HomeMy WebLinkAboutMiscellaneous - 166 REA STREET 4/30/2018 (2) `_�� i �..0�,r���. _� j„, I �� i i '�' �� 4 . _ 9 � L� Lot & Street -z& Map/Parcel 8 X02 r CONSTRUCTION APPROVAL Has plan review fee been paid YES NO Permit# &6 Plan Approval: Date: 9��z (�/ Approved by:.-,'J-JJ Designer:/y�!_ yo�,s6DCb Plan Date: /l 6 Conditions: Water Supply: < Town Well Well Permit: Driller: Well Tests: Chemical Date Approved Bacteria I Date Approved Bacteria II Date Approved Plumbing Sign-Off: Wiring Sign-off: Comments: Form "U" Approval: Approval to Issue: YES NO Date Issued By: Conditions: Final Approval: All Permits Paid? YES NO Well Construction Approval? YES NO Septic System Construction Approval? YES NO Certification? YES NO Other? YES NO Any Variance Needed? YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: APPROVED BY: l SEPTIC SYSTEM INSTALLATION CONDITIONS: Is the installer licensed? WESW NO Type of Construction: REPAIR New Construction: Certified Plot Plan Review —YES--- Floor -YES --Floor Plan Review E, - NO---- Conditions of Approval from Form U -E: - ------NO— Issuance of DWC permit: NO DWC Permit Paid? NO DWC Permit# Installer: Begin Inspection: YES O Excavation Inspection: Needed: kk Passed: By: r �� Construction Inspection: Needed: As Built Plan Satisfactory: YES: Approval of Backfill: Date: By: Final Grading Approval: Date: By: Final Construction Approval: Date: By: Certificate of Compliance: Approval: Date: Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 166 REA STREET Property Address CHARLENE HART Owner Owner's Name information is required for every N. ANDOVER MA 01845 05/01/14 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 A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not John J. Soucy use the return Name of Inspector key. Soucy's Sewer Service, Inc. VQ Company Name 78 North Broadway Company Address Salem NH 03079 City/Town State Zip Code 603-898-9339 13397 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 ❑gNher Evaluation by the Local Approving Authority 05/01/14 nsre Date Thpector 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 1 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 166 REA STREET Property Address CHARLENE HART Owner Owner's Name information is N. ANDOVER MA 01845 05/01/14 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 t Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 166 REA STREET Property Address CHARLENE HART Owner Owner's Name information is required for every N. ANDOVER MA 01845 05/01/14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 166 REA STREET Property Address CHARLENE HART Owner Owner's Name information is N. ANDOVER MA 01845 05/01/14 required for 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 '/z day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 166 REA STREET Property Address CHARLENE HART Owner Owner's Name information is required for every N. ANDOVER MA 01845 05/01/14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection El 1:1 the —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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 166 REA STREET Property Address CHARLENE HART Owner Owner's Name information is required for every N. ANDOVER MA 01845 05/01/14 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previious two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 166 REA STREET Property Address CHARLENE HART Owner Owner's Name information is required for every N. ANDOVER MA 01845 05/01/14 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: See Attached Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 -6" -- Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 166 REA STREET Property Address CHARLENE HART Owner Owner's Name information is N. ANDOVER MA 01845 05/01/14 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: CURRENT Date Other(describe below): General Information Pumping Records: Source of information: BATESON ENTERPRISES INC Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: MAINTENANCE Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 166 REA STREET Property Address CHARLENE HART Owner Owner's Name information is required for every N. ANDOVER MA 01845 05/01/14 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: 2001 - 13 YEARS Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 12 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: n/a feet Comments (on condition of joints, venting, evidence of leakage, etc.): ALL TRUE Septic Tank (locate on site plan): Depth below grade: 18"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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 166 REA STREET Property Address CHARLENE HART Owner Owners Name e information is required for every N. ANDOVER MA 01845 05/01/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 37" Scum thickness 2 Distance from top of scum to top of outlet tee or baffle 7" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Tape and sludge tool Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.).- PUMP tc.):PUMP TANK EVERY YEAR Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 166 REA STREET Property Address CHARLENE HART Owner Owner's Name information is N. ANDOVER MA 01845 05/01/14 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ' Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 166 REA STREET Property Address CHARLENE HART Owner Owner's Name information is N. ANDOVER MA 01845 05/01/14 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 11 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.): FLOW CHECKED GOOD, BOX WATER TIGHT E Pump Chamber(locate on site plan): Pumps in working order: ® Yes ❑ No* Alarms in working order: ® Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 166 REA STREET Property Address CHARLENE HART Owner Owner's Name information is required for every N. ANDOVER MA 01845 05/01/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: El leaching its number: 9p ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 20'X45' ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): NO SIGN OF HYDRAULIC FAILURE t 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•3113 Title 5 Official Inspection Form: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 M 166 REA STREET Property Address CHARLENE HART Owner Owner's Name information is required for every N. ANDOVER MA 01845 05/01/14 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.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form N Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r� 166 REA STREET Property Address -- — —— -- - CHARLENE HOME _ Owner Owner's Name -- ------ – information is required for every N. ANDOVER _ MA 01845_ 05/01/14 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 of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately 3'00:00 I i rq 151,0 GrLLOtJ +MARK: SPIKE !N 12WSPLE -SEPTIC TANK Li.Eb' .-32_00 (ossur,edj .� U i 5 {o �10 I =� Moa N p J � WAV PFESSURC -PT 2 WATERUNE j I �._ L i E �ir.P. EKOHK1: .OF R10F I 1C'-----._.-. STEP. ELEV 100.00 (oss Pr 753 RL4 S1.2iE1 .0Pua:? ^ -1P 2 To -8 ASSES ASSESSOP.c y7 .9h. Loi ![ .4 47 .U. <'TO�-BOa �5s.� LUIT JF SAND1 TC H 133.4 -.. 11. ?i0 H ❑ r81.2' -VENT T 300.CIO' I i II t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' M 166 REA STREET Property Address CHARLENE HART Owner Owner's Name information is required for every N. ANDOVER MA 01845 05/01/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 4 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: 9/2001 Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: DUG HOLE WITH AUGER RIGHT REAR CORNER. NO WATER AT 4.5' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 166 REA STREET Property Address CHARLENE HART Owner Owner's Name information is required for every N. ANDOVER MA 01845 05/01/14 page. CityrTown 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 1 Summary Record Card generated on 4/29/2014 2:19:23 PM by Maureen McAuley Page 1 Town of North Andover Tax Map # 210-098.A-0012-0000.0 Parcel Id 14876 166 REA STREET HART, JEFF & CHARLENE 166 REA STREET NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.04 Acres FY 2014 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until HART,JEFF&CHARLENE Payor 166 REA STREET NORTH ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/inactive Bldg Id. 14036.0-166 REA STREET Last Billing Date 3/6/2014 2100498 02 Cycle 02 Active UB Services Maint. Account No.2100498 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.636/8 7.82 1/ ti 0 r c t WTR WATER 01 ALL METER SIZE 178.76 /1 UB Meter Maintenance Account No.2100498 Serial No Status Location BrandType Size YTD Cons 16337058 a Active ERT METE METE w Water 0.63 0.63 632 Date Reading Code Consumption Posted Date Variance 2/6/2014 1401 a Actual 39 3/17/2014 71% 10/31/2013 1362 a Actual 21 12120/2013 7% 8/2/2013 1341 a Actual 20 9/18/2013 -8% 5/2/2013 1321 a Actual 20 6/18/2013 -36% 2/6/2013 1301 a Actual 36 3/13/2013 66% 10/31/2012 1265 aActual 19 12/13/2012 -28% 8/6/2012 1246 a Actual 28 9/26/2012 22% 5/7/2012 1218 a Actual 23 6/20/2012 -56% 2/6/2012 1195 a Actual 55 3/14/2012 127% 11/2/2011 1140 aActual 23 12/15/2011 0% 8/3/2011 1117 a Actual 23 9/14/2011 -9% 5/4/2011 1094 a Actual 25 6/13/2011 -27% 2/3/2011 1069 a Actual 36 3/15/2011 20% 11/1/2010 1033 aActual 28 12/13/2010 _18% 8/5/2010 1005 a Actual 36 9/13/2010 53% 5/4/2010 969 a Actual 23 6/9/2010 -26% 2/2/2010 946 aActua1 31 3/11/2010 41% 11/3/2009 915 aActual 22 12/11/2009 -4% 8/4/2009 893 aActual 23 9/11/2009 -8% 5/5/2009 870 a Actual 25 6/16/2009 4% 2/3/2009 845 a Actual 24 3/16/2009 4% 11/4/2008 821 aActual 23 12/10/2008 .20% 8/5/2008 798 a Actual 29 9/12/2008 29% 5/5/2008 769 a Actual 23 6/18/2008 -35% 2/1/2008 746 aActual 34 3/14/2008 -3% 11/2/2007 712 aActual 34 1/15/2008 -18% 8/6/2007 678 a Actual 43 9/14/2007 44% 5/7/2007 635 a Actual 23 6/22/2007 -5% 2/26/2007 612 a Actual 40 3/23/2007 19% e � y Bateson Enterprises Inc. 111 Argilla Road Andover, MA 01810 (978)475-4786 Invoice Mr. Jeff Hart 166 Rea Street North Andover MA 01845 Invoice INVOICE # DESCRIPTION WORK DATE AMOUNT PAID 21227 1500 gals. Septic Tank Pumped 10/14/2013 230.00 0.00 Invoice Totals: 230.00 Total Paid: 0.00 Total Due: 230.00 NEW ENGLAND ENGINEERING SERVICES INC February 6, 2006 Ms. Susan Sawyer North Andover Board of Health 400 Osgood Street North Andover, MA 01845 RE: TITLE V REPORT: 166 Rea Street North Andover,MA Dear Ms. Sawyer: Enclosed is the Title 5 Report for the above referenced property. The system PASSES the inspection. If there are any questions please call me at my office, 686-1768. Sincerely, cam`-, C Benjamin C. Osgood, 7r Certified Title 5 Inspector 60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(9 78)685-1099 11 of 11' COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 166 Rea Street North Andover,MA 01845 Owner's Name: Charlene Hart Owner's Address: 166 Rea Street North Andover,MA 01845 Date of Inspection: February 7,2006 Name of Inspector:(please print) Benjamin C.Osgood,Jr.Certified Title 5 Inspector Company Name: New England Engineering Services Inc. Mailing Address: 60 Beechwood Drive North Andover,MA 01845 Telephone Number. 978-686-1768 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of the on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15340 of Title 5(3 10 CMR 15.000).The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 7 LN� The system inspection shall submit a copy of this'inqvmon report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 2 of It OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 166 Rea Street North Andover,MA 01845 Owner's Name: Charlene Hart Date of Inspection: February 7,2006 Inspection Summary: Check A,B,C,D or VALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that arty 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. Answer yes,no or not determined(Y,N,ND)in the 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. ND explain: 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 Obstruction is removed Distribution box is leveled or replaced ND explain: 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 Obstruction is removed ND explain: , 3ofit OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 166 Rea Street North Andover,MA 01845 Owner's Name: Charlene Hart Date of Inspection: February 7,2006 C. Further Evaluation is Required by the Board of Health: IV 0 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 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 (SAS)Soil Absorption System and the(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 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 coliform bacteria and volatile organize compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5ppm,provided that no other failure criteria are triggered A copy of the analysis must be attached to this form. 3. Other: 4of'11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 166 Rea Street North Andover,MA 01845 Owner's Name: Charlene Hart Date of Inspection: February 7,2006 D. System 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 overload or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overload or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any Portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply ✓ 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. r/ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (this system passes if the well water analysis,performed at a DEP certified laboratory for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrogen is equal to or less than 5ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form:) 7_ (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following- (Me ollowing(The followhi&criteriia apply to large systems in addition to the criteria above) Yes No The system is 400 feet of a surface drinking water supply The system is within 20 t of a tributary to a surface water supply The system is located in a nitrogen itive Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you answered"yes"to any question in on E the system is consi a significant threat,or answered"yes"in Section D above the large system has failed Th er or operator of any large system const a significant threat under Section E or failed under Section D shall upgrad system in accordance with 310 CMR 15.304. The syst owner should contact the appropriate regional office of the D ent. I d 5ofIt OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 166 Rea Street North Andover,MA 01845 Owner's Name: Charlene Hart Date of Inspection: February 7,2006 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 an inspection? 1z 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 sign of break out? Were all system components,excluding the SAS,located on site? Were all the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the / baffies or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if difference from owner)provided with information on the proper maintenance of the subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No 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) [3 10 CMR 15.302(3)(b)] 6of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 166 Rea Street North Andover,MA 01845 Owner's Name: Charlene Hart Date of Inspection: February 7,2006 FLOW CONDITIONS RESIDENTIAL 3 Number of bedrooms(design) : Number of bedrooms(actual): DESIGN flow based in 310 CMR 15.203(for example: 110 gpd x #of bedrooms): 3 UP D Number of current residents: f Does residence have a garbage grinder(yes or no) y E5 Is laundry on a separate sewage system(yes or no): N`n/V n [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): A[Q_ Water meter readings,if available(last 2 years usage(gpd): 2 3 cn Sump Pump (yes or no): Nc2 Last date of occupancy c rre x COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgk etc Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no) Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: N D1' Pu Al FE 0 S t•nice- zoo/ Was system pumped as part of the inspection(yes or no): Apo If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ( Septic tank, distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attached a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected wen arriving at the site(yes or no): f 0 . I •7ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 166 Rea Street North Andover,MA 01845 Owner's Name: Charlene Hart Date of Inspection: February 7,2006 BUILDING SEWER(locate on site plan) �v Depth below grade: Materials of construction: ✓ cast iron 40 PVC other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): PI PC wnol4s G0oo /A./ SEPTIC TANK: ,._ (locate on site plan) Depth below grade: 0 Material of construction concrete metal fiberglass polyethylene Other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: !SG o &)I-LL-0 N S Sludge depth: 11 Z Distance from top of sludge to bottom of outlet tee or baffle: .3 3 Scum thickness: 2 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle !3 How were dimensions determined: "c---4_so 2 e s-72C X Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): TANK IAJ &r�C C(Ty P)—(70 -po( —lFe /k", &Vt o CIbaile17c?,-/ �ecanne.nD rivsTA-Ll./�`')j oni r7F r2r,SEls 'Tc wig/�• [� '" yr— �tiVrsN U2WOG GREASE TRAP: .L_9 (locate on site plan) Depth below grade: Materials of construction: concrete metal fiberglass polyethylene other (explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffie: Distance from bottom of sludge to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition structural integrity,liquid levvels as related to outlet invert,evidence of leakage,etc. , 8 of It OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 166 Rea Street North Andover,MA 01845 Owner's Name: Charlene Hart Date of Inspection: February 7,2006 TIGHT OR HOLDING TANK: IVA (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Materials of construction: concrete metal fiberglass polyethylene other (explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:_ Comments(note if box is level and distribution to outlets equal,any evidnence of solids carryover,any evidence of leakage into or out of box,etc.): f3ox iN P 1Z0n. .v19 Cv c^!ct-7 t>F Al eve P�tl f f PUMP CHAMBER: (locate on sire plan) Pumps in working order(yes or no) � Alarms in working order(yes or no) �S Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Po (ti/ wQIZM l t Cr 2D E7 9 of-11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 166 Rea Street North Andover,MA 01845 Owner's Name: Charlene Hart Date of Inspection: February 7,2006 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required If SAS not located explain why TYPE leaching pits number leaching chambers, number leaching galleries number leaching trenches,number in length ✓ leaching fields,number,dimensions: 2C X Lis` overflow cesspool,number: innovativelalternative system Typetname of technology: Comments(note condition of soil,signs of hydraulic failure.Level of ponding,damp soil,condition of vegetation,etc) free' c)Y 1—�/Fe-D K S N p 2 -ti 42 NO PC) n�,Ma' sa �, 0�2 ;���s�A-� �,�E�c='�9--i"�a,✓. 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 or no) Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: locate on site plan) •�( P ) Material of construction: Dimensions: Depth of solids Comments(note condition of soil signs of hydraulic failure,level of ponding,condition of vegetation,etc. I ' . • 10 of•i l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 166 Rea Street North Andover,MA 01845 Owner's Name: Charlene Hart Date of Inspection: February 7,2006 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. PNcF5 �f Z- 27.b T z t f 11 of-11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 166 Rea Street North Andover,MA 01845 Owner's Name: Charlene Hart Date of Inspection: February 7,2006 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record—If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health—explain: Checked with local excavator,installers—(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: S�IsrC,M Pe,S:c riti,y W tq3oae wA-5!L i Town of North Andover � N°RTHq Office of the Health Department Community Development and Services Division # go s ;; 27 Charles Street North Andover, Massachusetts 01845 "SSRCNU`+E` Sandra Starr Telephone(978)688-9540 Health Director Fax(978)688-9542 040! r 01',1 TOWN OF NORTH ANDOVER p Y" ' `k r F,.Fa BOARD OF HEALTH AN �- CERTIFICATE OF COMPLIANCE �' � ,;r f�Yw� M1 DATE OF COMPLIANCE k 10/25/2001 This is to certify that the individual subsurface disposal system constructed ( ) or repaired (X) by John Soucy at 166 Rea Street has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. oard of Health I pector BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 NURSE 688-9543 PLANNING 688-9535 v<w , 12, Ca t = t t TOWN-- Or NOR,'rH ANDOVER SMVAGF, DISPOSAI: S) s`�'E�,z I_STALLA-rioN CE• RTu-iGATION , The under sig';ed here'Ov ceriiv that the S cwa2e Disposal System { ) coast;'Ict�d- (1C) repa.ired: by — located at ) R E-t• 5-- e e; -- --- -- was installed in cOntcrmance with the No-th And-over Board of die:ith afprovea plan, Svsteri Desi,-,n Permdt dated with. an ir;croved design 11ow ot" gailons per day The materli a?s.usea; were in conformancz- %vit`s those specined on the approved- plan; the syste*n was installed in accordar:ce :,.ith the previsions of 310 CNfR 15.000, Title 5 and local r etilatiors, and the final Qradicg agrees .- substantially V`zth the approved plan. d work ;s accurateiv reoresented ;)r, the As-built vl-dch has been submitted to the Board c:Health. Bed inspection •date: Io p w — - P, — Engineer R:or, s, efn:auve. Final inspecuon tate: _-- E-ntzir«eer Represe^tat:%:e Cnsta"er: ?? Date: _ /q7jS-01 LesiVTn EnQ ;eer: — _ Date /e/MW. oma/ RICHARD 1 C. TANGARD MAL OCT 2 42001 I TOWN N OA NORTH ANDOVER HEALTH DEPARTMENT 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01845 gACNUSE Sandra Starr Telephone(978)688-9540 Public Health Director FAX(978)688-9542 i ' September 17, 2001 Robert & Shirley Vanasse 166 Rea Street North Andover, MA 01845 Re: septic plan approval i Dear Mr. &Mrs. Vanesse: This letter comes as a confirmation that the proposed septic system plans dated 9/11/01 for the repair of the system at 166 Rea Street,North Andover have been approved. Accompanying this letter is a completed Design Approval Form#1163. Please do not hesitate to call me at 978-688-9540 should you have any questions. i Sincerely, Sandra Starr, R.S., C.H.O. Health Director Cc: B. Osgood, Jr. File Form No.3 Town of North Andover, Massachusetts BOARD OF HEALTH NORTH Of t+�'O e,•tip � O � F p DISPOSAL WORKS CONSTRUCTION PERMIT 1SSACHUSEt Applicant ADDRESS TELEPHONE NAME Site Location Permission is hereby granted to Construct ( ) or Repair�n Individu I Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. p CHAIRM N, BOARD OF HEALTH D.W.C. No. Fee j I I I BOARD OF HEALTH NORTH ANDOVER, MA 01845 978-688-9540 APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: 9 -- ,Q�—p� CURRENT INSTALLER'S LICENSE# LOCATION: LICENSED INSTA ER: 0 LkL . SIGNATURE: TELEPHONE# -7 —S7iC 7' CHECK ONE: ( - dr REPAIR: NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUILT. Administrative Use Only $160.00 Fee Attached? Yes No Foundation As-Built? Yes No Floor Plans? Yes No Approval Date: 28 , .a.. INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the property at �1�� T , relative to the application of &S00240 C00'iaied—el1 ^O( for plans by A&I and i dated –/ ^O with revisions dated � " t ( "<-1 I understand the following obligations for management of this project: 1. As the installer I am obligated to call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system is not ready then item two shall be applicable. i 2. As the installer I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Tile 5 and the Board of Health Regulations may result in a$50.00 fine being levied against my company. a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As-built or verbal OK from engineer must be. submitted to Board of Health, after which installer calls for inspection time. Installer must be present for this inspection. With pump system all electrical work must be ready and able to cause pump to work and alarm to function. c) Final Grade—Installer must request inspection when all grading is complete. Does not have to be on site. 3. As the installer I understand that persons or companies not associated with my company may not perform the work required by my company to complete the installation of the system identified in the attached application for installation. I further understand that work by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system, and/or revocation or suspension of my license in the Town of North Andover plus significant fines to all persons involved. 4. As the Installer I understand that I must be on site during the performance of the following construction steps: a) Determination that the proper elevation of the excavation has been reached. b) Inspection of the sand and stone to be used. c) Final inspection by Board of Health staff. d) Installation of tank, D-box, pipes, stone, vent, pump chamber, retaining wall and other components. 5. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Unders ed Licensed Septic Installer ZIA Date: O� Disp sal Works Co 'ruction P t# 28 � M Town of North Andover, Massachusetts Form No. 1 NORTH A- BOARD OF HEALTH 3�0,TEED GabYO 1 L Ew,= ,.. APPLICATION FOR SITE TESTING/INSPECTION 7 ADRATED PpP �h 9SSACHU5�� Applicant G C NAME ADDRESS TELEPHONE Site Location 16 e' Engineer NAME DRE55 TELEPHONE Test/Inspection Date and Time { j r-e' � CHAIRMAN,BOARD OF HEALTH Fee Test No. S.S. Permit No.�D.W.C. No. C.C. Date Plbg. Permit No. BOARD OF HEALTH -CCVVVN OF NORTH A -- NORTH ANDOVER, MA 01845 BOARD OF HEALTH, 978-688-9540 — h° F7MAY 2MI APPLICATION FOR SOIL TESTS � n DATE: ; MAP &PARCEL: LOCATION OF SOIL TESTS: 166 RVA- A) - OWNER: Roel-oz:i TEL. NO.: !3-70,— Q`3-7, 1620 a.�ase. ADDRESS: j(y i2eu /J - -4e, j-7 ENGINEER: New England Engineering Services TEL.NO.: 978-686-1768 CERTIFIED SOIL EVALUATOR: Benjamin C. Osgood. Jr. and Richard C. Tangard Intended Use of Land: Residential Subdivision 4�f.Single Family Home Commercial Is This: Repair Testing: Undeveloped lot testing: In the Lake Cochichewick Watershed? Yes No' THE FOLLOWING MUST BE INCLUDED WITH THIS FORM 1. Proof of land ownership (Tax bill, or letter from owner permitting test) 2. Plot plan & Location of Testing 3. Fee of$275.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of$75.00 per lot for repairs or upgrades. GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system disposal area. 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan(no smaller than 1"-100') shall be submitted to the Board of Health showing the location of all tests (including aborted.tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. SOWN OF NORTH ANDOVER/ Please Do Not Write Below This Line 1 BOARD OF F�EALTH � MAY 2 f 2001 N.A. Conservation Commission Approval: Date Received: Check Amount: Check Date: I ,^t yd�G�S (L..,: Y � �•'. .. x' � (N tJ rry` ..�: .'4N � � 7�'��s��'37t'�'„a�t4t�� ,+� e � ��,�'j`-' K'�i''¢. 4•s! ',1,' �S'a '• >p�'""'q v-0 ,�,,;yi" f���/_7 y/Y/. ..�. � �. 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"r••M':� :•J;rcr" �`�r:7 ':;t � .... '�: F<j�' . '.i ! 4 .:3.Y:{?.Y.••,f"i:;`•�n:,'i:; �- �f�ri�. .l�i:�,. .. .l i'., .lr ,1,Z•r A y� J. qa. V •f u •Ec- a 1 /� •3' ,1' '�' vnr;Y,t'titY i•,"' d::+.t:'• �%^ �cf �''•. : //f( ' .. /�j�•i�'�`r, ''RfCN'o"tP,• �tN:,�I:,, �r:i :?� .y[.•:(}a,4,,� "��'...� .. -. ,"'•`. •v'.,;.�ti r I I FORM 11 - SOIL EVALUATOR FORM Page I of 3 No. Date: Commonwe*th of Massachusetts Massachusetts Soil Suitabilitv Assessment,fQ—r Qn-s it &wagg Disposal Performed By: ...... ..... Date: WitnessedBy: ........... ........ . ............................................................................................... ............. tmalm Addrat or /< --17r orwr's Ut I A=04 16,6 TC N I ewConstructlon [TRepair El .0fElm Review Published Soil Survey Available: No ❑ Yes Year Published -76.1............. Publication Scale / '- Soil Map Unit--::;�/� Drainage Class PW-1) Soil Limitations 741155�71..... . ...... ..... ..... .......... Surficial Geologic Report Available: No El Yes 13 - Year Published -=....... Publication Scale GeologicMaterial (Map Unit) .................................................................................................................... ....... Landform ..........................I............................................................................................................................................................. Flood Insurance Rate Map: Above 500 year flood boundary No 0Yes M Within 500 year flood boundary No 13yes 0 Within 100 year flood boundary No 0 Yes ❑ Wetland Area: National Wetland Inventory Map (map unit) ............................................................. Wetlands Conservancy Pro&ram Map (map unit) .............................................. .................... Current Water Resource Conditions(USGS): Month / / �.. ...... Range :Above Normal []Normal IBBelc-wNormalED Other References Reviewed: DEP APPROVED FORM 12/0719S FORM 11 - SOIL EVALUATOR FORM Page 2 or 3 Location Address or Lot No. /��, ����©• ��Gl� On-site Review Deep Hole Number � Time:. J? Weathe RZV-- �/6 � ..:I .,.,. Dat ...., � Location (identify on site plan) Land Use Slope M Surface Stones . �...:...:...... Vegetation . � �> �� .,:......:.. .n.::....:.....:...: .. . .. ...:...... .....:.:.. .. ... Landform Position on landscape (sketch on the back) .. �...:. G ,. Distances from: Open Water Body/_1_34� feet Drainage way..7!41 o feet Possible Wet Area feet Property Line .3Q,.... feet Drinking Water Well>'4. "P . feet Other . .__-...777.......... DEEP OBSERVATION HOLE x.00` Depth from Soil Horizon Solt Texture Soil Color Soil Other Surface(Inches) (USDA) (Munsell) Mottling (Structure, Stones, Boulders, Consistency, Gravel) A'Z> 0 0 144 ~ g!Ps� Parent Material(geologic) 77 i3 pthtoBedrock: Depth to Groundwater: Standing Water in the Hole: cig�:9 Weeping from Pit Face: Es(imated Seasonal High Ground Water: d �� I 6 DEP APPROVED F0101• 12/07/95 �Tit�cr- FORM 11 - SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot islo.�G� On-site Review / y Deep Hole Number . .: Date;:.�,r.: l..*/ Time:.:...<.�..�`~~� Weather Location (identify on site pian) '.: y ., / -........::..v......,..r..,... v..:..,:. Land Use Slope (%) ..,:..,'-`. ... Surface Stones vegetation , ,'�.._,....,.... ....., v..,...,.... ......... ..,.....,....,... ........ . : .. Landform Position on landscape (sketch on the,back) Distances from: Open Water Body .. feet . Drainage way....:.........:. feet Possible Wet Area feet Property Line .:. feet Drinking Water Well ;��.:•�''�..Q feet, Other ....�� �....�.:... ...._...... DEEP OBSERVATION HOLE LOG` Depth from Soil Horizon. Soil Texture SoTColor, Soil Other Surface(inches) (USDA) (Munsell) Mottling (Structure, Stones, Boulders, Consistency, % Gravel) 4 Z,5 Parent Material(geologic) „�"� ` _�/L t--' DepthtoSedrock: .� Death to Groundwater: Standing Water in the Hole: Weeping from Pit Face: Es(imated Seasonal High Ground Water: i DEP APPROVED FORM•12167/95' . Location Address or Lot No. Z4� ��� �'T•, �O LAG, eterminatien for_ Serio ' Water Table Method Used: ❑ Depth observed standing in observation hole.............. . inches ❑ Depth weeping from side of observation hole.................. inches ® Depth to soil mottles ...�.:.....,,., inches ❑ Ground water adjustment .................. feet 'Z " Index Well Number .................. Reading Date ................... Index well level .................. Adjustment factor................... Adjusted ground water level Depth of Naturalfy Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in 4H areas observed throughout the area proposed for the soil absorption system? If not, what is the depth of naturally occurring pervious material? .@rtification I certify that on9!e I (date) 1 have assed the soil evaluat p or examinationapproved by thepartment of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. Signatur ��� Date DEP APPROVED FORM•12/07/95 V 7 -y 7 t �� Li.► I� . �r 111111 n111 11.n1111i le IIE! VIII 1111111l�f11►11�111111 t 111111111111 11111111111111111111 � 1l�E11111!11!_ I�III�IJ!�l�1�11���IlI!®I � !!�!� IIIIIIIIIIIlil11111111i�ii111111111 _ � � IIIIpIl11111111la111�l�I�In1i _l�1111 ��� 711111111111111111111111111111 1111 �� 1111111111�111�!l11�111�i11�11 � � IIIIIIIIIII�Ilnlrlll(1111111111111 MINE Ipit RIM. 1111C1��J1��1i111Ie1111 � � 1111111111111111111111111l1111l�1®1 1111111111111111111111111111111111 IIIIIImilli IIIIIIIIIIIIn1111111 IIIIIIIIIIIIIn1111111111111111111 1111111111111111111111111111111111 IIIIIIIIIIIIIIIIn11111111111111n 111 III 1111111111111111111111111 � In111111111111111111111111111 MIN Inn1111111III 1111111 IIIIIIIIIn111111 n111111n11 111111111111111111111 111111111111 ��� 111 IIInn111111111111111111n11 ��� iln IIIIIn111111nIn111111111n � IIIIIIn1n111111111111111111n111 Q _ qt <I• 1 � I i— r- t l_ • JII v • c�,� 111 U IIJ •l v) Iti t") 01 -> liJ U.I lIJ UJ It: t►.t I-- - r_� Z U t i 1 I.I (1 t t IJ trt - - U) Z Z I�- I— I— U- �, c , 0c�. ION 'z0 T7ii OItiI Or — t C_,NICn i .�C! r w/ (� r tltiic - 1 �66 �� t I �G.1—i Oltil mac, i: �� CIS 3 I (IVIG 1...'r :.L-��.l-�. � �`t/ l � ��.i 1�=:i � � ^I':�:.__ �C•'.' 111\,'i E .^%T IMC ` c ii i ^' Eh Homes Rea St. APPLICATION FOR SEWAGE DISPOSAL IMIALIATION HEALTH DEPARTMENT - NORTH ANDOVER, MASS. I hereby make application for a permit for a sewage disposal installation at .nt 18 Rea St. . 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 tie grade shall not exceed 2%. I will install a con- crete septic tank of Xs °regcxired in size. A manhole (s) permitting easy cleaning will be provided with removable cover (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 -0 as required lineal (square-} 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 4/14/60 Signature of Applicant I hereby issue the above permit for the Board of Health of the Town of North Andover, Massachusetts, DA TE 4/14/60 Signature of Health Agent I have inspected the uncovered system indicated above and find everything done as described.- DA 7E escribed.DATE .�,.�..� 2-� , � tr��� �` Signature of Inspe ting Officer Percolation Tes t,-*5- 5 . Garbage Grinder .1 April 16, 1960 Miss Mary Sheridan R. N. Health Agent Board of Health North Andover, Mass. Dear Miss Sheridan: An examination was made as requested in order to determine the suitability of the soil for the subsurface disposal of sewage , on the proposed Rea Street building site of Sherwood Homes, Inc. The subsoil in the area was of a sandy clay content and a 5-minute percolation test was conducted. The land in general is high. It is recommended that a 1,000 gallon concrete septic tank be installed together with 200 lineal feet of drain pipe. Very truly yours, I� William J. Dri coil WJD:hd furc BOARD OF HEALTH � -- TOWN OF NORTH ANDOVER., MASS. 160 So' 1000 62- ---- Aj I 1. NAM---.4, . . . . . . . . . . . . . . . M DATE 2. ADDRESS �:3. . . 1 0 . 1 . LOT NO�g & �•� ` TEL' . . No 3. NO. OF BEDROOMS . . . . DEN YES .amu! NO. i 4, GARBAGE GRINDER YES . . . . . N0. 5. SHOW DIIENSIONS OF HOUSE b. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES 7. SHOW DIMNSIOIZ 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 BROOKSO STPEJUS., DITCHESS LEDGE OUTCROPS ETC. 11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY.