Loading...
HomeMy WebLinkAboutMiscellaneous - 163 SUMMER STREET 4/30/2018 �- �'� I _� �� C G���" n ��;� �- � �v ff �'V� l� U1r i• 5 5�i1�, C E� ,�.� � � __ i; i Date...., . .?-.1.5 11369 cF NORTN,~C TOWN OF NORTH ANDOVER ° n PERMIT FOR PLUMBING sBACHUS� P .0 This certifies that........................................................................................................................ . has permission to perform............�: y �....7 ................ plumbing in the uildings of...... ...h. ........................ / .................... at............. l -3................. h-n- ?.... 2e ....., North Andover, Mass. Fee. .''.'.....Lic. No. .... PLUMBING INSPECTOR dheck# I� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK �y Q ' CITY _. _ MA DATE ] PERMIT# 01 JOBSITE ADDRESS OWNER'S NAME _ POWNER ADDRESS 5.�,.; - C TEL TYPE OR OCCUPANCY TYPE COMMERCIAL E ;UC941- RESIDENTIAL PRINT CLEARLY NEW: RENOVATION:® REPLACEMENT: PLANS SUBMITTED: YESE11 NOD FIXTURES Z FLOOR--> BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB =1 CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN _I. ..--__-( FOOD DISPOSER FLOORIAREADRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET ---i k_. ___k —_ ._ _.____( .___ -- _ _I .--..__I ._— ___,_E -S— URINALI ....__.__I ____.___� ___► ____l __._.__! ..._.,___I __-..-_� _____.� .__.._._ f ...__._.J .___ :_.__-_(: __....._._k _.—_-.1 — WASHING MACHINE CONNECTION ( WATER HEATER ALL TYPES { k ( I I # ._. i _____J ._____. _ I -.__.___S k I WATER PIPING _! [ --__-- t 1 I-- k I f f R OTH� M.1-- [if_.._...._._k i INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO �1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY __i OTHER TYPE OF INDEMNITY [] BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER [Q AGENT SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and ac r to t]19-pest of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complianc I i" nt provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I i -- I LICENSE# I Y7 SIGNATURE IVIPfj—JP D CORPORATION 01# PARTNERSHIPS# (LLC COMPANY NAME DRESS CITY�s�' --- - - - -I STATE ZIPG/`1��1 —k TEL FAX i CELL — EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 _ Boston,MA.02114-2017 �< www.mass•gov/dia Workers!,Compensation insurance Affidavit:Builders/Contxactoxs/Electricians/Plumbers. TO BE FILED WITH THE PERNnTfING AUTHORITY- Please Print Le 'bl A licant Information //' (. Name(Business/Organization/Individual): Address: LG n City/State/Zit l�G Phone#: `7- 7 Are you ane Ioyer?Check the appropriate box: Type of project(required). em to ees fitll and/or part-time).' 7. ❑Nd*,d6nstruction I, am a employer with p Y 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. E]Remo deliiig any capacity.[No workers'comp.insurance required.] 9. ❑Demolition [ elf. No workers'comp.insurance required.] 3.0 I am a homeowner doing all work mys10❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.❑Electrical repaixs or additions ensure that all contractors either have workers'compensation insurance or are sole .. proprietors with no employees. 12T[]Plumbing repairs or additions 5.I]I am a general contr4ct9:and I have hired the sub-contractors listed on the attached sheet. 13.,V- theK- 6. epairs These sub-contractors have employees and have workers'comp.insurance$ 14❑We area corporation and its,officers have exercised their right of exemption per MGL c. 152,§1(4),and the have no employees:[No workers'comp.insurance required.] *Arty applicant that chdcks box#1 miliA also fill out the section below showing their workers'compensation policy information: i homeowners who submit•this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such $Contzactors that check this Box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. 'compensation insurance for°my employees. Below is the policy and job site X am an employer that is providing keys information. Insurance Company Name: Expiration Date:. Policy#or Self-ins.Lic.#: ,�„�� _City/State/Zip: Job Site Address: /&3 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL e.152,§25A is a criminal violation punishable by a flue up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby certify un de epai er2al2 e perjury that the information provided above is tr a and correc� Date: � Si ature: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): iInspector 5.Plumbing Inspector 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical g p 6.Other Contact Person: Phone#: I' d g� Information and IllStrU.CtI®nS Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hii , express or implied,oral or written." An employer is'defnied as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receivet'or,trustee of an individual,partnership,association or other legal entity,employing employees.•However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment b6 deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicazit who has not produced-acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants I Please fill,out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub=contractors)name(s),address(es)and phone number(s)along with their certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial-Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture I (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. I The Department's address,telephone and fax number: ' The Commonwealth of Massachusetts Department of Industrial.Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext.7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 wwwmass.gov/dia + Date....��............. ..1. ............ OF r►OR7�y.'� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION �ss�c►+us�t . r This certifies that ....5 . �d . ...... 'nod,.j................................................. has permission for gas installaon .bda..l,-......��.�<-,5?�-................... m the buildings of........0-a.12" -7-A. J............................................................... at....., (fit, .. ru. .rl ................1'?.-4......, North Andover, Mass. Fee. Lic. No. . `.��/3Z... GAS INSPECTOR Check# 10176 �,�- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITYMA DATE / PERMIT# &7� Cr JOBSITE ADDRESS NAME •� GOWNER ADDRESS _ _., T _ TELF --__IF r TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW:Q RENOVATION:® REPLACEMENT:® PLANS SUBMITTED: YES NO APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER -- . 1- - I.111---l- ( .. _ I_ - .. _- BOOSTER -- �� ..r-- -- ... _... �------ -F[7=71 - CONVERSION BURNER -�- COOK STOVE �!1 _ _ -.! 11_ -I L I DIRECT VENT HEATER + DRYER [-__J FIREPLACE _ FRYOLATOR FURNACE GENERATOR -.--( -=T.�=I ._ _ L—�I�y- -- ---- �-J - _. ,� GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER - UNVENTED ROOM HEATER _. _. I_ _. �.-� .. ! �. WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL.Ch.142 YES NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [3 OTHER TYPE INDEMNITY E] BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Q AGENT SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of details and information I have submitted or entered regarding this application are true and ac c to t est of my knowledge and that all,=In ork and installations performed under the permit issued for this application will be in compliance ertinent provision of the Massachusetts S e Plumbing Code and Chapter 142 of the General Laws. PLUMBE ASFITTER NAME G� S'� LICENSE# / SIGNATURE MP I MGF Ejl JP D JGF --L-P-GI�J— CORPORATION©# PARTNERSHIP©# LLC[1# COMPANY NAME: `f ,,i_ T/yc► PDDRESS CIN I _ K _ { STATE[e2uzlp TEL 7 7 7 FAX( �j�CELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No 11 THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES COMMONWEALTH OF MASETTS ; »: .BOARD Old PLIJM@ERS AND GASF l"ITRS ;i ISSUES THE FOLLOWING LICENSI LIGEtJSI AS A JOURIeEYM/AN�sPLUMD, GEORGE J CARSON JR r { t 970 CEfiIM RD �aP RO H 0 3 082-6;100 . .L:YADSBQ +v - Grant, Michele To: peter@usaswim.com Subject: 163 Summer st Attachments: 201508121005.pdf Good Morning Peter, Attached, please find the Title 5 As-Built from the last inspection. Please draw in...To Scale...the proposed Pool. Set Back Guidelines for an Above Ground Pool are 5 Feet from the Tank 10 Feet from the Field If you have any further questions, please don't hesitate to call me. Sincerely, Michele E. Grant Public Health Agent Town of North Andover 1600 Osgood St I Suite 2035 North Andover, MA 01845 Phone 978.688.9540 Fax 978.688.8476 Email mgrant@townofnorthandover.com Web www.TownofNorthAndover.com -----Original Message----- From: noreply@townofnorthandover.com [mailto:noreply@townofnorthandover.com] Sent: Wednesday,August 12, 2015 10:06 AM To: Grant, Michele Subject: Message from "ComDev-Health-Ricoh" This E-mail was sent from "ComDev-Health-Ricoh" (Aficio MP C3002). Scan Date:08.12.2015 10:05:50(-0400) Queries to: noreply@townofnorthandover.com 1 IL —« lel North Andover Health Department Community Development Division October 19, 2012 Barbara and Frank Fay 163 Summer Street North Andover, MA 01845 Re: Title 5 Inspection—Failure of Laundry system Dear Homeowners, This correspondence is in regards to the Title V Inspection conducted on October 5, 2012 by Dean Luscomb. The Inspector identified that your home is serviced by two separate leaching systems. The primary system passed the inspection. The secondary system passed the state criteria, however the local Board of Health regulations require that this cesspool automatically fails. (see section II, 1.1) The reasoning is that water sent to this system is not receiving proper pretreatment prior to encountering the water table. The laundry system must be abandoned and tied into the plumbing system within the. Please observe all plumbing codes. The Health Department must receive proof that the system has been properly abandoned and that all plumbing has been rerouted as required. Thank you for your cooperation in this matter. Sincerely, Su n Sawyer, S/R Health Director Cc: Dean Luscomb, Title V Inspector Enc. Local Wastewater regulation, section II, 1.1 1600 Osgood Street,unit 2035,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com y r II. PROCEDURES AND STANDARDS FOR PROPERTY OWNERS AND ONSITE WASTEWATER PROFESSIONALS I. INSPECTIONS OF EXISTING ONSITE WASTEWATER SYSTEMS("TITLE S INSPECTIONS") 1.1 When identified in the course of a Title 5 inspection,cesspools and privies are deemed failed systems and shall be replaced with a new onsite wastewater system. 1.2 Any Title 5 inspection that identifies a tank or distribution box at an elevation of greater than 36 inches below grade,without an access riser, shall have a riser and cover installed within 9 inches to grade by a North Andover licensed onsite wastewater system installer. 2. SOIL TESTING PROCEDURES 2.1 After review of a completed soil test application,the Health Department will contact the applicant to set up a soil testing date. 2.2 The Health Department reserves the right to adjust estimated seasonal high groundwater elevation,as it deems necessary. 2.3 Soil evaluation and percolation test results shall be submitted by the soil evaluator on current forms as created by the Massachusetts Department of Environmental Protection(DEP). 2.4 If soil testing is conducted on a vacant lot,all deep observation test pits and percolation tests shall be located on a scaled site plan. Tie distances from two permanent monuments or structures to each test pit and percolation test shall be provided. If no permanent monuments or structures are within 200 feet of the testing area then the test pits and percolations tests shall be survey located in reference to the property lines. 3. DESIGN REQUIREMENTS 3.1 Three (3) sets of plans shall bear a wet stamp and original signature of the onsite wastewater system designer; or,one(1)set of plans bearing a wet stamp and original signature of the onsite wastewater system designer and an electronic file of the plans,may be submitted to the Health Department for review. If a professional engineer stamps a design plan the engineering discipline must be provided. 3.2 Design plans and specifications must include the following; a. Names of abutters from recent tax map b. Lot area and dimensions c. A scaled profile of the onsite wastewater system no less than 1"=2' vertical and 1"=20' horizontal d. A notation that all piping shall be a minimum of schedule 40 PVC -- ----- —__— _ . Page 4• 7RECENED ; 2u 12 ` TOWN OF NORTH ANDOVER HEALTH DEPARTMENT FILE# N A r)d C) 5 J . r nu5e- System V LNSPEMONS 'Dean G.Luscomb]I& Sans P.O.Box 135 Middleton,MA 01949 J 0778-774-4065 Licensed Phauber#20285 1 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INPSECTTON FORM PROPERTY OWNERS NAAr`Fi . Fav PROPERTY ADDRESS_ ( , (A hr� pr �� I� �1 nC.QaLC�1C A ADDRESS OF OWNER(i€diffcrW) DATE OF INSPECTION ()CIO beer a C) I Q NAME OF INSPECTOR ► 1 e.Q I) (3, e0 M b !T QUALITY IS NUMBER OISM TO US. J. i 7 RECEIVES :,; Commonwealth of Massachusetts Title 5 Official Inspection Form OCT 16 2012 Subsurface Sewage Disposal System Form -Not for Voluntary Assess ments TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 163 Summer St. Property Address FayP{Ifiun�` Owner Owner's Name information is required for North Andover MA 01949 October 5, 2012 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 forms on the computer,use 1. Inspector: only the tab key to move your Dean G. Luscomb II cursor-do not Name of Inspector use the return key. Dean G. Luscomb II &Sons Company Name P.O. Box 135 Company Address Middleton MA 01949 rens» City/Town State Zip Code 978-774-4065 S1848 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 October 5, 2012 Inspec is Signature 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 I ti Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 163 Summer St. Property Address Fay Owner Owner's Name information is required for North Andover MA 01949 October 5, 2012 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Chec6B,C,D or E/always complete all of Section D A) System Passes: vv ® I have not found any information which indicates that any of the failure criteria described e� 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): t5ins•11/10 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 M 163 Summer St. Property Address Fay Owner Owner's Name information is North Andover MA 01949 October 5 2012 required for 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): ,t.0 ❑ 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 163 Summer St. Property Address Fay Owner Owner's Name information is required for North Andover MA 01949 October 5 2012 every page. City/Town 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: n ) ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within f v 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: V 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 1/2 day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 163 Summer St. Property Address Fay Owner Owner's Name information is required for North Andover MA 01949 October 5 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. ❑ ® 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. f � For large systems,'ybta�must indicate either"yes"or"no"to each of the following, in ition to the questions in Section D. Yes NoA - ❑ ❑ the system is within 40G feet of a surface nking water supply ❑ ❑ the system is within 200 feet of .-p utary to a surface drinking water supply ❑ ❑ the system is located in I rogen sensitive area (Interim Wellhead Protection Area—IWPA)or a pped Zone II of a public•water supply well If you have answered"yes"t question in Section E the system is consic red a significant threat, or answered "yes" in S 'on D above the large system has failed. The owner or operator of any large system considers significant threat under Section E or failed under Section D shall upgrade the system in accor nce with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 17 I Commonwealth I h of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 163 Summer St. Property Address Fay Owner Owner's Name information is required for North Andover MA 01949 October 5, 2012 every page. Cityrrown 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 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): 3 Number of bedrooms (actual). 3 DESIGN flow based on 310 CMR 15.203 for example: 110 d x#of bedrooms 330gpd ( P 9P ) t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 163 Summer St. Property Address Fay Owner Owner's Name information is required for North Andover MA 01949 October 5, 2012 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Owner and town Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ® Yes ❑ No Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d private well 9 ( Y 9 (gP ))� Detail: 6 /' Sump pump? ❑ Yes ® No Last date of occupancy: Current Date ommercial/Industrial Flow Conditions: Type o tablishment: Design flow(base 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/pe s/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank ❑ Yes ❑ No I Non-sanitary wa Ischarged to the Title 5 system? ❑ Yes ❑ No Water me er readings, if available: t5ins•11/10 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System• 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 163 Summer St. Property Address Fay Owner Owner's Name information is required for North Andover MA 01949 October 5 2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occ /u Date ✓.- Other(describe below): ' General Information Pumping Records: Source of information: Last pumped a year ago. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: No need at this time 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-11110 Title 5 Official Inspection Forth: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 °w 163 Summer St. Property Address Fav Owner Owner's Name information is required for North Andover MA 01949 October 5, 2012 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: Septic tank is the same age as the home. The d-box and the leaching field are from 1974-38 years old. 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.): Main line is 4"cast iron. Main line and joints are in good condition with no signs of any problems. Septic Tank(locate on site plan): �j Depth below grade: 15"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) Precast round concrete- 1000 gallons If t Is mea, �r ,,— eMj�s Is Irmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes o Dimensions: 5' Deep x 6' round Sludge depth: 1" t5ins•11/10 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 163 Summer St. Property Address Fay Owner Owner's Name information is required for North Andover MA 01949 October 5, 2012 every 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 34" 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 15 How were dimensions determined? sticks and 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 septic tank and baffles are in very good condition. The solids in the tank are very light. The liquid in the tank is running at it's correct working heigth. The tank does not require pumping at this time. Grease Trap(locate on site plan): Q Dep elow grade: feet Material of co ruction: ❑ concrete etal ❑ fiberglass ❑ ethylene ❑ other(explain): Dimensions: Scum thickness Distance from to scum to top of outlet tee or baffle Distance om 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 a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 163 Summer St. Property Address Fay Owner Owner's Name information is North Andover MA 01949 October 5, 2012 required for every page. Cillylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on p inip'm.g recommendations, inlet and outlet tee or baffle condition, structural integrity, PY liquid levels as related to7tlet invert, evidence of leakage, etc.): y,... Ti ht or Holding Tank(tank must be pumped at time of inspection) (locate on site"plan): �D Depth b ow grade: Material of co ruction: ❑ concrete metal ❑ fiberglass ❑ polyethylene ❑ other"(explain): i' Dimensions: Capacity: gallons j Design Flow: gallons r day Alarm present: Yes ❑ No Alarm level: Alarm i orking order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and at switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 ' Commonwealth of Massachusetts 4 Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 163 Summer St. Property Address Fay Owner Owner's Name information is North Andover MA 01949 October 5, 2012 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): 1 " Depth of liquid level above outlet invert Zero �l 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.): The d-box is 1' below grade and is 14"x 21". it is structually sound and level. The liquid in the d-box is running at it's correct working heigth. The soil in this area is clean and dry with no signs of any problems. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ElYes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): L Soil Absorption System (SAS) (locate on site plan, excavation not required): 7 If SAS not located, explain why: S.A.S. was located by d-box and level area of yard and owners knowledge. a t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 163 Summer St. Property Address Fay Owner Owner's Name information is required for North Andover MA 01949 October 5, 2012 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: ® leaching fields number, dimensions: 1 -20' x 40' ❑ 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.): The S.A.S. is in very good condition with no signs of any problems. The soil in this area is clean with no signs of ponding or breakout. This 4x- w—o—r r cat vz &VC11 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 D� 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 W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form Not for Voluntary Assessments w 163 Summer St. Property Address Fay Owner Owner's Name information is required for North Andover MA 01949 October 5, 2012 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.): i (� Privy(locate on site plan): v Materials struction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic ur , vel of ponding, condition of vegetation, etc.): I i t5ins•11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 163 Summer St. Property Address Fay Owner — In is requiredaired for North Andover MA 01949 October 5, 2012 for. every page. City/Town 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 o the bo es below: ® hand-sketch in the are Blow ❑ drawing attached separa ly a- l 0 pl� 0.1 3 'c T�.r+lC 3`1 A tvD ?o Clots` t5ins•11/10 'le 5 Official Inspect' �orm:Subsu�rfaweSew—age Disposal System prop6r j .p,-a1.I G w G ' �a.— M ` + Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 163 Summer St. Property Address Fay Owner Owner's Name information is required for North Andover MA 01949 October 5, 2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope Gr-a_du&( ® Surface water P ^e- ® Check cellar tc-Li ® Shallow wells KDo A-AL- 6' plus below grade Estimated depth to high ground water: 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: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: No info on this property on file. ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: This house sits on a higher elevation than the property that sits directly behind it. 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 163 Summer St. Property Address Fay Owner Owner's Name information is required for North Andover MA 01949 October 5, 2012 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-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 RECEIVE® ' OCT 'IF, 201z . � FILE#�hd I0s/1) `Tyr l - Lout-)dry V INSPECTI®1_VS Dean G.Luscomb II&Sons P.O.Box 135 Middleton,MA 01949 978-7744065 Licensed Plumber#20285 SUBSURFACE SEWAGE DISPOSAL SYSTEM WSECTION FORM PROPERTY OWNERS NAME P PROPERTY ADDRESS ) 'O?) -7 U,YY)me r )� A ADDRESS OF OWNER(if different) DATE OF INSPECTION 00-in h(_r S Q L NAME OF INSPECTOR 1 e Q h CD, LLL-s aD rn V) QUALITY IS NUMBER ONE TO US. t i RECEIVED Commonwealth of Massachusetts ti Title 5 Official Inspection Form '�. OCT 16 2012 Subsurface Sewage Disposal System Form -Not for Voluntary AssessmTnts TOWN OF NORTH ANDOVER HEALTH DEPARTMENT M 163 Summer St. Property Address Fay � t Owner Owner's Name information is required for North Andover MA 01949 October 5, 2012 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: When filling out A. General Information forms on the computer, use 1. Inspector: only the tab key to move your Dean G. Luscomb II cursor-do not Name of Inspector use the return key. Dean G. Luscomb II & Sons Company Name P.O. Box 135 Company Address Middleton MA 01949 City/Town State Zip Code 978-774-4065 S1848 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 �- �`% October 5, 2012 Inspe6jis Signature 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•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 163 Summer St. Property Address Fay Owner Owner's Name information is required for North Andover MA 01949 October 5, 2012 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: ChecI(3B,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: 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 163 Summer St. Property Address Fay Owner Owner's Name information is North Andover MA 01949 October 5, 2012 required for 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): i ❑ 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•11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 163 Summer St. Property Address Fay Owner Owner's Name information is required for North Andover MA 01949 October 5, 2012 every page. City/Town 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 '/2 day flow t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 163 Summer St. Property Address Fay Owner Owner's Name information is North Andover MA 01949 October 5, 2012 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No o ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: . I� ❑ ® 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. i ❑ ® 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 ign flow of 10,000 gpd to 15,000 gpd. -� For large s ems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Se " n D. Yes No ❑ ❑ the system I 'thin 40 of a surface drinking water supply ❑ ❑ the syst within 2 et of a tributary to a surface drinking water supply ❑ ❑ e system is located in a nitro sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone I a public water supply well If you a answered "yes"to any question in Section E the sys is considered a significant threat, or answered "yes" in Section D above the large system has failed. T wrier or operator of any large system considered a significant threat under Section E or failed under Se ' n D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contac a 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 163 Summer St. Property Address Fay Owner Owners Name information is North Andover MA 01949 October 5, 2012 required for every page. Cityrrown 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? ® F-1information 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): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330gpd t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 163 Summer St. Property Address Fay Owner Owner's Name information is required for North Andover MA 01949 October 5, 2012 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Owner and town Number of current residents: Does residence have a garbage grinder? ❑ Yes ® 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 d private well 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of lishment: Design flow(based on CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/s . etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Titl system? Yes ❑ No Water meter readings, if avail -le: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 163 Summer St. Property Address Fay Owner Owner's Name information is required for North Andover MA 01949 October 5, 2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) L ate of occupancy/use: Date --� Other(describe below): General Information Pumping Records: Source of information: Last pumped a year ago. Was system pumped as part of the inspection? /°t El Yes ® No If yes, volume pumped: � J gallons How was quantity pumped determined? Reason for pumping: No need at this time Type of System: ® Septic tank, distribution box, soil absorption system N 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 Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 163 Summer St. Property Address Fay Owner Owner's Name information is required for North Andover MA 01949 October 5, 2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Septic tank is the same age as the home. The d-box and the leaching field are from 1974-38 years old. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): / Depth below grade: 25 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.): Main line is 2"cast iron. Main line and joints are in good condition with no signs of any problems. Septic Tank(locate on site plan): 0 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: Sludge depth: t5ins•11/10 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 s. 163 Summer St. Property Address Fay Owner Owner's Name information is North Andover MA 01949 October 5, 2012 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) r1 Septic Tank(cont.) V Distance from top of sludge to bottom of outlet tee or baffle � Scum thickness i Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap(locate on site plan): PIX Depth below grade: feet v 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 li Date of last pumping: Date t5ins•11/10 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 163 Summer St. Property Address Fay Owner Owner's Name information is North Andover MA 01949 October 5, 2012 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.): i *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 Commonwealth of Massachusetts u Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 163 Summer St. Property Address Fay Owner Owner's Name information is required for North Andover MA 01949 October 5, 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 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): V 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 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 163 Summer St. Property Address Fay Owner Owner's Name information is North Andover MA 01949 October 5, 2012 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: 0 ❑ leaching pits number: El leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): / Number and configuration 1 -primary Depth—top of liquid to inlet invert unknown Depth of solids layer unknown Depth of scum layer unknown Dimensions of cesspool unknown Materials of construction a pit of stone Indication of groundwater inflow ❑ Yes ® No t5ins•11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w� ,.•'� 163 Summer St. Property Address Fay Owner Owner's Name information is required for North Andover MA 01949 October 5, 2012 every page. Cityfrown 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.): It was indicated to me that at the end of the 4" PVC line from the house to the laundry there is a pit filled with stone that the laundry water dumps into Privy(locate on site plan): Materials onstruction: Dimensions Depth of solids Comments(note condition of soil, signs r failure, level of ponding, condition of vegetation, etc.): i t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 • Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4 M 163 Summer St. Property Address Fay Owner Owner's Name information is North Andover MA 01949 October 5, 2012 required for every page. CityrFown 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 57k t,.,w drawing attached separately /6.3 S�am.>Lersi< Nr A�olovcl 3ac�.o��I•basc. S� ti to V a' S s ft4- t5ins•11/10 �.-� rG p a 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 163 Summer St. Property Address Fay Owner Owner's Name information is North Andover MA 01949 October 5, 2012 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope G—rvLdttrJ ® Surface water ® Check cellar 1)rit St._'p Isar-%p ® Shallow wells PO^c- Estimated depth to high ground water: 6' plus below grade 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: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: No info on this property on file ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: This house sits on a higher elevation than the property that sits directly behind it. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11110 Tide 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 wM V•,a 163 Summer St. Property Address Fay Owner Owner's Name information is North Andover MA 01949 October 5, 2012 required for every page. City/Town 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 i I I i t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 I • 1 ,1 C+h'7 rrl 4-�.4 APPLICATION FOR SEWAGE DISPOSAL INSTALLATION HEALTH DEPARTMENT - NORTH ANDOVER, MASS. I hereby make application for a permit for a sewage disposal installation at -?, 4P:- '-;;�. . I will install this system in ac- cordance with all the laws of the Commonwealth of Massachusetts and regulations of the Board of Health of the Town of North Andover. Further, I will construct the house sewer of bell and spigot pipe, the minimum diameter being 4 inches, and will maintain a minimum grade of 1/ until 10 feet pre- ceding the septic tank, where the grade shall not exceed 2%. I will install a con- crete septic tank of /a o o r in size. A manhole (s) permitting easy cleaning will.be provided with remova lecover (s) of iron or concrete within 12 inches of the ground surface. I will provide subsurface disposal field with 4 inch perforated or open jointed pipe and laid in a series of trenches, the bottom of which will pro- vide a minimum of f D lineal (zgnaxe) feet of effective absorption area. The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar material to a height of 2 inches above the crown of the pipe. The joints of these -pipes will be protected from clogging and before filling the trench, 2 inches of gravel or stone 1/8" to 1/4" (dia.) will be placed over the course gravel or stone. The disposal field will be installed at a grade of 4 to 6 inches/100 .feet. No single tile line will exceed 100 feet in length and in any case, two lines of tile will be installed. A minimum of 6 feet will be maintained between the center lines of the disposal field trenches and the average depth of trench shall not exceed 36 inches. No part of the installation will be less than 100 feet from any private water supply, 25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line. I further agree not to cover any portion of this installation until approved by the inspection officer, as provided below, and to incorporate any additional requirements that may be attached to the permit. Plot Plans must be submitted with application. DATE � � 6 ' Signature of A` licant I hereby issue the above permit for the Board of Health of the Town of North Andover, Massachusetts. DATE �.�-,>. �i �1 4 Signature of Health Agent I have inspected the uncovered' system indicated above and find everything done as described. f zJ�1 6 ' DATE j r Signature of n pecting Officer r. Percolation Test !k? Garbage Grinder IV16 BOARD OF HEALTH OF NORTH ANDOVER, MASSACHUSETTS SEWAGE DISPOSAL DATE NAME OF APPLICANT-;cank p 2a LOCATION Sumnjer 'St' Address of lot no. BUILDING: Dwelling x Other SYSTEM: New X Repair GENERAL DESCRIPTION OF LAND T412h SUBSOIL: Clay Gravel_ Sand PERCOLATION TEST 6 minutes per inch. - - - - - - - - - - - - - - - - - MINIMUM INSTALLATION RECOMMENDATIONS CONCRETE SEPTIC TANK 1,000 gallon capacity. LEACH FIELD lu"0 lineal feet of drain pipe. William J. grscoll , Engin er Board of Health i I e / vn:; {. I BOARD OF HEALTH TOWN OF NORTH ANDOVER, MASS. e. -30 0 4-5" �-- 7 -� } 1. NAME , DATE 2. ADDRESS . S, I LOT NO. TEL. 3. NO. OF BEDROOMS DEN YES NO 4. GARBAGE GRINDER YES NO 5. SHOW DIMENSIONS OF HOUSE b. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES 7. SHOW DIMENSIONS OF LOT 8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL 9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM 10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC. 11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY.