Loading...
HomeMy WebLinkAboutMiscellaneous - 1689 SALEM STREET 4/30/2018 1689 SALEM STREET 210/106.6-0023-0000.0 (/ / r Commonwealth of Massachusetts Luse DED u W City/Town of NORTH ANDOVER a System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms may information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, use only the tab 1689 SALEM STREET key to move your Address cursor-do not NORTH ANDOVER MA 01845 use the return key. City/Town State Zip Code 2. System Owner: MARK SHEA Name aam Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 6/4/14 2. Quantity Pumped: GallonDates 3. Component: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ® Yes ❑ No If yes, was it cleaned? ® Yes ❑ No 5. Observed condition of component pumped: GOOD CONDITION 6. System Pumped By: JAMES H CURRIER II H79 406 Name Vehicle License Number X SEPTIC & DRAIN Company 7. Location where contents were disposed: GLSD " 6/4/14 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts ` I City/Town of NO. ANDOVER Raec .�� System Pumping Record O� Form 4 D M DEP has provided this form for use by local Boards of Health. Other forms information must be substantially the same as that provided here. Before u ur 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 Important: When filling out 1. System Location: forms the 1689 SALEM ST. computer,use only the tab key Address to move your NO. ANDOVER MA 01845 cursor-do not City(rown State Zip Code use the return key. 2. System Owner: r� MARK SHEA Name r Address(if different from location) t City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 11/30/09 2 Quantity Pumped: 1500 Date Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank E3 Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Benjamin Shute H79 406 Name Vehicle License Number J's Septic& Drain Company 7. Location where contents were disposed: GLSD s 11/30/09 4ure auler Date t5form4.doc•06/03 System Pumping Record.Page 1 of 1 } � Commonwealth.of Massachusetts City/Town of I RECEIVED System Pumping Record MAY 2 2 2006 Form 4 TOWN OF NORTH ANDOVER DEP has provided this form for use by local Boards of Healt T_iieingRecord must be submitted to the local Board of Health or other approving authority. . X Facility Information Important: When filling out ..1. System Location:forms on the computer,use only the tab key Address J( f to move your ; cursor-do not use thereturn Cit Town State Zip Code key. 2._ System ,rr¢ Name Addressif different Brent from location) City.FrownStatef Zip Code Telephone Number B. Pumping Record I. _Date.of Pumpingpa—� 2. Quantity `Pumped: t �� Gallons 3. Type of system: ❑ Cesspool(s) [Septic Tank ❑ Tight.Tank ❑ Other(describe): � 4. Effluent Tee Filter present? ❑ Yes Ly No Ifes was s It cleaned? El Yes ❑ No 5. Condition of System: . 6. System Pumped By Name Vehicle License Number Company _— 7. Location where contents were disposed: (0 Signature of au er Date h.ttp://www.mass.govidep/water/;3pptovalt/t5forms.htm#inspect t5form4.doc•06/03 System Pumping Record•'Page 1 of 1 C nmonwealtlt �f Massacltuselis N* Massachusetts system Pumping Rel dmrd System Owiter Systtstn Location eA `'` Date of t'umping: l �—��— Quantity I'uirip4 a Cesspool: Nu Yes �..� eptia tik: bits Vo System !'moped by- Fetrei'm 5d6lo ¢d Licettsfr Contents transfertred tc Grerltet Lavirtettt:� aniiary blstrft:! _> ro} llate: Intectt5t: Commonwealth of Massachusetts 4"Vp'Massachusetts System Pumping Record System Owner System Location Date of Pumping: CS — 91 Quantity Pumped: 1 �49�-- gallons Cesspool: No Septic Tank: No Yes �— System Pumped by: g4rederf 461ftavlaW4 License# Contents transferrred to : Greater Lawrence Sanitary District Date: Inspector: h TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD OCT 2 6 2001 DATE: i SYSTEM OWNER &ADDRESS SYSTEM LOCATION (example: left front of house) < P� k6�-j - �, DATE OF PUMPING: U� QUANTITY PUMPED C(S Z<--G--ALLONS CESSPOOL: NO 'AYES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE a ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: � COMMENTS: r J3 CONTENTS TRANSFERRED TO: �� s NORTH Pt T^ 5496 h AL 9, • Town of North Andover HEALTH DEPARTMENT s t s CMU 5 CHECK#: � DATE: �Sa�© LOCATION: ' H/O NAME: CONTRACTOR NAME: 17 I 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 S_s�: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ �Title 'Inspector $ IlY' Report ❑ Other:(Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer FILE# T EMT Dean G.Luscomb II&Sous P.O.Box 13� Middleton,MA 01949 978-774-4065 Licensed pl=ber#20285 S SUBSURFACE SEWAGE DISPOSAL SYSTEM INPSE=<)N FORM v V ` PROPERTY OWNNFM NAME Mark- PROPERTY ADDRESS ADDRESS OF OWNER(if Maw) -..)' ^� DATE OF INSPECTION NAME OF INSPECTOR QUALI TY IS NUTMBER ONE TO US. R Commonwealth of Massachusetts H Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1689 Salem Street Property Address Mark Shea Owner Owner's Name information is North Andover MA May 25 2011 required for Y every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your Dean G. Luscomb II cursor-do not Name of Inspector use the return key. Dean G. Luscomb II & Sons Company Name P.O. Box 135 Company Address Middleton MA 01949 City/Town State Zip Code 978-774-4065 S1848 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority i May 25, 2011 Inspector's Signature IDate 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 t Commonwealth of Massachusetts Title 5 Official Inspection Form _ e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1689 Salem Street Property Address Mark Shea Owner Owner's Name information is North Andover MA May 25, 2011 required for y 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: ® 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 �J determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1689 Salem Street Property Address Mark Shea Owner Owner's Name information is North Andover MA May 25 2011 required for y , every 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): F, ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): (' ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 1689 Salem Street Property Address Mark Shea Owner Owners Name information is North Andover MA May 25 2011 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 R j v 100 feet of a surface water supply or tributary to a surface water supply. Iv ❑ 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. N� 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1689 Salem Street Property Address Mark Shea Owner Owner's Name information is North Andover MA required for May 25, 2011 every page. CityTrown 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�'are systems, you must indicate either"yes"or"no" to each of the f wing, in addition to the questions`i Section D. Yes No the s 11 Elystenis within feet of a surface drinking water supply ❑ ❑ the syswmlis within-200 feet of a tributary to a surface drinking water supply El 1:1e system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zon411,of a public water supply well If �avewered "yes"to any question in Section E the sysys ern,is considered a significant threat, or answered "yes" in Section D above the large system has failed. Theo -ner�or operator of any large system considered a significant y n ficant threat under Section E or failed under Secti n 9 o D`shal. u rade 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 r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 1689 Salem Street Property Address Mark Shea Owner Owner's Name information is North Andover required for MA May 25, 2011 every page. Cltyfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440gpd t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 =` Cornmonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments <C�M 1689 Salem Street Property Address Mark Shea Owner Owner's Name information is required for North Andover MA May 25, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information Description: **owner and physical check of house. Number of current residents: 4 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 years usage(gPd))� town water Detail: Sump pump? ❑ Yes ® No a Last date of occupancy: currentDate Commercial/Industrial Flow Conditions: `-'Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per da d) Basis of design flow(seats/pftoris/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharg, o the Title 5 system? Yes E] No Water meter read s, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1689 Salem Street Property Address Mark a Shea Owner Owner's Name information is North Andover MA May 25, 2011 required for y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): -� " ._ .4 General Information Pumping Records: Source of information: owner and town, pumped 1998, 2001,2006,2009,2011 Was system pumped as part of the inspection? �j El Yes ® No If yes, volume pumped: `' gallons How was quantity pumped determined? Reason for pumping: No need at this time Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Corhmonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1689 Salem Street Property Address Mark Shea Owner Owner's Name information is North Andover MA May 25, 2011 required for y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 20 years, estimate Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 15"feet Material of construction: ® cast iron ❑40 PVC ❑ other(explain): 4 Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): **pipe and joints are in good condition. Septic Tank(locate on site plan): 'f 5" Located in brick walkway Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) ** Precast rectangular 1500 gallon If tank is metal, list age: Is age confirmed Certificate of Compliance? (attach�copy=fcert�ificate) ❑ Yes No Dimensions: 5'Wx5'Dx101 /500�e Sludge depth: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 1689 Salem Street Property Address Mark Shea Owner Owner's Name information is North Andover MA May 25, 2011 required for Y every page. CityTTown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 34" Scum thickness <1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Sticks and tape measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): **The septic tank and baffles are in very good condtion. The baffles are PVC type and the outlet has a Zabel Filter in it. The liquid in the tank is working at it's correct working heigth. the solids are light and do not require pumping at this time. Grse Trap belo (locate on site plan): n f o Depth ade: feet Material of construction: ❑ concrete ❑ metal `❑ fiberglass ❑ polyethylene ❑ er(explain): Dimensions: Scum thickness f. Distance from top of scum to top of outlet tee or baffle Distance from bottom ofrscu'm to bottom of outlet tee or baffle _o_ 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 1689 Salem Street Property Address Mark Shea Owner Owner's Name information is North Andover MA May 25, 2011 required for Y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels asrelated 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 ❑ polyethylen ❑ other(explain): "s. Dimensions: Capacity: ZN-" gallons Design Flow: ' perday Alarm present: ❑,n Yes ❑ No Alarm level: Alarm it Vorking order: ❑ Yes ❑ No Date of last pumping: ��✓ Date �m Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ElYes [_1No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts u - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1689 Salem Street Property Address Mark Shea Owner Owner's Name information is North Andover MA May 25 2011 required for , every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): a Depth of liquid level above outlet invert Zero" 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 is level and in good condition both working and structurally. the liquid in the D-box is running at it's correct working height. The D-Box is plastic type with speed level in it. D-Box is 4" below grade and is 16"x16"square. Pump Chamber(locate on site plan): Pumps in working order: ❑ ❑ No Alarms in working order: ' ^� ❑ Yes ❑ No Comments(note condition of pump chamber, ition-of_R, mps and appurtenances, etc.): ell, Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: ** Located by D-box to level area of the yard. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1689 Salem Street Property Address Mark Shea Owner Owner's Name information is North Andover MA May 25, 2011 required for y every 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: ® leaching fields number, dimensions: 20'x40' ❑ 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.): " Leaching field is made up of 5-4" pvc lines in a 20'x40' bed of stone, estimated. The S.A.S. is in good working condition with no signs of any problems. This area is covered with well maintained green grass. There are no signs of ponding or breakout to be noted. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inletinuertA Depth of solids layer Depth of scum layer Dimensions of cesspoo Material construction Indication of groundwater inflow ❑ Yes ❑ 'No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1689 Salem Street Property Address Mark Shea Owner Owner's Name information is North Andover MA May 25, 2011 required for y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy locate on site plan): Materials ofstruction: Dimensions Depth of solids Comments (note condition of soil, signs of by aNJ.icS i ure, level of ponding, condition of vegetation, etc.): ,.F t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 V mmonwealth of Massachusetts W Ti _5 Official Inspection Form Subsurface Sewage Dtsposal System Form - Not for Voluntary Assessments .'' 1689 Salem Street 41M Property Address Mark Shea R Owner Owner's Name information is required for North Andover MA �, May 25, 2011 every page. CityrTown State Zip Code \Rate of Inspection D. System Information (cont.) \ Sketch Of Sewage Disposal System: Provide a view of the sewage disposal sSyystem, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within,,100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately C Ic C,.�� r-1 ,A). t nc�vvie/f�`�a, d Ek p; i 11 1 t a1LW wa.l k�C- 2- IV —I r 331 4; tf 4 13 ..2 -7 7 t5ins•11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 17 r i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1689 Salem Street Property Address Mark Shea Owner Owner's Name information is required for North Andover MA May 25, 2011 _._ every page. CityTrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar—E)✓ tJU pur»p ® Shallow wells pjo,,C, 8' Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked date of design plan reviewed: No info Date Observed site (abutting hole within 150 feet of SAS) ® ( 9 ® Checked with local Board of Health -explain: Pumping information only 5/25/11 ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database-explain: Topsfield 1 You must describe how you established the high ground water elevation: **The basement is 8' below grade with no sump pump and no water. The driveway is 7' below grade, with no signs of water. The back yard drops off to a swampy area with is approximately 9 - 10' below the system. 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 li Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1689 Salem Street. Property Address Mark Shea Owner Owner's Name information is North Andover MA May 25, 2011 required for Y every page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17