HomeMy WebLinkAboutMiscellaneous - 151 RALEIGH TAVERN LANE 4/30/2018 (3) 161 RALEIGH TAVERN I_ANF_W
210/107.A-0111-0000.0 VERN LANE
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Contingency Plan
for
151 Raleigh Tavern Lane
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Failure of the Fast Septic System can be classified as two types of failures:--,--------
TYPE
ailuresR--'" -----TYPE 1:
Failure of pump system indicated by an alarm in the pump chamber.
In the event of an alarm in the pump chamber the following procedure should be followed.
II 1. Silence the audible alarm in the basement.
2. If not an external power outage proceed to step# 3
3. Open pump control box in the basement of the dwelling.
4. Locate On/Off/Auto switch and switch to manual On mode.
5. If alarm goes off switch back to Auto and wait to see if problem i fix
g p s ed.
6. If alarm comes back on there is a problem with the pump and a septic system service
company should be contacted immediately to repair the pumps.
7. The N. A. Board of Health and the State D.E.P. must be notified within 24 hrs.
TYPE 2
Failure of Fast System or failure of the leach field.
1. Contact the N.A. Board of Health within 24 Hrs. for authority to:
A. Turn off gate valve between the Fast Septic Tank and the Pump Chamber.
B. For instructions on system operation.
2. Notify New England Engineering Services, Inc., the design engineer.
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Lot & Street /c v Map/Parcel
CONSTRUCTION APPROVAL
Has plan review fee been paid: YES NO Permit# /4�2�o r
Plan Approval: Date: Approved by:
1
Designer: Plan Date:
Conditions:
Water Supply: Town._ _ _._._ _ WeII
- - -
Well Permit: _Driller: t
Well Tests: Chemical Date Approved -
Bacteria I Date-Approved
Bacteria II Date Approved
Plumbing.Sip-Off. ... Wiring Sign-Off-
Comments:
Form"U" Approval: Approval to-Issue: YES _r NO
Date Issued By: -
Conditions: -
Final Approval:
All Permits Paid? YES NO
Well Construction Approval? YES NO
Septic System Construction Approval? YES NO
Certification? YES NO
Other ` YES NO
Any Variance Needed? YES NO
FINAL BOARD OF HEALTH APPROVAL:
DATE: Z) 4
APPROVED BY: �_ �U
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�RaTED
North Andover Health Department
(ommunity and Economic Development Division
1
November 28, 2017
�O
D
Brendon McCarthy
151 Raleigh Tavern Lane
North Andover,MA 01845
Re: Wastewater Treatment Service System Contract
Dear Homeowner:
Please note The Health Department has received a letter by Wastewater Treatment Services Inc.
notifying the town that you have discontinued the maintenance contract for your alternative
septic system. The maintenance contract is required by the Health Department and was
conditional upon approval and installation of your alternative septic system.
According to the Department of Environmental Protection, throughout its life, the system shall
be under a maintenance agreement with no less than a one year contract. Please send a copy of a
new contract with a maintenance company to the North Andover Health Department on or before
December 31, 2017.
Some information regarding regular maintenance of your septic system is attached. Please call
the Health Department at 978.688.9540 if you have any questions, or e-mail your questions to:
healthdept@northandoverma.gov.
Thank you for taking the time to consider the benefit that routine maintenance has on your septic
system and the environment.
Sincerel
BrianaGrasse, CEHT
Director of Public Health
120 Main Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.9542 Web http://www.northandoverma.gov
44 Commercial Street
Raynham; MA
02767
Tel: (508)880-0233
V Fax: (508) 880-7232
October 9, 2017
Mr. Brendon McCarthy
151 Raleigh Tavern Lane
North Andover, MA 01845
Re: Serial Number: MCF215
Location: 151 Raleigh Tavern Lane,North Andover MA
Dear Mr. McCarthy:
We understand you do not wish to continue your Operations and Maintenance contract
with our company. Please be advised the Massachusetts Department of Environmental
Protection requires a maintenance contract be in place for the life of the alternative septic
system.
Also, we are required to inform both the state and local agency of your decision.
if you have any questions or need additional information please call cur office at -
(508) 880-0233.
Sincerely,
Wastewater Treatment Services
Copy to: Massachusetts DEP
North Andover Board of Health
1600 Osgood Street
North Andover, MA 01845
'v Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /1
,M 151 Raleigh Tavern Lane G
Property Address
David Pinson
Owner Owner's Name
information is
required for every North Andover Ma 01845 8/18/15
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:When
filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Kevin Usilton
use the return Name of Inspector
key.
Wastewater Treatment Services
�y Company Name
44 Commercial Street
Company Address
Raynham Ma 02767
City/Town State Zip Code
508-880-0233 S113528 RECEIVE®
Telephone Number License Number
SEP 2 9 2015
E. Certification
-[QWN qi q
HEALTH3 R(T�Mf`f�t�T i � !
I certify that I have personally inspected the sewage disposal system at this address and that the
information
4
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
❑ Ne/Furthr jaluation by the Local Approving Authority
j
8/18/15
Inspect 'r's Si na ure Date
The system inspector 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
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M01151 Raleigh Tavern Lane
Property Address
David Pinson
Owner Owner's Name
information is
required for every North Andover Ma 01845 8/18/15
page. City/Town 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
® 1 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:
The system is operating as designed
13) 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
F ®Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 151 Raleigh Tavern Lane
Property Address
David Pinson
Owner Owner's Name
information is North Andover Ma 01845 8/18/15
required for 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
u
Title 5 ®ficial Inspection i®n Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
151 Raleigh Tavern Lane
Property Address
David Pinson
Owner Owner's Name
information is
required for every North Andover Ma 01845 8/18/15
page. CityTrown 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 '/day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
151 Raleigh Tavern Lane
Property Address
David Pinson
Owner Owner's Name
information is North Andover Ma 01845 8/18/15
required for 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
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 151 Raleigh Tavern Lane _
Property Address
David Pinson
Owner Owner's Name
information is
required for every North Andover Ma 01845 8/18/15
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?
0 ❑ 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): 440gpd
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
z Title 5 Official Inspection l=oan
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
151 Raleigh Tavern Lane
Property Address
David Pinson
Owner Owner's Name
information is North Andover Ma 01845 8/18/15
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
The system @ 151 Raleigh Tavern Lane is designed for 440gpd. The system includes a 1500 gallon
tank with a I/A technology (FAST),system in the 2nd compartment for treatment. The treated effluent
flows to a dosing chamber by gravity. The dosing chamber feeds a 30'x50' leaching field.
2
Number of current residents:
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
Seasonal use? ® Yes ❑ No
Water meter readings, if available (last 2 years usage (gpd))� est.43gpd
Detail:
the system is under its daily design flow of 440gpd
Sump pump? ❑ Yes ® No
Last date of occupancy: n/aDate
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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspecti®n Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
° M s 151 Raleigh Tavern Lane
Property Address -
David Pinson
Owner Owner's Name
information is North Andover Ma 01845 8/18/15
required for every
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: n/aDate
Other(describe below):
General Information
Pumping Records:
Source of information:
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 151 Raleigh Tavern Lane
Property Address
David Pinson
Owner Owner's Name
information is
required for every North Andover Ma 01845 8/18/15
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:
18 years
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 3+1
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
All piping looks good no signs of leakage and venting is good.
Septic Tank(locate on site plan):
Depth below rade: COT
p g feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
The septic tank has access covers to grade for pump out.
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 gallon
Sludge depth:
10"
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
v W Title 5 Official
Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
;M 151 Raleigh Tavern Lane
Property Address
David Pinson
Owner Owner's Name
information is
required for every North Andover Ma 01845 8/18/15
page. Cityrrown 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
Scum thickness
0"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
i
How were dimensions determined? sludge judge
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 structural integrity of the septic tank is good. No signs of leakage or infiltration. The inlet tee is in
good condition and the outlet tee is built into the FAST system. The liquid level is at operating level
for a FAST system. No pump out recommendations were made the system, the system has been
pumped in the last 2 years and is operating as designed
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•3113 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
;M 151 Raleigh Tavern Lane
Property Address
David Pinson
Owner Owner's Name
information is North Andover Ma 01845 8/18/15
required for every
page. City/Town 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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 151 Raleigh Tavern Lane
Property Address
David Pinson
Owner Owner's Name
information is North Andover Ma 01845 8/18/15
required for 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 n/a
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.):
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.):
The dosing chamber is in good condition with no signs of leakage or infiltration. The pump and on/off
float was tested as well and the high water float. The tank alarm is located in the basement and is
working as intended
* 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
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 151 Raleigh Tavern Lane
Property Address
David Pinson
Owner Owner's Name
information is North Andover Ma 01845 8/18/15
required for every
page. CityTrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions:
1-30'x50'
❑ 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.):
No signs of hydraulic failure, the vegetation looks normal. No signs of ponding or damp soils.
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
Title 5 Of'f'icial Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 151 Raleigh Tavern Lane
Property Address
David Pinson
Owner Owner's Name
information is
required for every North Andover Ma 01845 8/18/15
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
W Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
wM 151 Raleigh Tavern Lane
Property Address
David Pinson
Owner Owner's Name
information is
required for every North Andover Ma 01845 8/18/15
page. CityfTown 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
Ste`
34 lam,
1
® " � sc�)
0
t Fay
r�
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 151 Raleigh Tavern Lane
Property Address
David Pinson
Owner Owner's Name
information is
required for every North Andover Ma 01845 8/18/15
page. Cityrrown 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+'
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: 1998
Date
❑ 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:
Established ground water from the design plan on record with the Board of Health.
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
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 151 Raleigh Tavern Lane
Property Address
David Pinson
Owner Owner's Name
information is North Andover Ma 01845 8/18/15
required for every
page. Cityfrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® 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
Rug. 26, 2015 1 : 33PM No. 6408 P. 1
Summary Record Card generated on 6/28120151:36:23 PM by Karen Hanion Page 1
Town of North Andover
Tax Map # 210-107.A-0111-0000.0
Parcel Id 17938
151 RALEIGH TAVERN LANE
DAVID & CAROLINE PINSON
151 RALEIGH TAVERN LANE
NORTH ANDOVER, MA 01845
Class 101 Single Family Property Type 1 Residential
Zoning2 1 Residential Zoning3 1 Residential
Size Total 1.06Acres
FY 2016
UB Mailing Index
Name/Address Type Loan Number Active/Inact. From Until
DAVID$CAROLINE PINSON Owner
151 RALEIGH TAVERN LANE
NORTH ANDOVER,MA 01845
ANTINORI,PAUL Previous Customer Inactive 11/15/2006
151 RALEIGH TAVERN LANE
NORTH ANDOVER,MA
01845
UB Account Maint,
Account No Cycle Occupant Name Active/Inactive
Bldg Id.14139.0.151 RALEIGH TAVERN LANE Last Billing Date 6/4/2015
2100123 02 Cycle 02 Active
UB Services Maint,
Account No.2100123
Service Code Rate Charge Multiplier/Users
MISCFEE ADMIN FEE 0.635/8 7.82 1/
WTR WATER 01 ALL METER SIZE 04.60 /1
UB Meter Maintenance
Account No.2100123
Serial No Status Location Brand Type Size YTD Cons
32892263 a Active ERT HH b badger w Water 0.63 0.63 767
Date Reading Code Consumption Posted Date Variance
8/4/2015 1118 aActual 39 124%
5/4/2015 1079 aActual 17 6/2212015 16%
2/3/2015 1062 a Actual 15 3/20/2015_ -45%
11/3/2014 1047 a Actual 28 12115/2014 190/0
8/112014 1019 a Actual 22 9/11/2014 34%
515/2014 997 a Actual 17 6/12/2014 -1%
2/3/2014 980 a Actual 18 3/17/2014 -41%
10/31/2013 962 a Actual 29 12/20/2013 9°/G
8/1/2013 933 aActual 27 9/16/2013 35%
511/2013 906 a Actual 18 6/18/2013 20%
2/7/2013 888 a Actual 18 3/13/2013 -27%
10/30/2012 870 aActual 22 12/13/2012 -9%
8/2/2012 848 aActual 25 9126/2012 36%
5/2/2012 823 aActual 18 6/20/2012 -11%
2/2/2012 805 a Actual 21 3/14/2012 15%
11/1/2011 784 aActual 18 12/15/2011 -34%
8/1/2011 766 a Actual 27 9114/2011 72%
5/2/2011 739 a Actual 15 6/13/2011 9%
2/4/2011 724 a Actual 15 3/15/2011 -49%
11/1/2010 709 a Actual 28 12/13/2010 -30%
8/3/2010 681 a Actual 41 9/13/2010 31%
5/3/2010 640 a Actual 31 6/9/2010 -3%
2/1/2010 609 aActual 32 3111/2010 -9%
11/2/2009 577 aActual 35 12/11/2009 -32%
813/2009 $42 aActual 50 9/11/2009 1%
2 492 a Actual 51 6/16/2009 2%
5/6/ 009
44 Commercial Street
Raynham,MA
02767
Tel: (508)880-0233
Fax: (508)880-7232
October 16, 2014
North Andover Board of Health
1600 Osgood Street
North Andover, MA 01845
Attention: Health Agent
Reference: FAST® Wastewater Treatment System- Serial Number: MCF215
Attached please find the Field Inspection& Service Report with field test results for
services performed on 10-9-14 at the property of David Pinson located at 151 Raleigh
Tavern Lane,North Andover, MA.
Please call if you have any questions or require additional information.
Sincerely,
Wastewater Treatment Services, Inc.
Service Department
Enclosures
Copy to: David Pinson
Massachusetts DEP
A 7 E D.
8450 Cole Parkway, Shawnee, KS 66227, Phone 913-422-0707, Fax 913-422-0808
e-mail:onsite biomicrobics.com, www.biomicrobics.com, 800-753-FAST(3278)
FIELD INSPECTION & SERVICE REPORT
For Bio-Microbics Single Home FAST'System
22663
k + ' INSTALLATIO+N AUTHORIZED SERVICE PROVIDER x
Installation Address: 151 Raleigh Tavern Lane Name:Wastewater Treatment Services,Inc.
North Andover,MA 01845
Owner Name:David Pinson
Mail Address: 151 Raleigh Tavern Lane Mail Address: 44 Commercial Street
North Andover,MA 01845 Raynham,MA 02767
Phone:978-681-6468-Home Fax: e-mail: Phone:(508)880-0233 Fax:(508)880-7232 e-mail:
INSTALLATION INFORMATION .=yh w
Model No. Serial No. Date of Installation Date of last pump out
MicroFAST.5 MCF215 9/21/1998 7/1/2008
'EQUIPMENT i + Via. y^YES . k NO' " MAINTENANCDT ERFOCOMMENTS
Electrical Panel(s)
Visual Alarm Operating N/A
Audio Alarm Operating
(if present)
Blower(s)
Air Inlet Filter Clean x
Blower Hood Vents Clear x
Excessive Noise x
Excessive Vibration x
Treatment unit(s)
Unusual Odor x
Pumpout Required x
Primary Settling Zone 9"
Aerobic Treatment Zone 9"
EFFLJENT(optional) µF r w i LIMIT t zRESULT4 :,t.
Estimated Daily Flow 440 gpd
pH(Standard Units) 7
Color Clear
Temperature 69
Odor Earthy
Comments:Pumps and floats were inspected and are operational.Alarm not accessible.
" r a i7L r3 rpt SERVICEDATEG. r� � �?i,�i�
�
David Zavelle 10-9-14
/Y LGCl�iGGC� V/ (.44L// aff/V N &, Ylw.
44 Commercial Street
Raynham, MA
02767
Tel: (508) 880-0233
Fax: (508) 880-7232
INSPECTION AND TESTING AGREEMENT
Agreement entered into by and between Wastewater Treatment Services,Inc. (herein called WTS) and the
FAST®System OWNER(herein called OWNER)for the inspection by WTS of certain equipment of OWNER
which is described below.
Upon acceptance of this agreement at WTS's office,WTS will render the following services only:
Equipment will be inspected at least 2 times per year that this Agreement remains in effect,with the first
inspections beginning These inspections will include:
1) Testing of the sludge depth in the septic tank.
2) Inspection,power testing and clean/replace intake filter of the air blower.
3) Inspection of the alarm system.
4) Inspect overall condition of FAST®System.
5) Notify OWNER of'any problems encountered.
6) Service other than routine maintenance will be billed at an hourly rate,plus travel and parts.
WTS shall notify the local Board of Health and Department of Environmental Protection in writing within 24
hours of a system failure or alarm event including corrective measures that have been taken.
OWNER will be billed standard WTS charges for any parts used in repairs or maintenance. Any additional labor
time will be billed to the OWNER at current labor rates of$78.00 per hour.
Emergency service between regular inspections will be provided at standard labor rates during normal business
hours; at time and oneilalf after 5:00 PM and or.Saturdays; and at double time on Sundays and holidays.
Emergency service charges will include a minimum four(4)hours of labor, plus standard WTS charges for parts,
plus mileage and travel charges. The annual rate includes routine maintenance,but does not include repairs
required for damages caused by abuse,accident,theft, acts of third persons, forces of nature, or alterations made to
the equipment. WTS shall not be responsible for failure to render the agreed services if caused by strikes, labor
disputes,non-cooperation by OWNER,or other factors beyond the control of WTS.
OWNER understands and agrees that WTS is not responsible for special,incidental or consequential damages,
including but not limited to loss of time, injury to person or property, or equipment failure.
OWNER agrees that WTS may enter OWNER's property and have acceptable access to all areas deemed by
WTS to be necessary or appropriate for WTS to perform its duties hereunder.
Current WTS practice is to send OWNER approximately 10 days before expiration of the term of the current
contract(1) either a new contract or an offer to extend the current contract's term, and(2) an invoice for one year
of service. It is OWNER's responsibility to timely return the payment and either the new contract or the accepted
extension, completed and signed. WTS must receive the payment and document before expiration of the then
current contract year,to assure continuous contract coverage. Failure to return such documents on time or to
r
otherwise comply with this contract,may result in suspension of service, cancellation of the contract and/or
nullification of warranties, at the election of WTS. OWNER may not assign this contract without the prior written
consent of WTS. It will remain in force until a party cancels by written notice to the other at the address given
herein, or until the contract term expires,whichever is sooner.
MANUFACTURER MODEL NO. SERIAL NO. LOCATION ANNUAL RATE PERMIT
Bio-Microbics HomeFAST MCF215 North Andover,MA $400.00 Remedial
Includes(2)Field Tests
EQUIPMENT OWNER Wastewater Treatment Services Inc.
*Signed by OWNER.
Si
David Pinson
Signed:
*Address:
151 Raleigh Tavern Lane 44 Commercial Street
Raynham,MA 02767
Tele: (508) 880-0233
*City: State: Zip: Fax: (508) 880-7232
North Andover MA 01845
Effective Date of Agreement
Telephone 978-681-6468
Daytime Telephone:
OWNER understands that( )1 ANNUAL RATE payment is for one year only commencing on the effective date set
forth above and is non-refundable; and(2)Current DEP Regulations require OWNER to maintain a service
agreement for the life of the FAST®Syste.HAVE READ AND UNDERSTAND THE FOREGOING.
*Signed by OWNER:
Field Testing
Onsite testing performed twice per year will be used to demonstrate that the systems are operating at a secondary
treatment standard of 30 mg/L of BOD5 and TSS. The following will be performed:
1) Visual examination of the effluent for color,turbidity and effluent solids.
2) Effluent pH to determine if the waste water is between 6 and 9 standard units.
3) Dissolved Oxygen, 2mg/L or more,to ensure that the system is operating.
4) Turbidity,less than or equal to 40 NTU.
If the effluent does not meet effluent quality standards, a grab sample will be collected for laboratory analysis.
Results sent to state and local Agencies as well as the OWNER. OWNER is responsible for providing acceptable
access to effluent for field testing and/or to enable a grab sample to be taken for laboratory testing performed. If
such laboratory sample is required, OWNER will be responsible for urges incurred. IF REQUIRED,THE
COST FOR THIS ADDITIONAL TESTINGE$190�0'()/Vl '1
*Approval for Additional Testing if Required
7./ 1���� .
Homeowner's Signature
Operator assigned: William Everett
Telephone: (508) 400-3868 *Engineer:
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DATE: /0 — 7-97
LOCATION:
ENGINEER: �
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BOH WITNESS:
PERCOLATION TEST# l
BOTTOM DEPTH OF PERC TEST:
I
i
TIME OF SOAK: (At least 15 minutes long)
TIME AT 12"
TIME AT 9"
TIME AT 6"
OVERNIGHT SOAK
TIME STARTED
NEXT DAY SOAK: (At least 15 minutes)
TIME AT 12"
TIME AT 9"
TIME AT 6"
i
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i
DATE: s
0
LOCATION: . -�
ENGINEER: --=- - _
BOH WITNESS.-
PERCOLATION
ITNESS:PERCOLATION TEST#
BOTTOM DEPTH OF PERC TEST:
TIME OF SOAK: , (At least 15 minutes long)
TIME AT 12" ,
TIME AT 9"
40
TIME AT 6"
OVERNIGHT SOAK
TIME STARTED — ',- ' v ,
-�-`� NEXT DAY SOAK: ,i 0 �� (At least 15 minutes)
TIME AT 12" 1
TIME AT 9" ` z
s
TIME AT 6" t
TE.-
LOCATION:
E:LOCATION: ` •
ENGINEER:
BOH WITNESS: Lime =2
PERCOLATION TEST#
BOTTOM DEPTH OF PERC TEST: (�
TIME OF SOAK: -l.l __ (At least 15 minutes long)
TIME AT 12" L
TIME AT 9"
r •
J TIME AT 6"
i
OVERNIGHT SOAK �' .1 '9
TIME STARTED
NEXT DAY SOAK I (At least 15 minutes)
TIME AT 12"
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TIME AT 9" l
TIME AT 6" f
a
Commonwealth'of Massachusetts RECEIVE
u _ City/Town of North Andover
w° System Pumping Record 2-20 '
Form 4 Tr4@r� l
troa»surr
DEP has provided this form for use by local Boards of Health. Other forms may be use the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer, I 11—
�
use only the tab (
key to move your Address
cursor-do not North Andover Ma 01886
use the return City/Town State Zip Code
key.
2. Systgm Owner:
Name
raum
Address(if different from location)
City/Town State Zip Code
" Telephone Number
B. Pumping Record
1. Date of PumpingDate i� 2. Quantity Pumped: I n
Gal o s
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If Yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1