HomeMy WebLinkAboutMiscellaneous - 17 GRAY STREET 4/30/2018 17 GRAY STREET
210/107.B-0051-0000.0
RS PLAN 1078
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SITE ;j
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58,400 sf
)K 4113 PAGE 287
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FOR REGISTRY USE ONLY
PROP �l �4 �
OSED SITE PLAN , � a
OF LAND AT LOCUS PLAN
SCALE:.1" = 1,200'
17 GRAY STREET
N. ANDOVER,R
MASSACHUSETTS .
GENERAL NOTES:
JUNE 19 2003 1. BOUNDARY INFORMATION BASED UPON PLAN
ENTITLED "SUBDIVISION OF LAND, NORTH ANDOVER,.
MASS" DATED MAY 16, 1957 AS PREPARED BY D.J.
McCRACKEN, SURVEYOR AND DEED REFERENCE
4113-287 AS RECORDED AT ESSEX NORTH
REGISTRY OF DEEDS.
OWNER/APPLICANT. 2. TOPOGRAPHIC AND ADDITION INFORMATION WAS
COMPILED FROM ONSITE SURVEY PERFORMED BY
RAM ENGINEERING, HAVERHILL, MA.
JOHN A. & CHERYL A. READE
17 GRAY STREET
F
NORTH ANDOVER,_MA.01830 �
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"I CERTIFY THAT THIS PLAN CONFORMS TO THE RULES AND 0GRAPHIC SCALE
REGULATIONS OF THE REGISTRY OF DEEDS." 2
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8. a� ro 1 inch = 20 ft.
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EXISTING SCREENED
PORCH TO BE REMOVED.
NEW ADDITION TO BE '00 I
CONSTRUCTED WITH SAME c
FOOT PRINT. M 65.35'
26.53'
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65.50'
EXISTING STONE WALL o
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EXISTING PROPERTY LINE
150-00,
DH DH
GRAY STREET EXISTING EDGE OF PAVEMENT
(50' ROW - PUBLIC - DEVELOPED)
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
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TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:
_. 17 Gray Street
Owner's Name: North Andover MA 01845
Owner's Address: Sheryl Reade
Date of Inspection:—
nspection 6/17/2003
Name of Inspector Richard C. Tangard
Company Name:_ Richard C. Tangard, P.E.
Mailing Address: 33 Pillings Pond Road
Telephone Numbe Lynnfield, MA 01940
CERTIFICATION STATEMENT
1 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:
'X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: C,I Date: F ��
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.
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.
a f
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
17 Gray Street
Property Address:. North Andover, MA 01845
Owner: Sheryl Reade
Date of Inspection: 6/17/2003
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.
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:
Page 3 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
17 Gray Street
Property Address: North Andover, MA 01845
Owner: Sheryl Reade
Date of Inspection: 6/17/2003
C. Further Evaluation is Required by-the Board of Heann:
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 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 coliform
bacteria and volatile organic 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 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
17 Gray Street
Property Address: North Andover,MA 01845
Owners Sheryl Reade
Date of Inspection: 6/17/2003
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_ X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_ X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
NQ' Liquid depth in cesspool is less than 6"below invert or available volume is less than''/i day flow
k Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped I . .
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
NA Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
H,d Any portion of a cesspool or privy is within a Zone 1 of a public well.
K.4 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 coliform bacteria and volatile organic 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 5 ppm,provided that no other failure criteria
are triggered A copy of the analysis must be attached to this form.]
1�1a (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 flaw of 10,000 gpd to 15,000
You must indicate either"yes"or`oho"to each of the following: -
(The following criteria apply to large systems in addition to the criteria above)
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 11 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.
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 17 Gray Street
Owner:
North Andover, MA 01845 Date of Inspection: Sheryl Reade6/17/2003
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
�Y _ Pumping information was provided by the owner,occupant,or Board of Health
7\ Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
x _ 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?
X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
X _ 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:
Yes no
Existing information.For example,a plan at the Board of Health.
y� Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)]
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:, 17 Gray Street
Owner: North Andover, MA 01845
Date of Inspection: Sheryl Reade
6/17/2003
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual): 2--
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):220
Number of current residents:
Does residence have a garbage grinder(yes or no):/1��
Is laundry on a separate sewage system(yes or no):;K� [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use:(yes or no): No
Water meter readings,if available(last 2 years usage(gpd)): 14
Sump Pump(yes or no):H6
Last date'of occupancy:
COAMERCI ANDUSTRIAL "
Type of establishment:
Design flow(based on 310 CMR 15.203):' gpd
Basis of design flow(seats/persons/sgft,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:
Was system pumped as part of the inspection(yes or no):AtO
If yes,volume pumped:;gallons-How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
X Septic tank,distribution box,.soil absorption system
Single cesspool
Overflowool .
PrivycessP
Shared system(yes or no)(if yes,attach previous inspection records,if any) :
_Innovative/Altemative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
—Tight tank _Attach 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 when arriving at the site(yes or no):Ao
Page 7 of 11
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:, 17 Gray Street
Owner: North Andover, MA 01845
Date of Inspection: Sheryl Reade
6/17/2003
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction:_Lcast iron._40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: (locate on site plan)
Depth below grade: 16
Material of construction: concrete metal fiberglass_polyethylene
_other(explain) - '
If tank is metal list age:_ Is age confirmed by. Certificate of Compliance(yes or no)`. (attach a copy of
certificate)
i
Dimensions: d
Sludge depth: ±1
Distance from top of sludge to bottom of outlet tee or baffle: 32
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: /0
How were dimensions determined: AIA,4> ;0> 1.4-1 LS
Comments(on pumping recommendations,inlet.and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc)
GREASE TRAP:_(locate on site plan)
Depth below grade:
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:
Comments(on pumping recommendations,inlet and outlet tee or baffle.condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 17 Gray Street
North Andover,MA 01845
Owner: Sheryl Reade
Date of Inspection: 6/17/2003
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/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: x (if present must be opened)(locate on site plan)
Depth,of liquid level above outlet invert:`00`41 �N 7'
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.):
�u GAG: �m �'v�I�.�y�� �� �9�•D.S ���t/°vim
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no);
Alarms in working order(yes or no)::
Comments(note.condition of pump chamber,condition of pumps and appurtenances,etc.):
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:. 17 Gray Street
North Andover,MA 01845
Owner: Sheryl Reade
Date of Inspection: 6/17/2003
SOIL ABSORPTIOiv o x o-i rm tzna):. auc pwa,excavation not required)
If SAS not located explain why: -
wig Aoo 1vs
Type
leaching pits,number
leaching chambers,number
leaching galleries,number:
leaching trenches,number,length::
leaching fields,number,dimensions:: /d�7— .(/p4kl
overflow cesspool,number: ;
mnovative(alternative system Typetname of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
CESSPOOLS: (cesspool must be pumped as part of inspectionxlocate 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
o):Comments(note condition of soil,,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
4
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.):
• y
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 17 Gray Street
Owner. North Andover, MA 01845
Date of Inspection: Sheryl Reade
6/17/2003
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.
-
2?00
_ TP �Q.Q
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 17 Gray Street
Owner: North Andover, MA 01845
Date of Inspection: Sheryl Reade
6/17/2003
SITE EXAM
Slope
Surface water ✓
Check cellar ✓�
Shallow wells
Estimated depth to ground water�feet
Please indicate(deck)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 excavators,installers-(attach documentation)
Y Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
? ye-
J �f cry . '`e.,dY4�'e
o
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
t
,i
V
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION r �.a�—
a �DOF � Eta/
7-1
Property Address: HES T,--. ,f
_. J.7 Gray Street F—
Owner'sA - 72003
�Name:_' North Andover MA 01845 A _ 7 2003
Owner's Address: Sheryl Reade
Date of Inspection:_ 6/17/2003 r
Name of Inspector Richard C. Tangard
Company Name:_ Richard C. Tangard,P.E.
Mailing Address:.
33 Pillings Pond Road ,
4"
Telephone Numbe Lynnfield, MA 01940x ``
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 fimction 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
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: , Date: �3
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.
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 fatnre under the same or different
conditions of use.
Page 2 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
17 Gray Street
Property Address:. North Andover, MA 01845
Owner: Sheryl Reade
Date of Inspection: 6/17/2003
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.
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:
JI
e
Page 3 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
17 Gray Street
Property Address: North Andover, MA 01845
Owner: Sheryl Reade
Date of Inspection: 6/17/2003
C. Further Evaluation is Required by the Board of Heann:
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 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 coliform
bacteria and volatile organic 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 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
I�
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
17 Gray Street
Property Address: North Andover, MA 01845
Owner: Sheryl Reade
Date of Inspection.
6/17/2003
D. System Failure Criteria applicable to all systems:
You must indicate`yes"or`no"to each of the following for all inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
N4 Liquid depth in cesspool is less than 6"below invert or available volume is less than''V2 day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped .
lC Any portion of the SAS,cesspool or privy is below high ground water elevation.
NA Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
Nd Any portion of a cesspool or privy is within a Zone 1 of a public well.
KA Any portion of a cesspool or privy is within 50 feet of a private water supply well.
N 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 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.]
1�1a (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: -
(The following criteria apply to large systems in addition to the criteria above)
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.
+:fit
-Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 17 Gray Street
Owner:
North Andover,'MA 01845 Date of Inspection: Sheryl Reade6/17/2003
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
I� Were any of the system components pumped out in the previous two weeks?
X _ 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?
X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ 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?
X _ 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?
X _ 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:
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)]
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:, 17 Gray Street
t
Owner: North Andover, MA 01845
Date of Inspection.. Sheryl ry Reade
6/17/2003
RESIDENTIAL
Number of bedrooms(design): . Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of be(Yoms):2720
Number of current residents:
Does residence have a garbage grinder(yes or no):A1O -
Is laundry on a separate sewage system(yes or no)� [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use:(yes or no): 10o "
Water meter readings,if available(last 2 years usage(gpd)):Zs'o� /4 G' 2®a Z fit)
Sump Pump(Yes or no):K6 '
Last date'of occupancy: G�2
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): 2nd
Basis of design flow(seats/persons/sgtetc.):
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: Olf�ll -
Was system pumped as part of the inspection(yes or no):AtO
If yes,volume pumped:;_gallons--How was quantity pumped determined?
Reason for pumping: .
TYPE OF SYSTEM .
Septiatank,distribution box,soil absorption systema
- 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 —Attach 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 when arriving at the site(yes or no):No
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
:.. PART C
SYSTEM INFORMATION(continued)
Property Address:. 17 Gray Street
Owner: North Andover, MA 01845
Date of Inspection: Sheryl Reade
6/17/2003
BUILDING SEWER(locate on site plan)
/i
Depth below grade: 2 16
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.):
SEPTIC TANK: (locate.on site plan)
to '�
Depth below grade:
Material of construction: concrete metal fiberglass_„polyethylene
_other(explain)
If tank is metal list age:. h age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: c::5
Sludge depth:__ Q /AcCsS ,
Distance from top of sludge to bottom of outlet tee or baffle: 32
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:
How were dimensions determined: 05'115401414�P 141 f=/ELS
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,'etc):
GREASE TRAP:. (locate on site plan)
Depth below grade:
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:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 17 Gray Street
North Andover,MA 01845
Owner: Sheryl Reade
Date of Inspection: 6/17/2003
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: cbncaete 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: x (if present must be openedxlocate on site plan)
,Depth,of liquid level above outlet invert: C/Q��
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.): ;
----
Nay
PUMP CHAMBER: (locate on site plan) ,
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note.condition of pump chamber,condition of pumps and appurtenances,etc.):
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:. 17 Gray Street
North Andover, MA 01845
Owner: Sheryl Reade
Date of Inspection: 6/17/2003
SOIL ABSORPTIOiv o r zo it m kaAa);-4—twvauc on anc p,nu,excavation not required)
If SAS not located explainwhy: -
Type
leaching pits,number:
leaching chambers,number:
leaching galleries,number;
leaching trenches,number,length:
leaching fields,number,dimensions::A&F T Pe-X1
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.):
CESSPOOIS: (cesspool must be pumped as part of inspectionxlocate 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)
Materials of construction:
Dimensions:
Depth of solids:
_. Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued) -
Property Address: 17 Gray Street
Owner. North Andover, MA 01845
Date of Inspection: Sheryl Reade
6/17/2003
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.
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I NaTUKE OFSERYICE: `ROUTINE EMERCEN'CY
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FORM U - LOT RELEASE FORM 4
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits
Boards and Departments having jurisdiction have been obtained. This does-not relieve
ve
the applicant and/or landowner from compliance with an a requirements.
""APPLICANT FILLS OUT THIS SECTION
APPLICANT p w C�p �+�{ I Z,ea eX`2 PHONE 3T8
LOCATION: Assessor's Map Number—IP--) [J PARCEL C5
SUBDIVISION
LOT(S)
STREET n y /1
ST. NUMBER__
USE ONL
RECOENDATIONS OOWN AGENTS:
ZZ/ ze
CONSERVATION ADMIN!S ATOR DATE APPROVED fiJ
/ DATE REJECTED
COMMENTS s�
TOWN PLANNER DATE APPROVED
DATE REJECTED
COMMENTS
FOOD►NSPECfOR-HEALTH DATE APPROVED
DATE REJECTED _
SEPTIC INSPECTOR-HEALTH DATE APPROVED
DATE REJECTED
COMMENTS e,,Qrle�
f
PUBLIC WORKS-SEWER/VYATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR DATE
Revised 9197 jm
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR,RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUELDING PERMIT NUMBER: DATE ISSUED:
SIGNATURE:
Building Commissioner/I for of Buildings Date
SECTION I-SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map and Parcel Number:
6'
Map Number Parcel Number
7d
-1.3 Zoning Information: 1.4 Property Dimensions:
baa
Zoning District Proposed Use Lot Area(4) Frontage(11
1.6 BUILDING SETBACKS 00
Front Yard Side Yard Rear Yard
Required Provide Required Provided Required Provided
36 fes , T6 s —A--& 1749 yr
1.7 Water Supply M.G.I-C.40. 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System:
Public $ Private 0 zone Outside Flood Zone 0 Municipal 0 On Site Disposal System 71e ]
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
17
Name(Print) Address for Service:
Signature Telephone
2.2 Owner of Record:
_-:�-14_e4--z--.<-
Name Print Address for Service:
Signature Telephone
SECTION 3-CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor: Not Applicable 0
e,!?
Licensed Construction Supervisor: 6ZO 0
4oj / s—/- License Number
Address
/�-
Expiration Date
Signature Telephone
41,,
3.2 Registered Home Improvement Contractor. Not Applicable 0
7:��,0,4f Aerl c-f
Company Name 6
Registration Number
Address f e— W,
Expiration Date
]�
Si nature Telephone
l CIO
Age'
C3)
/,Xl
of /�n