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HomeMy WebLinkAboutMiscellaneous - 155 LACONIA CIRCLE 4/30/2018 (2) - � �;vv vin viRcrLF— i le ' a 21-0/105.D-0133-0000.0 ninry CTRFFT I 1 i Insurance Adjustment Service, Inc. 936 Roosevelt Trail Unit 5 Windham, Maine 04062 207-892-0522 Fax 207-892-0526 UNDER MASSACHUSETTS GENERAL LAWS CHAPTER 139 SECTION 3B Date: June 30,2011 TO: Board of Health/Building Inspector RE: Insured: Jagdish Gar g Property Address: 155 Laconia Cir. No. Andover,MA Date of Loss: 2/12/2011 Policy Number: Type of Loss: File or Claim Number: 74433 Claim has been made involving loss,damage or destruction of the above captioned property,which may either exceed$1,000.00 or cause Mass. Gen. Laws,Chapter 143,Section 6,to be applicable. If any notice under Mass. Gen. Laws, Ch. 139, Sec. 38 is appropriate,please direct it to the attention of the writer and include a reference to the captioned insured, locations,policy number, date of loss and claim or file number. Thank you for your cooperation. Very Truly yours, Matt Martin Adjuster Ext. 109 WE u., EDTa-UAJ Ap ftu CD 0 yES CA WO M `', -- WfI G SY STEM VE'S1 6,k) /PR�oviAj6 / rtioi,�iTy CO,JPITiotis_ P/5V,0 Z -2 -87 p,K , . I05h � W7dgiGIM�(- J10AT t-(�SCMovgl>l L)�" �I�QPPK�VED DATE so 4�1� SGNEDcic�" yp ���ffc�, iHEy 6&//L,-r A 6609 DIA)6 7�2 D� ��'�. SrP1�c c sy5TEti1 1�sT,o�T�ou eK4v4T( ,r," 1tiSP6Z_(aAJ D/JrG Q P45S p FAIL 4�DIT(pNAL 1�15r�ci(O� s 11= yjy) F, r 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property IsS LGCc�wSC�rc�e t' oriI( Av\apvor t-�&S,f owner ' s name vlc-�ac«. 4o� kal Date of Inspectionl��larc� 28,14g5 TOWN T OFNOR aO F O R' H ANDOV Eii PART A HEALTH CHECKLIST Check if the following have been done: 8 V/ Pumping information was requested of th occupan , nd Board of Health. None of the system components have been pumped for 'at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. V/ As built plans have been obtained and examined. Note if they are not available with N/A. V/ The facility or dwelling was inspected for signs of sewage back-up. VIL The site was inspected for signs of breakout. A111 system components, excluding the SAS, 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. VThe size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential number of bedrooms number of current residents garbage grinder, yes or no laundry connected to system, yes or no seasonal use, yes or no If nonresidential , calculated flow: Water meter readings , if available: Last date of occupancy GENERAL INFORMATION Pumping .records and source of information: r Pu TheJ- on ��, \n-For w�Q-��. `�Y6 CUffC'1�'C 0G1'Y\-Pilr System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: Typ of system Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Snared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) Approximate age of all components. Date installed, if known. Source of information: 1 I J eY✓� tv� L Co f u L+ {'ce-- i n m t ed 5 o Sewage odors detected when arriving at the site, yes or no d 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B / SYSTEM INFORMATION continued SEPTIC TANK: (loca'.` on site plan) depth below grade: ) IA- material of construction: concrete metal FRP other(explain) �� i U' oC G� dimensions:_ � ISO O sludge depth -- distance from top of sludge to bottom of outlet tee or baffle o 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 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 r commendations for repairs, ,etc. ) Inu �n 0,0� ► �. , d 1 l o t-�- ems, � c- a o r —on,2 s s c, co v o r v I ' w -rt -tr- DISTRIBUTION BOX: \/ (locate on site plan) 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 ox, recommendEtion for repairs, etc. ) d 1 s b o-4 e e a!54vi o d !21o L n PUMP CHAMBER: �kon� (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc. ) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : V (locate on site plan, if possible; excavation not required, but may be l approximated by non-intrusive methods) If not determined to be present, explain: Type leaching pits and number 2 1 S S 2 2e leaching chambers and number leaching galleries and 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 vegetaion, recom endations for maintena ce or repair ,etc. ) S � 2 G to Ca 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, recommendations for maintenance or repairs,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, recommendations for maintenance or repairs,etc.�) G s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' m SF,allow �i� 11500 al s�-hcTcv,k. DEPTH TO GROUNDWATER q+15 depth to groundwater method of d ation or approxima ion: ,1 r _ v1AQ- toy p 5 S`t ��_ i {Zoe ow VV 11'f AC71 Wd S Is _ o 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicace yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined" , explain why not) N Backup of sewage into facility? Discharge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the distribution box above outlet invert? Liquid depth in cesspool <6" below invert or available volume< 1/2 day k flow? $' Required pumping 4 times or more in the last year? number of times pumped N Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? II Is any portion of the SAS, cesspool or privy: } below the high groundwater elevation? within 50 feet of a surface water? I n within 100 feet of a surface water supply or tributary to a surface water supply? within a Zone I of a public well? within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? within 50 feet of a private water supply well? 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. 13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector Ejwa4'd. Company Vame MoAQc-Y, C5htineA4-aI Eh4erjorscs (vi(_. Company Address 2.2`1'7 M.q.55CCLi� e_*- ' &ve C�.►Mb r�e M.r:�.ss c�2( �-� Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and manitenance of on-site sewage disposal systems. Chick gne: V I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15. 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails. to protect public health and the environment as defined in 310 CMR 15. 303 . The basis for this determination is provided in the FAILURE CRITERIA section of this , form. / o Inspector ' s Signature PL zt_ 30531 Date M0.V'C�n 2 laq Original to system owner Copies to: Buyer of applicable) Approving authority /i/ OF��\;. so NAL -4 p R., A p I / S, V/F. R o u.7`... .r.:-•�,.,.:.....,...,n.;-._..+vvw•.runawan::t^a.esr,.,..t,:xri•.i;�__'r:,•n nn.r:a.:arti.-.�,:.-�u...i•:.rt�vr..,.�......:...�. - i North Andover Board of Health Andover Septic 120 Main St. 47 Railroad St. ! North Andover Ma.01845 Bradford Ma. 01835 Haul Lic. #151-OOH Install Llc. # 128-0 Date Address Gallons Comments 11/1/2000 303 Chester St 1000 11/1/2000 50 Willow Rd 1000 11/1/2000 160 Carelton Ln 1500 11/1/2000 165 Bridal Path 1500 11/4/2000 174 Ingals St 1000 11/4/2000 1062 Salem St 1250 11/6/2000 373 Raligh Tavern Ln 1000 11/6/2000 252 Boxford St 1000 Leachfield Run Back/ Ex. Solids 11/6/2000 150 Liberty St 1500 11/6/2000 149 Osgood St 1000 11/7/2000 255 Haymeadow 1500 11/7/2000 850 Winter St 1250 11/8/2000 25 Windsor Ln 1500 11/9/2000 249 Carlton Ln 1500 11/9/2000 767 Johnson St 1500 11/10/2000 56 Academy Rd 1500 11/14/2000 Sugar Cane Ln 1500 11/14/2000 250 Abbott St 1000 Extra Solids 11/15/2000 195 Winter St 1500 11/15/2000 187 Winter St 1500 11/16/2000 85 Laconia Cir 1500 11/16/2000 86 Willow Ridge 1000 11/17/2000 2135 Turnpike St 1500 11/20/2000 203 Grandville Ln 1000 Flooded 11/20/2000 391 Pleasant St 1500 11/20/2000 124 Tucker Farm Rd 1500 11/22/2000 394 Boston Rd 1500 11122/2000 728 Forest St 1500 i 11/22/2000 18 Johnney Cake St 1500 11/24/2000 106 Rockey Brook Rd 1500 11/24/2000 258 Rea St 1000 11/28/2000 1815 Great Pond Rd 1000 11/28/2000.1420 Great Pond Rd 1500 11/29/2000 266.Lacy St 1000 11/29/2000 155 Laconia Cir i 1500 U .._., .F:.•r.`" � i..iyr •i+::.r.'S.t�t:'ti:r.r,. .y :._ o,(s y,,_Yi:'N*i�'.r°`k-.•`.��n�'n���f!.�4'O" r,A t ..a-.E �k ,,,y ,.. .. .. • a COMMONWEALTH OF MASSACHUSETTS { T EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION t - TITLES OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSES� SUBSURFACE SEWAGE DISPOSAL SYSTEM FORINT � H Q. o���� "�RC�Cis=FI�� tTFI PART A CERTIFICATION ' Property Address: b. A,,snarl Ma . nn Owner's Name:t�k% Owner's Address: Date of Inspection: frl Name of Inspector: (please print) Company Name: Mailing Address: U rj •.f, %j X'(3(40 t'l,Cj{rX-ej Telephone Number:(2111x»3r72.-9 4`11 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: —�/Passes Conditionally Passes Needs F er Ev luation by the Local Approving Authority Fai Inspector's Signature: ate: 414 The system inspector shall bmit a copy of this inspection report to a 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 I ._.. A � _ ..-.. ....�-,�:.fTw.,:>.:�`^F i'*r..,r+Y,^.,r`h<w?eyev J4r•y,-,"�.,Glk. .. •.w'�"''.ti:�,+"%�"G'.+i:y(�a..".f aiin+ Y s TM 4 Page 2 of 11 OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ` CERTIFICATION(continued) Property Address:: k5L5 l..aCn�u.� t^. � Owner:/ l2 t y— Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Coniinents -1- -�.: ,: B. System Conditionally Passes: i 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 jpipe(s)Qr due to a broken,� _se_tle_d or.uneven.d_istribut_ion box_. System-will pass inspection if(with -. approval of Bbard of Health): ` broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced , ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 - - r �. � ,,� ... .vr.:,.:.. �.^"bVa ,.4 .,'R.Y�'` �`'1+r1ri+•el S3.-�^''�. .-�.;c.,�„w«.+1.:3.W .. '";:.+'„H t`NJtiti%*t1..T1'4o,xm., r �v tiV' 7 v � f } 6°-A - i Page'3 of I I .,l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) ' Property Address: N ' Owner: Date of Inspecti : I 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(l)(b)that the system is not fu .-tioping in;a4panner ivhkch..will protect. ublicrhealth,safely 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 f 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°ammonta`n Bogen and'nifrate nitrogen-is equal to'or less than S ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: t 3 .� ,... ....... .. ,. .;, w}.,,,.. _ ._ ..K._,.rte. r-.--m.�v--..-:r-,. .. ... .r Y....,.,y>...yr a .:-,;y- _ - -.,, - .,r a;*jwi W',.r✓,t "-„..e,. .,,, Page`4 of 11 s' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1 ( C�j7” N. 4mt�wr } Owner: Date of Inspecti l,fJ•Jr D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ischar a or pondingof effluent to the surface,of the ogged S,4S� ground or surface waters due to an overloaded or _ g 1 r'cLsspool �. _ t/ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or /cesspool _ (/ iquid depth in cesspool is less than 6"below invert or available,volume is less than 1/2 day flow equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped y portion of the SAS,cesspool or privy is below high ground water elevation., _ I/Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. = _ _✓Any portion of a cesspool or privy is within a Zone 1 of a public well. _ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ' An onion of a cesspool or n is less than 100 feet but � Y P P privy 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 r� 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: Tobe consi8ered'alarge sysfein he system musf'serve a facility with a design flow ot10,000`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. 4 Pagg . of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B k CHECKLIST ' Property Address: "�C�jOL 0--A, (` Owner: (` Date of Inspecti : Check if the following have been done.You must indicate`des"or"no"as to each of the following: Yes o Pumping information was provided by the owner,occupant,or Board of Health i..,. �,_ ere any o- th6 systein�omponents�pur.pe Fi out in the'previous two,w eks`? +' Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) ' V1000 Was the facility or dwelling inspected for signs of sewage backup Was the site inspected for signs of break out 4 — Were all system components,excluding the SAS,located on site? Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System.(SAS)on the site has been determined based on: Yes ..o� ,�.-•,:- ..,.,�: _ - .,,.. .� ,,;.. . _�.. , .h:;� ;_ � - � P - .._ •. : ,j , — _ Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation'of distance is unacceptable)[3 1'0 CMR 15.302(3)(b)] r 5 f _....,,-tip. �„->,c,,.+i�y:#-4'i�'.�-��:-w„'%,�. .. w'S1"i tF°-x �.t^ro: �ty„�,; �, ; ..,.,,. ;sw.,. ,. y,,,....'- 7y,<•h� .. ter..r,;m%rF+irlc:'�,ii.tr..+ r -... ,.-..7 Page 6 of 11 �t OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: a Date of Inspecti : r i FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 05.203 (for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no): Ve5 Re w rAx.,Voltd -7-6 • Is laundry on a separate sewage system(yes or no if yes separate inspection re aired] Lat}ndry system inspectedI( es.or;no), r ,d r.. Seasonal use: (yes or no); Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no)ALQ Last date of occupancy: !--Cj COMMERCIAVINDUSTRIAL 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: Aje 6 6 Was system pumped as part of the inspection(yes or no):_ If yes,volume pumped: gallons--How w4ampatity pumped determined?51*6 _p 4_ Reason for pumping: /V !�L GT O Ad . sA`- •,.�. TYPE F SYSTEM eptic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _InnovativeWternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ,. —Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if n)and source of u-iformation: /,v a G .vS Were sewage odors detected when arriving at the site(yes or no):/�G1 6 - Page 7-of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C Qf SYSTEM INFORMATION(continued) z, F Property Address: Owner. Date of Inspection': Q -5 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_L#<At iron _40 PVC_other(explain): Distance from private water supply well or suction line: H Comments(on condition of joints,venting,evidence of le age,etc.): g ffi t t r SEPTIC TANK:kl (locate on site plan) Depth below grade: 190 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:(_ X J p-i Sludge depth: << Distance from top of sludge to bottom of outlet tee or baffle:? Scum thickness: A01 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Ab .nyo t Comments(on pumping recommendationg,inlet and outlet tee or baffle condition,structural integrity,liquid levels as retaWA to out et invert evidence of)j*kage, tc.): (:l L5 e Gv Oo(jf /,q GREASE TRAP: (locate on sitelan . W �1 P ) m + t, w _ P Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other !r (explain): Dimensions: y� Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 ,i.aYd.v.�+evro.tr k.ysM'is :d�'"`�`+Cwx:^Sh:'+!P"' .. .. S4f�il::i;'e�P<#3i„.a':s1/'� 'sh"r-N*.,a!'.k,1.r'_„�f": .�."r�,.7+,�,t _ 'Y'�,y'ro"}...,�"v.";...•+.v.'^:, • � ' MJk Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM a PART C SYSTEM INFORMATION(continued) .Property Address: � y Owner: Q. �j Date oflnspection: TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dunensions Capacit�: + gallons Design Flow: gallons/day . Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): k DISTRIBUTION BOX: (if present must be opened)(locate on site plan) r Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage.O'into o�r,Ot� cpc,� ).1J (.0 1X1 D .SO r-d G(.f( ©L"r" c PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(Apto condition of pump chamber, onditiowof pumps`and-appfrtenptes; 4, 1. .q 8 Page 9 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) F c �8 Property Address: Owner:' t� 1�1 Date of Inspection: —�- i ' SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not-required) If SAS not located explain why: s. Yoe Peaching 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, H etc.) :f 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: Dimenss nsbf esspool: Materi s o co str action: Indication df.p�didwater inflow(yes or no): Commentsl(note condition of soil,signs of hydraulic failure,level ofponding,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.): 9 Page 0 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM'INFORMATION(continued) Property Address: _ L�ih-mao.jr Owner. DSC' Date of Inspecti — 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. JNj I t. 10 r t � Page 11 ,< } ° OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM ' 4 PART C ` . A., `{ SYSTEM INFORMATION(continued) { Property:"Atldress tkfll'Owneu Date of Inspecti n: -- + SITE EXAM ', 1',, till•, Slope Surface water Check cellar Shallow wells II " . Estiihated depth to ground watel deet Please indicate,(check)all methods used to determine the high ground water elevation. VObtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: , Checked.with local excavators,installers-(attach documentation) Accessed USGS database-explain: ` You m st de sc ibe how.you established tghigh ground water elevation: y i " r 11 r J r uC,lll'rJ'r•'Y19 �tlfl��J! .�"�:'� 1; � ISI EI : A11D0 ,r i R'T� VE M S�"CG SE •, �. e r • 'm o rd DOVER TOWN'OF (�IORTHYMENT EALTH DE PAR �EP..has proVlded jh4 form for use by local Boards of Health, The System Pumping n be subml(led�to the local Board of Hoalm or other approving authorlty, A;. Facility lnforrMa lon ��..t,'nRorun t ° c out 1; System LQUUon f�74 Oil �� No W goy Address Qjid&LA)rdo(1G1 `u� lM rtitum''Y • '., ';;. CltY�fvwn ; .,: ;. Slag key, . ,,, • � .,, ;, ... ZJp Coca :�:•,S,� ,,,', ,�:. m Own a�r,. . :�;1• /1't,'�.t;,rr ,�J.r.sySl9 ,c�.•;;. . ,. 1 1. ' .,.���, .r 'fi:�1,'»`J,'Y�''Nuno �V.;a r.•„y,ti' 1.r.': ....,... I rr'ACdro�f (IldlNoronl rom buUon) / a—� 4an-M-/ Ta fl'-Rumping Record ool0 2. Quantity Pumped: -- • •. Cill n ❑ Casspool(s) optic Tank p ❑ Tight Tank '';.,• ' C�' Other „ ''la 4 Ef 'a Tae Fllfa(���sent? ;❑ Yes o If y a lcleaned? es. W 9 I ❑ Yes ❑ i::..:..y'•�),..yal''W',�/�:N;ril j�'�••f,, l J l.fi '�`�. Condl�l0n'Q(3y; 1. m.. . ._ r'! l�r'•1.,'�rul or; Ir,It'r,(,/Ili\, ' -----_.. Pumpsd By, Cl �' ' air' �},cr>>' �! �,('�� i:��l �� ,�,� ,y1'•'�t' i'�• VT Vehicle U a N /7Z� • � �'�� •i v'i�:r.,.,�'Iµ q , r �4 Cr ��!/'( "'q:"'i co�lents',wara dl;3posad; •.,r,. . .. .L''.y'..�'(; ;,',,�'•''.J'f•',r —Jf•,.;.fir., • 1 ` 'i':,h'j� �!' r �' Sbnalwo vl H ulo�;�y,',ir�,.Y,,,•,,.,,1 , dole hft�) !ww.mass'gov/dapNrafer/approvaJs/i6(orms,hlmin sPecc SyYjam Punpinp Rococo ; Commonwealth of Massachusetts RECEIVED H W City/Town of No. Andover JUL182011 System Pumping Record Form 4 TOWN OF NORTH ANDOVER ^M HEALTH DEPARTMENT 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 within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out 1. System Locatio� forms on the L(;�Q)aa 'I c computer, use only the tab key Address to move your No.Andover Ma 01845 cursor-do not City/Town State Zip Code use the return key. 2. System Owner: am Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: Date Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No � 5. Condition of System: DCrA Cood. i 6. System Pumped By: n n Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stj4arts Pre-treatnient Plajit,20 So. Mill Bradford, Ma 01835 ure of auler Date LJ - 22 -11 ignature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1