HomeMy WebLinkAboutMiscellaneous - 167 DUNCAN DRIVE 4/30/2018 167 DUNCAN DRIVE
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SEPTIC SYSTEM INSTALLATION
IS THE INSTALLER LICENSED? YES NO
TYPE OF CONSTRUCTION: NEW REPAIR
NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW YES NO
CONDITIONS OF APPROVAL YES NO
(FROM FORM U)
ISSUANCE OF DWC PERMIT YES NO
DWC PERMIT PAID? YES NO
DWC PERMIT NO. INSTALLER: O-:!�<nOb
BEGIN INSPECTION YES 0:
EXCAVATION INSPECTION: NEEDED:
SAn)b C a vE�'iyr 0/0
PASSED BY
CONSTRUCTION INSPECTION: NEEDED:
AS BUILT PLAN SATISFACTORY: YES:
APPROVAL TO BACKFILL: DATE: �Q J BY
FINAL GRADING APPROVAL: DATE BY
FINAL CONSTRUCTION APPROVAL: DATE: ,lzl�KBY--
Commonwealth of Massachusetts 6� C�1�lEr�
City/Town of
System Pumping Record �,T; 2 2014
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use-by local Boards of Health. Other forms may'a timed;but#he
information must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. Information
1. System Location: Left i t front of hou , Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address Fft
Citylrown State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town
F
Telephone Number `3
B. Pumping Record
1. Date of Pumping Y2. Quantity Pumped:
Date Gallons
3. Type of sYs.tem: ❑ Cesspool(s) 94 pPtic Tank
Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yeas a No If yes, was it cleaned? ❑ Yes ❑ No:
' 5. Condition of Sy tem:
6. System Pumped By.-
Nell.
y:Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca' re contents were disposed:
0-l-S. Lowell Waste Water
Sign a Haul Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
6440
. o
O S-
s i
Town of North Andover
HEALTH DEPARTMENT
CHUStS
CHECK#: UO DATE: I
LOCATION:
H/O NAME: I La
CONTRACTOR NAME: no� ft
Type of Permit or License: (Check box)
❑ Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service-Type: $
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal(Septic)Hauler $
❑ Recreational Camp $
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ Trash/Solid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
�❑[ Title 5 Inspector $
/L Title 5 Report $-,510
❑ Other:(Indicate) $
Health Agent Initials
White-Applicant Yellow-Health Pink-Treasurer
Commonwealth of Massachusetts
` RECEIVED
Title 5 Official Inspection Form MAR 01 2013
Subsurface Sewage Disposal System Form- Not for Voluntary Assessment
167 Duncan Drive HEALTH DEPARTMENT
Property Address
Earle Seeley fl
Owner Owners Name
information is North Andover MA 01845 2/26/2013
required for every
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Neil James Bateson
use the return Name of Inspector
key.
Bateson Enterprises Inc.
Company Name
111 Argilla Road
_+ Company Address
Andover MA 01810
City/Town State Zip Code
978475-4786 SI-15
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
❑ eeds Further Evaluation by the Local Approving Authority
2/26/2013
Inspe o Signa a 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
y W Title 5 Official. Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,M 167 Duncan Drive
Property Address
Earle Seeley
Owner Owners Name
information is
required for every North Andover MA 01845 2/26/2013
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
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
m W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M s 167 Duncan Drive
Property Address
Earle Seeley
Owner Owner's Name
information is
required for every North Andover MA 01845 2/26/2013
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•11/10 Title 5 Official Inspection Forth: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
w167 Duncan Drive
Property Address
Earle Seeley
Owner Owner's Name
information is
required for every North Andover MA 01845 2/26/2013
page. Cityrrown 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 Y/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
M 167 Duncan Drive
Property Address
Earle Seeley
Owner Owners Name
information is
required for every North Andover MA 01845 2/26/2013
page. CityrFown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304.The system owner should contact the appropriate
regional office of the Department.
t5ins.11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
m Title 5 Official Inspection Form
}
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
° M 167 Duncan Drive
Property Address
Earle Seeley
Owner Owner's Name
information is
required for every North Andover MA 01845 2/26/2013
page. CityTrown 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?
E ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑
Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
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
w„ 167 Duncan Drive
Property Address
Earle Seeley
Owner Owner's Name
information is
required for every North Andover MA 01845 2/26/2013
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
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 Yes
9 ( Y 9 (gP ))=
Detail:
Has well for outside water usage. Well head >100'to d-box
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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 167 Duncan Drive
Property Address
Earle Seeley
Owner Owner's Name
information is
required for every North Andover MA 01845 2/26/2013
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: October 2009, owner
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1500
gallons
'How was quantity pumped determined? Measure tank
Reason for pumping: Inspect tank&tees
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 Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
167 Duncan Drive
Property Address
Earle Seeley
Owner Owner's Name
information is
required for every North Andover MA 01845 2/26/2013
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:
Tank original, d-box&trenches installed 7/2/1995, as bult plan
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.3
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.):
4" Cast iron through wall, 3" PVC in house, no leaks
Septic Tank(locate on site plan):
Depth below grade: .3feet
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: 10'x 5'x 4'
Sludge depth:
4"
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Titles Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 167 Duncan Drive
Property Address
Earle Seeley
Owner Owner's Name
information is North Andover MA 01845 2/26/2013
required for every
page. Citylrown 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
24"
3..
Scum thickness
Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom of outlet tee or baffle
17"
How were dimensions determined? Tape measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumped septic tank. Inlet tee clogged, cleaned same. Inlet tee ok. Outlet tee ok.Depth of
liquid at outlet invert. No evidence of leakage.
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-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
w„ 167 Duncan Drive
Property Address
Earle Seeley
Owner Owner's Name
information is
required for every North Andover MA 01845 2/26/2013
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•11/10 This 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
;M 167 Duncan Drive
Property Address
Earle Seeley
Owner Owner's Name
information is
required for every North Andover MA 01845 2/26/2013
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
q
Depth of liquid level above outlet invert
0
P
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box cover broken re laced it. D-box level &distribution equal. No evidence of
P q
leakage. Evidence of light carryover, pumped d-box to clean.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 167 Duncan Drive
Property Address
Earle Seeley
Owner Owner's Name
information is
required for every North Andover MA 01845 2/26/2013
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 4 trenches 41'
long
❑ 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.):
Snow covered lawn. No sign of ponding to surface.
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•11110 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 167 Duncan Drive
Property Address
Earle Seeley
Owner Owner's Name
information is
required for every North Andover MA 01845 2/26/2013
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•11/10 Title 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 s 167 Duncan Drive
Property Address
Earle Seeley
Owner Owner's Name
information is
required for every North Andover MA 01845 2/26/2013
page. CityTrown 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. Checkone of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
F .
n�
oa
D
!�
t5ins•11/10 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
4'M 167 Duncan Drive
Property Address
Earle Seeley
Owner Owner's Name
information is
required for every North Andover MA 01845 2/26/2013
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: 5/18/1995
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
Design plan
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
As per design plan test pit info.Ground water at 5'.
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
5 167 Duncan Drive
Property Address
Earle Seeley
Owner Owner's Name
information is
required for every North Andover MA 01845 2/26/2013
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left ight fronCouild
eft/Right rear of house, Left/right side of house, Left/
Right side of building, Le / Ig ing, Left/Rightrear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name 1
Address(if different from location)
City/Town State
Zip Code
Telephone Number
B. Pumping Record
p g d
IS
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ❑-9eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes U-90 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
fi
6. System Pumped By: VI 0 ( MCL,
Neil Bateson -�'t
F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
ncCompany
7. Locatio ere contents were disposed:
a., S. Lowell Waste Water
Sign t e Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Summary Record Card generated on 2/27/2013 10:00:05 AM by Karen Hanlon Page 1
Town of North Andover
p Tax Map # 210-104.B-0182-0000.0
Parcel Id 16504
167 DUNCAN DRIVE
SEELEY, EARLE
167 DUNCAN DRIVE
NORTH ANDOVER, MA
01845
Class 101 Single Family Property Type 1 Residential
Zoning2 1 Residential Zoning3 1 Residential
Size Total 1 Acres
FY 2013
UB Mailing Index
Name/Address Type Loan Number Active/Inact. From Until
SEELEY, EARLE Payor
167 DUNCAN DRIVE
NORTH ANDOVER,MA
01845
UB Account Maint.
Account No Cycle Occupant Name Active/Inactive
Bldg Id. 17704.0-167 DUNCAN DRIVE Last Billing Date 1/3/2013
3170375 03 Cycle 03 Active
UB Services Maint.
Account No.3170375
Service Code Rate Charge Multiplier/Users
MISCFEE ADMIN FEE 0.635/8 7.82 1/
WTR WATER 01 ALL METER SIZE 45.60 /1
UB Meter Maintenance
Account No.3170375
Serial No Status Location Brand Type Size YTD Cons
40535279 a Active ERT HH b Badger w Water 0.63 0.63 102
Date Reading Code Consumption Posted Date Variance
12/12/2012 89 a Actual 12 1/9/2013 38%
9/13/2012 77 a Actual 9 10/15/2012 -21%
6/12/2012 68 a Actual 11 7/16/2012 30%
3/14/2012 57 a Actual 9 4/14/2012 2%
12/9/2011 48 a Actual 8 1/17/2012 -25%
9/13/2011 40 a Actual 12 10/13/2011 -6%
6/7/2011 28 a Actual 12 7/20/2011 45%
3/7/2011 16 a Actual 8 4/13/2011 -19%
12/8/2010 8 a Actual 8 1/12/2011 -100%
9/27/2010 0 n New Meter 0 10/15/2010 -100%
9/27/2010 784 r Replacement 13 10/1 51201 0 -3%
6/8/2010 771 a Actual 11 7/15/2010 22%
3/9/2010 760 a Actual 9 4/14/2010 -22%
12/8/2009 751 a Actual 12 1/12/2010 1%
9/4/2009 739 a Actual 11 10/15/2009 -9%
6/8/2009 728 a Actual 12 7/20/2009 30%
3/13/2009 716 a Actual 10 4/29/2009 -13%
12/9/2008 706 a Actual 11 1/20/2009 -2%
9/10/2008 695 a Actual 12 10/10/2008 -28%
6/6/2008 683 a Actual 15 7/16/2008 31%
3/11/2008 668 aActual 12 4/11/2008 16%
12/11/2007 656 a Actual 11 1/22/2008 -20%
9/5/2007 645 a Actual 11 10/12/2007 -25%
6/19/2007 634 a Actual 18 7/20/2007 74%
3/15/2007 616 m Manual estimate 10 4/16/2007 -2%
12/12/2006 606 a Actual 10 1/19/2007 -18%
9/12/2006 596 a Actual 12 10/20/2006 32%
Trouble Code:03
6/14/2006 584 a Actual 10 7/10/2006 -24%
UR ANu(,.
t i OF -4EALT.1
TO" OF NORTH ANDOVER
SYSTEM PUMPINC ESEC0 �lU
E ti� OWNER & ADDRESSsYsTIM
if (lX',lmPle: IC 11 (rDnl Ur nO �c +
7j,
C OF PUMPINC::10 `31 `62,- (QUANTITY PUMPED/560
1)U0L: N0 ,' YEs SEPTIC, TANK : NO yC
TU k C
OF SERVICE: ROUTINE EMERCENCY
>I'RV \TIONS:
C OCD CONDITION (,'ULL TO C'OV-r i
HFAVY CREASC BAFFLLS IN
ROOTS LEACHFIELD
CXCESSIVE SOLIDS FLOODED ro
SOLIDS CARRYOVER O�;HER (EXPLAIN )
• , > I
cm P U M I'C D By CZ 1 � Y� j _ --
I'S TANSFEIZIZED '1'U:
Del leChiaie,Pamela
From: DelleChiaie, Pamela
Sent: Thursday, September 06, 2007 2:33 PM
To: 'dfarrell@ushomesystems.com'
Cc: Sawyer, Susan; Grant, Miche
Subject: Form U's-325 Berry Street 167 Duncan Drive- R_ uest for As-Builts re: building of decks
Importance: High
Message from Message from
KMBT_600 KMBT_600
Dan Farrell
US Home Systems
Phone: 617.785.8744
Fax: 775.458.9667
Dear Dan,
Probably the easiest way is to print them, draw in the deck on the As Built, scan, and send back. Or, if you can, fax to the
below number. Otherwise, you will need to come in and draw them directly on the As-Builts.
8¢8!R¢gwzd8,
Pwtiy¢Ba D¢BBaL�ljiai¢
Health Department Assistant
Town of North Andover
1600 Osgood Street
Building 20,Suite 2-36
North Andover,MA 01845
2978.688.9540-Phone
Q 978.688.8476-Fax
http://www.townofnorthandover.com
healthdept@townofnorthandover.com
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Form No.4 .
Town of North Andover, Massachusetts
BOARD OF HEALTH
July 7, 19 95
CERTIFICATE OF COMPLIANCE
This is to certify that
the Individual Soil Absorption Sewage Disposal System constructed or repaired
by Ben Qsgcmd, 7r
INSTALLER
at 167 Dun an pHirp,. "'-0EMTWr"Z'-r.- MA 01845
SITE
has been installed in accordance with Board of Health Regulations as described in the Design
Approval Site System Permit No. dated 19—.
The issuance of this certificate shall not be construed as a guarantee that the system will
function satisfactorily.
Address_L1�`7, . Oujuc:A.,v J,p Title of File
Page 9 of
Date File Open: Date fie closed:
Doc Document/Action Title Date of Refer to other Purpose of Documernt/Action
action Document/ document/ and notesT
Num. Action Department
Board of Appeals — Board of Health — Planning Board — Conservation Commission Building Department
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Commonwealth of Massachusetts
&. 44�_4f, Massachusetts
System Pumping Record
System Owner System Location
Date of Pumping: Ca
1 �� Quantity Pumped: G gallons
Cesspool: No44/ Yes [I Septic Tank: No [] Yes
System Pumped by: 644"" License#
Contents transferred to: Greater Lawrence Sanitary District
Date: Inspector:
' II
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Town of North Andover, Massachusetts Form No.3
t NORTH BOARD OF HEALTH
OL u.'V V 6 19 5�c-
F 9 G
•,�,o��^"� DISPOSAL WORKS CONSTRUCTION PERMIT
,SSACHUSEt
Applicant :)00A
NAME ADDRESS TELEPHONE
Site Location /K7c_1�1�.4.(�
Permission is hereby granted to Construct ( ) or Repair ( n Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No.
CHAIRMAN,BOARD OF HEALTH
i
Fee '(' D.W.C. No.
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NEW ENGLAND ENGINEERING SERVICES
INC
North Andover Board of Health
120 Main Street .
N. Andover , Ma . 01845
Re: 16? Duncan Drive
Dear 11r . Chairman:
Please accept this letter as a request for variances for a
repa.rr to a failing system at the above mentioned lot .
The var- iences that are needed are as follows :
i . A reduction in the offset distance co a t,:etiard from
a required distance of 100 feet to 60 feet . This varienr_e is
a varience to the North Andover bylaw only .
2_' . A reduction in the offset distance to a cellar wall
from a required distance of 85 feet to a distance of 20 feet .
This is a varience to the North Andover bylaw only .
A reduction in seperation to the water- table from the
requi .-edrour feet to three and one half feet . This is
req:_: . red to meet the slope requirements which can not be
varied . This request is a varience to title five, but is
allowed under sections 15. 4f;4 and 15. 405.
i will be at; your Board of Health meetinq to discuss this
mit P_r
Yours Truly
Z5.f�-
Ben aurin C . 04Os Jr .
� q
33 WALKER RD. - SUITE 22 - NORTH ANDOVER, MA 01845 - (508) 686-1768
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
FILE NO. 95-5
Address of Property 167 Duncan Drive, North Andover
Owner ' s Name John and Debie Finn
Date of Inspection May 2, 1995
PART A
CHECKLIST
Check if the following have been done:
X Pumping information was requested of the owner , occupant ,
and Board of Health .
X None of the system components have been pumped for at
least two weeks, and the system has been receiving normal
flow rates during that period . Large volumes of water
have not been introduced into the system recently or as
part of this inspection.
X As-built plans have been obtained and examined . Note if
they are not available with N/A.
X The facility or dwelling was inspected for signs of
sewage back-up .
X The site was inspected for signs of breakout .
X All system components, excluding the SAS, have been
located on the site.
X The septic tank manholes were uncovered , opened , and the
interior of the septic tank was inspected for condition
of baffles or tees, material of construction, dimensions,
depth of liquid , depth of sludge, depth of scum.
X The size and location of the SAS on the site has been
determined based on existing information or approximated
by non-intrusive methods.
X The facility owner (and occupants, if different from
owner ) were provided with information on the proper
maintenance of SSDS.
PAGE NO. 2 FILE NO. 45-5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If Residential :
4 Number of bedrooms
4 Number of current residents
Y Garbage grinder , yes or no
Y Laundry connected to system, yes or no
N Seasonal use, yes or no
If non-residential , calculated flow:
Water meter readings, if available: on well
current Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information:
2.5 years ago . Info from owner .
----------------------------------------------------------
Y System pumped as part of inspection, yes or no
If yes, volume pumped 1500 gal .
Reason for pumping :
----To_inspect-tank .-Also-it-needed_pumping ..............
---------------------------------------------------------
Type of system
X Septic tank/distribution box/soil absorption system
--- Single cesspool
--- Overflow cesspool
--- Privy
--- Shared system (yes or no ) . If yes, attach previous
inspection records, if any.
Other (Explain)
--- ........................................
Approximate age of all components. Date installed , if known.
Source of information:
As in ground plan dated 5/ 13/83
-----------------------------------------------------------
N Sewage odor detected when arriving at the site, yes or no
PAGE 3 FILE NO. 95-5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK:
( locate on site plan)
Depth below grade: 6"
Material of construction: X concrete metal FRP
---other (explain)
---------------------------------------
Dimensions: 1500 gal
4" sludge depth
25" distance from top of sludge to bottom of outlet tee or
baffle
1 " scum thickness
2" distance from top of scum to top of outlet tee or baffle
21" distance from bottom of scum to bottom of outlet tee or
baffle
Comments: (Recommendation for pumping , condition of inlet and
outlet tees or baffles, depth of liquid level in relation to
outlet invert , structural integrity, evidence of leakage,
recommendations for repairs, etc . )
Tank looks good
-------------------------------------------------------------
-------------------------------------------------------------
DISTRIBUTION BOX :
( locate on site plan)
box full depth of liquid level above outlet invert
Comments: (Note if level and distribution is equal , evidence
of solids carryover , evidence of leakage into or out of box ,
recommendation for repairs, etc . )
-------------------------------------------------------------
-------------------------------------------------------------
-------------------------------------------------------------
PUMP CHAMBER:
( locate on site plan
_________ pumps in working order , yes or no
Comments: (Note condition of pump chamber , condition of pumps
and appurtenances, recommendations for maintenance or
repairs, etc . ) ..............................................
PAPE S F'I l.:E'NQ 95 -5
SUBSUF;FACE SEWAGE A I SPOSAI 'SYST.EM INSPECT I 0N` FOF
�f (?ART ;:B
SYSTEM 1,NF,Qf. T T`ON cant a Hued;
SKTCH` QF SWAGDISP(7SA,1� SYSTEM: Include tie5` t 0- at .least
two«T permanent referen�es;;y la'ndmar-:.ks .qr, ' benchmarks ` :'Locate
w I t h"-
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n
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DERTI_I: I 'LG GRQIJNDWATER ,
n .. depth 'to `g;-aundwater
Meted -of de'term.ination or apprax''imat ;on:
:.�
S tem full, of iva'ter ; test:. wi:I.l. .be.` done with redesi' n
�T.
PAGE 7 FILE NO. 95-5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
Name of Inspector : Benjamin C. Osgood Jr .
Company Name: New England Engineering Services Inc .
Company Address: 33 Walker Road , Suite 22, N.Andover , Ma.
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage
disposal system at this address, and that the information
reported is true, accurate and complete as of the time of
inspection. The inspection was performed and any
recommendations regarding upgrade, maintenance and repair are
consistent with my training and experience in the proper
function and maintenance of on-site sewage disposal systems.
Check one:
I have not found any information which indicates that
the system fails to adequately protect public health or
the environment as defined in 310 CMR 15.303. Any
failure criteria not evaluated are as stated in the
FAILURE CRITERIA section of this form.
X I have determined that the system fails to protect
public health and the environment as defined in 310 CMR
15.303. The basis for this determination is provided in
the FAILURE CRITERIA section of this form.
Inspector ' s Signature
Date 5/8/95
Original to system owner
Copies to:
Buyer ( if applicable)
approving authority
WELL,DATABASE
i
ADDRESS:
AGE OF WELL: WELL DRILL:
WELL PERMIT is LL LOC TION: s,
WELL PERMIT DATE: �' PTH OF WELL.
TYPE OF WELL: a. DRILLED �. b. DUG c. UNKNOWN
TYPE OF WATER BEARING ROCK:
WATER ANALYSIS DATE. HIGH MANGANESE: Y N
HIGH IRON: Y N OTHER CONTAMINANTS: Y N _
-C-\ Commonwealth of Massachusetts
City/Town of FRVED
System Pumping Record o09
Form 4 0 2DEP has provided this form for use by local Boards of Health. Othlue
Ainformation must be.substantially the same as that provided here. s-form, with your
local Board of Health tQ determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or-other approving authority.
A. Facility Information
1. System Location: Left side of house, Right side of house, Left front of ho se, Right front of house
Left rear of house, Right rear of house. Left rear of building. Right rear of
Address
Cityrrown State Zip Code
2. System Owner:
Name \i
Address(if different from location)
CitylTown State i ode
& �� T
Telephone Number
B. Pumping Record
1. Date of Pumping Date Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
El Other(describe):
4. Effluent Tee Filterresent?
p El Yes No If yes, was it cleaned? E] Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L. .D Lowell Waste Water
Signature of Hauler Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1