid subsurface drains within 100' of sewage disposal system or''disclaimer I(i) location any drainage easements within 100' of serge disposal system or disclaimer-Planning Board files 1(j) known sources of water supply within 2001 of sewage disposal e system or disclainer (k) location of any proposed well to serve lot-1001 Brom leacbing facilit, (1) location of water lines on property-101 from leaching facility .- _--..- - (.m}-location of benchmark ------- (n) driveways (o) garbage disposals (p) no PVC to be used in construction (q) profile of' system-elevations of basement, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and Other elevations (r) maximum ground water elevation in area sewage disposal system (s) plan must be prepared by a Professional Engineer or other ..__professional authorized by law to prepare such plans Reg 6 Se ptic Tanks (a) capacities-1507, of flow, water table, tees, depth of tees, access, pumping (b) cleanout (c) 10' from cellar wall or inground swimming pool (d) 25+ from subsurface drains Reg 10.2 Distribution Boxes (a) slope greater than 0.08 Reg 10.1 b) s ohn engineers alIahan s s o c i a t e s . surveyors 166 No. Mai n SI reel Andover, M a s s a c h u s e I I s • 01810 / 617 475 0606 planners DEEP WATER, Test Boring Report To John T. Dolan Date 5/14/84 Job No. 83-18 Location 1514 Salem St . , No. Andover, MA Fc. 3ft . (!Ares in riCiit hanc.l col ifimi inclicate, number of bl ows require] to dI- iv(' inch Gimhl. i.nC r,poort 1 foot. , l.rs.int; -lb. we:i.t;bt fa11. int, 30 iiiclhes . Open pit excavations (via a backhoe) were used. C/ l� D01'.J.NG j;'T-3 DOR:T.NG i; T-4 DORI\TG /lT-S j LIev. ��� C1cv . ��� Elev . 0 i dark loam & dark loam & sub- dark loam & subsoil soil subsoil lg _ 18" bony, fine sand med. sand w/ fine sand w. silt w/ silt & clay silt & clay & some 36" stones sandy gravel w/ i i clay --- - -- - -_60" ---- ---- -- 6011 gravelly clay gravelly clay, w/ boulders scattered stones 811 gravelly clay, V tight w/ scatterad embedded stones 08' 108' fine sand w/ gra— velly clay pockets and stones_ --- 120' *High water table @ 6.0' *High water * High water table @ 4.5' table @ 4.0' REMARKS : ?-;,iter levels indicates] are tbor. e observed at ilia completion of each. bor ltig, and do no neees.—iri ly t. pernu'nc�nt 1 round. water levels . PI-A ,01'ATION TEST RESULTS a --— -— — — —--- —_ •Lot:, No . _ C Tost, i:aken hy : I Cfri.ef : Street: S/�LE` Si� _ 1f l�� i4 �`�-- --1-- -- Trans i. tmain t Town tiG- A!v�L` �i_-_ Roclnran Date of Test : �Z►��>3i� With this fort z submit: a topogr•a)phy of the areal showizz.g . the major changes in cc,rztours . Locate exi.stinf; drainage systems including brooks and water linos and water service to home , private wells within 150 feet of house , other leaching areas In the vicinity . Be sure to get a sill elevation j and cellar fl.00.r, as well as a. location and elevation of top of each test /0eZCCV_A7"10.1,/ /-/04.E SOIL CLr96S1F1CMTlON TEST 1)/1'1'1\ rp hole c rv= I�'�,C� 1' i 1 1 1 rr :;ke f.ch showi III; HI I c1moss of' each .layer with description of s _i.l. in each layer (use correct terms )--:if you cannot classify b so.i .l. , bring a good sample back to I I office . F 11ot.t:oin e.levat. ion - �,��\�� . Water table elevation = ("L Ledge elevation = Bottom test--observation holc Time of percolation pit, satrzrit.ion 16 minutes Time for 12'1_911 drop i.zr water level 2_5 minutes 'Time for 9"-6" drop in water level ,3U minutes . ( if 1 2"-p" or 9" -6" drop re(lu.ires more than 30 mina read instructions for• flrrther• test ) PLRCOLATION RATE' = time for 9'1 -0" drop 10 min/inch ....... 3 I cert:i fv that this test, Ims been performed according to the standards of the Massachusetts !)elrartmerit; of Pubic lleail. th and the results are accurate to the best of' my kri.owledge . Subordinate to Registered l;nf;.i-nee.r Ref;i.s i.neer b � Chief of Party : o tiG 1);r tr G =; -�--- -- - -------- 1( Dat e (l� POS G/STEQ�� .1011N' CA] ' 111,\N ASSn�`7nTl sf NAL �, 4 OE Profess i oli;, l I rr��i n,.or .-',��z•\ >� nr t:--Lazrrd ers 1 (0) Norl.lr Nrz i n Street Andover , llass . TIL `a 14 >71� 111 S7�Z�1 hl.,)trM,AT I-ON TE-ST RESULTS Lo 1. NTest trll<en hy : -- -_-- Strr ci S - _ ti ' Chief : -S. J�� �► ►�� _ L�LLt� ST�_-..� _1.5�-- Traits i t.nlrin Towel _'_J�?_.._�N_+�i��t=.= Rodman 1)<ate of 'rest : t"Z� �$tj Wi t h this form submit i topot rr.lplly of the area showing the major changes i_n c(,ntorlrs . Loc ite exi-stint; drainage systems including brooks and water lines and water service to home , private wel- Is within 150 feet of house , other lea.rhi.ng areas i.n the vi.cini t.y . Be sure to get a sill. elevation and cellar floor , as we'll ;is n location and eleval.ion of t.op of each test 10Er2C0e-ATio14,/ 1—/046 SOIL CGASaIFIC,9T/oh! 11;ST DATA Top h0% ET-C V. Ib .(` I•' 1 1 I ill -:ke 1.01 show I nt; I.h i r.icness ,,, ,m.7��rn• of each l.:ayer with description of F soil, in each layer ( use correct terms -- i f yoll cannot classify b F r, soi ] print; a ' good sample back to office , i Pottorn el.evat. ioll = 11ate.r table elevation = - -�e� i,ecl.ge e.1 evat, i oil _ Hot- 1 om test=-observation ho.lc = Time of percolation pit saturation tri minutes Time for 12"-9" droll in waf.ei- Level 20 minutes Time for 9"-01' drop in water level. Z, minutes ( .if l.?" -()" or ()" -0" drop req lli.re,, more than 30 mill , read instruct.-ions For flarther test ) P1,i1COLATION RnT'L = gime for " -G" (ll•op �_ min/inch I certify that- this fest, h;-is keen performed lecor•dint; to the standards of. the Massachusetts Depart.menl, of Public llea.l t17 incl the results are accurate to the, tient of' my Know]-ed(-,e . Sut)ordinite to Registered 1',nt;ineer }te g:ineer Chief of Party : o JOHN J.f LLA6 4 xejL� Date 9 GIST JOHN CA ' ':11/1N ;1SSricT T ONS I'i'oCess, i cir��i 1 I r '� r J ("� l,r`r`1'c`-- I7'\ (`�'r�l"`;--l :llld l 11111e1•c lr,l, N(�r t.h �1ai.n street. .lrldover , plass , ' I Page 1 of 2 DelleChiaie, Pamela From: Sawyer, Susan Sent: Monday, May 03, 2004 11:00 AM To: DelleChiaie, Pamela Subject: RE: Scott Roy of Decked Out re: 1504 Salem Street All set. FYI, I told him, it is ok to put the footings no closer than 5'to the tank and the deck platform as close as he wants, but not over the tank itself. -----Original Message----- From: DelleChiaie, Pamela Sent: Monday, May 03, 2004 10:20 AM To: Sawyer, Susan Subject: Scott Roy of Decked Out re: 1504 Salem Street Importance: High Hi Susan, Scott Roy of the Decked Out company called to follow up on his calls from last week regarding the properb 1504 Salem Street. Please call him at: 978.468.3002. Thanks, Pam Pamela DelleChiaie, Health Dept. Assistant Town of North Andover Community Development& Services 27 Charles Street North Andover, MA 01845 pdellechiaie@townofnorthandover.com Tel. 978-688-9540 Fax 978-688-9542 5/3/2004