HomeMy WebLinkAboutMiscellaneous - 152 VEST WAY 4/30/2018�LN Commonwealth of Massachusetts
W Cit /Town of No Andover RECEO�ED
Y
a System Pumping Record • u 013
Form 4 JUN 1 Z
'GOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. Other fo m '
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
6. System Pumped By:
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
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SianAture of Hauler
Date
Date
t5form4.doc• 03/06" System Pumping Record • Page 1 of 1
A. Facility Information
Important: When
filling out forms
1. System Location:
on the computer,
use only the tab
152 Vest wy
key to move your
Address
cursor - do not
No AndoverMa
use the return-
key.
-
City/Town
State
Zip -Code -
2. System Owner:
Roche
renin
Name
Address (if different from location)
Cityrrown
State
Zip Code
Telephone Number
B. Pumping Record
/ 12.
<�1
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1. Date of Pumping Date
Quantity Pumped:
Ga/ns
3. Type of system: ❑ Cesspool(s)
eptic Tank ❑ Tight Tank
❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No
If yes, was it cleaned?
❑ Yes ❑ No
5. Condition of System: 6000
6. System Pumped By:
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
z
SianAture of Hauler
Date
Date
t5form4.doc• 03/06" System Pumping Record • Page 1 of 1
1.
0wo Date . ` ........ t�
f,Na 't,. - � r/
"OR'� TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
SS�cMus
This certifies that ...:.... , .. - . :.. ..`.-.................. .
has permission to perform ..................
.plumbing in the buildings of . :1.... f. ..................
r........ North Andover, Mass.
Fee.. ... Lic. No,,�,//�t...... .
3-7.PLUMBING INSPECXOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Print or Type) /
AJ0 A 11\JZ)Qu/W , Mass. Date Zvi Permit
Bi
Building Location A 4 Owner's Name AS Ka f� Leto SV uNK,
— N O r`1 �'- tl� ► Type of Occupancy 2t5l D E ; j i I Air_
New ❑ Renovation ❑ Replacement 9Y' Plans Submitt Yes ❑ No ❑
FIXTURES
Installing Company Name I'Sl2r3EeZ Q - r?mMATAe0 Check one: Certificate
Address �� �� �'(; RC H (Y1r1n) /-&) ❑ Corporation
I71 E TK i' F_ Aly Al A 0 ❑ Partnership
Business Telephone r-i7FZ -i9� 9-6lCo.
Name of Licensed Plumber r=,f? T fry 5,4 e mt4 req ee .
INSURANCE COVERAGE:
I have a current I' bility insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No ❑
If you have checked yes. please
/indicate the type coverage by checking the appropriate box.
A liability insurance policy 1d Other type of Indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Aaent Owner ❑ Agent ❑
I hereby certify that all of the details and information 1 have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that all plumbing work and installationspoormed under the permit issu for this application will be in compliance with all
pertinent provisions of the Massachusetts State Plum ' g e and apter of the eral Laws.
BY it
v(sL
Title re of Licensed Plurntmr
Type of License: Master ` Joumeymah ❑
City/Town _
APPFiOV0(OFFICE USE ONL License Number �33 1 ,d
i
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Y
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Installing Company Name I'Sl2r3EeZ Q - r?mMATAe0 Check one: Certificate
Address �� �� �'(; RC H (Y1r1n) /-&) ❑ Corporation
I71 E TK i' F_ Aly Al A 0 ❑ Partnership
Business Telephone r-i7FZ -i9� 9-6lCo.
Name of Licensed Plumber r=,f? T fry 5,4 e mt4 req ee .
INSURANCE COVERAGE:
I have a current I' bility insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No ❑
If you have checked yes. please
/indicate the type coverage by checking the appropriate box.
A liability insurance policy 1d Other type of Indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Aaent Owner ❑ Agent ❑
I hereby certify that all of the details and information 1 have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that all plumbing work and installationspoormed under the permit issu for this application will be in compliance with all
pertinent provisions of the Massachusetts State Plum ' g e and apter of the eral Laws.
BY it
v(sL
Title re of Licensed Plurntmr
Type of License: Master ` Joumeymah ❑
City/Town _
APPFiOV0(OFFICE USE ONL License Number �33 1 ,d
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TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:t 5
SYSTEM OWNER & ADDRESS
N Ando-cr, /k p l3 LlS
SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING: 1I 5 10 o QUANTITY PUMPED I ti GALLONS
CESSPOOL: NO 1"' -YE S SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE / EMERGENCY
OBSERVATIONS:
GOOD CONDITION / FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
a.
COMMENTS:
CONTENTS TRANSFERRED TO:�N t'''Q� H A, SDC`
1
FEB 2 8 2001
r
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500
00-3
TRUDY CORE
skmtary r
ARGEO PAUL CELLUCCI DAVID $. STRUHS
Governor . Commisdoner
"DCPC SEWAGE DISPOSAL $YSTEM•INSPECTION FORM -
SU
' PART A
CERTIFICATION
Property Address: 15 2 Y ES'T W,4-1) N oRrlt f}NDOV i i2 Name of Owner M irt. C F4R�S MDE N
AddressofOwner: 1Rp COVE04Ttt•4 t-.h9F,,Nel2i'It PrHOLUG1Z
Date of Inspection: t l%1 00
Name of Inspect«: (Please Print) Benjamin C. Osgood, Jr.
I am a DEP approved system inspector pursuant to Section 15.340 of Tide 5 (310 CMR 15.000)
Company Name: New England Engineering SeXxj Ps, Inc.
Mailing Address: 60 Beec r, MA 01845
Telephone Number 686-1768
CERTIFICATION STATEMENT
I certify that 1 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-sitesewage disposal systems. The system:
V Passes
Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Feil
Inspectors Signature: Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty 130) -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 Pratection. The original should'be sent IOVM
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
revised 9/2/98
Pik eeIofII
.. CJ.-Pm1ed on R"Ied Piper .. .
I I I I
SUBSU0,%CE SEWAGE DISPOSAL SYSTEM INSPECTION FORM '
PART A
CERTIFICATION (continued)
Property Address: 152 Vest Way, North Andover
Owner: Mr. Chris Moen
Date of Inspection: 1/11/00
INSPECTION SUMMARY: Check A, B, C, or A
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:
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 NO). 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 pipes)
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 pumpirtg•rrmam than four -times a yeardue to broken or obst, cted pipe(s). The system VAIpess „
inspection if (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
revised 9/2/98
rage 2 or it
n
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOAM
PART A
CERTIFICATION (continued)
Property Address: 152 Vest Way, North Andover
Owner: Mr. Chris Moen
Date of Inspection: 1/11/00
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 td protect the
public health, safety and the environment. <
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WRIT 310 CMR 15.303 (1)(b) THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH JKILLPRQTECT THE PUBLIC HEALTH AND SAFETY AND THE EHVJBONMEKT:
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 tS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBUC 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 supply well.
_ 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 e
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 velid).
3) OTHER
revised 92/98 Page 3orII
• 1 I i I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 152 Vest Way, North Andover
Owner: Mr. Chris Moen
Date of Inspection: 1/11/00
r 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 failure conditions 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 4ecilityor-"stem component -due to an overloaded or -,cogged SAS or -cesspool. •=�- 1
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" or "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
the system•is-within 200 feet of4-Nibutary-le-aeurfooa•d«nk:0g•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)
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 infortnation.
revised 9/2/98.
Page 4 or I 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 152 Vest Way, North Andover
Owner. Mr. Chris Moen
Date of Inspection: 1/11/00
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 systen}:compnae+u.sAn,ra.baan pvcnpod+forstleas t two wade and•the'syctem has J3*"=ecainiag waaal 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 (it any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
/ 115.302(3)(b))
v _ The facility owner tand.occurpaats,if different frorn_oWner).weraprnvided.with infor atlon.en t a proper rnalntanane. ..f
SubSurface Disposal Systems.
revised 9/2/98 Pace sern
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK{
' PART C
SYSTEM INFORMATION ,
Property Address: 152 Vest Way, North Andover
Owner: Mr. Chris Moen
Date of Inspection: 1/11/00
' FLOW CONDITIONS
RESIDENTIAL:
r Design flow: g.p.d./bedroom. r r
Number of bedrooms (design):_ Number of bedrooms (actual):
Total DESIGN flow
Number of current residents: 5�
Garbage grinder (yes or no):%WS
Laundry (separate system) (yes or no):Ab ; If yes, separate inspection required
Laundry system inspected (yes or no)
Stasonal use (yes or no): 11D
Water meter readings, if available (last two year's usage (gpd):
Sump Pump (yes or no) -._h&
Lest date of occupancy: ZO DAYS
COMMERCIALIINDUSTRIAL:
Type of establishment:
Design flow: opd ( 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:
YJWt PEt> E) Ez-1 `t t"Z -O(n-
System pumped as part of inspection: (yes or no)_
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
L Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system lyes or no) (if yes, attach previous inspection records, if any)
1/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) -end source of -information:
Sewage odors detected when arriving at the site: (yes or no)
revised 9/2/98 page 6orit
w
St1RSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
,SYSTEM INFORMATION (continued)
Property Address: 152 Vest Way, North Andover
Owner: Mr. Chris Moen
Date of Inspection: 1/11/00
BUILDING SEWER:
(locate on site plan)
Depth below grade: Z.
Material of construction: _✓cast iron _ 40 F.VC _ other (explain)
Distance from private water supply well or suction line A19
Diameterq 11
Comments: (condition of joints, venting, evidence of leakage, -etc.)
Pt PE Ihl L4-000 CONDI-noK /N BRStnacNT.
SEPTIC TANK:_
(locate on site plan)
rl
Depth below grade:
Material of construction: '_✓concrete _metal _Fiberglass _Polyethylene _other(explain)
It tank is (petal, list age _ Is.age.confirmed by Certificate of Compliance _ (Yes/No)
Dimensions: /500 �( 4L LVV f
Sludge depth:_ 11/
Distance from top of sludge to bottom of outlet tee or baffle: 3
Scum thickness: <I " t I
Distance from top of scum to top of outlet tee or baffle:_ ft
Distance from bottom of scum to bottom of outlet tee or baffle: 13
How dimensions were determined: ME4S'*F- STILLC
Comments:
(recommendation for pumping, condition of inlet and outlet tees or -baffles, depth of liquid level in relation to outlet invert, structureF•integrity,
evidence of leakage, etc.) 7-4WX //V (,rIOD LONDIT! 0A/ RVC 7WES IN 9910/9 -O&A/nw.
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 battle: '
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 7orII
! SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION. FORM,
r PART C
SYSTEM INFORMATION (continued)
Property Address: 152 Vest Way, North Andover
Owner. Mr. Chris Moen
Date of Inspection: 1/11/00
TIGHT OR HOLDING TANK: NA (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(explein)
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)
/r
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) — —
JWX IN OK CONDITION ONF SIDF LS ZOTrED SOk SHOULO Rt i2E PL'4cEN
IN µEArlt FWVQiL ' IS OK
PUMP CHAMBER: A
(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 1*2tr9erII
Property Address: 152 Vest Way, North Andover
Owner: Mr. Chris Moen
Date of Inspection: 1/11/00
cr16SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART C ,
SYSTEM INFORMATION (continued)
SOIL ABSORPTION SYSTEM ($AS) _ I I
(locate on site plan,. if possible: excavation not required, location may be approximated by non -intrusive methods)
If not located, explain:
Type:
leaching pits, number:_
leaching chambers, number:_
leaching galleries, number:_
leaching trenches, number, length: L-E� -r4Xtf 4
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.)
Lac M'ZIE4 LCI(XS NOF -"L. oto to v ; obia or-
U MVS t)a-1, AdIrk "001 -
CESSPOOLS:
(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 (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: u�
(locate on site plan)
Materjels 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
s
Page 9 or 11
.."ftl
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SUBSURFACE SEWAGE DISPOSAL SYSTEM I14SPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 152 Vest Way, North Andover
Owner. Mr. Chris Moen
Date of Inspection: 1/11/00
NRCS -Report name 5,,^.)r C„^�iL�/ ESSEJC (00)'LT`( 1YItTJSrTt'.1t%.S(-T%S Nolew o 1 ►7►�! 1
Soil type_ r
Typical depth to groundwater ` > ra. O
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow —Moderate --Deep
SITE EXAM Slope
Surface water W0,A16
Check Cellar AVO i w4aK
Shallow wells N,,N6
Estimated Depth to Groundwater 1/ Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
L 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)
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revised 9/2/98 Page II ortt
NEW ENGLAND ENGINEERING SERVICES
INC
January 12, 2000
North Andover Board of Health
Town Hall Annex
27 Charles Street
North Andover, MA 01845
RE: TITLE V REPORT: 152 Vest Way, North Andover, MA
Dear Sirs:
Enclosed is a copy of the Title V report for the above referenced property. The systemap sses our
inspection.
If there are any questions please call me at my office, 686-1768.
Sincerely
Zi�. s er,.I.T.
President
JAN 1 4 ?^rq
60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099
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' PLAN SNMING SUBSURFACE SEWERAGE
DISPOSAL SYSTEM AS BUI LT
LOCAT I ON. LOT 52 NEST WAY
OWNER" 1AYSON R.T.
{ DATE 4-13-53 SCALE 1=40
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PLAISTO , N.H. 03865
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ELEVATION
TOP FOUNpATION 166-Jcf
HOJOE OUTLET 164.2—j
S.T. INLET f64.OS
r T OUTLET TLET 16v.80
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D- BOX INLET 162.44
D -60X OUTLET IGZZ4
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PIT "1 161.91
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I
WAY
---- RZ506,Z�fi
+ rS 0.
O
70'
�I 1
I OFRTIFI THAT THE SEPTICSYSTEM WAS
INSTALLED AS SHOWN,THIS PLAN ISNOT
INTENDED AS A WARRANTY OF THE SYST E Iota
LOT .52
4S, 613
s
Pt -AN SHOWING SUBSURFACE SEWERAGE
DISPOSAL SYSTEM AS -BUILT
LOCATION:LOTb2 VEST WAY
OWNER*u, YSON R.T.
DATE 4-18-83 SCALE 1=4g'
PREPARED BY—
Q, N/V �-ISSC�Ca P �,0
PoU.jFO,.\,(569
PLAISTOWfVHa n7 6,5
7
w
J 1
C ,
E
TOP FOUNDATION 166 Od
HUU:"E OUTLE f I6425
S.T. fNLET 164-05
S {'CUTLET 1630
D- BOX I NLET IG2.44 i
D -BOX OUTLF—T IGL34
PIT 41 161.91 ?
PIT42 161a53
PROPERT)' DESCRIPTION FROM NERD
PLAN *6012
�I
i
VEST
WAY
f 1 CEFMFY THAT THE SEPTIC ;YSTE M WAS
INSTALLED AS SHOWN.THIS PLAN ISNOT
INTENDED ASAWARRANTY OF THF SYSTEMo
L DT 52
4S;r68
_y
PlAN SHOLtiINS 5L�BSU(ACE --
SEWERAGE
DISPOSAL SYSTE[vl AS-BUI LT
l_OC,AT I ON.' LOT b2_ VEST k,%AY
OWNER'uAYSON R.T.
DATE 4-18-&3 SCALE f= -1Q'
PREPARED BY --
1
1
1
I
1
� 1
r/
ELEVATION
TOP FOUNDATION 166,id
} H(01,1 E OUTLET 164.2"
S.T. INLET 164.05
"-).-r. OUTLET 163.80
r
D- BOX INLET 162044
D -BOX OUTLET 162034
PIT"I 161.91
PIT"2 16105.3
PROPERTY DESCRIPTION FROM NERD
PLAN "8012
ill Jf{� UC.
69
I
+
�T-AIS`1-70W N.H. 07,865 1
PlAN SHOLtiINS 5L�BSU(ACE --
SEWERAGE
DISPOSAL SYSTE[vl AS-BUI LT
l_OC,AT I ON.' LOT b2_ VEST k,%AY
OWNER'uAYSON R.T.
DATE 4-18-&3 SCALE f= -1Q'
PREPARED BY --
1
1
1
I
1
� 1
r/
ELEVATION
TOP FOUNDATION 166,id
} H(01,1 E OUTLET 164.2"
S.T. INLET 164.05
"-).-r. OUTLET 163.80
r
D- BOX INLET 162044
D -BOX OUTLET 162034
PIT"I 161.91
PIT"2 16105.3
PROPERTY DESCRIPTION FROM NERD
PLAN "8012
ill Jf{� UC.
69
I
+
�T-AIS`1-70W N.H. 07,865 1
PROPERTY DESCRIPTION FROM NERD
PLAN "8012
ill Jf{� UC.
69
I
+
�T-AIS`1-70W N.H. 07,865 1
Of
QVID DATE
I
OK
IN STALLATICE' CMK LI ST LOT
DI SUM XCAVATI Qui Cg i hI L
IIM)b3 41
b P_40 N
1. Distance Tos s� t
a. Wetlands
b. Drains
c. Well
2. Water Line Location
3. No PPC Pipe
}�. Septic Tanis _
a. _Tees --Length & To Clean flat Cowers
b. Cement Pipe to Tank On Both Sides of Tank 3 j -.� w• '3
5. Distribution Box oerzv �D
a. Covers & Box - No Cracks
. o✓nzrs
bAll Lines Flowing Bgna3. Amounts
c. No Back Flow
6. - Leach Field ? Trench
a. DVeanDaubl.
b. Sh
c. Cs
W. C Washed Stone
7. Leach Pits
a. Dimensions
b. Stone Depth
c. Splash Pads
d. Tees
e. Cment Pipe to. Pit - Both Sides
f. Clean Double Washed Stone
8. No Garbage Disposal
J,
9. Final Grading Inspection
10. Barricading Covered System
11. As Built Submitted
a. Lot Location
b. Dimensions of System
c. Location with Regard. -to Pert Test
d. Elevations
e: Water Table
;rid of Eaath
o-
Title V F=_ I M
SUBSO-FACE DI&DOSAL DMO CK:"K LIST
LOT f 52 VC-257—
Title
Es -
DISAPPRUM DAA_______
Reasons: / I
s 'F. c coo Vj
Reg 2.5 The submitted plan must show as a minimums
a) the lot to be served-area,dimensions lot #,abutters
b localocator and on and lresultsppercolat on testsobservation -distanceeto ties
to :
c leaching area
d
design calculations do calculations shaving required
e) location and dimensions of system -including eeserve area
f) existing and proposed contours
g) location any wet areas within 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 1001 of serge disposal
system or disclaimer -Planning Board files
(j) knosm sources of water supply within 200' of sewage disposal e
system or disclaimer
(k) location of any proposed well to serve lot -1001 from leaching facilit,
location of water lines on property -10' from leaching facility
(m) location of benchmark
fi) driveways
o) garbage disposals
no PVC to be used in construction
q) profile of system -elevations of basement, plumb, pipe, septic tank,
distribution box inlets and outlets, distribution field piping and
Other elevations
r) maximum ground pater elevation in area sewage disposal system
s) plan mast be prepared by a Professional Engineer or other
professional authorized by law to prepare such plans
Reg 6 Septic Tanks
�(a) capacities -150% of flow, 1„ater table, tees, depth of tees,
access, pumping
(b) cleanout
OW (c) 10t from cellar All or inground swimadmg pool
(d) 251 from subsurface drains
Reg 10.2 Distribution Boxes
t4a) supe greater thm 0.08
Reg loaf b) sump
(� sE�C ec�ks
R-
�Q�41NE�
1204, tlo-r nz l
IbM\101
CV
- L .. V
F JL
Leaching Pits
Leaching pits are preferred it,,here the installation is possible
Reg 11.2
11.11
11.10
11.11
Reg 15.1
15.8
3.7
Reg 14.1
111.3
14.4
111.6
111.7
111.10
'�
a) calculations of leaching area-ndnimum 500 sq ft
) spacing
) surface drainage 2%
) cover material
21 x2 f x4l, splash pad
tee at elbow
g) no bends in pipe from d -box to pipe
Leaching Fields
a) no greater tf-- minutes/inch
b) area- sq ft15.1, c) constroc on of field
d) sarf drainage 2 %
e) 2 from cellar wall or inground mdmadng pool
Leaching Htmche
a) calculations eaching area-rdn 500 eq ft
b) spacing • t min 6 ft with reserve between
c) aimenmr, ns
d) ca ction
e) stone
if) surface drainage 2%
Dounhi.11 Slope
x
slope y be shown)
y/x X 150 = (to be shown)
- s
Reg 9.1 a) val
9.6 b tared -by power
M y SOIL PROFILE & PERCOLATION TEST DATA
Noith,Andover, Mass. Street No C/��/y wl Lot No c�Z
Loc/Subdiv. // Pland Owner
Investigator %�G� /�G� Observer 71
SOIL PROFILE DATES
l.'Flev V 2.Elev 3.Elev 4.Elev
/ � C
0
0
1
2
3
M
5
6
7
8
9
10
0
1
2
3
M
5
6
7
8
9
10
Ties Pits est
Benchmark Location
Elevation Datum --
PERC0;,ATION TESTS
DATES
Pit Number
1
2
3
�+
Start Saturation
Soak -Minutes
Start e
Drop of 3" -Time
Drop of 6" -Time
M6ns.lst 3" drop
Mins.2nd " Drop
Percolation
SOIL PROFILE & PERCOLATION TEST DATA
f
1 � S
North Ana. ... ,•_.... U„ _ R�+ ,-AA+ ^ T.nt Nn.
Loc./Subdiv.__ �� �S Plan Owner
Investigatory ✓oE
Observers
SOIL PROFILES -DATE
1' Elev. Elev. 3'4'Elev.
Elev.
0 0 0 = - �0
Ties to Test Pits
Benchmark
Elevation
2
3
4
5
2
2
3
_ .4
5
4
2
3
- 4
5
Start Saturation
_-
Soak -Mins. 1 w-•
Start Test—Time
6 6 6
7
8
9
10
7
8
9
10
Location
Datum
Percolation Tests -Date
CA/// /J•9
7
8
9
10
eye------ v —
Pit Number 1
2
3
4
5
Start Saturation
Soak -Mins. 1 w-•
Start Test—Time
Drop of 3" -Time- ,,D
Drop of 6" -Time
Mins. 1 st . 3"Dro 3
Mins . 2nd 3"Drop 3
-
Percolation Rate
IWestAn & 4ncatchea nn Back
'i TF( i
SOIL PROFILE &
PERCOLATION
TEST DATA
_
4
North Ari''--- " ,• .... tJ� - sr �t roo�- _ %-
1-)4 L T.nt
No.
Loc./Subdiv.__
Plan
Owner
Investi-gator-=��%'3�'�'
Observer„
6-•
,��/4/fl3 SOIL PROFILES -DATE
1 •- _ -' 2' Elev.
Elev.
3' Elev. 4 •Eley.
0
`\
0
7
0�
Mins. lst. 3"Drop
p
Mins . 2nd 3"Dro /A
Percolation Rate �.
Ties to Test .Pits
2
2
2
2
3
FA
G1
rA
7
F
5
L(
Benchmark
Elevation
3
2
4
_
4
Start Saturation q:44
1 5
L)
� 5
0 6
S
7
Start Test -Timed
FM
7
10
3
2
3
4
4
Start Saturation q:44
_ 4
� 5
-SA-Vivi
S
6
Start Test -Timed
6-•
0
7
7
81—I s
9 ��ysc•L 9 vcST
10 10
Location 1411
Datum
Percolation Tests -Date
G Rlr!,A
Pit Number 1
2
3
4
S
Start Saturation q:44
Soak -Mins. i5
Start Test -Timed
Drop of 3" -Time- Q`1
Drop of 6" -Time
Mins. lst. 3"Drop
Mins . 2nd 3"Dro /A
Percolation Rate �.
Lo� r 3
N -stem Owner
P��j 6
FORM 4 - SYSTEM PLNIPL\G RECORD
Commonwealth of Massachusett
Massachus
System Pumping Record
ystem Location
Date of Pumping: �S- a (— qS— Quantity Pumped: /S� gallons
Cesspool: No � Yes ❑ Septic Tank: No ❑ Yes
System Pumped by: � License .
Contents transferred to: �- • �•
Date Inspector
FORM 4 - SYSTEM Pt11PL\G RECORD
Commonwealth of Massachusetts
Massachusetts OwIWADUf
System Pumping Record
ystem Owner
P,t) V\
ystem
Asa A:1U-zr�p����(/
Date of Pumping: ���`�?— (F!5— Quantity Pumped: gallons
Cesspool: No Pi Yes ❑ Septic Tank: No ❑ Yes Z
7--7
System Pumped by- License #:
Contents transferred to: t—' �- D
Date Inspector
F_
William F. Weld
Gowmor
Trudy Coxe
secw.y, EOEA
David B. Struhs
Commissioner
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
®apartment of
Enironmiental Protection
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
r. -e Y4A
Property Address: i a ire �� ° N p a V Address of Owner:
Date of Inspection: ?11851s -
,q
(if different)
Name of Inspector: 'g IffN [SSG-OoD a2
Company Name, .Address and Telephone Number: 1V Cy w Z0iC
33 U"gLkse Rd Ivicef-�Wndov�ae �4
9 �o
TH
OCT 1 0 1995
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. The system:
Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
-fails
inspector's Signature: / �j (/ Date: l,)-Ilgj—
The System Inspector shall submit a copy of this inspection report to the Approving Authority 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 ovmer shall submit
the report to the appropriate regional office of the Department of Environmental Protection
the original should be Beni i(.. the Svstem owner and cop,e5 sen! to tnE du\Cr, if applicable and the app(o',Ing ailih0(IC}'
INSPECTION SUMMARY:
Check6D B, C, or D
AI SYSTEM PASSES:
J/ I have not found any information which indicates that the system violates any of the failure criteria as uelwed in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B) SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not)
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health
irevised 9/15/95)
One Winter Street + Boston, Massachusetts 02108 + FAX (617) 556-1049 + Telephone (617) 292-5500
1J Panted on Recycled Paper
t
Property Address:
Owner:
Date of. Inspection:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
51 �a tA,t�</, )Uj eth i�h�o� �, rl1t� oi8ws
1
R a E2T Ci-ue 1.A)
..'
BI SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high statievenwater
distebut ovel n boxes, Thethe
sysembution box is will pas inspection
broken
approval of he
pipe(s) or due to a broken, settled or un
Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The systern required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
Inspec"'on if (++Ith approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
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.
1) SYSTEM WILL PASS UNLESS BOARD OF A DETERMINES SFEiY AND THETENESYSTEM IS VIRONMENT;OT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH
Cesspool or pm•, is within 50 feet of a surface water
Cesspool or pri+-)• 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 APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONTME, 'NT,S-
a sep!,lC ton K 8n0 5011 a050tp 0n 51Sle7al0 IS wul 1Uv lee) to d NAiCi u , VI i,fiL�:iul, i.c
surface ,+'aier su,)PlV
1 n c, s;e—• hal a septic tank and soil absorption system and is within a Zone I of a public water supply +yell.
.
The 5%,sle-) has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
sept c tank and soil absorption system and is less than 100 feet but 50 feet or more from a pri+�ate ++ater
Y,Ip�i,. +,tall, units; a well water analysis (or 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.
DI SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303• The basis
for this determination is identified below, The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
C?ischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged. SAS or
cesspool.
2
,:ev:sed 8/i5i55;
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
�(l�27y�d���r,
Property Address:
Owner: Ro a 6; 07/ %�- OR I JV
Date of Inspection: % �/� /9j—
D] SYSTEM FAILS (continued):
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day.flow.
_ Required pumping more than 4 times in the last year NOT due to ciogged or obstructed pipeis),
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.
Ary portion of a cesspoof or privv is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of"a private wate, supply well.
Anv 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.
EJ LARGE SYSTEM FAILS;
The foilo\\ing criteria apply to large systems in addition to the criteria above:
"he o' sy stem is 10:000 gpd or grea'.er barge System) and the system is a sig rif cant threat to public health Ind safety
and the ernironniert because one or more of the following conditions exist.
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 \Nellhead Protection Area (IWPA) or a mapped Zone II of a
_— puoll;. Wdlef supply well.
te
The owner or,°�14 Ch1Rany
5 OOsuch
andsystem
6500 leashall
sebring
consult thetlocal reg onlaryofficinto
efull
the Departmentwith
forthe
fugherrinfoamatioeatment program
requirements o/ 3
3
;re' -'-'Sed 8/15/9511
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: D
Owner: /i 0 e& --4e% (5: ele" /U
Date of Inspection:
9 li$l9.�-
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of Health.
v None o° the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
durin,_ t'r•.at ;.ger od large volumes of water have not been introduced into the system recently or as part of this inspection,
Vlq As built plans nave been obtained and examined. Note if they are not available with N/A.
The far,ihi y or d.velling was inspected fof signs of sewage back-up.
101ZThe system does not receive non-sanitar), 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.
P" The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees, material ct construct on, dirnensiors, 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 or
appro,orna ter' non- ^"rusive methods
�r^'ation on .rotor mai tenace of Sub-
nf
Surface Disposal Svstem.
l:tv-:Sed 81"5/95: 4
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART L
SYSTEM/ INFORMATION
Property Address: GI. `/ r i'l�o�PT hl,''4C�0°//Z`�, )W Al O/ �'%S•
Owner:
Date of inspection:
FLOW CONDITIONS
RES14ENTIAL
Design flow: . gallons
Number of bedrooms.
Number of current residents: J
Garbage grinderle or no):
Laundry connected to system CQ31 or nol.
Seasonal use lyes or t`ic):—AZ _
Water meter readings, if available, 1'J e &114
)"v
Last date of occupant; � "��'�`�
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flow:allons/day
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 occupane>:
GENERAL INFORMATION
Sov,[ice
PUMPING RECORDS and source of information, /
6e)
System pumped as pan of inspection: y s r no)—IV
If yes, vo!umc, p-, .!) /SDD gallons _
Reason for pum,)ing •0A O.- >eCJ ¢.10
TYPE OF SYSTEM
t/ . Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Other (explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information: 1 e IrIle'�i
Sewage odors detected v:hern arriving at the site (yes or no) n�
(:'evise6 8!-,5/95:
93' -wo
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: /,5oL w V,) eA #4 move l%%!i 0 V"',
Owner: ,�'p Q 2 j 6; ve "iV
Date of Inspection:
SEPTIC TANK:,
(locate on site plan)
Depth below grade: l9
Material of construction. ✓concrete metal —FRP `other(explain)
D,mensions:
Sludg:° depth: el�
Distance from top of sludge to bottom of outlet tee or baffle:—?8-
Scum thickness: 6
Distance from top o' scum to top Of outlet tee or baffle: ,
Distance from bottom of scum to bottom of outlet tee or baffle:_
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,) ! � � n.' ? 'a - G �/o TeCs Z K 5, 44G4r n� s
T /vS X14 Q' �sG l v F' e'* .1 t ,C
/ t- "' •o "r . 7M /t f P" oc /< _
GRE.,SE TIRA P:�
(iocate on site plan!
Depth below grade.
Material of construction. concrete „metal _FRP—other(explain)
Dimens ons:
scut., to 6lness
Distance from top of sc.rm to too of outlet tee or baffle!
ou ?'. tee o' bahle:
C,,: -.menu
(re;ommendat on for pump,n&. ccordsi!on of inlet and outlet tees or baffles, depth of liquid level in relation to outlet Invert, structural
ie egrirf, evidence of ieakaee, e+c - --
t:r.vised E/15/95! 6
7 j Lk'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
L/ Vi? (e 0 1,6 4�
Property Address: 1.5,;
Owner: 7-6-oie,'A.)
Date of Inspection
TIGHT OR HOLDING TANK:_
(locate on site plan)
Depth below grade:,,
material of construction: concrete metal _FRP —other(explain)
Dimensions:
Capacity!_- gallons
Design fiow:—gallons/day
Alarm level:
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:_
Ccmnnent;. 1 4 ; lealka— in!-, ou! of bc.,,,. etc
0 C j n,4 -1 e% o" e�'Ider-'-e 0 C, I
vv C 'r'D r; S
e v o i -JO 2
I
PLJ&AP CHAMBER:—
(locate"'on site plan)
Pumps in working order:(yes or no)
Comments!
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised S/I5/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: yBS7 0,4Y
Owner: Ci r t CoU,er'.i
Date of Inspection: S /1'q /y3"
SOIL ABSORPTION SYSTEM (SAS):_,_,
(locate cn site plan, if possible; excavation not required, but may be approximated by non -intrusive methods)
If n,t determined to be present, explain:
Tape
leaching pits, number:_
leaching chambe,s, number:
leaching galleries, number.
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments. (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetanon,etc.)
j G ?If,v P4'ao < S U
CESSPOOLS: —
(locate on site plan)
~'umber and configuration
Depth -top of liquid to inlet ;even:
Defah of so! ds Jaye, _
Depth of scum layer
Dimen5!ons of cessPL:,C .
!^,afeaal� Oi COnSIf(!c'inn.
ind;canon.of ground,%a;e-
inflov,, (cessr)ooi must be pumped as part of inspection)
Comments: (note coedit on of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY: _
ilocate 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.)
f -e.;ed 8;:5%95`
M y 3
- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
i
Property Address:
Voe
Owner: o EQ l C U 2 r N
Date of inspection:
SKETCH. OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
DEPTH TO GROUNDWATER
Depth to groundwater: h f feet
method of determination or approximation: 45S T; M # I~r3
i:L%ised e/1-5/5.1 9
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: kS4tO1-A
--L4
Name:
Owner's Address:
Date of Inspectio
Name of Inspectc
Company Name:
Mailing Address:
Telephone Numb
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 Sertion 15.340 of Title 5 (310 CMR 15.000). The system:
Passes
Conditionally Passes
Needaurther valuation by the Local Approving Authority
F ils
Inspector's Signature: Dater / 3 '� Z -
The system inspector shall bmit a copy of this inspection report t16 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
4- � = Page 2 of I f
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner-
Date of Inspection:
Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D
A.' System Passes:
V 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):
ND explain:
broken pipe(s) are replaced
obstruction is removed -
2
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: / 5 Z. V�S+ (�-XL L -
Owner:
Date of Inspection: Z5 11»
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(i)(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:
• A Page 4 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 3-
10 -
Owner:
Date of Inspection: Z
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or "no" to each of the following for all inspections:
Yes No/
_ V ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
1/ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
te."Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
esspool
tiquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow
!/ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped
//Any portion of the SAS, cesspool or privy is below high ground water elevation.
_4,,,,Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
y portion of a cesspool or privy is within a Zone 1 of a public well.
y 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 compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
(Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303. therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either "yes" or "no" to.each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
— _ the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped
Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
Page 6 of 1 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: /
Owner
Date of Inspection: '
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): Number of bedrooms (actual):
DESIGN flow based on 310 CN�y 5.203 (for example: 110 gpd x # of bedrooms):
Number of current residents: _1
Does residence have a garbage grinder (yes or no):C,S e co re , r p� t c� %gyp f7 e rr'
Is laundry on a separate sewage system (yes or no). L[if yes separate inspection required]
Laundry system inspected (yes or no):
Seasonal use: (yes or no):
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump (yes or no):"
Last date of occupancyo G; Lj e'-1
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: P, rn P`�-
Was system pumped as part of the inspection tyes or no):S
If yes, volume pumped:,�gallons -- How was quant ty pumped determined?
Reason for pumping: / N 5 QC C_?" G1 N 1 L
TYPF 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/Altemative 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):
age of all components, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site (yes or no)�Q
Page 7 of I 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: /5—a VL' 47�—"
Owner 5 QP1,
d .
IX07/1 Al
Date of Inspection:
BUILDING SEWER (locate on site plan)
Depth below grade: / 6 ,
Materials of construction: st iron _40 PVC _other (explain):
Distance from private water supply well or suction Be:
Comments (on condition of joints, venting, evidence of leakage, etc.):
SEPTIC TANK: (/ (locate on site plan)
Depth below grade:
Material of construction: oncrete _metal _fiberglass _polyethylene
—other(explain)
If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): — (attach a copy of
certificate)
Dimensions:
Sludge depth: .s `�C
Distance from top ofs 1pAge to bottom of outlet tee or baffle: -�
Scum thickness: Z ,
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom outlet tee or baffle:
How were dimensions determined: 7 4 o e J -'j u_s V "-L
Comments (on pumping recommendations, ' l -et and outlet tee or baffle condition, structural integrity, liquid levels
as�rel to outlet invert, evade ce o�Iei
akager�etc.): //G2 A,AG %%ti� .,W�`eS �GD01 Lc��
GREASE TRAP: _(locate on site plan)
Depth below grade: —
Material of construction: _concrete _metal _fiberglass __polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 15-oW
/-) AQ 1//
Owner: (/ G
Date of Inspection: /
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass _.yolyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present (yes or no):
Alarm levet: Alarm in working order (yes or no):
Date of last pumping:
Comments (condition of alarm and float switches, etc.):
DISTRIBUTION BOX: I/(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
le#cVe into or o t of box, etc.):
S _
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.):
Page 9 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: �s a Mrs/ -a -)1w
/f /�, 7 _
Owner
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required)
If SAS not located explain why:
Type //��
V leaching pits, number:: -
leaching chambers, number:
leaching galleries, number:
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.): / v1
/V fjo Gl
A 7'.-
CESSPOOLS:
''
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.):
I . ` Page 10 of 1 l
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1.-5.;2 Ves� QC
�
," • �/ SIL
Owner:-/ /U/) L
Date of Inspection: ,5 /
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.
10
4
Page 11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
j /SYSTEM INFORMATION (continued)
Property Address: I��
.., UD. A/ %"f.
Owner:_—Y-W/)
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
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:
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:
YQu must desc�`ibe ow you establish, d the high ground water elev tion:
!1 �o // 6 or
lic.J yq 91- ( r S q S r 1"/" /f /-)V U 54" 'S A/ h lr -1-e G, --j ri f rr'
4bZe—
k
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
Sl STEM OWNER & ADDRESS
A4 16-domb,
SYSTEM LOCATION
(example: left front of house)
D. -\ TE L O PUMPING: �3� _ QUAN'T'ITY PUMPED js� GALLONS
('h:)'SPOOL: NO V YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
U[35[=ll\`.VI'IONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
sl'S"I'LM PUMPED BY:
1I:Y1I:N'TS:
FULL TO COVER
BAFFLES IN PLACE
LEACI-IFIELD RUNBACK
�— FLOODED
OTHER (EXPLAIN)
(_ ON"1 LNTS TRANSFERRED TO:
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER,
System Pumping Record
Form 4
MAY 19 2008
TOVAJNI (`I'
DEP has provided this form for use by local Boards of Health. LT -he -Sys
be submitted to the local Board of Health or other approving authority.
VER
- MI44 cord must
B. Pumping Record
1. Date of Pumping
I. Type of system: ❑
❑ Other (describe):
Telephone Number
Date 2• Quantity Pumped
Cesspool(s) [Septic Tank
4. Effluent Tee Filter present? ❑ Yes No
5. Condition of System:
6. System Pumped By:
c) c
ons
❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No
Name I VehicleKIR t4i
License Number
Company
7. Location where contents were disposed:
Signature of R&Ier v
http://www.mass-gov/dep/water/approvals/t5forms.htm#inspect
H,'-,4,: '' �
Date
t5form4.doc• 06/03
System Pumping Record • Page 1 of 1
A. Facility Information
Important:
When filling out
1. System Lodation:
forms on the
computer, use
)
ij \i .,
only the tab key
to move your
Address
_Y
°� \'('� �...y �,' l�t"�
cursor - do not
use the return
• }'` 1�w \r''S"
City/Town
State �d Zip Code
key.
2. System Owner:
LD
M1 (a� is k �
Name
Address (if different from location)
City/Town
State Zip Code
B. Pumping Record
1. Date of Pumping
I. Type of system: ❑
❑ Other (describe):
Telephone Number
Date 2• Quantity Pumped
Cesspool(s) [Septic Tank
4. Effluent Tee Filter present? ❑ Yes No
5. Condition of System:
6. System Pumped By:
c) c
ons
❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No
Name I VehicleKIR t4i
License Number
Company
7. Location where contents were disposed:
Signature of R&Ier v
http://www.mass-gov/dep/water/approvals/t5forms.htm#inspect
H,'-,4,: '' �
Date
t5form4.doc• 06/03
System Pumping Record • Page 1 of 1