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Miscellaneous - 159 FOREST STREET 4/30/2018
t r 159 FOREST STREET / 210/106.A-0179-0000.0 ` trc i / = p Commonwealth of Massachusetts = v Title 5 Official Inspection Form I _ Subsurface Sewage Disposal System Form Not for Voluntary Assessments ~c 159 Forest Street M Property Address Brett Guisinger Owner Owner's Name information is North Andover MA 01845 7/24/15 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out i� forms on the RECEIVE® computer, use 1. Inspector: only the tab key AUG 17 2015 to move your Jonathan Granz cursor-do not Name of Inspector use the return TOWN OF NORTH ANDOVER key. Preventative Septic and Drain L.L.C. HEALTH DEPARTMENT Company Name rQ 327 Asbury Street 2L If Company Address South Hamilton MA 01982 tenon Cityrrown State Zip Code 978-468-9001 S113405 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority QAZ� 8/12/15 Ins=tem ature Date Thnspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 C Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 159 Forest Street Property Address Brett Guisinger Owner Owner's Name information is North Andover MA 01845 7/24/15 required for every page. CityFrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System is in good condition. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 159 Forest Street Property Address Brett Guisinger Owner Owner's Name information is required for North Andover MA 01845 7/24/15 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 159 Forest Street Property Address Brett Guisinger Owner Owner's Name information is required for North Andover MA 01845 7/24/15 every page. CityTTown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 159 Forest Street Property Address Brett Guisinger Owner Owner's Name information is required for North Andover MA 01845 7/24/15 every page. City(Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 . Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 159 Forest Street Property Address Brett Guisinger Owner Owner's Name information is North Andover MA 01845 7/24/15 required for every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15:302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 600 GPD per plan t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form f Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 159 Forest Street Property Address Brett Guisinger Owner Owner's Name information is North Andover MA 01845 7/24/15 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: System is composed of 1500 Gallon septic tank, distribution box and four 34' leaching trenches. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gPd))� n/a Detail: Private non-metered well. Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 159 Forest Street Property Address Brett Guisinger Owner Owner's Name information is required for North Andover MA 01845 7/24/15 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Last pumped two years ago, per homeowner. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 159 Forest Street M Property Address Brett Guisinger Owner Owner's Name information is North Andover MA 01845 7/24/15 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: The As-built is dated 5/1/90, per BOH records. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 20" Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 90'+/- feet Comments (on condition of joints, venting, evidence of leakage, etc.): Building sewer is in good condition with no signs of leakage, backup or any other problems. Septic Tank(locate on site plan): 6" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 101 x 5'W x 4'D effective Sludge depth: 6" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 159 Forest Street Property Address Brett Guisinger Owner Owner's Name information is required for North Andover MA 01845 7/24/15 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 27" Scum thickness 4" Distance from top of scum to top of outlet tee or baffle 3" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? SludgeJudge/Tape measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The 1500 gallon septic tank is in good condition, structurally sound, no leakage in or out, liquid level at outlet invert, inlet has a concrete baffle in good condition, outlet has a PVC T in good condition. "this tank does not require pumping at this time** Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 159 Forest Street Property Address Brett Guisinger Owner Owner's Name information is required for North Andover MA 01845 7/24/15 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° ay 159 Forest Street Property Address Brett Guisinger Owner Owner's Name information is required for North Andover MA 01845 7/24/15 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): . Distribution box is in new condition (replaced due to inspection, see BOH records), no signs of solids carryover, no leakage in or out, level, distributiing equally. The cover is 13" below grade: Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 . Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 159 Forest Street Property Address Brett Guisinger Owner Owner's Name information is North Andover MA 01845 7/24/15 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 4 @ 34'L ❑ 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.): Soil over system is dry,grassy and consistant with surounding yard with no signs of ponding, breakout or abnormal vegetation. 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 ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 ., Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 159 Forest Street Property Address Brett Guisinger Owner Owner's Name information is required for North Andover MA 01845 7/24/15 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 r � Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 159 Forest Street Property Address Brett Guisinger Owner Owner's Name information is North Andover MA 01845 7/24/15 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 159 Forest Street N SV 6 Property Address Brett Guisinger Owner Owner's Name information is required for North Andover MA 01845 7/24/15 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 4' Below SAS feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 4/8/86 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Plan on file for the design of this system. ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Soil testing was performed for the design of this system on May, 8-9, 1984 by Dan O'Connell &Steve Durso, witnessed by Mike Graf& Mike Rosati, no groundwater was found at 108" &96" (two deep holes) below grade. This system was installed in an elevated area with a 4' seperation from groundwater, it is not interfacing with groundwater. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 159 Forest Street Property Address Brett Guisinger Owner Owner's Name information is required for North Andover MA 01845 7/24/15 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked E Inspection Summary D (System Failure Criteria Applicable to All Systems) completed E System Information—Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 39 3'' 13 7hIle ° G�4ClfttVG- T R FAXHFIr f / �! v� 0 2` La-EDI FILE COPY PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 7/27/15 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Repair of D-box By: Peter Breen At: 159 Forest Street Map 106.A Lot 0179 11 North Andover, MA 01845 /I 4h.e uance of this cert'fic t all no be construed as a guarantee that the system will function satisfactorily. Michele Grant Public Health Agent 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com • �� � Commonwealth of Massachusetts Map-Block-Lot • 106.A0179 BOARD OF HEALTH ----------------------- Permit No North Andover BHP-2015-031,7 ------------------------ P'I' FEE F.I. $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Peter B-reen - - --------------------------------------------------------------------------------------------- to(Repair)an Individual Sewage Disposal System. at No 159 FOREST STREET as shown on the application for Disposal Works Construction Permit No. BHP-2015-03 Dated July 22,2015 ----------- _ C01-Y---------------- Issued On:Jul-22-2015 BOARD OF HEALTH • Application for Septic Disposal System Construction Permit — TOWN OF TODAY'S DATE NORTH ANDOVER, MA 01845 ("�00 $ -Full Repair Component Important: Application is hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on the computer,use ❑ Repair or replace an existing on-site sewage disposal system* only the tab key to move your 42'Repair or replace an existing system component—What? cursor-do not use the return A. Facility Information keey.sr��—I. _ Address or Lot# �b5g- I 4z v�--- City/Town' 2.-*TYPE OF SEPTIC SYSTEM*: ➢ ❑ Pump 'Gravity(choose one) ***If pumps stem, attach copy of electrical permit to application— ➢ [`Conventional System (pipe and stone system) ➢ ❑ Infiltrator or Biodiffuser(Gravel-Less)(Attach a copy of your certification to install this type of system.) ➢ ❑ Pressure Distribution S.A.S.(No D-Box) ➢ ❑ Pressure Dosed(D-Box Present)S.A.S. ➢ ❑ Does the system require an effluent filter? Yes No If yes, does plan specify make and model of filter? YES =(no further info. needed) NO=(installer must specify brand of filter before DWC issuance) Whatis the Make? What is the Model. 2. Owner Information r Name 6tj 61 V,) G-e, - Address(if different from above) ra/L--S ; City/Town State 33 02 Zip Code Email address Telephone Number 3. Installer Information n C3�e� Pk T<-r 61te, Cmc y r Name Name ofCompany Address ^✓�i�""V"`-- City/Town State Zip Code Telephone Number(Cell Phone#if possible please) 4. Designer Information Name Name of Company Address City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 • Application for Septic Disposal System TODAY'S DATE Construction Permit - TOWN OF NORTH ANDOVER MA 01845 $250.00-Full Repair, $125.00-Component PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: ❑Residential Dwelling or❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover. I understand that until a final Certificate of Compliance has been issued by this Board of 1Health, the installed system is not approved. Name Date li�dn Approv y (Boar of Health Representative) am Date Application Disapprove for the following reasons: For Office Use Only: 1. Fee Attached? Yes-/ No 2. Project ager Ohligation Form Attached? Yes/ No 3. Pump S sY tem? Attach coQE ofElectrical Permit Yes No Applicantreceived co of "Elects, Inspection tes for Septic Systems" Yes No Handout? 4. Reviewed approvalle r, all paperwork receivedP Yes No Missing. 5. Foundatl As-Bur P(new construction only): Yes No (Sam Cale a pproved plan) 6. F1oorPlans?(new nstruction only): Yes No Application for Disposal System Construction Permit•Page 2 of 2 SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: (Address of septic system) For plans by (Engineer) Relative to the application of ��T`C1� 1 (Installer's name) And dated (Original ate Dated o ay ate With revisions dated (Last revised date) I understand the following obligations for management of this project: 1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the apbroveed plans and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner,contractor,project manager,or any other person not associated with my company schedules an inspection and the system is not ready,then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection,without completion of the items in accordance with Title 5 and the Board of Health Regulations majresult in a$50.00 fine being levied against me and/or my company. a. Bottom of Bed—Generally, this is the first(V5 inspection unless there is a retaining wall,which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection—Engineer must first do their inspection for elevations,ties, etc. As-built of verbal OK(or e-mail to: healthdeptt@townofnorthandover.com) from the engineer must be submitted to the Board of Health,after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system,all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade—Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation)and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible. 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board of Health staff or consultant. d. Installation of tank, D-Box,pipes, stone, vent,pump chamber, retaining wall and other components. 6. As the installer_I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor,or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: Alz (Today's Date) (Name—Print) (Name—Signed) North Andover Health Department (ommunity and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES s LOCATION INFORMATION ADDRESS: 159 Forest St. MAP: 106.A LOT: 0179 INSTALLER: Peter Breen DESIGNER:`- PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS D-BOX INSPECTION: 7/27/15 DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ [Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base - ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by '-visual testing ❑ Inlet tee installed, centered under access port t ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROLPANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION-BOX ❑ / Installed on stable stone base 0/ H-20 D-Box F nlet tee (if pumped or >0.08'/foot) Hydraulic cement around inlet & outlets 'Observed even distribution 0 Speed levelers provided (not required) Schedule 40 PVC Pipe Comments: NEW ENGLAND ENGINEERING SERVICES INC December 14, 2002 North Andover Board of Health Town Hall Annex 27 Charles Street North Andover, MA 01845 RE: TITLE V REPORT: 159 Forest Street,North Andover, MA Dear Sirs: Enclosed is a copy of the Title V report for the above referenced property. The system PASSED our inspection. If there are any questions please call me at my office, 686-1768. Sincerely - �-� Benjarrrin �C. Osgood, 60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 4 , COMMONWEALTH OF MASSACHUSETTS s EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION i r� V� TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: /,fig �QES i sT2E ,t�0(L7}/ i4�DOyC� Owner's Name: S,js Op s.Tt/yu P l7LL-/`l1 A-&j Owner's Address: /,s q fjo az i s i R E,677, A)O flly &N70LJt /1- Date of Inspection: I z j 13/o z- -.Fir ��` � �F-% Name of Inspector:(please print)_ . LAST,,Atv C ds(roan -4- DEC 16 2M Company Name: h2cw EEI24Z 6- MailingAddress: &0 ogtye ___ /VO4-D-( RNa o')641""O Telephone Number: -7 0 r 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 tooS�Section 15.340 of Title 5(310 CMR 15.000). The system: _Vasses Conditionally Passes Needs Further Evaluation by the Loral Approving Authority Fails .Inspector's Signature: Date: r 3 o:;? The system inspector shall submit a copy of this inspect 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. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Fo 2 Es r s7-2 Cc NO2Tlt A Owner: _SLrs&— Rti- �J'i M po"MP94/ Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: 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: e or more system components as described in the"Conditional Pass"section need to be replaced or repaired a system,upon completion of the replacement or repair,as approved by the Board of Health, 1 pass. Answer yes,no not determined(Y,N,ND)in the for the following.statements.If"not ermined"please explain. The septic tank is etal and over 20 years old*or the septic tank(whether etal or not)is structurally unsound,exhibits substantt infiltration or exfiltration or tank failure is imm' t.System will pass inspection if the existing tank is replaced with mplying septic tank as approved by the d of Health. *A metal septic tank will pass ins ion if it is structurally sound,not liking and if a Certificate of Compliance indicating that the tank is less than years old is available. j ND explain: \\ Observation of sewage backup or brew or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settledteven distribution box.System will pass inspection if(with approval of Board of Health): 4oken pipe(s)*Are replaced obstruction is re�ved distribution box is 16yeled or replaced ND explain: The system required pumping more than 4 times a year d 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: Page 3 of l l OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: /5-,� . rva s - /L c i d/DIz7N Pr.UDoyrFrZ A44 Owner: S'aS AAI t J-JM PoAAl Date of Inspection: i,2 jI 3Aa Z 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 pr tett public health,safety or the environment. I. System pass unless Board of Health determines in accordance with 310 CMR 15.30 )(b)that the system is no ctioning in a manner which will protect public health,safety and the vironment: Cesspool or vy is within 50 feet of a surface water Cesspool or pri is within 50 feet of a bordering vegetated wetland or a salt 2. .System will fail unless the Board o ealth(and Public Water upplier,if any)determines that the system is functioning in a manner that p tects the public heal t safety and environment: _ The system has a septic tank and it a rption (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface er su ly. _ The system has a septic tank and SAS and e�SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SA and the SAS\Js within 50 feet of a private water supply well. _ The system has a septic tank� SAS and the SAS is leis than100 feet but 50 feet or more from a private water supply well".Method used to determine distance 1 "This system passes if th e11 water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile or c compounds indicates that the well is fr from pollution from that facility and the presence of amm a nitrogen and nitrate nitrogen is equal to or 1 than 5 ppm,provided that no other failure criteria are 'ggered.A copy of the analysis must be attached to s form. 3. 0t er: Page 4 of 11 OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 4,579 T QC S Si REc 1tlQ/L'TV ANDbJE2 rnA Owner: r5 US HN s.TIM POLLrn AN Date of Inspection: 1-0 0311 a 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 ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ,i 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%z 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. _f 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. f Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gld. You m dicate either"yes'or"no"to each of the following: , (The following eril,r apply to large systems in addition to the criteria above) yes no _ — the system is within 400 - of a surface drinking water ply _ — the system is within 200 feet of aattrii to a surface drinking water supply the system is located in a nitgen sensitive area In im Wellhead Protection Area–IWPA)or a mapped Zone II of a public er supply well If you have answ "yes"to any question in Section E the system is cons ed a significant threat,or answered 'yes"in S on D above the large system has failed.The owner or operator of large system considered a si t threat under Section E or failed under Section D shall upgrade the system ' accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department, Page 5 of 11 OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 6-r/ A,,o 2'l-1 A e%J p Du E2 JA eq Owner: -sFin. j _j-jAi Pv+.-1-mA.v Date of Inspection:_ J2.fes/ z 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 _ -AZ 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 7 _ -1Z Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ — Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? �_ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no jZ_ Existing information.For example,a plan at the Board of Health. r// Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: _>,S 1/ F�o It Cs7-. _si 2E, Owner: rl A l pd 1-L.Yy1 A V Date of Inspection: i 2) 3 f 0 2 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): y Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: _M _ Does residence have a garbage&inch(yes or no): Is laundry on a separate sewage 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 2 years usage(gpd)): We Lc_ Sump pump(yes or no):—v o Last date of occupancy:G,rrre KT COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): 2nd 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: IW&R(K I Qiq 4 Was system pumped as part of the inspection(yes or no):A&�> If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool —Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 8V/1— Were sewage odors detected when arriving at the site(yes or no):10 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: t5y2�s i Ste/ ,v o271t A ejy ocl 2 n.r/a Owner: S u s,9.�. f v�inc �OLLivi A N Date of Inspection: BUILDING SEWER(locate on site plan) Depth,below grade: Materials of construction: cast iron 40 PVC other(explain): Distance from private water supply well or suction line: Zp ` Comments(on condition of joints,venting,evidence of leakage,etc.): Pips' tyo K5 6-oo7 )N $FFSr.+�6nr SEPTIC TANK:_(locate on site plan) Depth below grade: 9" Material of construction: --concrete metal fiberglass_polyethylene other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: /,Soo CrAf-�oNs Sludge depth: -.7-11 Distance from top of sludge to bottom of outlet tee or baffle: 3o" Scum thickness:1 `_ Distance from top of scum to top of outlet tee or baffle: 6 Distance from bottom of scum to bottom of outlet tee or baffle: .21 How were dimensions determined: 44 C,tsvtzc S7C-K Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): -'7i4^.)11, lav G-oop e'5 N P 17004. e0-1c 12F,- iEL% i�1 lsoo0 GREASE TRAP IAVocate 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: 15el /vba e—cT ,EZA R�cD 2TN AAJ D D Jc`2,0'* Owner: .T1M po" ^-v9.v Date of Inspection: TIGHT or HOLDING TANK:/Of (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: O Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): !N 6-opl? Cova�?7/�vr /s I SLI U�J/1 Fq�l L. /1 GcJ�ACN!L Or EAK 14 frL /N f�2 OyT c�2 6D 4'j PS OaC14 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: f 4-9 F-/t e sT -s �'/0/2� 1Y,,000Q 2 A4�4 Owner: ,sysft�v } Jtnn r 0`c+�►9�v Date of Inspection: f'Ll o.J6 Z- SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: beaching trenches,number,length: J AGK Ctt is �D " leaching fields,number,dimensions: overflow cesspool,number: innovativetalternative system Typetname of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): &ter v IF �Sy S i�M ti.vofc s 6-000, �/� �cJr D L N GS D i- PQ A) n2 �'vJ.SuA1 vE/ E—Ilq-t70A CESSPOOLS:(cesspool must be pumped as part of inspectionxlocate 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:1Ile (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 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: IS,? lfb2 r sT /'2c /002919 f'r�c/a oclr✓L .,.�/� Owner• r�,'iia--/ J/," Date of Inspection: Lk/13/oz, 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. 3g f lot l.V L`v Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: lS 9gc—s7 -S:—( Owner: Date of Inspection: )�V,.3[6 z SITE EXAM Slopej� Surface water hoNG Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: -t- 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: You must describe how you established the high ground water elevation: Tse P1 T5 tAiDjco9TF oo L.-wnWX 7 ` �iL ,Sv2�Ey ivpiCA�s t,.9f�'�(L 'T)9�31.G 7 6-t1 DRINKING WATER LABORATORY - CERTIFIED Quick Results, Sample Pick-Up 4 36 Pelham Rd. (603) 898-2504 Salem, NHI 03079 (603) 898-6526 Laboratory Number: 487 Sample Date: 8-24-R7 Submitted By: Saracino Coast . Sample Source: Lot # 27 Forest Street North Andover , Mass . Analysis: According to Standard Methods of Water & Wastewater Analysis, 15Th Ed. Total Coliform . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . o per 100 ml Chlorides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 . 5 mg/L PH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 . 51 Hardness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 mg/L Manganese . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0. 07 mg/L Sodium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 . 1mg/L Iron . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0. 064mg/L Nitrate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 . 01 mg/L Nitrite . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0. 01 m9/L Arsenic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 003 P.P.B. Comment: This sample meets *EPA recommended limits . An st 2�:� RD �F H ,,�-1 ; ;� nor z� r-�- (�65T r 7-0(��C-5 RE WqTEf� SyPF'L7 d- wl� APPROUeD QyE5 �,.1NC7 WTI c vEst6 ) D,4rt I-3a-g� /Jl�i v G Aurhol'?iTy CotiP! FI av5: `� 'Z�442 row • f Z—M 5Y,5-,&44 vc,� /2,3/5° - Dw� _ (0/1) st PT t C SYSTEtiI t STA 1-C.QT►o�lJ C'YG/�U/JTt� ,�•l JAJSFt:Z►iDti1 D/J-rc Q P/JSS Q F411..._ a FINALr I VSPF�rlonj � ' F ,�PPI�DVED 0 _ � y G 4TC APMi Z)VI )G AUT+to�RtTy G,;/�PP>`DvED D,arC FkAL APP(;�QvAL APP►3o1(A)6 4v►NoR1ty., Commonwealth of Massachusetts City/Town of System Pumping Record APR 2 3 2007 Form 4 TOWN OF NORTH ANDGVER HEALTH DEPARTI,?ENT DEP has provided this form for use by local Boards of Health.. The stem Pumping FTtecord must be submitted to the.local Board of Health or other approving authority. . A. Facility Information Important: When filling out 1. System cation- comps the computer.use VV�� only the tab key Address to move your (Lr�J VJIU cursor-do not use the return Cityrrown State Zip Code key. 2. System Owner: Name Address(if different fromaocation) City/TownS f/ `l '`7 '� 'pe Telephone Number B. Pumping. Record .Date.ofPumping Date 2. Q.uantity`Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank- ❑ Tight:Tank ❑ Other(describe)` 4: Effluent Tee Filter present? ❑ Yes 11440 If yes, was it cleaned? ❑ Yet`❑ No 5. Condition of Sysfem:. 6. Syste Pumped By cx)t(? -a- Name Vehicle License Number Comp - 7. Locatio hererrconten were osed:: Signa.r f aider Date C http://www.mass.go. ete .. pprovals/tsforms.htm#inspect t5form4.doc-06103 system PuinReco(d•Page 1 of t Waverly Realty Trust 671 Waverly Road No. Andover, Ma. 01845 508-687-1923 May 30 , 1990 No. Andover Board of Health Town of North Andover 120 Main Street No. Andover , Ma. 01845 Re: Lot 27A Forest Street Dear Board Members , " r I have recently installed a septic system on lot 27A Forest Street. The system, installed by Avellino General Contracting, was inadvertently installed too close to the side yard lot line. The system is 5 feet off the lot line instead of the required 10 feet. Therefore, I am requesting a variance from the 10 foot requirement. I would appreciate your under- standing in this matter. Thank you. Sincerely, William K. Barrett Waverly Realty Trust 671 Waverly Road No. Andover, Ma. 01845 508-687-1923 May 30 , 1990 No. Andover Board of Health Town of North Andover 120 Main Street No. Andover, Ma. 01845 Re: Lot 27A Forest Street Dear Board Members , I have recently installed a septic system on lot 27A Forest Street. The system, installed by Ave.11ino General Contracting, was inadvertently installed too close to the side yard lot line. The system is 5 feet off the lot line instead of the required 10 feet. Therefore, I am requesting a variance from the 10 foot requirement. I would appreciate your under- standing in this matter. Thank you. Sincerely, William K. Barrett NEW ENGLAND ENGINEERING SERVICES lk INC TOWN OF NORTH ANDOVER/ BOARD OF HEALTH t IMAM March 20, 1999 North Andover Board of Health Town Hall Annex 27 Charles Street North Andover, MA 01845 G�Tor�estStr RE: TITLE V REPORT: eet,North Andover___ 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. Yours truly, -6 2 Benjamin C. Osgood Jr., E.I.T. President 33 WALKER ROAD-SUITE 23-NORTH ANDOVER, MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 r r C 9 9-13 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617)292-5500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Conuniss;oner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: (� ( �,�lYit St (, R �c Nmie of Owner Address of Owner: j.5 ��,�_�T 5 T iY i f /(,;., f};tci'C>✓t'n.� Da3t te of Inspection: '2 (��C� Name of Inspector:(Please Print) Benjamin C. Osgood, Jr 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: New England Engineering Services Inc. Maisng Address: 33 Walker Rd. , Suit-t- 23, North Andover, MA 01845 Telephone Number: 978-686-1768 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-site sewage disposal systems. The system: _✓ Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails / Inspector's Signature: A,_% �Y_.: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days.of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should'be sent to1hE system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS _St t lick S, llrttr S r/ h , tc.•C, rSTi' �i t> hi.' revised 9/2/98 Pagel of 11 L� Prim rd on RrcK4d 1'at�' t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: s7= /V. Owner: .,./ Date of Inspection: / •Y'Sri Ll` (��.-; INSPECTION SUMMARY: Check A, B, C, or D: A. SE1Jl PASSES: V//YS1I 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: S�'C vv�wrl {� •i rC-� 1, 0. S 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 pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping-mare than fourlimes a yeardue to broken or obst, cted pipe(s). The system wiltvess inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed revised 9/2/98 Page 2ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: l,S-c Date of Inspection: C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 11 SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH-MLL.PRQTECT THE PUBLIC HEALTH.AND SAFETY AND THE ENIOBONMEKT: _ 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. 21 SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water 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 revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of Inspection: D. SYSTEM FAILS: You must indicate either "Yes"or "No- to each of the following: I have determined that one or more of the following 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"Wage into 4ecilit}-of-9"tem component-due ao 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 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 ib-within 200 feet of-04f4uteryyoe eurtooa.d.inki"- atw.supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area .IWPA)or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further infortnation. revised 9/2/98 Page aofI SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 15`1. 1= ;[moi I A.' 19 A-D ./- Owner: _k. = T.F , Al Yii Date of Inspection: ` 3 t'.-,I qri Check if the following have been done: You must indicate either "Yes- or -No" as to each of the following: Yes No 1 Pumping information was provided by the owner, occupant, or Board of Health. None of the systemcompovwnts.l%&w&twen pumpodJoratleast two weakc and-the rystem hasbwawcraiaiog-*NNv 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. L _ 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 orr the site has been determined based on: Existing information. For example, Plan at B.O.H. L _ 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 land-ocr-upants.if difleratu from_owj3e0.were.provided.with informal On On.tha_RnW_zna1a1&aAQ - Qf SubSurface Disposal Systems. revised 9/2/98 P;Agr5ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1.7c'( f�•,Y>z `'T Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: g.p.d./bedroom. Number of bedrooms(design):_ Number of bedrooms(actual): Total DESIGN flow Number of current residents: 4 Garbage grinder(yes or no):_A4-) Laundry(separate system) (yes or no);16�1; If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use(yes or no):-J:! Water meter readings,if available (last two year's usage(gpd): L') Sump Pump(yes or no):4ii Last date of occupancy:_('C(- COMMERCIAL/INDUSTRIAL: (-COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: qpd 1 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 infowmation: System pumped as part of inspection: (yes or no)t}C If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM ' Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records,if any) UA Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other t e, APPROXIMATE AGE of all components, date installed4if known)-end source o 4nforrnetion: 49 Sewage odors detected when arriving at the site:(yes or no)[VL,' revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 15`f ('c•+�sr s7 ti� r`).,c�`�>_ iZ Date of Inspection' hy, t �`• `<` D t,n ' 312 BUILDING SEWER: (Locate on site plan) Depth below grade:,/' Material of construction:-14-st iron—40 PVC—other(explain) Distance from private water supply well or suction line Diameter !f" Comments:(condition of joints, ventin evidence of Iva e,etc.) SEPTIC TANK:_ (locate on site plan) Depth below grader Material of construction: [concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ Is.age.confumed by Certificate of Compliance_(Yes/No) Dimensions: /Sc:U 1-�-C' /on S Sludge depth: Z" �! _ Distance from top of sludge to bottom of outlet tee or baffle:2 Scum thickness:_ Distance from top of scum to top of outlet tee or baffle: (a Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined:41L<{S G.,e i71G'e-1 Comments: (recommendation for pumping, condition of inlet and outlet tees or-baffles, depth of liquid level in relati n to outle invert, structuret-integrity, evidence of leakage,etc.) -e L .s // I 1 >.• I' •.( 6C•n ./" iii 1 '� C4- 7-4-4' ! -!S i Jr` ] (-.. �•< Slc7tlrC r I" C t e'&J&0ty.. 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: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 1' Date of InspectkM: TIGHT OR HOLDING TANK (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order:Yes _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX:— (locate on site plan) it Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evipfnce of solids,ca ryover, evidenc�ot leakage into or out of box, etc.) - – ~Ci S /!1 CTZCrG C V•e -C_ PUMP CHAMBER:Az� (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 p2geRofII SUBSURFACE SEWAGE DISPOSAL SYSTEMA INSPECTION FORM PART C SYSTEMA INFORMATION(continued) Property Address: f,,Scr' Owner: ,�sT Date of Inspection: Pt<I /, 312v)17c( SOIL ABSORPTION SYSTEM(SAS):_ (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: leaching fields, number, dimensions: overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydro )ic failure, level of ponding, damp/soil,condition of vegetation, etc.) CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: 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 pending,condition of-vegetation, etc.) PRIVY: ` (locate on site plan) Meterjals of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation;etc.) revised 9/2/98 Page 9of t( SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: %.S`/ ��^.r'.�i `7 '1 �• .,�/�h�. Z�'� Date c f Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) 1-1 c n� t' � L--J t� revised 9/298 --- Page 10 of 11 ---�.-- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ,�C'o,� c Date of Inspection: •Y sc 311- I�c�r NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater_Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site (Abutting property, observation hole. basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators. installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) revised 9/2/98 Page 11 of 11 V � a T z.7' �LtH 0i s RI IANSEN H No. 28895 SLOPE /Z�QU/2it�1t�/V Tr150) X X 50 . .. .. . ^v +rt DES/GN EGEI/4T/ON ,47.. ..... . .(TOP OF STONE) _ EXISTING ELEI/.4T/ON .4T.. ... .. . . 2EQ411PED 61-E!/.4T/O1415 ops/�N �s aUrcr ,4S BU/L T /NV PIPE OUT OF 1/OUSE /6Z,80 �+ /NV P/PE /HTO TWNK /EZ.2-C) �6/. �8 SU� "'J .4Z /NV PIPE.OUT OF T-!/VK /G/1-5 ,�-1, --fZ. SYSTEM /NV RIPE /NTD D. BOX / /gs- 11(1/1 z,� /NV P/PE OUT OF D. BOX /G/. g /C/, /7 /N /NV END OF PIPE i °. 8 C � 7,�- is9 is9, pi FOR 5 kV,4TE& a E11,4 T/ON r c.. .4Vae.46E STONE SC.4CE: D4TE. DEPTH QT PROBE NOTE. T1//5 Pl-.4N is NOT ,4 w,4e e41vTY C14815 TIA NSEN SER GI, INC. OF THE SYSTEM BUT .4 1/E.Q/F/C,4T/ON 16'0 SUMMER STREET YAV5q q/LL ,MASS. Of THE LOC14T/ON OF 7WE E'/ST/Mf STRUCTURES. r-� % 2-3 aN Z7 t } �LtH OF RI IANSEN H No. 28895 .SLOPE 2691111FIFUEN7 �r �fCfSTER`�� 50) x /50 - . .. . . . .. ... . . ..... .. .. .. .. . DES/GN 6-1 67V AT.. ..... . .(TOP OF STONE) _ ... EX/5TIM: EZDWZON 47 .. . .. .. . . le64 zeED F/LL = aFZEy4TiON.5 oEs/(�N Qs aU/�T .4S �3U/L T INS P/PE OUT OE/10USE /6Z.80 --- ,Q INV P/PE INTO T4NK /6z.Zo ��/, 8 SUU — 54YRF�CLC D/SPOSQL /NV P/PE OUT OF T<INK /�/yS' �n�, .�z SYSTEM INI PIPE INTO D. BOX / /,�;S INV P/PE OUT OF D. BOX 49 v /� / IN INI! END OF PIPE FO!e s15 15. Leei GV4TE'2 EL CV,4 TION / c_ M �.4 �- 'T1 ,4VE2,40E STONE 5C,4L E: DFPT�/ 47 REQ,5E NOTE T1//S P1-.4N /S N07- ,4 ;f1,4.e e,4NTY CuR 15 TI A NSEN SER G l , INC. OF T11F SYSTEM BUT .4 11E21F/C,4T10N f&O SUMMER STREET -- HAVERH/LL,MASS. OF TXIE LOC,4TION OF TWE EXISTING ST�eUCTU2ES. r' r �. f�• i .: '- ` > `�' '7/ r .� �/ :�^ i' - �� � j x,11. k� _ 1 1 I �� '+.�.......,, .� . _ ._T .,.�._.�. } ,. C�. � , �, '. ��, �s � . �� �� m � ___— �� C� w cr -T- Z-7 s w'1`fl �3 u �LtH Of v RI IANSEN H # " No. 28895 SLOPE Pe:uENT x f DE-516N FCEI/,4T/ON 4r.. ..... . .(TOP OF STONE) _ EXIST/NCS ie-aldT/ON ,QT.. ... .. . . REQU/PFD F&L = ....... ... ... .. .. . . .... ...... z7/-El/4T/0/i15 oz.s/$N .4s SIS &aT /NV P/PE, OUT 0,4-110115C /ga-So /Z /Nl!P/PE INTO TgNK /�z.za 16/, f8 SUa -SU/eFi�CE DIS` O QL /NV P/PE OUT OF T,4NK /6/ Z SYSTEM I/VI/. RIPE INTO D. BOX /� g INV P/PE OUT OF D ,30)( INl! END OF PIPE ©.s 151 i s 9. 9-i F02 s � , GV.4Tt")2 EL E11,4 TION �/, c_ , ,t. M �.�r. 'i.)a- .4V FRWOE STONE SC 4L E DEPT,/ 47 P,eOBE NOrE.' rA//5 PL,4N /5 NOT ,4 !t/,4,e e,4NTY CgRI STIQ NSEN SER Gl, INC. OF TILE SYSTEM BUT ,4 1PE,2/F/C,4T/O/V f&O SUMMER STREET HAVEMI/LL,MASS. OF T,yE LOC-4T/ON OF AT EXISTING ST,eUCTU2ES.