HomeMy WebLinkAboutMiscellaneous - 162 GRAY STREET 4/30/2018 (2) 162 GRAY STREET �s
210/107.D-0101-00.00.0
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of NORTh 6272
s a
Town of North Andover
�`�'• `� HEALTH DEPARTMENT
'SSACNUstt
CHECK#: � DATE: C, /
LOCATION: & -L
H/O NAME:
CONTRACTOR NAME: ��
Type of Permit or License: (Check box)
❑ Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service-Type: $
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal(Septic)Hauler $
❑ Recreational Camp $
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ Trash/Solid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
❑ Septic-Soil Testing $
❑ Septic ep c-
Design Approval $
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
'Title 5 Report $
❑ Other:(Indicate) $
lth Initials
White-Applicant Yellow-Health Pink-Treasurer
' I
th
Commonwealth of;Massachusetts RECEIVED �
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary OCT 16 2012
Ass ssme s
TOWN OF NORTH OVER '+
162 Gray Street MEALTH pEp
Property Address
Marlin Stella
Owner Owner's Name �J �
required for ,/
information is North Andover Ma 01845 9/26/2012 s �
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 y
way. Please see completeness checklist at the end of the form.
Important:
When filling out A. General Information
forms on the
computer,use 1. Inspector:
only the tab key .
to move your Neil James Bateson
cursor-do not Name of Inspector
use the return
key. Bateson Enterprises Inc.
Company Name
111 Argilla Road
Company Address
Andover MA 01890
Citylrown State Zip.Code
978-475-4786 S115
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 Conditional) Passes
i ® y El Fails
❑ Needs Further Evaluation by the Local Approving Authority
9/26/2012
Inspectors Signatur 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 s
Y P 9 stem or
P
Y Y
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.
� I
t5ins-11/10 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
162 Gray Street
Property Address
Marliyn Stella
Owner Owner's Name
information is
required for North Andover Ma 01845 9/26/2012
every page. Cityrrown 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 anyinformation which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
® One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
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):
i
15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
i
I
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
• a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
162 Gray Street
Property Address
Marliyn Stella
Owner ! Owners Name.
information is
required for North Andover Ma 01845 9/26/2012
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
I
Commonwealth of Massachusetts
a Title .5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
162 Gray Street
Property Address
Marliyn Stella
OwnerOwner's Name
rati n is
required for North Andover Ma 01845 9/26/2012
requir
every page. Cityfrown 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-box 1 needs to be replaced with pipe
i
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 dile to overloaded or
Clogged SAS or cesspool
El ® 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•11/10 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
162 Gray Street
Property Address
Marliyn Stella
Owner Owner's Name
information is
required for North Andover Ma _ 01845 9/26/2012
every page. Cityrrown 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.
El ® 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
El ❑ 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•11/10 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 162 Gray Street
Property Address
Marliyn Stella
Owner Owner's Name
information is
required for North Andover Ma 01845 9/26/2012
every page. Cityfrown 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?
El ® 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® El Were o es 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:
3 3
Number of bedroomsn desi : Number of bedrooms
( g ) (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 300
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
u W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
162 Gray Street
Property Address
Marliyn Stella
Owner Owner's Name
information is
required for North Andover Ma 01845 9/26/2012
every page. Citylrown State Zip Code Date of Inspection
D. System Information
Description:
I
Number of current residents:. 1
Does residence have a garbage grinder? ❑ Yes 0 No
Is laundry on a separate sewage system?[if yes separate inspection required) ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage Yes
9 ( Y 9 (gPd))�
Detail:
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? s ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system?
El Yes ❑ No
Water meter readings, if available:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 17
it i i
Commonwealth of Massachusetts
Title 5 Official Inspection Form .
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 162 Gray Street
Property Address
Marliyn Stella
Owner Owner's Name
information is
required for North Andover Ma 01845 9/26/2012
every page. Cityfrown 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: Pumped 2000, owner
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1000
gallons
How was quantity pumped determined? Measured tank
Reason for pumping: Inspect tank
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Official Inspection Form
Title 5 O p
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
162 Gray Street
I
Property Address
Madiyn Stella
Owner; Owner's Name
information is
required for North Andover Ma 01845 9/26/2012
i
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
32 years old, 8/9/1980, final inspection of installation
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 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.):
Unable to see piping,finished cellar, pipe under cellar floor.
Septic Tank(locate on site plan):
Depth below grade: feet E
c
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: e
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: Tx 5'x 4'
51'
Sludge depth:
I
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
m Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
162 Gray Street
Property Address
Marliyn Stella
Owner Owner's Name
information is
required for North Andover Ma 01845 9/26/2012
every page. Cityfrown 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
22" '
5"
Scum thickness
Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom of outlet tee or baffle
16°
How were dimensions determined? 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.):
Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. Center cover has
riser cover to grade
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•11110 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
162 Gray Street
Property Address
Marliyn Stella
Owner Owner's Name:
information is
required for North Andover Ma 01845 9/26/2012
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
y
• Commonwealth of Massachusetts
u ti Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
162 Gray Street
Property Address
Marliyn Stella
Owner Owner's Name
information is
required for North Andover Ma 01845 9/26/2012
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.):
D-box# 1 is a drop box, has corrosion holes, evidence of leakage. Evidence of solid
carryover.D-box 2 level&distribution eqaul. No evidence of leakage. Evidence of carryover,
piumped d-box to clean
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.):
Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
i
Commonwealth of Massachusetts
4 . Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
162 Gray Street
Property Address
Marliyn Stella
Owner Owner's Name
information is
required for North Andover Ma 01845 9/26/2012
eerypge. Cit
v a !Town State Zip Code Date of Inspection
Y
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions: 20'x 45' leachfield
❑ 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 ok. Vegetation ok. No sign of ponding to surface.
i
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
u
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 162 Gray Street
Property Address
P
Marlin Stella
Owner Owners Name
information is
required for North Andover Ma 01845 9/26/2012
every page. Cityrrown 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.):
m
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 4•''y 162 Gray Street
Property Address
Marliyn Stella
Owner Owner's Name
information is � 1845 9/26/2012
North Andover Ma 0
required for
every page. City[rown 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
C�Se
P
O ��G
c
I
A-�-o
0311
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
• Commonwealth of Massachusetts
N Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
162 Gray Street
Property Address
Marliyn Stella
Owner Owner's Name
information is
required for North Andover Ma 01845 9/26/2012
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
I
® Shallow wells
Estimated depth to high ground water: 5
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 Ian reviewed:
6/12/1976
' n g p Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
Design plan
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Test pit data on design plan
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-11/10 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
.'r 162 Gray Street
Property Address
Marliyn Stella
Owner Owner's Name
information is
required for North Andover Ma 01845 9/26/2012
every page. Cityrrown 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
- A
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
r
i
Commonwealth of Massachusetts
w City/Town of
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left side of house, Right side of house, Left front of house,qzafront of ho_UW
i
Left rear of house, Right rear of house. Left rear of building. Right rear of building.
Address / { 's�
City/Town (� State Zip Code
2. System Owner:
Name
F
Address(if different from location) I
City/Town Stated Q Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
I Type of system: ❑ Cesspool(s) aeptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No j
5. Condition of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location whem contents were disposed:
c
.L D Lowell Waste Water
g toe of Haul(r/ Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Summary Record Card generated on 10/9/2012 2:54:40 PM by Maureen McAuley Page 1
Town of North Andover
Tax Map # 210-107.D-0006-0000.0
Parcel Id 18505
162 GRAY STREET
STELLA, MARILYN A.
162 GRAY STREET
j N. ANDOVER, MA
01845
FY 2013
UB Mailing Index.
Name/Address Type Loan Number Active/lnact. From Until
STELLA,MARILYN A. Payor•
162 GRAY STREET
N.ANDOVER,MA
01845
UB Account Maint.
AccounfNo Cycle Occupant Name Active/Inactive
Bldg Id. 13719.0-162 GRAY STREET Last Billing Date 8/3/2012
1090397, 01 Cycle 01 Active
UB Services Maint. I
Account'No. 1090397
Service Code Rate Charge Multiplier/Users
MISCFEE ADMIN FEE 0.635/8 7.82 1/
WTR WATER 01 ALL METER SIZE 38.00 /1
UB Meter Maintenance
Account No. 1090397
Serial No Status Location Brand Type Size YTD Cons
32772661 a Active 00 b Badger w Water 0.63 0.63 226
Date Reading Code Consumption Posted Date Variance
7/23/2012 340 a Actual 10 8/14/2012 -17%
4/23/2012 330 a Actual 12 5/9/2012 -8%
1/23/2012 318 a Actual 13 2/13/2012 34%
1'0/24/2011 305 a Actual 10 11/14/2011 -12%
7/22/2011 295 a Actual 11 8/15/2011 -19%
4/22/2011 284 a Actual 13 5/16/2011 -10%
1/25/2011 271 a Actual 16 2/11/2011 17%
10/21/2010 255 aActual 13 11/12/2010 -7%
7/22/2010 242 a Actual 14 8/16/2010 -12%
4/22/2010 228 a Actual 16 5/12/2010 0%
1/21/2010 212 a Actual 16 2/12/2010 14%
'10/22/2009 196 a Actual 14 11/11/2009 7%
'7/23/2009 182 a Actual 13 8/12/2009 -12%
4/24/2009 169 a Actual 15 5/13/2009 18%
1/23/2009 154 aActual 13 2/10/2009 -1%
10/22/2008 141 a Actual 13 11/12/2008 -9%
7/22/2008 128 a Actual 14 8/15/2008 11%
4/23/2008 114 a Actual 12 5/19/2008 3%
1/28/2008 102 a Actual 13 2/19/2008 0%
10/24/2007 89 a Actual 13 11/16/2007 4%
7/20/2007 76 a Actual 12 8/15/2007 -5%
4/19/2007 64 a Actual 11 5/21/2007 10%
1/29/2007 53 m Manual estimate 12 2/20/2007 1%
ERT N/R
10/25/2006 41 a Actual 11 11/16/2006 -17%
7/28/2006 30 a Actual 13 8/18/2006 -10%
5/2/2006 17 'a Actual 17 5/16/2006 -100%
1/20/2006 0 n New Meter 0 2/13/2006 -100%
1/20/2006 1311 r Replacement 11 2/13/2006 0%
10/27/2005 1300 a Actual 12 11/9/2005 -6%
7/26/2005 1'288 a Actual 13 8/10/2005 0%
4/22/2005 1275 a Actual 11 5/13/2005 -49%
2/1/2005 1264 a Actual 26 2/15/2005 90%
• I
i
Of NORTH'7 6264
OL
9
,may Town of North Andover
HEALTH DEPARTMENT
s�CHL,
CHECK#: DATEU9
LOCATION:
H/O NAME: b /7t - .
CONTRACTOR NAME:
Tvve of Permit or License:(Check box)
❑ Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service-Type: $
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal(Septic)Hauler $
❑ Recreational Camp $
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ Trash/Solid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
❑ Septic-Soil Testing
Septic-Design Approval $
Septic Disposal Works Construction(DWC)
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
❑ Title 5 Report $
❑ Other:(Indicate) $
T—
'70`- C'7C S`7`3 , Hea th Ag
Lnitials. �. _ Pry- Aq
White-App 'cant Yellow-Health Pink-Treasurer
r o - r
• 5� p% ' , Commonwealth of Massachusetts Map-Block-Lot
107.D0006
BOARD OF HEALTH -----------------------
Permit No
North Andover BHP-2012-0731
-----------------------
P.l. FEE
F.I. $125.00
-----------------------
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Todd Bateson
-------------------------------------------------------------------------------------------------------
to(Construct)an Individual Sewage Disposal System.
at No 162 GRAY STREET
-----------------------
as shown on the application for Disposal Works Construction Permit No. 13HP-2012-073 Dated October 09 2012
-----------------------------------------------------------------
Issued On:Oct-09-2012 BOARD OF HEALTH
• e�' �r'�s . Commonwealth of Massachusetts Map-Block-Lot
107.D0006
BOARD OF HEALTH ---------------------
North Andover
CERTIFICATE OF COMPLIANCE
THIS IS TO CERTIFY,That the Individual Sewage Disposal System (Construct)
by Todd Bateson
Installer
at No 162 GRAY STREET
- --------------------------------------------------------------------------------------------------------.-------------------------------------
has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the
application for Disposal Works Construction Permit No. 13HP-20127073 Dated -October-0-9,20-12
Printed OOct-09-2012 ---- ---------------------- ----------
-- BOARD OF HEALTH
r r
Ot,AORT"
3 ' o
� w
9
• Town of North Andover
�,s .•'�� HEALTH DEPARTMENT
s�cNust
CHECK#: tet DATEJq,
r 1-
LOCATION: `� ,1
H/O NAME: r-
CONTRACTOR NAME:?�— ��
Type of Permit or License: (Check box)
❑ Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service-Type: $
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal(Septic)Hauler $
❑ Recreational Camp $
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ Trash/Solid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
❑ Septic-Soil Testing13 $
i3 Septic-Design Approval $
Septic Disposal Works Construction(DWC) $3
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
❑ Title 5 Report $
❑ Other. (Indicate) $
a
Health Ag .initials
White-Applicant Yellow-Health Pink-Treasurer
� Ytm
pp •cation forSe tic Dis osa
of,....,•�Nc TODAY'S DATE
Construction Permit--�TOWN OF
$ 5,0� Ulf,
pair
'ER MA. 01 45 RE ,���y� om Anent
.�... D p
ORTH AN �
S
AC►Wg
Important: Application is fiereby made for a permit to: OCT a 9 2012
when furing out [j Construct a new on-site sewage disposal system*
forms on the T N OF NORTH ANDOVER
computer,use ❑Zpair
it or replace an eXlsting on-Site Sewage disposal S WLTH DEPARTMENT
only the tab key
to move your, or replace an existing system component—What a
cursor-do not
use the return A. Facility Information
key.
a/f1� I I Address or Lot# r
L ^ I
Sao CRYITOM M 1 4 :i,
2.-*TYPE OF SEP IC SYSTEM*:
•f I
Pump vity(choose one)
***If pump system,attach copy of electrical p
Conventional System(pipe and stone system l
❑Infiitrator or Blodiffuser(Gravel-Less) (Attach Y � �� I
❑Pressure Distribution S.A.S.(No D-Box)(An
❑Pressure Dosed(D-Box Present)S.A.S. C��o 0 ) `
2. Owner Information
Name jl `
Address(N different from above)
CiVrown 2 — State Zip Code
Gds3 — 43_3
Telephone Number
3. Installer Information
• /�4 ��►-T�so�
Name Name ofCompani1 ARGILLA ROAD,,INC.
_ /I/ Al,��"t 1 A_ P4 AMOVER__SAA of a4 o
Address J
Ckyfrown Strte' Zip Code
Telephone Number(Cell Phone#ffpossible please)
4. —Designer Information
Name Name of Company
Address
City/Town State . Zip Code
Telephone Number(Best#to Reach)
Apptication for Disposal System Construction Permit•Page! of 2
I
SEPTIC SYSTEM.INST T.T; ".I PROJECT MANAGEMENT' OBLIGATIONS
As the North Andover-licensed installer for'the.construction for��the septic system-for.the property at
j Co
(Address of septic system) For plans by
n ' er)
Relative to the.application ofAnd dated
(In'staller's name)
cLatej.
Dated With revisions dated
y-rl'o a s ate
(Las revise X 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
pg y
erfonnin an work on a site. I must have the approved: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 in}stallet,I aw'x.eq=ed to.have.the necessary work completed priot;to the.applicable inspections as
indicated below:, I uindetstand that rerliestin 'an inspection,without completion:of the items in,accordance
with Title 5 and the Board of Health%6m&i6ns $50:00-fine.being.levied against:me..6d/or
mv, eompmy. .
a,. Bo'ttom of Bed Generally,this-is the first(1�`j,inspection unless.,there ns a retauung wall,which
should�be do A- rpt. The'installet must request'the inspection.but does-not have to be present. .
b. Final Constfuctiori.Inspection—E.ngineeritwt first.do their inspection for elevations;ties,etc.
As-built of verbal OK(or e-mail'to:heaps deptnu,townofiiorthandover.com)from the engineer must
be submitted to.the,Board of Health,after wlucli installer.canis for an inspection time. Installer must
be present for this.inspecdon. with a pump system,all electrical work must be ready and able to
cause pump to work and alarm.to fu d.tion..
c. FinalTGtade installer must request inspection when,4 grading is complete._ .Installer does not
have to be on=site.
4. As-the installer,'I understand that only I ruay perform the work(other than ample excavation)and I am required
to coffiplete the installation of the system identified in the attached application:for installation:'1 further
underntand:•that work done by.other s unlicensed:to-install septic systems-in North Andover can constitute
reasons for denialof the system and/or:revocation or suspension of.my lieense:to operate in.the Tjown.of
North Andover.significant fines.to all Iiersons iri'volved are also possible.
5.. ,As the:installer,:I understand that:I mti§t be on-site during the.pesforrriance.of the'following construction.
steps:
a: Dctem2ination i&at.the proper elevation of the eieea7vation bas been reached
P
b. Inspection oftheb sand and stgne to be used.
.
c. Finallnspection byBoard ofhTealth staffor consultant.
d. Installation.,of Link,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:blans. No instructions by thehomeowrrer,general.contractor_.or•mn r.other.12ersons shall-absolve
me gfthis obligation.
Undersigned licensed Septic 1iistaller: (Today's Date): 9,—/
�Ns}aaae—Innt� °s ffi-.Kill PAM,,. 3 "r
S
N�=h
Application for Septic Disposal System
M x =Construction Permit - TOWN OF TODAY'S DATE
' °�' •°' , MA 01845 $250.00-Full Repair
ORTH ANDOVER
$125.00-Component
ssAC►p15!
PAGE 2 OF 2
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, and not to place the system in operation until a Certificate of Compliance has
been issuedolsIlloard of Health.
t, A� �f
Name Date
7
Application pproved By: (Boa,d of Health Representative)
A91411 2
N e Date
Gam"" /61
Application Disappror th ollowing reasons:
For Office Use Only:
L Fee Attached. Yes No
i
2. Project Manager Obligation Form Attached? Yes No
3. Pump System? If so,Attach copy of Electrical Permit Yes_ No
4. Foundation As-Built?(new construction ronly): Yes No
(Same scale as approved plan)
.5 Floor Plans?(new construction only): Yes No
Application for Disposal System Construction Permit•Page 2 of 2
i
'I
FORM U - IAT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: M ,4 Phone C/e 3 -° -3 3 3
LOCATION: Assessor's Map Number 10-7- L) Parcel /o /
Subdivision Lot(s)
Street St. Number l lit
************************Official Use Only************************
RECOMMENDATIONS OF TOWN AGENTS:
Date Approved
Conservation Administrator Date Rejected
Comments
Date Approved
Town Planner Date Rejected
Comments
Date Approved
Food Inspector-Health Date Rejected
_ 1 . '7�. Date Approved
Septic .Inspector-Health Date Rejected
Comments
Public Works - sewer/water connections
- driveway permit
Fire Department
Received by Building Inspector Date
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
i
DATE:
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
t (example: left front of house)
��V t
I C/
P-,4-
DATE
OF PUMPING: a I -0'W1jVANTITY PUMPED /40GALLONS
CESSPOOL. NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
i
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
r
COMMENTS:
I
i
CONTENTS TRANSFERRED TO: C'
i�.IOIR IH Air . ;is�:i �,:, D Or
--�+ , ------ -- - -^-- -J----- DISAPPROVED PATE TIME
FA
$PkOVED D4TE PROVIDED _ —
#te5
Reg. 2. 5 Fail OK The submitted plan must show as a minumum:
(a) the lot to be served (area,dimensions ,lot //, abutters)
(Planning Board -files)
(b) location and log of deep observation holes-distance
to ties
(c) location and results of percolation tests-distance
to ties
(d), design calculations & calculations showing required
leaching area
(e) location and dimensions sf system (including reserve
area)
existing and proposed contours
location of any wet areas within 100' of the sewage
disposal system ot-• disclaimer (check wetlands mapping
(h) surface and subsurface drain's within 100' of sewage
disposal system of disclaimer
(i) location of any drainage easements within 100 ' of
sex..age disposal system or disclaimer (planning board
files)
' ) ter supply within 200' of set�age
known sou-rces: of_-wa
disposal- -system_ ar. disclaimer
(k)- location of any proposed well to serve- the lot (100'
from leaching facility)
(1) location of water lines on property (10' from. leachin
facilities)
m) location of benchmark
n' driveways
IL garbage disposers
no PVC is to be used in construction
q a profile of the system (elevations of basement , plum
pipe septic tank, distribution box inlets and outle
dis-ribution -field piping and any other elevations)
(r) maximum ground water elevation in area of sewage disc
system
( s) plan must be prepared by a Professional Engineer or
thorized by law to prepare such
other professional au
plans
S tic Tanks
Reg. 6 (a.) Capacities - 150° of flow, water table , tees , depth
of tees , access , pumping,
Cleanout
e 10' from cellar wall or inground swimming pool
d 25' from subsurface drains
�— INSTALLATIOilCHS$ LIST
LOT f
DATE UI PROVED AVATICIN Old FAH
- _..
Beau st
CKi
- 1. Distance Tot
- a. Wetlands
` b. Drains
a. Well
2. Water Line Location
30 NoMpipe
.
Septic Tank
a. . -Tess--_Length & To Clean-out Covers. .
b. Cement Pipe to Tank Oa Both Sides of Tank
J
5- Distribution Box
a. Covers & Box - No Cracks
-� b. All Lines Flowing Equal Amounts
c. No Back Flow
Leach Field or Trench
a. Dimensions
b. Stone Depth
c: Capped lhds ..
d. Clew Double'Washed Stone
7. Leach Pits.
a. Dimensions
b. Stone/Depth
e. Splash Pads'
d. Tees
e. Cement Pipe to Pit - Both Suedes.
f. �dean Double Washed Stone
v/ 8. No Garbage Disposal
9. .Final Grading Inspection
10. Barricading Covered System
/L1. As Built Submitted.. - U / -
-- a Lot Location .. ' _ _ :..._ ... .
b. sion of System
C. Lo ion Kith Regard-to Perc Test
d. atND
` 'a er Table
F
CERTIFICATION STATEMENT
I� -7--X crass Aorl-%s , Registered
Sanitarian #610 hereby certify that I have observed the con-It
struction of the sewage disposal facility at &Z
,,o. nc �e✓r /J___�/I�ss . and that it has been
constructed according to the plans submitted to the Board of Health
for approval, and for which said Board of Health had issued a
Sewage Disposal Permit, and in accordance with the provisions of
Title 5 of the State Environmental Code.
� CU. /�Gu�u� /c•S.
CO3N
of ,ysn
// SOIL PROFILE & PERCOLATION TEST DATA
Town/City No.&Street r Lot No._____
D)
Loc./Subdiv. Plan Owner
e MCC .
Investigator+��C&M d Observer
SOIL PROFILES-DATE
Elev. Elev. Elev. !—'Elev.
00 p � 0 0
1 2 02 2 2 -�
3 3 3 3Qj
t 4 4
5 5
3 6 6
7 7 7c
8
9 -- 9
10 10 10 tV
Benchmark Location
Elevation Datum
Percolation Tests-Date
� / 7G
/'7/V
z_e-
Pit Number 1 2 3 4 5
Start_Saturation 3
Soa'c-Mins o /5►nj %4
Start Test-Time q 50
Drop of 3"-Time 0 7 0
Drop of 6"-Time 5
Mins.lst 3"Dro mih
Minso2nd 3"Dro ,2
Notes & Sketches on Back Frank C. Gelinas & Associates, North And.
• jar`.. -. r ,.
1
Of SHORTN 1 6264
� A
9
t Town of North Andover
HEALTH DEPARTMENT
. .. 7SS•1CNUSEt (,
CHECK#:
DATE
LOCATION:
H/O NAME:
CONTRACTOR NAME:-&rr—- �r`f�I�Z�
Type of Permit or License: (Check box)
❑ Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service-Type. $
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal(Septic)Hauler $
❑ .Recreational Camp $
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ Trash/Solid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
❑ Septic-Soil Testing $
C� Septic-Design Approval $
�)] Septic Disposal Works Construction(DWQ
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
❑ Title 5 Report $
❑ Other.(Indicate) $
Dor 6JA
W C
He th Ag nitials
White-App 'cant Yellow-Health Pink-Treasurer
1 r�
.JcuELGrN�
� f
{ � a
16Z l')?4y ST
ti
G
STp-LLA
T '/6 2 6 Rq y STP L&T
14. 17NDov6p
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