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Home My WebLink AboutMiscellaneous - 151 CARLTON LANE 4/30/2018 (2) 151 CARLTON LANE 210/106.0-0082-0000.0 \ cam/ e"4 Commonwealth of Massachusetts Title 5 Official Inspection Form RECEIVED a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments DEC 8 CUiii 151 Carlton Lane XIMM'Fl- Property Address HEALTH DEPARTMENT ER Kathy Casey Owner information Owner's Name is required for every page. North Andover MA 01845 12/2/2016 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. r Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not use Neil J. Bateson the return key. Name of Inspector Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover MA 01810 City/Town State Zip Code 978-4754786 St-15 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 ❑ ee s Furth r Evaluation by the Local Approving Authority N 12/2/2016 InsiecVrIsksignatury 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 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .' 151 Carlton Lane Property Address Kathy Casey Owner information Owner's Name is required for every page. North Andover MA 01845 12/2/2016 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 forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not use Neil J. Bateson the return key. Name of Inspector VQ Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover MA 01810 City/Town State Zip Code 978-475-4786 St-15 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 ❑ ee s Furth r Evaluation by the Local Approving Authority 12/2/2016 InsiecWASignaturV 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 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 oy ! ` Mho W FAtVA r Y71 i D I� • • PUBLIC HEALTH DEPARTMENT Town of North Andover Community and Economic Development Division CERTIFICATE OF COMPLIANCE As of: 11/30/16 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Repair of outlet tee in tank, outlet pipe to D-box, install new D-box, replace leach pipes next to D-box By: Todd Bateson At: 151 Carlton Lane Map 106.0 Lot 0082 N rth Andover, MA 01845 Th• I�suance of this 76�e 'f a hall not be construed as a guarantee that the system will function satisfactorily. 1 chele Grant Public Health Agent 120 Main St.,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.9542 Web www.northandoverma.gov w • SSS W1Y • North Andover Health Department fommunity and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 151 Carlton Lane MAP: 106.0 LOT: 0082 INSTALLER: Todd Bateson DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS Outlet tee in tank/outlet pipe to D-box/install new d-bo replace leach pipes next to d-box: I (L Ali DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing y r ' ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION-BOX Installed on stable stone base H-20 D-Box ❑ Inlet tee (if pumped or >0.08'/foot) Hydraulic cement around inlet & outlets Observed even distribution Speed levelers provided (not required) Schedule 40 PVC Pipe Comments: ;�� . • yl,�si�',�: „ Commonwealth of Massachusetts Map-Block-Lot 106.00082 ____ BOARD OF HEALTH Permit No North Andover -BHP-2016-0472---- ------------------ FEE $175.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd B-ateson - - - - -------- -------------------------------------------------------------------------------- to(Repair)an Individual Sewage Disposal Syst ,.l ''��.. ''ee at No 151 CARLTON LANE �� b�l� �� ` ��U�_� ( � --------------------------------------- - ----- - (.,Q. ------------- Q. t t` I�— as shown on the application for Disposal Works Construction Permit No. BHP-2016=047 Dated November 15,2016 ----------------------- ------------------------------ --------------- -------------- -- Issued On:Nov-15-2016 ------- -------L ---,------;-�-4_ -------�----�--------------- B6A-!ObF HEALTH r Application for Septic disposal Ssterny- Construction Permit — TOWN OF TODAY'S DATE NORTH ANDOVER, MA 01845 $��°oo Repair Componentent Application is hereby made for a permit to: i Construct a new on-site sewage disposal system* ❑Re or replace an existingon-site sewage disposal system* B-Ilepair or.replace an existinSyst� compo errt–What? d�'�Cr?f 1 -P�2. c "i 1 � rn(��c A. Facility Information1�-2�� Lc�� r�,d.t3 / 4, Address or Lot# RECEIVED— Cily/Town e/14 2:*TYPE OF SEP SYSTEM*: NOV 15 LU 1 b ➢ ❑ Pump EgGravity(choose one) * If pump system,attach copy of electrical permit to application— TOWN OF NORTH ANDOVER ❑Conventional System (pipe and stone system) HEALTH DEPARTMENT ➢ []Infiltrator or Biodiffuser(Gravel-Less)(Attach a copy of your certification to install this type of system.) ➢ ❑Pressure Distribution S.A.S.(No D-Box) ➢ ❑Pressure Dosed(D-Box Present)S.A.S. ➢ ❑Does the system require an effluent filter? Yes No V If yes, does plan specify make and model of filter? YES=(no further info. needed) NO=(installer must specify brand of filter before DWC issuance) What is the Make? What is theModW 2. Owner Information Name /S f �it✓��on-/ 1-�►/i Address(if different from above) Al, AA Cityrrown State Zip Code Telephone Number 3. Installer Information Name Name of Comjfwc ON ENTEIRPRISES,INC. 111 AFCILLA ROAD A-21 21 t (A P ANDOVFR MA 8181 Address Citylrown State Zip Code _ y Telephone Number(Cell Phone#if possible please) 4. Designer Information Name Name of Company Address City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 dR7� Ap;plicati-oh..for Septic Disposal - Metn o wTODAY'S DATE F �Construction Permit TOW SOV '" •f' x.250.00,.Full Repair ORH AND bV � MA 01845 $125.00:-Component PAGE 2 OF 2 A. Facility.Information continued.... S. Type* Buiidin : esidentlal Dwelling-yp ' 4 g or❑Com mercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system.ln accordance with the provisions of Title 5 of the Envlronmenta/Code,as well as the Local Subsurface Disposal Regulations for the Town of North Andover,and not to place he system in operation until a Certificate of Compllance has been issu oard of Health. V& Name Date Applicata y: (Board of Health Representative. Name Date Application Dl -approved.for the following reasons: For Office Use Only: 1 --FeeAtuched? Yes ' No 2.• PtojectMariaget Obligation Attached? Yes No 3.: Pumn System? Ifso, f No 4. FoundldOftAs Built.?(hew construction nly); Yes No (Same scale as apptoved plan) — A FloorMwsp thew construction-only). xes NO - r4ppllcatidn'{or.p�spOsal Systerit: onstractloii Permft'-Poo&2 rif 2 SEP'T`IC VIJ sATIQM As 6W-NpithAadover•lictmetlaieailtafardtewmtmctQft'fd •theaepticsyetagafo�xthapYe�prxtyaiw (A ofmpft } P'Cltpbmby (=Maws mma AM dated Dated o a V:a• — With t+a WOM dated • . . (ywe -'sed dace} �'� I undemtaad the fonowlog oblkadons fat a> agemcut of os p ccC 1. As the}astster,I s m.obtigsW#p obmist aff peMxb and"loud of�edffi q' provcd phos . �petlag aap:aro�tc cia R ei#c. 2. 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North Andover Health Department (ommunity and Economic Development Division 10/31/16 Address: 151 Carlton Lane All North Andover Residents with Septic Systems and Garbage Disposals Please note that due to a recent review of a Title 5 Report, your property has been identified as maintaining a working garbage disposal that is being used in conjunction with a septic system. The Health Department is concerned for the longevity of your septic system. Garbage disposals are never recommended where septic systems are used, but if they are installed,the system must be specifically designed to handle the waste from them; your system can not handle the waste as designed. Please note that continued use of this disposal could quickly cause a pre-mature failure of your septic system, resulting in a large expenditure to replace it. The North Andover Health Department recommends that you remove it from your home as soon as possible. Some information regarding regular maintenance of your septic system is attached. Please call the Health Department at 978.688.9540 if you have any questions, or e-mail your questions to: healthdept@northandoverma.gov. Thank you for taking the time to consider the impact that your current setup has on your septic system and the environment. Sincere y, ti Ba LaGrasse, CEHT Director of Public Health 120 Main Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.9542 Web http://www.northandoverma.gov Commonwealth of Massachusetts Title 5 Official Inspection Form4 1 bq � Subsurface Sewage Disposal System Form-Not for Voluntary Assessments RECEp 151 Carlton Lane OCT 31 1 v Property Address TOWN OF NORTHAND�' Peter Casey MAIRInmAnva Owner Owner's Name information is required for North Andover MA 01845 10/21/2016 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Neil J. Bateson cursor-do not Name of Inspector use the return key. Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover MA 01810 Cityrrown 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 ❑ Needs Further Evaluation by the Local Approving Authority 10/21/2016 Inspector's Signature V 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•3113 Title 5 Offloal Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 151 Carlton Lane Property Address Peter Casey Owner Owner's Name information is North Andover MA 01845 10/21/2016 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ® N ❑ ND(Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 151 Carlton Lane Property Address Peter Casey Owner Owners Name information is required for North Andover MA 01845 10/21/2016 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ® N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ® N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 151 Carlton Lane Property Address Peter Casey Owner Owner's Name information is required for North Andover MA 01845 10/21/2016 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Outlet tee in septic tank, outlet pipe to d-box, d-box&broken leach pipes, needs to be replaced. Water jet leach pipes. 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 <�N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 151 Carlton Lane Property Address Peter Casey Owner Owners Name information is required for North Andover MA 01845 10/21/2016 every page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in,Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts UJ Title 5 Official Inspection Form 'v- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 151 Carlton Lane Property Address Peter Casey Owner Owners Name information is required for North Andover MA 01845 10/21/2016 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? E ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 600 t5ins-3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments t 151 Carlton Lane Property Address _Peter Casey Owner Owner's Name information is North Andover MA 01845 10/21/2016 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d Yes 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Forth: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 y 151 Carlton Lane Property Address Peter Casey Owner Owner's Name information is required for North Andover MA 01845 10/21/2016 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 this year, owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: 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•3113 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 t r 151 Carlton Lane Property Address Peter Casey Owner Owner's Name information is North Andover MA 01845 10/21/2016 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 30 years old, 7/17/1986, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 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 through wall, 3" PVC in house, no leaks visible. Septic Tank(locate on site plan): Depth below grade: 0.5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'x5'x4' Sludge depth: 0" t5ins-3/13 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 151 Carlton Lane Property Address Peter Casey Owner Owner's Name information is required for North Andover MA 01845 10/21/2016 every page. Cityrrown 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 N/A Scum thickness 1" Distance from top of scum to top of outlet tee or baffle N/A=Outlet tee has holes in it Distance from bottom of scum to bottom of outlet tee or baffle N/A 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.): Inlet tee ok. Outlet tee has holes at flow line, needs to be replaced. Outlet pipe to d-box has belly in it, needs to be replaced. 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 Date of last pumping: Date t5ins-3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts uytTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 151 Carlton Lane Property Address Peter Casey Owner Owner's Name information is North Andover MA 01845 10/21/2016 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 151 Carlton Lane Property Address Peter Casey Owner Owner's Name information is North Andover MA 01845 10/21/2016 required for 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 has bad corrosion holes. Evidence of leakage. Evidence of heavy carryover. D-box needs to be replaced. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Ip spection Form Subsurface Sewage Disposal S stem Form-Not for Voluntary Assessments p Y , 151 Carlton Lane Property Address Peter Casey Owner Owner's Name information is required for North Andover MA 01845 10/21/2016 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chamb Irs number: ❑ leaching galleries number: ® leaching trenche� number, length: 2 trenches 82' long ❑ leaching fields number, dimensions: ❑ overflow cesspool number: i ❑ innovative/alternative system Type/name of technology: Comments(note condition of sail, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok.Vegetation ok. No sign of ponding to surface. Both pipes out of d-box have broken pipes. Solid carryover into trenches. Leach pipes needs to be water jettted. I I Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet inve Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 151 Carlton Lane Property Address Peter Casey Owner Owner's Name information is North Andover MA 01845 10/21/2016 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 151 Carlton Lane Property Address Peter Casey Owner Owner's Name information is North Andover MA 01845 10/21/2016 required for every page. Cityrrown 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 Lf 1 tt > 33 a =3q 3 �-t�`�t u 0- Dec w 7 y� tJ`se� !' (3 r �paiG D.tom Y, r. t5ins-3113 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 Carlton Lane Property Address Peter Casey Owner owner's Name information is required for North Andover MA 01845 10/21/2016 every page. Cityrrown 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: 8/8/1985 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Design plan ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: As per test pit data on design plan. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 151 Carlton Lane Property Address Peter Casey Owner Owner's Name information is North Andover MA 01845 10/21/2016 required for every page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, of E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Summary Record Card generated on 10/5/2016 2:39:20 PM by Karen Hanlon rage i Town of North Andover Tax Map # 210-106.C-0082-0000.0 Parcel Id 17718 151 CARLTON LANE PETER CASEY KATHLEEN CASEY 151 CARLTON LANE NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1 Acres FY 2017 UB Mailing Index Name/Address Type Loan Number Active/lnact. From Until PETER CASEY. Owner KATHLEEN CASEY 151 CARLTON LANE NORTH ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 14164.0-151 CARLTON LANE Last Billing Date 9/12/2016 2100150 02 Cycle 02 Active UB Services Maint. Account No,2100150 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 68.40 /1 UB Meter Maintenance Account No.21001.50 Serial No Status Location Brand Type Size YTD Cons 13242183 a Active ERT HH METE METE w Water 0.63 0.63 855 Date Reading Code Consumption Posted Date Variance 8/2/2016 1813 aActual 18 9/21/2016 -10% 5/3/2016 1795 a Actual 20 6/21/2016 1% 2/2/2016 1775 a Actual 20 3/28/2016 -2% 11/2/2015 1755 a Actual 20 12/30/2015 -11% 8/4/2015 1735 a Actual 23 9/14/2015 25% 5/4/2015 1712 a Actual 18 6/22/2015 -8% 2/3/2015 1694 a Actual 20 3/20/2015 28% 11/3/2014 1674 aActual 16 12/15/2014 -12% 8/1/2014 1658 aActual 17 9/11/2014 -13% 5/5/2014 1641 a Actual 20 6/12/2014 12% 2/4/2014 1621 a Actual 19 3/17/2014 0% 10/31/2013 1602 aActual 18 12/20/2013 -80% 8/1/2013 1584 a Actual 92 9/18/2013 419% 5/1/20131492 aActual 16 6/18/2013 -23% 2/7/2013 1476 a Actual 25 3/13/2013 39% 10/30/2012 1451 a Actual 16 12/13/2012 -13% 8/2/2012 1435 a Actual 19 9/26/2012 16% 5/2/2012 1416 a Actual 16 6/20/2012 -8% 2/2/2012 1400 a Actual 18 3/14/2012 19% 11/1/2011 1382 aActual 15 12/15/2011 -35% 8/1/2011 1367 aActual 23 9/14/2011 16% 5/2/2011 1344 a Actual 19 6/13/2011 -6% 2/4/2011 1325 a Actual 22 3/15/2011 -45% 11/1/2010 1303 aActual 38 12/13/2010 -52% 8/3/2010 1265 a Actual 81 9/13/2010 264% 5/3/2010 1184 a Actual 22 6/9/2010 -8% 2/1/2010 1162 aActual 24 3/11/2010 26% 11/2/2009 1138 aActual 19 12/11/2009 -26% 8/3/2009 1119 aActual 25 9/11/2009 -8% 0911112006 •16:34 978-897-3848 RAGGS INC PAGE 02 a COMMONWEALTH OF MASSACEMSMM EXECU IVE OFFICE OF ExmoNMENTAL AFFAIR$ DEPARTMENT OF ENvIRONMENTA,L pitOTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A. CERTIFICATION Property Address; 160 CARLTON LANE NORTH ANDOVER,MA 01845 Owner's Name: DARREN AND LAURA WINNIE Owner's Address: 160 CARLTON LANE NORTH ANDOVER,MA 01845 Date of inspection; AUGUST 1,2006 Name of Inspector:(please print)HAROLD T.LINCOLN,JR. Company Name: RAGGS,INC. Mailing Address; P.O.BOX 101.7 CONCORD,MA 01742 Telephone Number: 978»360-1100 CERTIFICA'T'ION STATEME1%rT 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 CM 15.000), The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority .Fails Inspector's Signature: Date: 'c>6 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 systems owner shall submit the report to the appropriate regional office of the DEP_The original should be sent to the system owrxer 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 ander the conditions of use at that time.This inspection does not address haw the system will perform in the future under the same or difte en conditions of use. Title 5 Inspection Form 6/15/2000 page I tiv COMMONWEALTH OF MASSACHUSETTS EXECUTIVEOFFICE EC L� a OF ENVIRONMENTAL AFFAIRS � d DEPARTMENT OF ENVIRONMENTAL PROTECTION M V V TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 160 CARLTON LANE RECEIVED NORTH ANDOVER,MA 01845 Owner's Name: DARREN AND LAURA WINNIE Owner's Address: 160 CARLTON LANE AUG 2 9 2006 NORTH ANDOVER,MA 01845 Date of Inspection: AUGUST 1,2006 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Name of Inspector: (please print)HAROLD T. LINCOLN,JR. Company Name: RAGGS,INC. Mailing Address: P.O. BOX 1027 CONCORD,MA 01742 Telephone Number: 978-369-1100 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 Inspector's Signature: / Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments: ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 • Page 2 of i l.• OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 160 CARLTON LANE NORTH ANDOVER,MA 01845 Owner's Name: DARREN AND LAURA WINNIE Date of Inspection: AUGUST 1,2006 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: Titles G Tncnrartinn Fnr 411 vInnn 2 'Page 3 bf 11. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 160 CARLTON LANE NORTH ANDOVER,MA 01845 Owner's Name: DARREN AND LAURA WINNIE Date of Inspection: AUGUST 1,2006 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: Titlo C i-v—t— T7nr Aii c»nnn 3 Page 4 bf i 1- OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 160 CARLTON LANE - NORTH ANDOVER,MA 01845 Owner's Name: DARREN AND LAURA WINNIE Date of Inspection: AUGUST 1,2006 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool —X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool —X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/Z day flow —X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. —X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. —X_ 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 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.] 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. Title TnenArNnn P-4/1 cnnnn 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 160 CARLTON LANE NORTH ANDOVER,MA 01845 Owner's Name: DARREN AND LAURA WINNIE Date of Inspection: AUGUST 1,2006 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No _X_ _ Pumping information was provided by the owner,occupant,or Board of Health _ _X_ Were any of the system components pumped out in the previous two weeks? _X_ _ Has the system received normal flows in the previous two week period? _ _X_ Have large volumes of water been introduced to the system recently or as part of this inspection? _X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ _ Was the facility or dwelling inspected for signs of sewage back up? X_ _ Was the site inspected for signs of break out? _X_ _ Were all system components,excluding the SAS, located on site? _X — 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? _X _ 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 _X_ _ Existing information.For example,a plan at the Board of Health. _X_ 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)] Title i Tnc-tinn P^n A/I;MAAn 5 Page 6ofIF OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 160 CARLTON LANE NORTH ANDOVER,MA 01845 Owner's Name: DARREN AND LAURA WINNIE Date of Inspection: AUGUST 1,2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_4_ Number of bedrooms(actual):_4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):600 Number of current residents:4 Does residence have a garbage grinder(yes or no):YES Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required] Laundry system inspected(yes or no):N/A Seasonal use:(yes or no):NO Water meter readings,if available(last 2 years usage(gpd)): 446.16 avg.gpd(6/14/04-6/20/06) Sump pump(yes or no):NO Last date of occupancy: OCCUPIED COMMERCIALANDUSTRIAL Type of establishment: 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: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: LAST SERVICED 1/11/06—OWNER&RECORD Was system pumped as part of the inspection(yes or no): YES If yes,volume pumped: 1,500 gallons--How was quantity pumped determined?FIELD ESTIMATE Reason for pumping: TANK AND TEE INSPECTION 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/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:20 YEARS,OWNER& RECORD Were sewage odors detected when arriving at the site(yes or no):NO Title G fncnartinn Aran 4114P)nnn 6 Page 7'of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 160 CARLTON LANE NORTH ANDOVER,MA 01845 Owner's Name: DARREN AND LAURA WINNIE Date of Inspection: AUGUST 1,2006 BUILDING SEWER(locate on site plan) Depth below grade: 14" Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): GOOD;OK;NONE SEPTIC TANK:_(locate on site plan) Depth below grade: 8" Material of construction:—X—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: 10' X 6' X 5'10" Sludge depth: 5" Distance from top of sludge to bottom of outlet tee or baffle: 17" Scum thickness:4" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 14" How were dimensions determined: FIELD ESTIMATE Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): RECOMMEND ANNUAL PUMPING;BAFFLES INTACT; STRUCTURALLY OK;LIQUID LEVEL NORMAL;NO EVIDENCE OF LEAKAGE 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.): T41. 4/1 VII)AA 7 Page 8 of 1 I' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 160 CARLTON LANE NORTH ANDOVER,MA 01845 . Owner's Name: DARREN AND LAURA WINNIE Date of Inspection: AUGUST 1,2006 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: (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.): BOX WAS LEVEL WITH EQUAL DISTRIBUTION.HEAVY CARRYOVER; NO LEAKAGE 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.): Tit1a C r.'nrm Ail crnnnn 8 Page 9 of 11' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 160 CARLTON LANE NORTH ANDOVER,MA 01845 Owner's Name: DARREN AND LAURA WINNIE Date of Inspection: AUGUST 1,2006 SOIL ABSORPTION SYSTEM(SAS): (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: 2 @ 52' RECORD 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.): LOAM;NO SIGNS OF HYDRAULIC FAILURE OR PONDING ABOVE GROUND;DRY;NORMAL (GRASS) 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 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.): Tiflo G inc—f;— V—Al Iqnnnn 9 Page 10 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 160 CARLTON LANE NORTH ANDOVER,MA 01845 Owner's Name: DARREN AND LAURA WINNIE Date of Inspection: AUGUST 1,2006 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. THIS SKETCH IS NOT TO SCALE. DESCRIPTION A B C TANK 20' 6715" D D-BOX 2614" 59'4" LOT / 7-A \ 4a, 3 3 Sq �J A S. -fZ4, IIG :-C Or 4?0 51 J ,o- Tolo G Tnonontinn 17^r 4/1 G/MMUI 10 Page 11 of If OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 160 CARLTON LANE NORTH ANDOVER,MA 01845 Owner's Name: DARREN AND LAURA WINNIE Date of Inspection: AUGUST 1,2006 SITE EXAM Slope Surface water Check cellar X Shallow wells Estimated depth to ground water 4+feet 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: _X_Observed site(abutting property/observation hole within 150 feet of SAS) _X_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:CHECKED CELLAR—DRY WITH NO SUMP PUMP. SYSTEM DESIGNED AND INSTALLED IN ACCORDANCE WITH TITLE 5 (1978) WHICH REQUIRED A MINIMUM FOUR FOOT OFFSET BETWEEN THE BOTTOM OF THE SOIL ABSORPTION SYSTEM AND GROUNDWATER. CHECKED OLD REPORTS AND SOIL LOGS. NO INDICATION OF GROUNDWATER WITHIN ACCEPTABLE OFFSETS. Tit1. G incnortinn i'nrm r,ii v,)nnn 11 JUL-" THU 11:11 M FAX M P. 18 LOT / %"A 3 3 .� u S, y �.1 f 7. t IN ; i- �� ro' FIEE =)RS ArNUMMI /O N WALL. 17„1 7S Ar TAl K IdLE7' - . .. . . . . • 12-h7S Al-7 NK oul-a-r- - - /i-/23 Ar b1SrB6X0u77f7-. Al Enlb 0 F'T OP4 . . . . .. 173. 0 } CAI�l X)h1 F4KM5 ; t I � co i -I 12'eq=5 9 IZ-I to"dd 12. 1 "�lc 2A 11=5 9 Z IIrl: 3 2y 1Z= g 12:)i 30.5 :2r _T }5 . 9 `,01L I'RUFIIX b RC'O Tlqp TES ATA. V'orth Arndz)ver,l:!ss. No.&Street ) Lot No/ Loc./Subdiv. Plan Owner _ v Investigator - Observer -VY SOIL PROFILES-DATE ' 1 • Elev.Elev. ?• Elev. 3• — 4.Elev. 0 O 0 0 2 2 2 2 Ties to Test r` 3 `I 3 h -- ' 3 4 4 4 4 S S _ S S 6 6 6 6 7 7 7 7 8 .: i 8" _ 8 9 - - g - 9 - 9 - LO 10 10 10 Benchmark Location Elevation Datum Percolation Tests-Date Date----- Pit Number 1 2 3 t 4 S Start Saturation Soak-Mins_ - STest-Time ... .--- -- Dr. of 3"-Time - - Dr�_of -Time tins 1st 3"Dr0p n s 2nd 3"Dro _ Percolation Rate ---- -_ - - --- JUL-:OB-Q6 THU 11:1i M FAX NO. P. 17 .1u) 0C 06 11 t l0e P' 1 60%"Pla;Wd Card err."AIM on 7*2000 1*.".54 AM by Wt W~ �t l Town of North Andover Tax Map # 210-107.A-0192-0000.0 160 CARLTON LANE MN141E, DARREN 160 N ANDOVER,NE A 01845 Closs�•.••.•.. • 101 8inplc Famdy� -- -- — '—Prov4Av TY 1 Ikftldenllal Sir*Total 1.06 Acta; FY 2000 UB MailingIndex Nemo/Addimst Typo Loan Number Activohnact. From Until WINNIE,DARREN Payor 160 CAI;/TON LANE N.ANDOW11,MA 01845 UB Account Maint. No Acmmt N '^ Cycle Occupant Noma Activo/kwetive Doig Id.14196.0. 160 CARLTON LANE Lost Bliling Date all 3/2006 2.100188 02 Cvcie 02 Active UB Services Maint. SOPACe Codo Rate Chotgn MultipfialUsorS MISCITE ADMIN%Ck 0.635/8 7.92 11 WTR WATER 01 ALL METER SIZE 115.08 /T UB Meter Maintenanco Sorial No Stotuo Location Brand Typo site YTD Cors 13242008 it Active ERT HIA METE METE w W,31or 0.63 0.63 0 Date Feading Code Consumption Postod Dale Varlarre 6/412006 460 a Actual 29 6/20/2006 0% 2/112006 431 a Actual 29 31131200E •74% , 11/112005 - 402 a Actual 108 12/1412005 78% 8.14/2005 294 a Actual 64 911212005 152% 5,112005 230 a Actual 24 618/2005 -19% ?12/2,005 206 a Aotval 31 3/1512005 •46% 11/1/2004 178 a Actual 51 12/17/2004 •24% 8/10/2004 124 a Actual 72 9/20/2004 140% 5!13/2004 52 a Actual 31 6/14/2004 •8% 2111/2004 21 c Correction 36 4/16/2004 0% C/O 14 r ERT 21=35 1117/2003 2296 n Now Motor 0 110/2003 0'K �� lU0 cubic fq or7 If #10;1.5 izG youSineGS, 1i General Maintenance Recommendations Proper maintenance of your septic system can help prevent premature failure of your soil absorption system. RAGGS, INC. recommends the following: 4 DO PUMP your system on a regular basis, preferably ANNUALLY for most households. Larger systems, such as those serving multi-family locations or commerical properties, may require more frequent pumping. The purpose of pumping is to remove solid material and scum material from the tank. This will help prevent unwanted material floating out to the leaching facility. 4 DO OPEN your D-Box every THREE TO FOUR YEARS. This is a good way to spot little problems before they grow into bigger ones. 4 DO ensure that your VENT PIPES are INSTALLED properly. Vent pipes are used to allow oxygen into the system, thereby allowing bacteria to breathe and grow. 4 DO make sure you know WHERE your TANK is LOCATED. Check the covers to make sure that they are not deteriorating and causing a potential hazard. 4 DO make sure you know WHERE your LEACHING FIELD is LOCATED. If the field ever goes into failure and "break out", it would be necessary to isolate the area for health protection. 4 DO look for GREEN STRIPES over leaching field. If you see this, it is indicative a field starting to back-up. Act immediately when you see this warning sign. 4 DO check to determine if you can smell any ODORS from field location. Odors can indicate that the leaching facility is having a problem. 4 DO raise the tank COVERS up to WITHIN 6" OF GRADE. 4 DO USE LIQUID DETERGENTS and USE SMALL AMOUNTS OF BLEACH when cleaning toilets, etc.. 4 DO USE NON-ABRASIVE HOUSEHOLD CLEANING PRODUCTS. RAGGS SEPTIC SERVICE,INC. d.b.a. E.A.COMEAU SEPTIC P.O.Box 1027 Concord, Massachusetts 01742 (978)369-1100 (800)287-5541 FAQ(978)897-3848 website:http://www.raggsinc.com e-mail:info@raggsinc.com IX �p)� ung You Since 1 �. `gGGS, 4 DO USE ENVIRONMENTALLY SAFE PRODUCTS. 4 DO INSTALL WATER SAVING DEVICES, where appropriate. 4 DO AVOID having roof gutters and downspouts DRAIN ONTO the LEACHING FIELD. THE DON'TS 4 DON'T DISPOSE any NON-BIODEGRADABLE MATTER IN TOILETS. Foreign items can cause blockages in the lines and back-ups. (i.e.: cigarettes, sanitary napkins, diapers) 4 DON'T wash paint brushes used in latex or oil PAINT. Paint residues are not broken down by a leaching system. In fact, they will travel out to the leaching facility and impede its ability to function. 4 DON'T allow any PAINT, THINNERS, OR ANY OTHER TOXIC OR CAUSTIC LIQUIDS, to go down sink or toilets. 4 DON'T allow ANY GREASE or FAT to enter system. Residential sites do not have grease traps. Therefore, if grease is allowed into the system it will congeal and travel out to the leaching facility leading to damage. 4 DON'T DISPOSE BONES, EGG SHELLS, COFFEE GROUNDS, DENTAL FLOSS, OR FIBROUS MATERIAL, etc. when using a garbage disposal. However, it is recommended that garbage disposals aren't used at all. 4 DON'T use POWDERED DETERGENTS with phosphates. They don't break down and can re-solidify. 4 DON'T use any DRAIN CLEANERS, such as Drano®, LiquidPlumbr®. Call a rooter professional or buy a small rooter snake at the hardware store. Drain cleaners KILL bacteria. Bacteria keeps your system alive. RAGGS SEPTIC SERVICE,INC. d.b.a.E.A.COMEAU SEPTIC P.O. Boa 1027 Concord, Massachusetts 01742 (978)369-1100 (800)287-5541 FAX(978)897-3848 website:httpJ/www.raggsinc.com e-mail:info@raggeinc.com v d you Since 1 G. GGS, 11`� THE DON'TS 4 DON'T use any ENZYMES or BACTERIAL ADDITIVES. These products usually have too low a pH to be effective. Often they are sitting on a shelf too long. Normal activity and proper use of a septic system should provide plenty of bacteria naturally. 4 DON'T use any GREASE DISSOLVERS. Degreasers allow grease to flow out of the tank and into your field. 4 DO NOT ADD ANY ADDITIVES TO YOUR SYSTEM FOR ANY REASON. In the event of a clog or other plumbing problem, contact your local plumber, rooter or pumper. 4 DON'T PLANT any trees or shrubs WITHIN 10 FT. OF THE LEACHING FIELD. Root systems can cause damage to the piping in the leaching facility. 4 DON'T ALLOW SPRINKLER SYSTEMS or other WATERING DEVICES OVER the LEACHING FIELD. Doing so will saturate the field, damaging the system's performance. Systems are designed to handle up to a certain quantity of flow. -� DON'T DRIVE any VEHICLES or place any HEAVY OBJECTS ON TOP of the LEACHING FIELD. Damage to piping could result. 4 DON'T INSTALL a swimming pool, a patio, or a driveway over the tank or leaching field. If installing a swimming pool, ensure that the backwash does not enter the leaching system. Do not obstruct access to the tank otherwise it will be difficult to maintain. 4 DON'T CONNECT a basement SUMP PUMP to a household DRAIN. 4 DON'T ALLOW WATER USAGE to EXCEED the DESIGN FLOW OF YOUR SYSTEM. 4 DON'T ALLOW a WATER SOFTENER TO BE HOOKED UP to a SEPTIC SYSTEM. Check with the local authority to see if anialternative place for the backwash can be used. RAGGS SEPTIC SERVICE,INC. d.b.a.E.A.COMEAU SEPTIC P.O.Boz 1027 Concord,Masaachusetta 01742 (978)369-1100 (800)287-5541 FAX(978)897-3848 website:http://viww.mgpinc.com e-mail:info@raggsinc.com t ��,,•�\ COMMONWEALTH OF MASSACHUSETTS Z EXI!i tV-TTVL'DFFICE OMENTAL AFFAIRS r DEPARTMENT OF ENVIRONMENTAL PROTECTION t w" V� V TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 1 ro Owner's Nam Owner's Address• Date of Inspection: J 0 oEC — 8 Name of Inspector: (please print) f-Ss Company Name: `( V Ce _ Mailing Address: n Telephone Number: Ge— 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 Inspector's Signature: 117,14,Z �� Date: a-0 - 3 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 time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 P*0 2 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) ' Property Address: / egAz!AZA Ik-4 ,1.. r Owner: Q Date of Inspec ion: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X-f 5 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$riteria not evaluated am 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 ucltsound,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: A 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 I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) r Property Address: Owner: Date of Inspecti n: c C. Further Evaluation is Required by the Board of Health: L�, 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. A 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. i� _ 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 `Page 4 of 11 ¢ OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:A r- Owner: t Date of Inspecti n: — 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 s}stem 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''/s 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 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 coliform bacteria and volatile organic componads 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 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) yep- 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. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B / CHECKLIST Property Address: revA0 f Owner: tv Date of nspe tion: Check if the following have been done.You must indicate"yes"or"no"as to each of the following: ,Yes o Pumping inforrnatioi4 was providdby the owner,occupant,or Board of Health LXWere any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up ? Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yesf�o ✓ _ 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 ?Page 6 of I I V OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: J61rC7117ZCV,1411)� l Owner: Date of Insp ion: _�— / :::(;) FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 44 Number of bedrooms(actual): y DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no):f, 'Is laundry on a separate sewage-system(yes o no): '[if�es'sepazate inspection required] Laundry system inspected(yes or no):_ Seasonal use:(yes or no): / . Water meter readings, if I able(last 2 years usage(gpd)): Sump pump(yes or no): Last date of occupancy:cC o) i t COMMERCIALANDUSTRIAL Type of establishment: h� Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,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: Was system pumped as part of the inspection(yes or no): /1 S If yes, volume pumped: SOdallons--How was quantity pumped determined? Reason for pumping: /"/t f oc 4— a4 - TYPf'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 ob_tained from system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of al l components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): 6 Page 7 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner Date of Insp tion: _ f BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron 1--'40 PVC_other(explain): Distance from private water supply well or suption line: , -_ - Comments(on condition of joints,venting,evidence of leakage,etc.): ) 0ikrs r� oua rOW1917"/0A" SEPTIC TANK:blo locate on site plan) Depth below grade: G � 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: l Lir A Sludge depth: 5-/1 Distance from top of sludge to bottom of outlet tee or baffle: 3 y y Scum thickness: I ` t 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: 0// S /TE Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAP:;_(locatae on site plan) - r.. 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.): 7 { a Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 I p" , n e Date of Inspee 'omy.."rf ` - .3 TIGHT or HOLDING TANK(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete meol fiberglass,_Rolyetbylene 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: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: o 2 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.): fyr'y 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 apourtenances,etc.): ' R 8 *Page 9 of 11 9 or OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 15/ n-w-4-1n, c Owner• Date of nspe tion: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: D Type leaching pits,number:_ leaching chambers,number: aching galleries,number: i leaching trenches,number,length: 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.): 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 or no). Comments(note condition of soil,signs of hydraulic failure,level of ponding,Ondition 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.): 9 r w $age 10 of 11 s a OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: / ! 0 . _-L-AP Dkllo Date of Insp tion: 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. D Y `f � Y I 10 ?age 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Prope4nspecon: Address: ( f Owner Date o SITE EXAM Slope by f Surface water /lo X Check cellar Shallow wells Estimated depth to ground water feet ' Please indicate(check)all methods used to determine the high ground water elevation: w` Oeibtained 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) Accessed USGS database-explain: You must describe how you established the high ground water elevation: ,PV `I U 1_7GwA-0' W 1-tea 0 A aJ rl"17 11 C0D1M0i�TWEALTH OF MASSACHUSETTS ei EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION t OI;E WINTER STREET, BOSTON NLA 02106 (617) 292-5500 TRUDY CORE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: /�/ �b A. Name of Owner \ pQ Address of Owner: / (� j� L—�-n r,/ f} aV t~ Date of Inspection: G / ( a ' T a (��' -3sName of Inspector:(Please Print) � i/ 1 am a DEP approved system ins or pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: ►•r 0 Q 0('Y &04(C, Marring Address: rN '� Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site see e disposal systems. The system: _V passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails p� Inspector's Signature: Z f Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page Iof11 COO, un^ted or Recycled Pape. IN SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A t' CERTIFICATION (continued) "top"Address:I.a I �j I� 4 A/ � 1 N /f! Date of Inspection: INSPECTION SUMMARY: Check/A, A C, o/ D: A. /SYSTEM PASSES: ( � I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: 1114. 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. 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, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is 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 complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed revised 9/2/98 Page 2of11 � 4 `4 1 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A �7 CERTIFICATION (continued) ,q O .SUSAN pperty Address: N C !V o��f !+ //✓ a�e 2 Date of Inspection: 6 _ q ^9 ervteS C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: . Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 11 SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1111b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(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 soil absorption system and the SAS is within a Zone 1 of a public water supplµwell. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply<well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3of11 ° SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A d` CERTIFICATION (continued) r Property Address: �� C 4 A W C 1yo / T h A N e"'" Owner: S A e 10 S Date of Inspection: D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following(/, I have determined that one or more of the following fai ler, exist as described 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. Yes No Backup of sewage into facility or system component due to an overloaded orclogged 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 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: . You must indicate either "Yes" of "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply 4 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 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Pagc4of11 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: �S � � 44 Al N Z /yp 1Q N J` Owner: d S ry Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. _,/� _ The facility or dwelling was inspected for signs of sewage back-up. " The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles / or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _ Existing information. For example, Plan at B.O.H. _ Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)) The facility owner (and occupants,if different from owner) were provided with information on the proper maintenance-of Subsurface Disposal Systems. revised 9/2/98 Page 5of11 , �t. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATIOLNt �Q 'roperty Address:�S s' ^//9 1; 'f 0 fel 4 ,{ A e /V D �T /1 /� N D U vc' Owner: *J J M C IQ Date of Inspection: G _ C/ _ (� 7 FLOW CONDITIONS RESIDENTIAL: Design flow: g.p.d./bedroo Number of bedrooms(design): Number of bedrooms(actual):_ Total DESIGN flow r Number of current residents: 3 Garbage grinder lyes or no):--J—V- Laundry(separate system) (yes or nod: ; If yes, separate-inspection required Laundry system inspected (ye§or no) Seasonal use(yes or no): Water meter readings,ifavai able (last two year's usage(gpd): ilk Sump Pump(yes or no): - Last date of occupancy: 'eme 4 COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gpd ( Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no) P'S If yes, volume pumped: oy allons Reason for pumping: TYPE OF,SYSTEM 4f 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known)and source of information: Sewage odors detected when arriving at the site: (yes or no)_ revised 9/2/98 P2gc6of11 e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'roperty Address: (r � /j C. AJ A #N C A/oVA 11 1V D4) t/C /F /,�/1.a 3 Owner: l u S/4e //1 Cs Date of Inspection: BUILDING SEWER: (Locate on site plan) Ct Depth below grader Material of construction:_cast iron V'40 PVC_other (explain) Distance from private water supply well or suction line 7V/y Diameteri1 Comments:(condition of joints, venting, evidence of leakage,-etc.) ,, / SEPTIC TANK:_ (locate on site plan) G rr Depth below grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal, list age— Is age confirmed by Certificate of Compliance—(Yes/No) Dimensions: �/,f ` (F Sludge depth:' O Distance from top ofludpe to bottom of outlet tee or baffle: Scum thickness: /IiY 1 Distance from top of scum to top of outlet tee or baffler '� N Distance from bottom of scum to bottom of outlet tee or baffle:�`� How dimensions were determined: 'omments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) 5` Irl e o f/D/T/s t 1-4-04V Z i,LJ ?Z QU LE' r/ GREASE TRAP: (locate on site plan) /� l 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: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / SYSTEM INFORMATION Icontinued) 'roperty Address: S C,. L `�O rrV k'I N C /r D 7 /C{ 4 D L) Owner: s 5 ti Al ^i1(7II'1 N S, Date of Inspection: �( TIGHT OR HOLDING TANK(Tank must be pumped prior to, or 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 Alarm level: Alarm in working order:Yes— No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: 1 , Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) *J4 PUMP CHAMBER:_ n/ (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.) revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / //� / SYSTEM INFORMATION(continued)) 'roperty Address: /�� t�L / O tv /f 4J C Na ✓ / p Jwner: 3o 77. C yyr R S Date of Inspection: 7 T y _ ( SOIL ABSORPTION SYSTEM(SAS):— �S (locate on site plan, if possible;excavat((((on not required, location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number:_ r leaching trenches,number, length: ,-. leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) CESSPOOLS:_ (locate on site plan) Number and configuration: ' Depth-top of liquid to inlet invert: Depth of solids layer: )epth of scum layer: Oimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 9/2/98 Page 9oft) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / SYSTEM INFORMATION (continued) Noperty Address: ! C A � �- �D ,✓ � � N C /1!0 l�'f ry � Al D 1/ 'F )wner: o S .4 4) ! t1!1 e Date of Inspection: � SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) f i r 13, G C ;o ' b revised 9/2/98 Page 10 oftt r • � r � r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 1 SYSTEM INFORMATION(continued) q operty Address: /�/ 1. g 1 a oU 4 # A/c Il d�T � �� D ✓C 1�� Ay, 11 S.S � weer: D '7 s A W -0 C' ✓v c Ic' S Date of Inspection: ,r NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater v Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) A-1 /go-i"x The revised 9/2/98 Page 11 of 11 THOMAS E. NEVE ASSOCIATES, ING August 8, 1985 Board of Health Town Hall North Andover, MA 01845 RE: Lot #35, Carlton Lane, No. Andover Gentlemen: This letter is a response to the DEQE's disapproval of a variance to the provisions of 310 CMR 15. 14, for Lot #35, Carlton Lane. This letter will address each of the deficiencies with the septic design as mentioned in the DEQE's letter, dated May 3, 1985 The street drain is not 12 feet from the reserve area. It is 55 feet (subsurface drain located on the opposite side of the street) . The 10 mil polyethylene barrier will be changed to a clay barrier which will be located between the septic system and driveway. Details regarding the barrier have been added to the plan, A barrier is no longer required between the septic system and the street line. It now conforms to the slope requirement, through a change in the grading design. The clay barrier is now 35 feet from a catch basin and 10' from the property line. A retaining wall has been added to the design to improve the design with respect to the depth of the trenches and the existing water table gradient. This information and revised plan should be acceptable to DEQE requirements. Very truly yours, WAS VE AS CIATES, INC. ve, P.E. ,R.L.S. President ENGINEERS 447 OLD BOSTON ROAD LAND SURVEYORS TOPSFIELD, MA 01983 LAND USE PLANNERS (617) 887-8586 Y THOMAS Es NEVE ASSOCIATES, INC. January 29, 1985 Board of Health Town Hall North Andover, MA 01845 RE: Request for Variance from Slope Requirements, Lot 35, Carlton Lane, North Andover, MA Dear Mike: Please find attached a blueprint of the Sanitary Disposal System for Lot #35 Carlton Lane. At your request, we have extended the drain line and relocated the location of the headwall so that open channel drainage discharge would be at 100' from the proposed system. With the design as shown, we are unable to comply strictly with the slope requirements, therefore we have designed for the installation of a 10 mil thick polyethylene barrier on the downslope of the system. This barrier will eliminate the possiblity of "breakout". Please consider our request for this variance. We feel we have met the performance standards of your regulations. Thank you for your consideration. Very truly yours, �A THOMAS E.—NEV.E ASSOCIATES, INC. H OF Mq S - ✓ o THOMAS THOMAS Sgcy EUGE NEVE EUGENE �, f Thomas E. Neve, P.E. , R.L.S. U 'A No.31724 NEVE N President �'�,STR�°� A No. 30138 �No S URN -'�° �o� 'FFG/STER`�� NAL Enc. ENG Enc. ENGINEERS 447 OLD BOSTON ROAD LAND SURVEYORS TOPSFIELD, MA 01983 LAND USE PLANNERS (617) 887-8586 t NORTH 1 3?O`S ``O b•b�OO` OF B ARD HEALTHO . �°" '; ,' 120 MAIN STREET 9 <oc•c...,K °",rt° NORTH ANDOVER, MASS. 01845 TEL. 682-6400 9SSACHUS�� April 4, 1985 Department Environment al Quality Engineering 5-Commonwealth Ave Woburn, Mass . Gentlemen: Enclosed is a copy of a lett< r sent to a applicant of a request for a variance to Title V. This Board has accepted the applicant's proposal to install a plastic barrier on the "d, .4nlill" side of the leach area where design considerations have made the fulfillment of the minimum fill requirements in Title V impractical . Please let us know if you have any addi- tional comments . Sincerely, - Michael Gr, f, R.S . Inspector r mg;mj cc : Neve Assoc Plan enclosed NORTp, ?ot �� ,. o - q 6.6 ° BOARD OF HEALTH 3 c A 120 MAIN STREET ''9S",• °''�t�y NORTH ANDOVER, MASS. 01845 TEL. 682-6400 SACHUS April ; , 1985 Thomas E. Neve Associates Inc - 447 Old Boston Rd. Re Variance Request Topsfield, Mass 01983 Lot 35 Carlton Lane Dear Sir: - The Board of Health has agreed to grant a variance to breakout fill requirements on this lot. We feel that the impervious barrier shown on the plan would provide sufficient protection against sewage breakout to satisfy the intent of Title V. This variance shall be considered to be in effect as long as .the conditions proposed on the revised septic system plan prepared by Neve Associates , dated 11/19/85 have been met . Sincerely yorrs , Michael Grlf, R.S . Inspector mg;mj cc : D.E.Q.E. AR V S. RUSSELL SYLVA 5 Zo�p Commissioner 0&� , 935-2160 May 3, 1985 North Andover Board of Health RE: NORTH ANDOVER- Variance- Town Building Title 5- State Environmental 120 Main Street Code-Lot #35 North Andover, MA 01845 Carlton Lane-General Store Realty Trust Gentlemen: The Metropolitan Boston/Northeast Regional Office, Division of Water Pollution Control, of the Department of Environmental Quality Engineering on April 5, 1985 received notification that the North Andover Board of Health had approved a variance to the provisions of 310 CMR 15.14: Illustration A of Title 5 for the installation of a "10 Mil Polyethylene Barrier" in lieu of slope requirements for the subject site. Accompanying the notification is a plan which is titled: Sanitary Disposal System General Store Realty Trust Carlton Lane - Lot #35 North Andover, MA 01960 Eng:Thomas E. Neve Associates, Inc. Scale: As Shown Date: November 19, 1985 Revised: April 3, 1985 (hand written) An engineer of the Department has reviewed the plan and notes that the location of the proposed polyethylene barrier is shown on the plan view but is not addressed on the system profile as required by the Department. Additional details of the barrier (proposed method of installation, depth and etc.) must be shown. Additionally, be advised that the Department has approved clay and concrete barries in lieu of the slope requirements. A singular polyethylene barrier has not been previously approved. The Department considers any barrier installation, in lieu of slope requirements, to be an intrinsical component of a subsurface sewage disposal system and must be in compliance with Title 5. The barrier, as proposed, is approximately seven (7) feet from the property line whereas regulation 310 CMR 15.03:7 requires a minimum separation of ten (10) feet. It also appears as though there is an existing subsurface drain (street) at the southerly property line which is less than twenty five (25) feet from the proposed reserve leaching trench (12 feet) in violation of Title 5. North Andover Board of Health Page-2- Based upon the above noted deficiencies, the Department at this time, disapproves the Variance granted by the North Andover Board of Health for the installation of A 10 Mil. polyethylene barrier for the subject site. If additional information is required, contact Thomas F. Clougherty at the above address or at 935-2160. Very truly yours, William A. Krol, P.E. Deputy Regional Environmental Engineer WAK/Etfc/bc cc: Thomas E. Neve Association, Inc. , 447 Old Boston Rd. , Topsfield, MA 01983 General Store Realty Trust, 7 Johnson St. , North Andover, MA 01845 FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *"************************APPLICANT FILLS OUT THIS SECTION*********************** CAPPLICANT r'J7J Am PHONE PHONE, V LOCATION: Assessor's Map Number PARCEL d4 SUBDIVISION LOT (S) STREET ST. NUMBER **************************************OFFICIAL USE ONLY********* *********************** REC MENDATIONS OF TOWN AGENTS: ONSERVATION ADM STRATOR DATE APPROVED_ DATE REJECTED I 1_1 COMMENTS r TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FpOD NSP CTOR-HEALTH DATE APPROVED DATE REJECTED -rrVNSPE90fOR-HEALTH DATE APPROVED t S. DATE REJECTED COMMENTS 15 AaD :L /iA le/sw 7�_ d►-AC 0".& PUBLIC WORKS -SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9W jm Subsurface Design Check List Pa&e 2 FAIL OK Leaching Pits Leaching Pits are Preferred where the installation is possible Reg 11.2 a) calculations of leaching area-minimum 500 sq ft 11.4 b) spacing 11.,10 c) anrface drainage 2% �1.1Z d) cover material e) 2 O x2'All splash pad f) tee at elbow , g) no bends in pipe from d-box to pipe L��Fieldss Reg 15.1 a) no greater thin— 20 minutes/inch b) area-minimum 900 Bq ft 15.4 c) construction of field 15,8 d) surface drainage 2 3.7 e) 201 from cellar wal.2. or inground swcimmir ,; pool Leaching; Tr�T�rmches Reg 14.1 a) ccu'laations of leaching area-min 500 sq ft 14.3 ib) spacing-4 ft min 6 ft with reserve betwe n 14.4 c) dimensions 14.6 d) construction 14.7 e) stone 14.10 f) surface drainage 2% Downhill Slope a) sl oPe y x = to be shown) b) y/x X 150 = (to be shown) s Reg 9.1 a) approval 9.6 b) stand-by power 1°. BOARD OF HEALTH No .Andover, Mass . SUBSURFACE DISPOSAL DESIGN CHECK LIST LOT #3 5 �'4RLT0� APPROVED DATE 13- S DISAPPROVED DATE Provided: Reasons: ST vN17 --C)vrL4j5-r >)601 +=,FoM 1,&VC4-t, 1?Q Title V FAIL OK Reg 2.5 The submitted plan must show as a minimum: a) the lot to be served-area dimensions lot #,abutters b es -distance to ties cd location and sdeep lttion Mes location and results percolation tests design calculations & calculations shoring required leaching area (e) location and dimensions of system-including reserve area f) existing and proposed contours (g) location any wet areas Athin 100' of sewage disposal system or disclaimer-check wetlands mapping (h) surface and subsurface drains within 100' of sewage disposal system or disclaimer (i) location any drainage easements within 100' of sewage disposal system or disclaimer-Planning Board files (J) known sources of water supply within 200' of sewage disposal d system or disclaimer (k) location of any proposed well to serve lot-100' from leaching facility (1) location of water lines on property-10' 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 Otter 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 Septic TTankse (a) capacities-�50% 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 10.4 1 sump sdrd of Health Ncr`k ."indoverj hass V/;IA ti<�L j?E)I RED POP, PEO-1 1 T SUBSURFACE DISPOSAL DESIGN CHECK LIST LOT 5 CrLTa� APPRWID DATE_- DISAPPROVED DATE Provided: Reasons: I _Nor GvovG+ 3 el rO.)T F(W_ )ZE,Kz-p pgAjNe6D5 V,41'%iAzzc, ,4 ,-100 6W0 TO MI�1Z �N�• - Title V FAIL 09 �Ca�dhav Reg 2.5 The submitted plan must show as a minim /`�d /O //I vie- a) ia) the lot to be served-area,dimensions b location, and log deep observation ho;�/Iw c� location and results percolation tea d) design calculations & calculations d`4WI /mak (e) location and dimensions of system-ins o f) exiating and proposed contours (g) location any wet areas within 3A0' o /�� disclaimer-check wetlands mapping / (h) surface and subsurface drains within system or disclaimer (i) location any drainage easements with- system or disclaimer-Planning Board f W known sources of water supply within 64 system or disclaimer (k) location of any proposed well to ser ty -- ---- (1) location--of water lines on property- (m) location of benchmark (n) driveways /. ` C,(7 t (o) garbage disposals /�- (p) no PVC to be used in construction (q) profile of, system-el ovations of base~ distribution box inlets and outlets, other elevations (r) maximum ground water elevation in a: s) plan mast be prepared by a Profes& professional authorized by law to I Reg 6 Septic Tanks (a) capacities-1507, of flow, water table, tees, depth of tees, access, pumping (b) cleanout (c) 201 from cellar wall or inground swimming pool (d) 251 from subsurface drains Reg 10.2 Distribution Boxes (a) slope greater than 0.08 - Reg 10.4 b) sump iPh,f hT{ w/riF f 3i • Y �a XA Al top 74 �YE� k� 1 VO It r r I �y1 ! � F � C a S s1y�' f ♦ t 1 'T w ,oma 149M, Rm- 4 „e• TA^�,�-+.� .. . i• F-luRb of HOUR, , G L-or 3_� &10017H AuLDOVC-l'�, MA, APPU COJ I sO PPl7lYJTC- s CO/JPITiays: �I�PPR�V�p 1ATE R�45oNS i . 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