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HomeMy WebLinkAboutMiscellaneous - 151 BOXFORD STREET 4/30/2018 J_ 151 BOXFORD STREET 210/106.A-0257-0000.0 1 Gf NORT:,y 6. 6290 O Town of North Andover HEALTH DEPARTMENT C14USt4 CHECK#: DATE: I V t LOCATION: H/O NAME: CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $� ❑ Other:(Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer e � Commonwealth of Massachusetts RECEIVED Title 5 Official Inspection. Form ocT 2,6 2012 Subsurface Sewage Disposal System Form-Not for Voluntary Assessmen s TOWN OF NORTH ANDOVER 151 Boxford Street HEALTH DEPARTMENT Property Address Jeff Kutz Owner Owner's Name information is required for North Andover Ma 01845 10/24/2012 % ti every page. City[Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: When filling out A. General Information - forms on the computer,use 1. Inspector: only the tab key to move your . Neil James Bateson cursor-do not Name of Inspector use the return key. Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover MA 01810 Fme-ACityrrown State Zip Code 978-475-4786 S115 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needp Furthe Evaluation by the Local Approving Authority 10/24/2012 Inspectors 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 1 , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 151 Boxford Street Property Address Jeff Kutz Owner Owner's Name information is required for North Andover Ma 01845 10/24/2012 every page. Cityrrown State Zip Code bate 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 Conditional) Passes: Y Y ❑ 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 structural) sound, not leaking and if a Certificate of Y 9 Compliance indicating that the tank is less than 20 years old is available. ❑ Y. Q N ❑ ND (Explain below): t5ins•11/10 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System Page 2 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,. 151 Boxford Street Property Address Jeff Kutz Owner Owner's Name information is required for North Andover Ma 01845 10/24/2012 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the sy$tem 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments i 151 Boxford Street Property Address Jeff Kutz Owner Owner's Name information is required for North Andover Ma 01845 10/24/2012 every page. Cityrrown 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 E ® 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 '/z day flow t5ins•11110 Title 5 Official Inspection Forth: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 151 Boxford Street i Property Address Jeff Kutz Owner Owner's Name information is North Andover Ma 01845 10/24/2012 required for 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 ❑ ❑ 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, j 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposai System•Page 5 of 17 i Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 151 Boxford Street Property Address Jeff Kutz Owner Owner's Name information is required for North Andover Ma 01845 10/24/2012 every page. Cityfrown 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? 9 9 ® ❑ 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: M ❑ 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): N/A Number of bedrooms(actual): 4 DESIGN flow ba N/A sed on 310 CMR 15.203 (for example: 1.10 gpd x#of bedrooms): t5ins•11/10 Tdle 5 Official Inspection Form:Subsurface rface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 151 Boxford Street Property Address Jeff Kutz Owner Owner's Name information is required for North Andover Ma 01845 10/24/2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 5 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage On well water 9 ( Y 9 (gpd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes C] No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 151 Boxford Street Property Address Jeff Kutz Owner Owner's Name information is North Andover Ma 01845 10/24/2012 required for , every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pumped 2006,owner Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Measured tank Reason for pumping: Inspect tank Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ - Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology..Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 151 Boxford Street Property Address Jeff Kutz Owner Owner's Name information is required for North Andover Ma 01845 10/24/2012 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1990, owner Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): 4" PVC thru wall 3"PVC in house, no leaks visible Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age:a years Is age confirmed by a Certificate of.Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'x 5'x 4' Sludge depth: 8" t5ins•11/10 Title 5 Official Inspection Forth: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 151 Boxford Street Property Address Jeff Kutz Owner Owner's Name information is required for North Andover Ma 01845 10/24/2012 every page. City/town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont:) Distance from top of sludge to bottom of outlet tee or baffle 19" C,1 Scum thickness J Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 16" 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.): Pumped septic tank. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. 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 I Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form " Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 151 Boxford Street Property Address Jeff Kutz i Owner Owners Name information is required for North Andover Ma 01845 10/24/2012 every page. 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: El concrete El metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working.order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 ficial Inspection Form:'Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 151 Boxford Street i Property Address Jeff Kutz Owner Owner's Name information is required for North Andover Ma 01845 10/24/2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box level&distribution equal. No evidence of leakage. Evidence of light carryover.. pumped d-box to clean i 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located explain why: P Y t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 P Y i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 151 Boxford Street Property Address Jeff Kutz Owner Owner's Name information is required for North Andover Ma 01845 • 10/24/2012 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 4 trenches 40' long ❑ 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.): Soil ok.Vegetation ok. No sign of ponding to surface. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 151 Boxford Street Property.Address Jeff Kutz Owner Owner's Name information is. required for North Andover Ma 01845 10/24/2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): r t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 151 Boxford Street Property Address Jeff Kutz Owner Owner's Name information is required for North Andover Ma 01845 10/24/2012 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately "ion A 3 -3�f A -7j Q �o� - g I` ID--a* ft t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 151 Boxford Street Property Address Jeff Kutz Owner Owner's Name information is required for North Andover Ma 01845 10/24/2012 every page. City1rown 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: 4 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: Essex County Soil Map You must describe how you established the high ground water elevation: Essex County Soil Map, Sheet#36, Hinckley Soil Water>6' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 151 Boxford Street Property Address Jeff Kutz Owner Owner's Name information is required for North Andover Ma 01845 10/24/2012 every page. Cityrrown State Zip Code Date,of Inspection E. Report Completeness,Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information.—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file b t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts City/Town of System Pumping Record 0` Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Location: Left front, left rear,'left side of house. Right fron , right re , right side f house. forms on the computer,use only the tab key Address to move your cursor-do not City/Town State Zip Code use the return key. 2. System Owner: ],._.. Name !eR"' Address(if different from location) City/Town StateRo C4^ c--) ip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: 0 Cesspool(s) __. eptic Tank 0 Tight Tank 0 Other(describe): 4. Effluent Tee Filter present? Yes If yes, was it cleaned? El Yes 0 No 5. Conditin of System: 04 6. System Pumped By: Neil Bateson F 5821 Name Vehicle License Number Bateson Enterprises Inc Company . 7. Location where contents were disposed: S. Lowell Waste Water Y f igna ure of H u r Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 N LU C/ LOT PiNNELLI P - ` 8- 121 SF EXIST TAW �S GSL 1401-t EXIST. Y Lo-r 2 "THIS IS TO CERTIFY THAT I HAVE INSPECTED THE CONSTRUCTION OF THE SAID DISPOSAL SYS'I`FV LOCATED. Al' L07 f - eolraRA 917._ N. ANDOWR MA. THE GRADES ARE AS SPECIFIED IN E PLANS AND SPECIFICATIONS DATED 30 F ARCHIONDA & ASSOC., INC. SiBAQ.EE ,���` ����, ELEVATION TO TOP OF PIPE PAUL DWEI.I.ING: -- aRcxlnran� TANK IN: TANK OUT: STEti� D-BOX IN, /5,6a72 z D-BOX OUT: A is&.04 DATE D I &,D C t- 6�04 END OF DISTRIBUTION AS BUILT SEWAGE DISPOSAL li EBM A t I'S.73 SYSTEM E PIAN B ISS,7 IN N. s tf A4A (LOT t- 460X�� 4P.) C t 7.9?- � D AS PREPARED FOR FVlV rLDCW INC. SCALE. f"—"40' DA.TF 6/1$1?0 AfARCHfONDA & ASSOC., IJVC.. ENGINEERING AND PLAN nNG CONSULTANTS 80 1lAPIX STREET R F.R. 18 STORETIAU ItASS. MOD -VANCHEriTE}t Mf 0=3 (8I7} 438-8121 (803) 434-8725 ,may . . .. � .� .. � ,� � . ... a � ., t_ _ ._ _.._ - , ., R COMMONWEALTH OF MASSACHUSETTS ` fD EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS i DEPARTMENT OF ENVIRONMENTAL PROTECTION i r TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFI�C—ATION Property Address: ) 51 'P5 C C,lz)1 > I. V . r C) { Owner's Name: h JV N i Owner's Address: 6 t. -3,T- Date T- Date of Inspection: { Name of Inspecto5please print)LD A' L Q (z/•( G, nL A t2( F fL i Company Name:'` IFA R C to Mailing Address: - �(,L 511 jyo" 1-i i Telephone Number: J71a 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 1 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: f asses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Inspector's Signature:9--) P-7--,47,-./j Date: 9 - 17 - 01 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 i gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the 1 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 This'report only describes conditions at the time of inspection and under the condition"-use=at-.t-hat,, • S, timeiThis Inspection does'not address how the system will perform in the future under tfi saine)or'iiifferent! conditions or use. APR 2 7 2001 i Title 5 Inspection Form 6/15/2000 page i t Page 2 of 1 I ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM' PART A CERTIFICATION (continued) Property Address: t—o 461 oV 9-n Owner: iz IV"pt- Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: 1 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 a5 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 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: Owner: Date of Inspection: 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 I 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 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,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 1 ' Page 4 of I 1 , 1fS f OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A f CERTIFICATION(continued) Property Address: O 1l6QCD C� ' Owner: P&,wVA t Date of Inspection: I D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No Vf-"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 ' _ 1�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 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 r water supply. _ _ Any portion of a cesspool or privy is within a Zone I of a public well. r Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ JAny portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water i 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 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,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 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 gid to 15,000 l gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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. f 1 4 r Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: � L ��l ��[Z-43 5 N, D N 1�QU E,tti. Owner:IIF IV&Pr Date of Inspection: a Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes o 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? V Have large volumes of water been introduced to the system recently or as part of this inspection? NP' _V,---_ 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? V — 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: 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 C is at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] 5, i Page 6 of 11 . OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 15 X I GELD 5 AQ Owner: NIV Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): - DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 3 O Number of current residents: 3 Does residence have a garbage grinder(yes or no):iv-0 Is laundry on a separate sewage system(yes or no):jk:O[if yes separate inspection required] Laundry system inspected(yes or no):'-- Seasonal o):'_Seasonal use:(yes or no):I10 Water meter readings, if available(last 2 years usage(gpd)): (,y fL C-C, LO43 I IL JVO 1)1 1 E_VL Sump pump(yes or no): &0 Last date of occupancy:—L7 I� COMMERCIAL/INDUSTRIAL Type of establisjunent: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding-tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: i OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no):_ If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYt�,OF SYSTEM Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy 1�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: N 5T�� l i�i� r` c� '� OL,3 N P Y�_ n Nn 2 E5 0Arz-4 Were sewage odors detected when arriving at the site(yes or no): 6 Page 7 of 1 1 Y. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C r SYSTEM INFORMATION(continued) Property Address: , J R U cl FO t''�:1 `,T. Owner: �tiNNA c Date of Inspection: -2 — — 01 BUILDING SEWER(locate on site plan) Depth below grade: 3`' f V Materials of construction: ast iron 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:/ (locate on site plan) Depth below grade: �+ 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: 16 L, (X '�,� Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: J 01 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined:—7-A IL M (,AS u 2 E- Comments on ( pumping rec ommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence o ge,etc.): 1, r1. %. 1 -)"ib L C9 l P (d r S (6 tzn GREASE TRAP:141�cate on site plan) Depth below grade:_ 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: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): I' Page 8 of 1 I ' a ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: <00 tiL CO Rb.'W- Owner:�(�h/71l � Date of Inspection! TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): I DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 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.): LS 6 OLi�S O S u 0.� 4ppeana 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,condition of pumps and appurtenances,etc.): • it 8 Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: FA Date of Inspection: 2-52—o SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: hing galleries,number: leaching trenches,number, length: _ J leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): o C Vin 9,/ Gtr 1�4 - ©dam 1QrjCDRL5-r S CESSPOOLS: esspool must be pumped as part of inspection)(locate on site plan) Number and con figuration: 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 or no): Comments(note condition of soil;signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: cate 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.): 9 i 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: , 6'1 Rb 57, , Owner E&N IV i Date of Inspection: 71%-- SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at leas two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public wa r supply enters the building. 5 0 u - 3e 1� V ti V�,rr- to i L r, Page 11 of I 1 V OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C +- SYSTEM INFORMATION(continued) Property Address: v L Q �© b Owner \f ff, O�� Date of Inspection: SITE EXAM Slope DoW nF 0/xe . A cc s l'bL5 Surface water ZttgAq- 43 J ok bd)w u 1T ( > 1 t Check cellar 'd P_-y Ho 1,Pv M Q Shallow wells N�Ive— Estimated depth to ground water—9—feet Please indicate(check)all methods used to determine the high ground water elevation: Y O tained from system design plans on record-If checked,date of design plan reviewed: served site(abutting property/observation hole within 150 feet f SAS) �T 1�`5' Checked with local Board of Health-explain: 1 1_I,V L i�w '1` i L L5, L A ��L� Checked with local excavators, installers-(attach documentation) rn I gS Accessed USGS database-explain: You must describe how you established the high ground water elevation: s L.o P a,,5 Q to^c s S t1-F, t.c7 S>Lsa- A9PS b 2 ►a- t 5 rn s 5 1iN(:� �a-- ?�F�-� t'�. PL. 0 � ��� ti,g tt �T N-1� `� �13 rz,c,H- L S E�N�O I N`�• t 11 i Commonwealth of Massachusetts RECEIVE' City/Town of 1 DEC 15 200 System Pumping Record 6 Form 4 TOM,e Ur NOR'!'H AW)OVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health.. The System Pumping Record must be submitted to the local Board of Health or other approving authority. . A. Facility Information Important: When filling out 1. Syste Location: fomes the computer.use only the tab key Address to move your cursor-do not �.f'� � 4,Ac use the return Cityrrown Stat Zip Code key. 2. System Owner. Name Address(if different from location) Cityrrown Sta Zip Code' 1671 Telephone Number .B. Pum�piri Record 1:_ .Date.of Pumping Date 2 QuantityPumped: 1 Gallons . 3. Type e of s stem: p ( � [�-�ic YP Y Cess ool s e tie Tank . ❑ Tight.Tank ❑ Other(descrlbe).` 4. Effluent Tee Filter present? ❑ Yes E3-11-0-- , if yes, was it cleaned? ❑ Yes`❑ No 5. Condition y4z;lc� 6: Systemd� y- Name Vehicle License Number I Company 7. Local ere c nts re disposed:: Sig ture Ha ter Date v�ww.mass.gov/dep/water/approvaltdt orms;httn#inspeet Lc-06103 System Pumping Record•Page t of t I Septic System Information 151 BOXFORD STREET Printed On: Tuesday, December 19, 20 System ID: BHS-2002-0195 General System Information Latest Permit Information Calcaluted Design Flow: Test Pits Septic Tank Disposal Trench Design Flow: One Two Capacity: Number: Design Flow Provided: Minutes per inch: Width: Width: Total Flow: Depth: Length: Length: Seasonal: No No Depth to Water: Diameter: Leaching: Grinder: No No Soil Type: Depth: Laundry: No No Inspections: Inspected: Expires: Inspector: Status: 12/14/2006 Neil J. Bateson Passes Comments: Title 5 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Page 1 of 1 i Of MOR71 ,� • . Town of North Andover HEALTH DEPARTMENT �SS�cNus°t CHECK#: 7 q p LOCATION: / S����, AT � a.- J- -5-t-- H/O NAME: CONTRACTOR NAME: X.l c-;7/ /3al LsA:rj TYpe of Permit or License:(Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ TrashlSolid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ b Title 5 Inspector $ 7 Title 5 Report $ ❑ Other. (Indicate) $ 2202 e A t Initials White-Applicant Yellow-Health Pink-Treasurer COMMONWEALTH OF MASSACHUSETTS m EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS 2 d DEPARTMENT OF ENVIRONMENTAL PROTECTION R C O� TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:_151 Boxford Street _North Andover_ Owner's Name:Jeff Kutz Owner's Address:_151 Boxford Street ll _North Andover,MA 01845_ Date of Inspection:_12/14/2006_ y �� z Name of Inspector:_Neil J.Bateson_ y �� Company Name: Bateson Enterprises Inc._ � Mailing Address:_111 Argilla Road_ Andover,MA 01810 Telephone Number: (978)4754786_ 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 approveds3' P� P stem inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority F ' Inspector's Signature: 11nDate: _12/14/2006_ 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: ****This report only describes conditions at the time of inspection and under the conditions of use at that stem r under the same or different how the s will perform in the future time.This inspection does not address o y conditions of use. I ' Page 2 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:_151 Boxford Street _North Andover— Owner:_Kutz Date of Inspection:_12/14/2006_ Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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 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: i i Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_151 Boxford Street_ _North Andover— Owner:_Kutz_ Date of Inspection:_12/14/2006_ 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. 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 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,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_151 Boxford Street_ _North Andover— Owner:_Kutz Date of Inspection:_12/14/2006_ D. System Failure Criteria applicable to all systems: You must indicate"yes"or`�no"to each of the following for all inspections: No_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool No Liquid depth in cesspool is less than 6"below invert or available volume is'/2 day flow. _No_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ No_Any portion of the SAS,cesspool or privy is below high ground water elevation. _No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _No_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _No_ 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 coliform bacteria and volatile organic compounds indicates that the well is flee 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.] No (Yes/No)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. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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. Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:_151 Boxford Street_ _North Andover_ Owner:_Kutz Date of Inspection:_12/1412006 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No Yes _ Pumping information was provided by the owner,occupant,or Board of Health No Were any of the system components pumped out in the previous two weeks? Yes_ _ Has the system received normal flows in the previous two week period? No Have large volumes of water been introduced to the system recently or as part of this inspection? N/A ` Were as built plans of the system obtained and examined? Yes — Was the facility or dwelling inspected for signs of sewage back up Yes _ Was the site inspected for signs of break out? Yes_ _ Were all system components,excluding the SAS,located on site? _Yes _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the bales or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _Yes_ _ 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: Yes No Yes Existing information.Old 11tle 5 Inspection. Yes_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distanceis unacceptable)[310 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:_151 Boxford Street_ _North Andover– Owner:_Kutz_ Date of Inspection:_12/14/2006_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): N/A Number of bedrooms(actual):_4_ DESIGN flow based on 310 CMR 15.203_N/A Number of current residents:_4 Does residence have a garbage grinder(yes or no):_NO Is laundry on a separate sewage system(yes or no):_No Laundry system inspected(yes or no): _ Seasonal use:(yes or no):_No_ Water meter reading: No,on well water Sump pump(yes or no): No Last date of occupancy:_Current_ COMIUERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203):___Md Basis of design flow(seats/persons/sgft,etc.):— Grease trap present(yes or no):— Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:_Pumped 2001,owner_ Was system pumped as part of the inspection(yes or no): Yes_ If yes,volume pumped:_1500_gallons--How was quantity pumped determined?_Measured tank Reason for pumping: Inspect tank&tee_ TYPE OF SYSTEM _X 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/Alterative 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:_1990,owner Were sewage odors detected when arriving at the site(yes or no):_No_ OFFICIAL INSPECTION FORM —NOT FOR VQLUNTAIRY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_151 Boxford Street _North Andover_ Owner:_Kutz_ Date of Inspection:_12/14/2006_ BUILDING SEWERS—X_ (locate on site plan) Depth below grade:_24"_ Materials of construction: _X_cast iron —X-40 PVC_other Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.) _4"Cast iron thru wall,3"PVC in house. No leaks visible. SEPTIC TANKS: X Depth below grade:_12"_ Material of construction: X concrete_metal_fiberglass_polyethylene other(explain) Is age confirmed b a Certificate of Compliance es or no : attach a co of If tank is metal list age:— g y p (y ) _( PY certificate) Dimensions: 10'x 5'x 49 _ Sludge depth3"_ Distance from top of sludge to bottom of outlet tee or baffle: 24"_ Scum thickness:_411 _ Distance from top of scum to top of outlet tee or baffle:-8"— Distance affle_8"Distance from bottom of scum to bottom of outlet tee or baffle: 17" 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 _Pumped septic tank.Inlet tee ok.Outlet tee was replaced with plastic by others. Depth of liquid at outlet invert.No evidence of septic tank leaking._ GREASE TRAP:_(locate on site plan) Depth below grade: 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_151 Boxford Street _North Andover_ Owner:_Kutz Date of Inspection:_12/14/2006_ TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X Depth below grade _20�� _ Depth of liquid level above outlet invert: 0 an evidence of solids carryover,an evidence of Comments(note if box is level and distribution to outlets equal, y arty y f leakage.Evidence of x c. : D-box level&distribution equal.No evidence o leakage into or out of box,etc.):_ q g carryover,pumped d-box to clean.D-Box cover broken,replaced it._ PUMP CHAMBER:_(locate on site plan) Pump in working order(yes or no): Alarm in working order(yes or no):_ Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):_ Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_151 Boxford Street_ _North Andover— Owner:_Kutz_ Date of Inspection:_12/14/2006_ SOIL ABSORPTION SYSTEM(SAS):_X (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: _ leaching chambers,number:_ leaching galleries,number: X leaching trenches,number,length: 3 trenches 40'long_ leaching field,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.):—Soil oL Vegetation oL No sign of ponding to surface._ CESSPOOLS: Number and configuration: Depth—top of liquid to inlet invert: Depth of sludge layer:_ Depth of scum layer:_ Dimensions of cesspool:_ Materials of construction: _ Indication of groundwater inflow(yes or 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.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:_151 Boxford Street_ —North Andover — Owner:_Kutz Date of Inspection:_12/14/2006_ 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 Well Driveway To well House >100' Well to Tank A B Deck Septi®ank A to Tank=36' A to D-Box=4918" B to Tank=3613" D-Box B to D-Box=4419" Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_151 Boxford Street_ _North Andover— Owner:_Kutz Date of Inspection:_12/14/2006 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water_>4'_ Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design 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) _X_Accessed USGS database-explain: Essex County Soil Map_ You must describe how you established the high ground water elevation:_Essex County Soil Map.Sheet#36, Hinckley Soil,Water>6'Deep_ i • Commonwealth of Massachusetts City/Town of System Pumping Record p` Form 4 �N DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information t, Important When filling out 1. System Location: {� forms on thet Q �� G�`� i, A,—ACk-La–r computer,use �` T only the tab key Address to move your cursor-do not City/Town state Zip Code use the return key. 2. System Owner: Name rz�n Address(if different from location) Cityrrown Stat 3 Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) E�Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes [5-- o If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. Syste► Pumped By: Name t— d Vehicle License Number Company 7. Location ere contents were disposed: X11,9A 67 Signature? au er t Date i t5form4.doa 06/03 System Pumping Record•Page 1 of 1 Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating-Water.& Sewer Lines-Septic Systems&Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 151 Boxford Street, North Andover Owner: Kutz Date of Inspection: 12/14/2006 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. Neil J. Bateson Bateson Enterprises, Inc. .I 1'11N f { 1 1,5 ppp.TiF ,.f1 I'', 1 1.11�� 4 + P . i •,'. .i''.' TOWN OP NORTH ANDOVER SYSTEM PUMPING RECORD ft♦f 31.74 F Y�1 t �' 1 4 `• � � , 4Y�'l+e9t�"'"�9I};t'iiarliyr,'1rf�,4'y��x}3,i1ki�»11•Ir��,�h}5di,'t,dF.f���aEi7,••i".:4��c),n pei�€�+;fl'atj��i��`d Kitl4L1n'G�F1�SriT1�1,'�rt1{`4�t��la{`,,i�yt,'n`�Kfix"Mf5R5y!`JR S�•lxaA4y�fif{r3�f.��r,tt�t�A'yJ�t.fa.:l lm5rat'�rs7., ,) ;•�'t1�f.`pOfItI.>�5�O J�S41+Yµrfl A1�Fl/—t TSI 5n{I+StT �I StrT'E1,ITtS fi I t M h i,Of W�TU_..4., �MN` Et'.PrRE}- D &I rE•.Ak fY�D'. DI RA fE"ll„7liS S _ti_•, ` SYSTEM STE..M �L�O CA, T+I O .. N (example: left front of h ouse ) jQUANTITY PUMPED l G A- LL. ONSROF PUMPINGSEPTIC TANK: NO YES POOL;: NO YES EMERGENCYNA, ` ROUTINE CE: ATIONS: FULL TO COVER.GOOD CONDITION HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) M wn 14 F +7,x7S - FF UPP3 ow C �' , {'rl ,.y�'1$1 7 # ETIa•�19`��VF 3"g�r1°. 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