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HomeMy WebLinkAboutMiscellaneous - 157 LACY STREET 4/30/2018 (2) __._ ____ �- -f� 1 r� Commonwealth of Massachusetts City/Town of RECEIVED System Pumping Record MAY 2 6 2009 s Form 4 TOWN OF NORTH ANDOVER DEP has provided this form for use by local Boards of Health. Other MaiM913W BEMUa information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Location: Left front, left rear, left side of house fi�tronright rear, right si a of house. forms on the computer,use only the tab key Address / ,r— to move your. /�' 1✓� cursor-do not use the return City/Town State Zip Code key. 2. System Owner: Name Address(if different from location) Cityfrown State 6(,�i�� Tel one Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: 8 Cesspool(s) _ Septic Tank Tight Tank Other(describe): 4. Effluent Tee Filter present? 8 Yes U�lo If yes,was it cleaned? El Yes [j No 5. Condition of®st��em: n n 6. System Pumped By: Neil Bateson F 5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Aigna o there contents were disposed: .S.D, Lowell Waste Water re of Hu r Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 - COMMONWEALTH OF MASSACHUSETTS. .TOWN OF N. ANDOVER -- - SYSTEM PUMPING•REPORT NAME OF PUMPING COMPANY �`�nu�u'S SjejAe-r c3 Pr vice- T_mc. REPORT FOR MONTH OF YYIGzu Dl�D CONTENTS CONDITION OWNERS GALLONS *H G TRANSFERRED OF DATE ADDRESS NAME PUMPED C D S TO SYSTEM �5 3xr. Lawrence-Tc rn' T ; r txn v 1 S o o QnD �' r, t'Aa J+'�YICC' 1►1 iktrC�i t a Ll N 1�j r i cl� 1 -�-n�. nle� 15v0 g - �r La.�a'e,.rtc��ccr►�tar �Cc.'t � ;5 ) 15 �o � t1-7y--ju.rn��i�•�7Rd< 1 t � 1 e COMMONWEALTH OF MASSACHUSETTS a EXECUTIVE OFFICE OF ENVIRONMENTAL AFF.A.IRS ' DEPARTMENT OF ENVIRONMENTAL PROTECTION i . TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: o Owner's Name e C v Owner's Address: � v�E Date of Inspection.—T Name of Inspector: lease prtn�t\ tC Company Name: ^C' Mailing Address: 13 X, Z v M 14 Telephone Number: 7� nca7 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 the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature��=— Date: The system inspector shall submit a copy of this inspec n report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Insnectinn Fnnn Fit tnnnn _ i r Page 2 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 97 Owner: c Date of Inspection: G ^ ??j _ Inspection.Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: XI have not found any information which indicates that anv 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: 2 e 1S t fie'' (.tee �Cc ct�c- B. System Co 'ovally Passes: One or more sys components as described in the "Conditional Pass"section need to be replaced or repaired. The system,upon ompletion of the replacement or repair,as approv y the Board.of Health,will pass. Answer yes,no or not determined( ,ND)in the for the fol ing statements.If"not determined"please - explain. The septic tank is metal and over 20 y old' or septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltra ' n tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic approved by the Board of Health. 'A metal septic tank will pass inspection if it is s crura sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old ' available. ND explain: Observation of sewage back or break out or high static water le I in the distribution box due to broken or obstructed pipe(s)or due to a bro n,settled or uneven distribution box. Sys m 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: c system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will p Inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -PART A CERTIFICATION(continued) Property Address: Owner c Date of inspection: r„ _2 Is C. Further valuation is Required by the Board of Health: Conditi s exist which require further evaluation by the Board of Health ' rder to determine if the system is failing to prote public health,safety or the environment. 1. System will p unless Board of Health determines in accords a with 310 CMR 153030)(b) that the system is not fun ioning in a manner which will protect pub ' health,safety and the environment: — Cesspool orprivy within 50 feet of a surface water _ Cesspool or privy is 'thin 50 feet of a bordering veg ted wetland or a salt marsh 2. System will fail unless the Board of He th (a Public Water Supplier, if any)determines that the t system is functioning ' o a manner that prate t e public health,safety and environment: _ The system'has a septic tank and soil a o tion system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surfs a ware supply. The system has a septic tank and S and the S is within a Zone 1 of a public water supply. _ The system has a septic tank SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic and SAS and the SAS is les an 100 feet but 50 feet or more from a private water supply well**. thod used to determine distance "This system passes if the ell water analysis,performed at a DE entified laboratory, for coliform bacteria and volatile org a compounds indicates that the well is free om pollution from that facility and the presence of ammon' nitrogen and nitrate nitrogen is equal to or less han 5 ppm, provided that no other failure criteria are tri ered. A copy of the analysis must be attached to thi form. 3. Other: Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARy ASSESSMEN-TS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Pct Date of Inspection: 6.,- ;LS `L-3 D. System Failure Criteria applicable to 211 systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than �/-day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number Of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation.. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water Any portion of a cesspool privy• P ter supply well. --- r spool or ri 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 forma �U (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-ves"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"yes to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 f OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: J Owner: Qk t, Date of Inspection: (a 23 Check if the following have been done. You must indicate `Yes"or"no"as to each of the following: Yes No — Pumping information was provided by the owner,occupant, or Board of Health Were any of the system components pumped out in the previous two weeks ? Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection ? Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up^. _ Was the site inspected for signs of break out? _ 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 o 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 tSAS)on the site has been determined based on: Yes no — _ Existing information. For example, a plan at the Board of Health. D,4-P,''� S^ S vU �— Determined in the field(if any of the failure criteria related to Pan C is at issue approximation of distance is unacceptable)(310 CMR 15.302(3)(b)] - rrl Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOS_4L SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: ear Owner: Date of Inspection: - ,p '5 RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x N of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no): Ali Is laundry on a separate sewage system(yes or no): _AJ[if yes separate inspection required] Laundry system inspected(ye?.or no): Seasonal use: (yes or no): Water meter readings, if avaable(last 2 years usage(gpd)): Sump pump(yes or no): Last date of occupancy: 1C�� COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 ;a15-203y d 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): Pumping Records GENERAL INFORMATION Source of information: act Was system.pumped as part of&i ction (yes or no):_ If yes, volume pumped: gallons— How was quantity,pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank, distribution box, soil absorption system ____Single cesspool _Overflow cesspool _Privy /A—)bShared 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 I _Other(describe): Approximate age of all component, datF ' stalled(if known)and source of information: — j W Were sewage odors detected when arriving at the site(yes or no):A Page 7 of 11 w OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART C SYSTEM INFORMATION(continued) Property Address: C.Stj Owner: 21Y Date of Inspection: 6Z t; BUILDING SEWER(locate on site plan) Depth below grade: /44 Materials of conswetion:�cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments (on condition of joints,venting, evidence of leakage, etc.): SEPTIC TANK:k(locate on site plan) 4 Depth below grade: Material of construction: ll�concrete metal fiberglass_polyethylene —other(explain) Al If tank is metal list age:, Is age confirmed by a Certificate of Compliance (yes or no): certificate) —(attach a copy of Dimensions: A` .. Sludge Sludge depth:Distance from top of slud�to bottom of outlet tee or baffle:o?(. t Scum thickness: a .,•�. e�S ,, Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of tlet tee or, baffle: 7't How were dimensions determined: 00 Comments(on pumping recommendations, inl and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, idence of leakage,etc.): 1 L y 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.): 1 Page 8 of I I All OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) , Property Address: - S� Owner: Date of inspection: TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass____polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: 2allons/day Alarm present Cves or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: K—(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 ejutp or out of box, tc.): 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 I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSM.EN-TS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: C Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not 1pcated explain why: Type leaching pits, number:_ leaching chambers,number. leaching galleries, number: leaching trenches, number, length: leaching fields,number,dimensions:_ "— overflow cesspool,number: innovativeialternative system Type!name of technology: u rau (note condition of soil, signs of hydraulic failure, level etc.):Comof ponding,damp soil,condition of vegetation, etc.): AAA cit All CESSPOOLS: (cesspool must be pumped as pan of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids laver: Depth of scum laver: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Page 10 of 1 l i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) , Property Address: Owner: t Date of Inspection: _�s z -� SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage age dis osal syst ties to benchmarks. Locate all wells within 100 feet Locate where publac lwate apeast two Permanent ly en erstthe building referencndm s or V, , • �; `? D/ Page 1 l of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART C SYSTEM INFORMATION(continued) Property Address: AA< l Owner: < Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water *7 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 propertyiobservation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators. installers-(attach documentation) Accessed USGS database-explain: You must describe hqw you established the hijgAhwater elevation: C w t���l� C.(�•�� s%`�-�. ter- 5,�-�,.� t�`���/� ��„�- � � � � ��, �-- ,ate `��� �.��,�•� �. L� �� • P .ti COMMONWEALTH OF MASSACHUSETTS s EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI Governor DAVID B.STRUHS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,.'- Commissioner PART A CERTIFICATION Property Address: I S� �T• • Name of Owner Or -;01. oe Address of Owner: Date of Inspection: Name of Inspector:( K am a DEP approved system ins to Section 15.340 of?"rde 5(310 CP_!R 15.000) Company Name: - MaTing Address: PP IVU' ✓-�� Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site disposal systems. The system: v Passes Conditionally Passes Needs urther Evaluation By the Local Approving Authority Fail kupwWa Signature: Date: QD The System Inspector sha submit lac py of inspection report to the Approving Authority(Board of Health or DEP)within thirty 130)days of completing this inspectio . If the Sys m is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable, and the approving authority. NOTES AND COMMENTS. revised , 9j2/98 Pagel of 11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) -Arepeny Address: u, A 0 ot r, 1'Yl A o l$t{6 Owner: Data of Insw6m:l51 I S D 0� INSPECTION SUMMARY: Chacko& C, or D: A. SYSTEM PASSES: I have not found any Information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: 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 Ecsrd of Health, will pass. Indicate yes;no,or not determined(Y,N,or ND), Describe basis of determination in all instances. If"not determined",explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection:or the septic tank,whether or not metal,is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to-a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of _ Health). broken pips(s)are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four times a year due to broken or obstructed pips(s). The system will pass Inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed *Note: � , TAE TITLE 5 INSPECTION IS NOT A GUARANTEE/WARRANTY OF THE FUTURE FUNCTION OF THE SEPTIC SYSTEM. f revised, 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A fi CERTIFICATION(continued) Property Address: I Sl S}. N. A nolo U t r' V`IA b i T L4 5 Owner: C, Oct r Dift of Inspection: 5-1 15100 . 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 HEALTH DETERMINES W ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _. Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. i 21 SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING W A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I 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 a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) , OTHER i E . t ' revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 151 Lctcl�St, N. Ando o-u, M Pf D I SL4 Owner: QR4biocl tt� .sof 5115100 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 facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet Invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 112 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 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. 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 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. '; revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST. Property Address: I5? Si. N. Aridevtr, MA 01$ 15 Owner: GC►t4 KD cl C ai Date.of Inspection: 5 1 15)0 0 Check if the following have been done:You must indicate either"Yes"or"No" as to each of the following: Yes No , Pumping information was provided by the owner,occupant,or Board of Health. None of the system components have been pumped for at least two weeks and the system has been•receiving-normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. „t f' The site was inspected for signs of breakout. _ AU 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 tee$,material of construction,dimensions,depth of liquid,depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: Existing information. For example,Plan at B.O.H. Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) 115.302(3)(b)) The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance.of SubSurface Disposal Systems. .r: t' ��' revised' 9/2%98 Page sottl • i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property address: i 5� lracc�S-t, N• �4nAo�u', Yhti d i rq5 Owner: Gc"j :Roc e Dow of kupeclaaon: 511510 0 FLOW CONDITIONS RESIDENTIAL: Design flow:( .p.d./bedroom. -' Number of bedrooms(design): Number of bedrooms(actual): Total DESIGN flow _ J Number of current residents:,, Garbage grinder(yes or no)-_W Laundry(separate system) (yes or no). If yes,separate inspection required Laundry system inspected (yes or no) , Seasonal use(yes or no):" Water meter readings,if available(last two year's usage(gpd):� Q Sump Pump(yes or no):.i- Last date of occupancy: 4- COMMERCIAL/INDUSTRWL• -Type of establishment: ./L�f�r`n " Design flow:- apd (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 mater readings,if available: Last date of occupancy: OTHER:(Describe) '.ast date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: Wor no)_ If yes,volume pumped:j�gallons Reason for pumping:_JMh jwwt' TYPE 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components,date installed(if known)and source of information: 0 Swap odors detected when arriving at the site:(yes or no)W t revlssd. 9/2/98 Page 6ot11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) "Property Address: 15-7Lctc-3�, X1, Anocoutr, MR DIFsyS Owner: .' Ctua��p cc+ Date of Inspection; t 5(00 " BUILDING SEWER: (Locate on site plan) lj Depth below grade:„7-� Material of construction:-),/Cast iron_40 PVC_other(explain) Distance from private water supply well or suction line Diameter Comments:(condition of joints,venting, evidence of leakage,etc.) SEPTIC TANK: locate.on site plan) Depth below grade:, Material of construction:/coh, rete metal,_Fiberglass _Polyethylene other ex Iain _ ( p ) If tank is metal,list age Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions; i!i ��� a. Sludge depth: &f Distance from top of sludge to bottom of outlet tae or baffle: -) l Scum thickness: ,_ -/� Distance from top of scum to top of outlet tee or baffle:_ • ' Distance from bottom of scum to bottom of ou–ttgt_too or baffle: w How dimensicis were determined:_A4- ;E*- 4p'(idL �—' Comments; (recommendation for pumping,condition of inlet and outlet tees or baffles,depthof liquid level in relation to outlet invert,structur I integrity, evidence of leakag etc r!. kP tf # c�ot� M-lb GREASE TRAP: (locate on site pla 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: Data of last pumping:T_ 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.) 9/2/98 revised Page zoru SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) c Property Address: I S OGk f.�i• A YIo�O U U YYl A D l�SL(5 Owner. (�f►u Dae of Inspection: 5115 1Do y' TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade: Material of construction:_concrete metal_Fiberglass_Polyethylene—other(explain) y 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) 'lepth of liquid Leval above outlet invert: d . °:: Comments: (note if level and distribution is equal,evidence of solids carryover,evi ence of leakage into or out of box, etc.) 1114.) + PUMP CHAMBER:-'��1 n (locate on site plan) .' Pumps in working.order.(Yes or No) Alarms In working order.(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) • revised 9/2/98 Page 8of11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1,5-1 L cg'�', .N.. A ndo o u', M A p to LI Owner: 0�. Det of Inspection: 51( 100 17 SOIL ABSORPTION SYSTEM(SAS) (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) It not located,explain; Type: leaching pits,number- leaching umberleaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: / overflow cesspool,number: Alternative system:. Name of Technology: Comments: . ,(note condition of soil, signs of hydraulic failure,level of ponding, damp soil,condition of vegetation, etc.) CESSPOOLS: (locate.on site an) Number and configuration: Dppth-top of Sluld 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; (locate on _its plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) . a i 'revised •9/2/98 Page 9or11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) yAddr s? .�5 Lat`'1 , Pl, Andovu, MA ovwLi owner;;�:.;•' ; , .{ Kt oc.k ec ' ' �of In>ipespc�n. 'a�I61O6 SWrCH OF SEWAGE DISPOSAL SYSTEM: include tie;to at least two per reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) I r 1 ii j ac, /0 v i J FES r }a e r + at ' q 7" � y 5j ..„ 90 a �F •F7• ��F D i a`�f�l1 1I�{ f +, a , , , - L!, Page 10 of 11 1R�•( a t �. t 4 . 4 ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) ' -�-Property Address:. i 5-7 L aaj S+, N A n4o o-cr l NA U 18 4 5 Owner: Or o ck.ec.i Dow of Inspection: 5(I 510 D NRCS Report name Soil Type_ Typical depth to groundwater USGS " Date website visited i Observation Wells checked j. Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater Feet 41. .;. Please Indicate all the methods used to determine High Groundwater Elevation: ✓ Optainod from Design Plans on record Observed Site(Abutting property,observation hole,basement sump etc.) determined from local conditions Chocked with local Board of health tt ti].' . Chocked FEMA.Maps F' ,1 Checked pumping records Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) al`l.3 F #Ole ;eeX47z1 ,j " rev.1.sed :' 9/2/98 Page 11 of 11 J/1 f TO: NORTH ANDOVER, MASS 9 19 7 F BOARD OF HEALTH FROM: DESIGN ENGINEER Re: Soil Absorption Sewage System Inspection This is to certify ,that I have inspected the construction of the said disposal system at Ze T rU 4 Z4 (!y -S 7 North Andover, Mass. SITE LOCATION The grades and construction are as specified in my plans and specifications dated 19 ora c01VI/W0111 D , eg. n er/ e nitarian 2, Fp o l9�/qN S 11�S�t\ A /3 t-c RL1�y r TG N /YI/a 5 i Ca/ a S As N G P o u �`LEV�T/oiy_S LF--&D A ° o �> is � Q L � i of REG\SCP��c 1 'ROFESS\�� i Yee i I i FX 1 c` r G ri 1 t t NORTH ANDOVER T 77 SUBSURFACE DISPOSAL SYSTEM CHECK LIST f I. General Information Reg. 2. 5 The submitted plan must show as a minimum: Wok- the lot to be served (b)y- location and dimensions of the system (including reserve area) (c)Cl'�--desi.gn calculations Wo) -calculations showing required leaching area (e),zl- existing and proposed contours (f)(/L location and log of deep observation holes - distance to ties (00 , location and results of percolation tests - distance to ties (h)t�_ location of any wet areas within 100' of the sewage disposal system or disclaimer . Ml' surface and subsurface drains within 100 ' of the sewage disposal system or disclaimer (j ) location of any drainage easements w_khin 100 ' of the sewage disposal system or disclaimer W;"4 known sources of water supply within 200 ' of the sewage disposal system or disclaimer ( 1 )4 location of any proposed well to serve the lot (m) location of water lines on the property _:An) maximum ground water elevation in the area of the sewage disposal system (o)C,�-a profile of the system (p)-,/,no PVC is to be used in construction (q),--i-' location of benchmark (r);'-- plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans. II. Garbage Disposers ne III. Septic Tanks Reg. 6. 1 ,(,,a) 4�,Capacities - 150% of flow Reg. 6. 7 �.— tb�)` Water table Reg. 6.8 (c)`,(- Tees Reg. 6.9 (d):)<Depth of tees Reg. 6 .12 (e)*-L Access Reg. 6. 18 (f) Pumping (g) Y-Cleanout IV. Pumps Reg. 9. 1 (a) Approval Reg. 9.6 (b) Stand-by power f V. Distribution Boxes Reg. 10. 2 (a) l� lope greater than 0.08 Reg. 10.4 (b) Sump VI. Leaching Pits Leaching pits are preferred where the installation is possible. Reg. 11.2 (a) Calculations of leaching area (minimum 500 S.F. ) Reg. 11.4 (b) Spacing Reg. 11.10 (c) Surface drainage 2% Reg. 11.11 (d) Cover material VII. Leaching Fields Reg. 15. 1 (a) 04-Greater than 20 minutes/inch Reg. 15.1 (b) '—Area (minimum 900 S.F. ) Reg. 15.4 (c)o4-Construction of field Reg. 15 .8 (d) © GSurface drainage 2% IX. Downhill Slope (a) Slope y/x = (to be shown) G � (b) y/x X 150 = (to be shown) SOIL PROFILE & PERCOLATION TEST DATA Town/City No.&Street Q Lot No. Loc./Subdiv. Plan Owner f \J Investigatorx�. //0 Observer SOIL PROFILES-DATE 3' Elev. 3' Elev._ 3. Elev. 4'Elev. 0 0 0 0 b`1 1 1 1 2 2 2 2 3 3 3 3 �4 4 4 4 S 5 5 S %6 3 6 6 G 'O 7 7 _ 7 7 8 8 8 8 9 9 9 9 10 10 10 10 Benchmark Location Elevation Datum Percolation Tests-Date 71) 2 177 Pit Number 1 2 3 4 S Start Saturation Soak-Mins-. Start Test-Time Drop of 3"-Time S Drop of 6"-Time Mins.lst 311Dro r,.,,rj Mins.2nd 3"Dro Notes & Sketches on Back Frank C. Gelinas & Associates, North And. RZA/c1 c5f-IOWIA147 .' • �,. _ _ 4 � t PeDPnssO Sussdex4e-e .TBWA a bl5Ps4c. 6srL r F- Z) • c5CAL.E 44rE 16 1Y 77 ' , �,. ---" ' -- --"�- �•�```` �r� ZOCAT/off/: ,L,- 67- A .r"""•`•" ANDO VF 1 l SAS v to oliv!)1�11RbIvIl /, �. /� � �� ` �! 4� tlo3EPN cT BAQBAcS�ILL o , /QS• � ua3�c, of RkAACVV4, MASS. • � f ((;',/ -.; 1 •- ���� �� TEL. G G ¢ -¢983 t` r` 't i �.�• ��/ 9 6 E.1/ST. G2At�E ---'- -_ � !!(o P,2D1? G2A1Dff Q q /G.Al• O A rA - } TYPE OF BL/!CO/A/G: `,� 8E0.e�ON! o K/ELL./&/U a^ ` •3pc, �° �` p F ,�+ �iI k7 � �p SS �►� DES16A-1 FLOW = B�2. X AE S' A eeA C2EQ%b J= 6.p p. X �F d S F. GAC. = c�c� s Abs. AQEA P,eOVIDEL] = .90CJ�S'G?. FT <.S'EPTlG T A.1V- / , G.4GLOA1S' '� �PE�QroGAT/o�/ T�STs �/ ++�Z �`3 �•GC 3. TUP ECEriAr/a v � u�Eu `� / ` _ _•_._._ ��r� ,aorroti ElE✓.�1 rn�/ •�7. 8 DROP M/N. MiA/. titiv. Mins rn 4, DRaP (9 ,yi v ,yi/v / � •- f�IPGOiGA T/Oit/ RAVE' , 2 M•.v /v. M.•• f/ �li .f/•v. Mi / 01 TEST PITS / `Z *k3 , *¢ DATE TOP ELEI/ATIMI /. o [t.[ST7k h W t TN ► /6 .. ' o t wEL } I t00 Fr, OF THE .sO/c r-YAF-S .4"41�n SUS �.-•,. ; f _ 'PQO¢flS�D S�S'�"Eu1. ,�.vo ;E, ��,s�r' , L 07" } �fl �,A-t2 �t SPz�SA L 400.4 7-/40 AJ � 1 � No 0 WATe;? I r BO rTOM EGEvAr/o ' A i (p"QA TESTS COK/DClC 7-&A^) BY �OSEP1/ .T. 64R&AGAC G o , R. S. (o O TESTS W17-A/ESS b BY' : Ala AeVvO VE-r- 146A TN D&P7 90 P4'4,V C' 0655,45," LAR/rER/A J�"EET / OF .� •rw-- 1 Zed °/o P IT'L H Z°f o -"'. ri ,( �SEAC ED c,7o-l v r-., SDG/D B/T. ,-rl-,,.P/PE CIO • _ — o• • e s • e CAPPED. &AlOS Z_�" • ; S_o" db � S'-O" ' Z'-�" �„�/�E.eFa2A rEL�`Br�FB.P/PE - , Ore EGtc//vAGEN'T) v 9,CT/AL BE,D Eyz) SECT/O Al SCALE IlZ=l/ O' AreEa 900s 1 ' /Foe SEc-r10 A/ AT LO N/ER reAiAIT- 1 � �IST,e/BUT/ON �Y : 0,,c- /000 f/DOO 67.4L. CONC2ETE SEPT/C TANK ¢5 ' ¢":;4 60e-1,n s/T. /B. PAPE, S o-00-T ¢' PE,eF BIT.•i /B. PIPE, <S°•O s , • H BSo.Q PT/ON ,�EL7 /�L.A�/ /L/DT TO cSCAGE 45” PROP. : OWEl . sEA[Eo <sEL.EG T �.. /Ov, U ! �4CKFlGL N sow/v WAS NEG • • -a / � C,C�USNEG STONE � ••• ¢"O(P6i6F ,@ATED _ • • • . • B/r.FJ� P/PE 4:%Q • • • • • • • • EQtJ/v.4 L EN T O / '41 Q . -�- 3/¢..ro /�Z'" Wr4SNE0 Q 1V to 54- d 61e4e/Sf•/E'D STONE O �vaUBGE YVASf/ED •ro MEET A.Aell •S•/�.O. 90 .Q,BSoePT/oN 96-1D SECT/DA! , t �ieOF/L E 2 S,4 T ,tea M f . ACCESS /V/A�IHOC E5 TO �j2.4vE O� BE'Grzw G�At�� �¢tom. C>R GESS $" I THE DErA/Ls SHow,v 0 /D . LE✓EL OAl •Tpi-s PLAN SHEET e ACE TYP/CA,- DC7 s OFA CE�t-A/ti �Aic% It ,Z�C•457- 2Ro,t1 TEE O v • � 4• ¢"�CAST I,eDN.TEE �, •.' ° 11FAC TG/.ed.2. �Q C!i dA -. \ °' GE/L// �.PODUGTS MAY � s. 3'¢ � •3f - ,.. � 3`/4" •. s 3'/4" ' B`E- .SUBST/TG/TE`D q • •' Gkl� y GtJiT,v TyE d � AP�..20!/,9L OF •�Tf� ¢„ TyE 30,4R6 ZIP 1'1EALrxl • Aw,o T,UE ci bes/GwE.e_ - 12 W. �i'RA�/EL SUB-$ASE JZ M/ill. RAvEL .ScIB-BAsE-. SEPTlc TA,vfk — cSECT/oN .Q A ,vor ro cSCA1-E c.SEPTlG TANk — c,.SEr-7-lo . it/OT ro - csCAc-E •;. C v.• is G .4 - a. - -_ •fx - _ 4 u _ V _•.4 'V•' :4'. 'PS.' 'V•-. Q.' Q. •- Q � - .8• p P 3 f�4a •0• tr a' q, 'p 4. - •: o o •a b• Q ♦ "77 • `• r(-�► / ZQ V Y �rd' Ztr. •Qi Z` --•• 6. a- C o 6RA VEL :•Q G,eAvE� SUB-B.G j ♦SclB-SASE 2)L17felaL/TJO. J 3 �¢w 3/4" PC.A AJ D�sTR�BurioN BOX .SEDT/ON-S SEPT/G T,4NK PL A N e A/OT TO cSCAG ,L/ETA/GS FD,e �D,.OD �7AG . CotiC. S'EPTlC 7A,vk DIST� ISZ177101V Box v`'yEEr 2 oF•3 r lc 1 , .