HomeMy WebLinkAboutMiscellaneous - 152 MILL ROAD 4/30/2018 152 MILL RUAU y
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Commonwealth of MassachusettsD
City/Town of .
System Pumping-Record NOV 6 414
rForm 4 TOWN OF NuK
• HEH DEPAR'rM�hrP
DEP has provided this form for use:by local Boards of Health. Other forms may be'used, but the
information must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. Information
1. System Location: Left f , Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
NO,\
Cityrrown state Zip Code
2. System Owner.
Name
Address(if different from location)
Citylfown � _� � Zip
f Telephone Number r
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yeas No If yes, was it cleaned? ❑ Yes No.
5. Condition of r6n �Wv l Ute'
6. System Pumped By.
Neil Bateson F5821
Name Vehicle!_ioense Number.
Bateson Enterprises Inc
Company
7. Locatiere contents were disposed:
S. Lowell Waste Water
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A.0
Sig Haule Date
t5form4.doc-06103 System Pumping Record•Page 1 of 1
Wearth Department
�iZQutin�SCp— Forwarded 6y Pamefa
Tease return after review. 2fiank
Yom
Date:
JUL 1 3 2005
TO 0"
o,.
HEALrh
RE:
➢ Susan:
➢ Michele
➢�e bie
Health Calendar Updated?
❑ Yes ❑ No ❑ n/a
RETURN TO PAMELA
❑ File:
❑ Dispose
NOTE:
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PETER F. REILLY
136 ANDOVER STREET
ANDOVER, MA 01810
(978) 375-3750
TITLE V
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION
Property Address: 152 Mill Road, North Andover, MA 01845 ^"
p Y
Name of Owner: James DeAngelo
Address of Owner: same JUL
Name of Inspector: Peter F. Reilly 3 2006
Company Name: same TOS"v,11 OF NORTH AND®WR
Mailing Address: 136 Andover Street, Andover, MA 01810 wit rH rERARTMENT
Telephone Number: (978) 375-3750
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
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
N/A Conditionally Passes
N/A Needs Further Evaluation By the Local Approving Authority
N/A Fails
Inspector's Signature: Date: July 2, 2005
PetTr F. Reilly
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 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 a the time of inspection and under 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 (See attached Disclaimer).
n
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION (continued)
Property Address: 152 Mill Road, North Andover
Owner's Name: DeAngelo
Date of Inspection: 7/2/2005
INSPECTION SUMMARY:
A. SYSTEM PASSES: Check A, B, C, D, or E /ALWAYS complete all of Section D
✓ I have not found any information which indicates that the system violates any of the failure criteria as
defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
The system met the Pass Criteria of Title V.
B. SYSTEM CONDITIONALLY PASSES:
N/A 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). Describe basis of determination in all instances. If"not determined",
explain why not)
N The septic tank is metal, and over 20 years old*or the septic tank (whether metal or not) is 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. *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:
N Observation of a sewage backup or breakout or high static water level 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):
N/A broken pipe(s) are replaced
N/A obstruction is removed
N/A 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):
N/A broken pipe(s) are replaced
N/A obstruction is removed
I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION (continued)
Property Address: 152 Mill Road, North Andover
Owner's Name: DeAngelo
Date of Inspection: 7/2/2005
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 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:
N/A Cesspool of privy is within 50 feet of a surface water
N/A Cesspool or privy is within 50 feet of a bordering vegetated wetland or 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:
N/A The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet to
a surface water supply or tributary to a surface water supply.
N/A The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply well.
N/A The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
N/A The system has a septic tank and SAS the SAS is less than 100 feet but 50 feet or more from a
private water supply well.*"Method used to determine distance N/A
This system passes if the water well water analysis, performed at a certified DEP 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. A copy of the analysis must be attached to this form.
I
3. Other
N/A
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A- CERTIFICATION (continued)
Property Address: 152 Mill Road, North Andover
Owner's Name: DeAngelo
Date of Inspection: 7/2/2005
D. System Failure Criteria applicable to all systems:
You must indicate "Yes" or"No" to each of the following for all inspections:
Yes No
No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
No Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool.
No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
N/A Liquid depth in cesspool less than 6"below invert or available volume<'/2 day flow.
No required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped: once
No Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
N/A Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water
supply.
N/A Any portion of a cesspool or privy is within a Zone I of a private water supply well.
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well.
N/A 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 laboratory,for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate
nitrogen is less than 5 ppm, provided that no other failure criteria are triggered. A copy of the
analysis must be attached to this form).
! N/A The system fails. I have determined that one or more of the above failure criteria exist as defined in 310
CMR 15.303,therefore the system fails.The property owner should contact the Board of Health should be
contacted 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 a large system in addition to the criteria above)
N/A The design flow of system is 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
N/A The system is within 400 feet of a surface drinking water supply
N/A The system is within 200 feet of a tributary to a surface drinking water supply
N/A The system is located in a nitrogen sensitive area (Interim Wellhead 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 such 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.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART B - CHECKLIST
Property Address: 152 Mill Road, North Andover
Owner's Name: DeAngelo
Date of Inspection: 7/2/2005
Check if the following have been done. You must indicate either "Yes" or "No" as to each of the
following:
Yes No
Yes Pumping information was provided by the owner, occupant, or Board of Health.
No Were any of the system components pumped out in the previous two weeks?
Yes Has the system received normal flow in the previous two week period ?
No Have large volumes of water been introduced to the system recently or as part of this inspection?
Yes Were as built plans of the system obtained and examined ? (If they were available note as N/A)
Yes Was the facility or dwelling was inspected for signs of sewage backup ?
Yes Was the site was inspected for signs of breakout?
Yes Were all system components, excluding the SAS, located on the site ?
Yes Were the septic tank manholes uncovered, opened and the interior of the septic tank inspected
for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of
sludge, depth of scum?
Yes Was the facility owner(and occupants of if different from the owner) provided information on the
proper maintenance of subsurface sewerage disposal systems ?
The size and location of the Soil Absorption System (SAS) on the site has been determined based on:
Yes No
Yes Existing information. For example, a plan at the Board of Health. (as built)
N/A 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)].
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION
Property Address: 152 Mill Road, North Andover
Owner's Name: DeAngelo
Date of Inspection: 7/2/2005
FLOW CONDITIONS
RESIDENTIAL:
Number of bedrooms(design): LINK
Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203
(for example: 110 gpd x#of bedrooms: UNK
Number of Current residents: 4
Does the residence have a garbage grinder(yes or no): no
Is the laundry on a separate sewerage 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]): about 350 gpd
Sump Pump(yes or no): no
Last date of occupancy: current
COMMERCIAL/INDUSTRIAL:
Type of Establishment: N/A
Design Flow gpd (based on 15.203): N/A
Basis of Design Flow(seats/persons/sq.ft.,etc): N/A
Grease trap present(yes or no): N/A
Industrial waste holding tank present(yes or no): N/A
Non-sanitary waste discharged to the
Title 5 system (yes or no): N/A
Water meter readings, if available: N/A
Last date of occupancy/use: N/A
OTHER: (Describe) N/A
GENERAL INFORMATION
PUMPING RECORDS
Source of Information: owner(about 18 months ago)
Was system pumped as part of inspection (yes or no): no
if yes,volume pumped(gallons): N/A
How was quantity pumped determined? N/A
Reason for pumping: N/A
TYPE OF SYSTEM
✓ Septic tank/distribution box, soil absorption system
Single cesspool
Overflow cesspool
Privy
NO 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 the 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: original system installed
in 1985.
Were sewerage odors detected when arriving at the site (yes of no): no
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 152 Mill Road, North Andover
Owner's Name: DeAngelo
Date of Inspection: 7/2/2005
BUILDING SEWER: (locate on site plan)
Depth below grade: about 36"-40"
Materials of construction: cast iron ✓40 PVC other(explain)
Distance from private water supply well or suction line N/A
Diameter: 4"
Comments: Condition of joints, venting, evidence of leakage, etc.)
Building sewer was watertight and appeared sound at foundation.
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: about 30"
Material of construction: ✓ concrete metal Fiberglass Polyethylene other(explain)
If tank is metal, list age N/A Is age confirmed by Certificate of Compliance N/A(Yes/No)
Dimensions: Rectangular- 1,500 gallons
Sludge depth: <1"
Distance from top of sludge to bottom of outlet tee or baffle: 28"
Scum thickness: <1"
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: 16"
How dimensions were determined: observation
Comments: (on pumping recommendations, of inlet and outlet tees or baffle condition, structural integrity, liquid
level as related to outlet invert, evidence of leakage, etc.)
Tank was watertight and appeared to be functioning properly. Deteriorated baffle was replaced with PVC Tee
following the inspection.
GREASE TRAP: N/A (locate on site plan)
Depth below grade:
material of construction: concrete metal FRP other(explain)
Dimensions: N/A
Scum thickness: N/A
Distance from top of scum to top of outlet tee or baffle: N/A
Distance from bottom of scum to bottom of outlet tee or baffle: N/A
Date of Last Pumping: N/A
Comments: (on pumping recommendations, of inlet and outlet tees or baffle condition, structural integrity, liquid
level as related to outlet invert, evidence of leakage, etc.)
N/A
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 152 Mill Road, North Andover
Owner's Name: DeAngelo
Date of Inspection: 7/2/2005
TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection) (locate on site plan)
Depth below grade: N/A
material of construction: concrete metal Fiberglass Polyethylene other (explain)
Dimensions: N/A
Capacity: N/A gallons
Design Flow: N/A gallons per day
Alarm Present (yes or no): N/A
Alarm level: N/A
Alarm in working order (yes or no): N/A
Date of last pumping: N/A
Comments: (condition of alarm and float switches, etc.)
N/A
DISTRIBUTION BOX: ✓ (locate on site plan)
0" depth of liquid above outlet invert
Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into
or out of box, recommendation for repairs, etc.)
D-box was level. Three lines leading to SAS were accepting effluent evenly. D-box was about 40" below
surface. Little solids carryover evident.
PUMP CHAMBER: N/A (locate on site plan)
Pumps in working order (yes or no) N/A
Alarms in working order (yes or no) N/A
Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.)
not applicable
i
i
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 152 Mill Road, North Andover
Owner's Name: DeAngelo
Date of Inspection: 7/2/2005
SOIL ABSORPTION SYSTEM (SAS): ✓ (locate on site plan, if possible; excavation not required)
If SAS not located, explain why:
Type
leaching pits, number N/A
leaching chambers and number N/A
leaching galleries and number N/A
✓ leaching trenches, number, length 3 trenches about 60' long each per"as-built" plan
leaching fields, number, dimensions N/A
overflow cesspool, number N/A
alternative system (name of technology) N/A
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.)
Soils in area of SAS appeared normal, no signs of breakout.
CESSPOOLS: N/A (locate on site plan)
Number and configuration N/A
Depth-top of liquid to inlet invert N/A
Depth of solids layer N/A
Depth of scum layer N/A
Dimensions of cesspool N/A
Materials of construction N/A
Indication of groundwater inflow(cesspool
must be pumped as part of inspection) N/A
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
recommendations for maintenance or repairs, etc.)
not applicable
PRIVY: N/A (locate on site plan)
Materials of construction N/A
Dimensions N/A
Depth of solids N/A
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
recommendations for maintenance or repairs, etc.)
not applicable
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 152 Mill Road, North Andover
Owner's Name: DeAngelo
Date of Inspection: 7/2/2005
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Provide a sketch of the sewerage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100'. Locate where public water supply enters the building.
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SEPTIC TANK TIES: A to Inlet(1) N/A B to Inlet N/A
A to Center(C) 3810" B to Center 1610"
B to Outlet(0) N/A C to Outlet N/A
D-BOX TIES: A to Box 39'0" B to Box 22'8"
NOTE: The system is in the front yard. Water service enters approx. at "B."
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
I
Property Address: 152 Mill Road, North Andover
Owner's Name: DeAngelo
Date of Inspection: 7/2/2005
SITE EXAM
i
Slope sloping in area of system
Surface water none observed
Check cellar dry
Shallow wells none observed
Estimated Depth to Groundwater >1" (below bottom of SAS)
Please indicate (check) all methods used to determine the high ground water elevation:
N Obtained from Design Plans on record - if checked, date of design plan reviewed: N/A
Y Observed site (abutting property, observation hole within 150 feet of SAS)
N Check with Local Board of Health - explain: information on file
Y Check local excavators, installers - (attach documentation)
N Accessed USGS Database - explain: website too complicated
You must describe how you established the high ground water elevation.*
The soils and grade changes in the area indicate no groundwater in the SAS. However, the precise
groundwater elevation cannot be determined for certain without a soil evaluation test.
*Inspector's Note: Soil Evaluation is the currently recognized method for determining
or establishing the high groundwater elevation. Since I am not a licensed or certified
soil evaluator, I am not qualified to determine or establish the high groundwater
elevation beyond the public information available, such as recent design plans of the
site or the nearby area. My estimation of the high groundwater elevation is based on
a due diligence effort to obtain all available information both on and off the site and my
experience as a certified subsurface disposal system inspector. (see attached
Disclaimer)
a
DISCLAIMER
This passing septic inspection under Massachusetts Title V is in no way a guaranty
or warranty of the inspected septic system. The inspection is a "snapshot in time"
and does not constitute a complete assessment of the quality or potential longevity
of the septic system. The pass/fail criteria are specific and outlined in detail in this
report. Under the limited criteria of a Title V inspection, it is impossible to determine
how long any septic system will last. The inspector made a diligent effort to certify
the septic system based on the criteria required under Title V.
Under Massachusetts Title V, soil evaluation is the accepted method of determining
the high groundwater elevation. This inspector is not a certified soil evaluator and is
therefore not qualified under Title V to determine or establish the high groundwater
elevation. The method used to estimate the high groundwaterfor this inspection was
based on the public records and methods of observation described on the previous
page. Groundwater levels can vary greatly from season to season, year to year and
soil evaluation is considered the most reliable method of groundwater determination
under Title V.
Peter F. Reilly
Inspector
July 2, 2005
Driscoll, Paul
Lot # 6, Mill St.
APPLICATION FOR SEWAGE DISPOSAL INSTALLATION Z �'
HEALTH DEPARTMENT - NORTH ANDOVER, MASS.
I hereby make application for a permit for a sewage disposal installation at
Lot # Mill St. . I will install this system in ac-
cordance with all the laws of the Commonwealth of Massachusetts and regulations of
the Board of Health of the Town of North Andover.
Further, I will construct the house sewer of bell and spigot pipe, the minimum
diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre-
ceding the septic tank, where the grade shall not exceed 2%. I will install a con-
crete septic tank of 000 gal, in size. A manhole (s) permitting easy cleaning
will be provided with removable. cover (s) of iron or concrete within 12 inches of
the ground surface. I will provide subsurface disposal field with 4 inch perforated
or open jointed pipe and laid in a series of trenches, the bottom of which will pro-
vide a minimum of 180 lineal (sX1&V[1LJ feet of effective absorption area.
The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging
in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar
material to a height of 2 inches above the crown of the pipe. The joints of these
pipes will be protected from clogging and before filling the trench, 2 inches of
gravel or stone 1/8" to 1/41' (dia.) will be placed over the course gravel or stone.
The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single
tile line will exceed 100 feet in length and in any case, two lines of tile will be
installed. A minimum of 6 feet will be maintained between the center lines of the
disposal field trenches and the average depth of trench shall not exceed 36 inches.
No part of the installation will be less than 100 feet from any private water supply,
25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line.
I further agree not to cover any portion of this installation until approved by the
inspection officer, as provided below, and to incorporate anyadditional requirements
That may be attached to the permit. Plot Plans must be submitted with application.
R 3u
DATE
Signature of Applicant
I hereby issue the above permit for the Board of Health of the Town of North
Andover, Massachusetts.
DATE FMR 3 1 1rqgg
(I Signature of Health Agent
I have inspected the uncovered system indicated above and find everything done
as described.
DATE 2 _ )is
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Signature ofkjnspecting Offi r
Percolation Test 5 min, Soil: clay
Garbage Grinder
BOARD OF HEALTH
TOWN OF NORTH ANDOVER, MASS.
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1. NAME 6 0L ►✓ r S co LC DATE
2. ADDRESS (� i L L 1�o ct p LOT NO. TEL.
3. NO. OF BEDROOMS DEN YES NO
4. GARBAGE GRINDER YES NO
5. SHOW DIMENSIONS OF HOUSE
6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES
7. SHOW DIMENSIONS OF LOT
8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL
q. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM
10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC.
11. AHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE
NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY.
BOARD OF HEALTH OF NORTH ANDOVER, MASSACHUSETTS
SEWAGE DISPOSAL
NAME OF APPLICANT
Paul Driscoll
LOCATION— Lot #6, Ei 11 Road
Address of lot no.
BUILDING: Dwelling x Other
SYSTEM: New x Repair
GENERAL DESCRIPTION OF LAND Ki;gra.
SUBSOIL: Clay x GravelSand
PERCOLATION TEST 5 minutes per inch.
MINIMUM INSTALLATION RECOMMENDATIONS
CONCRETE SEPTIC TANK 1,000 gallon capacity.
LEACH FIELD 180 lineal feet of drain pipe.
a
William J. iscoll , Engi eer
Board of kA4th
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0 MASSACHUSETTS DEPARTMEN F PUBLIC HfiALTH Of
DIVISION OF COMMUNICABLE ISEASE CONTROL
305 SOUTH STREET, JAMAICA PLAIN 02130 t�.
BACTERIAL/PARASITIC GASTROENTERITIS CASE REPORT FORM
I_ PERSONAL INEORMA ION //
Fume of case: Tele hone'":
li p
Address: a
fBir : Age Sex :M Occupation
Dste oR/ :
Physician: �m Telephones:
Vas case hospitalized" I N P( If yes, name of hospital-
Date admitted: ! Date discharged: I I
II- ETIOLOGIC AGENT
,Plea:c chcck all that apply)
Campylobacter ❑ E. coli Giardia ❑ Shigella ❑
Crnypiosporidium ❑ Entamoeb.-_=((amebiasis) ❑ Salmonella ❑ S.aureus... ❑
Other (specify) ❑ Yersinia ❑
Species and/or serotype (if knovm):
III_ SYMPTOM HISTORY
Date of onset of symptoms : % r' Duration of symptoms: specify 0 days- ti
Treatment received : None ❑ Prescription
If prescription,name of medication:
IV. EXPOSURE HISTORY
Ask only about items consumed/ activities/ exposures Fithin one incubation period prior
to onset of symptoms . Use the reference on the back page for incubation periods
for different etiologic agents_
Suspect food or drink (spe<~ify item:placer date and time vhere food and/or beverage vas consumed) :
lin ua esu '
Vas board of Health in toTm Where suspect meal(s)eras consumed notified ? Y ❑N P'
Date notified : !
Any foreign/out-of-state travelY D N 2'
If yes,please specifiy date(s)and placers ):
An('outdoor activities !.e.g. ramping) ? Y ❑N B'
If v e ,please specify date(s)and place(s):
Anvcontact with animals/ pets_� Y 9N ❑
If yes, please specify- :
Sources of drinking K,ater at home: to064C,;,a -� tovn ❑ veil/spring ❑ bottled
Sources of drinldnc eater at�rork::"scho ol : tovn veil/spring ❑ bottled Er
Did other people share any of these exposures ' Y [] *people
,'ere any of them ill with symptoms similar ,Yours Y IV N 0 *people ill :
Cases iL^r^•rev ion 0�c-,v .e : dd)_11•�-
N4�
(OY R)
•^'°V.tase contacts 'household and other close contacts?
Nsme F AC cupation kelationship S oms Lab test resulk/3 E 5 /� L o F.- 1 o c�a2 l
,bfiL)Y 0 it �i nro- wt
VI. Dap Care Information
Is the case enrolled in or employed at a av care -gnter� Y ❑ N [}�
If yes,name and location of center:
Is y.household contact of case enrolled in:emplove at a day care center ? Y N ❑
If les, name end location of center:
Are any of the staff!children at this center ill with similar sjrmF.toms ? Y RN ❑
yes:hov many? *staff *children
H v�of steff!~ ildren been diagnosed ,having gastroenteritis? Y ❑ N ❑
VII_ Foodhandler Information
Is the case a foodhandler ? Y ❑ N
Is a household',:lose contact of case a foodhandler? Y ❑ N R'
If yes,name of foodheindler(s) :
If yes,name of foodhandling facility:
Address: City/State
Vhen vas the board rf health of that person's place of employment notified ? _1 /
R,hers vw the foodhandler removed from work ? 1 1
If the foodhandler is back at work,when were the back to work criteria met
(refer to State Isolation and Quarantine Regulations, 105 CMR 305:000 }
Comments
Lea
�� ?
be
Name of Investigator : TelephoneHospitall'Board of Health: Date Report Completed : I I
Etiologic Agent Average Incubation Period
CzfIobac,ter spp. 3-5 days
Cryptosporidium spp. , 10 days
Entamoeba(amebiasis) 2-4 weeks
E. coli 12-72 hours
�•iar j 7-10 days
.s. monella spp. 1 12-35 hours
ShigellasPP• I 1-3 days
S. aureus 2-4 d s
a J
Yersinia spp. 1 3-7 dairs
I i
6/8 8
Commonwealth of Massachusetts .._._...
City/Town of RECEIVED
System Pumping Record ,a, 'Lull
Form 4
TOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. Other fo s - U
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/ iaht rout of house eft/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Citylrown l Vl /UState Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town Stat 87r `��� Zip�o�L/ r
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) �ic Tank ❑ Tight Tank
i
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes D-11�0 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition, f$ystem-
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locaf contents were disposed:
-/G.L�S.Q Lowell Waste Water
' Sign t e Haule Date
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