The URL can be used to link to this page

Home My WebLink AboutMiscellaneous - 170 LACY STREET 4/30/2018 170 LACY STREET -- i 210/105�19-M0.0� I 1 m'�J f � � ,�.� �`'� '� �� (�t - � t'� r' t:a.. � .. :.'�O� ;� -,-.., I i TO: NORTH ANDOVER, MASS 7? 19 BOARD OF HEALTH FROM: DESIGN ENGINEER Re: Soil Absorption Sewage System Inspection This is to certify that I have inspected the construction of the said disposal system at /Z 1-4. C --574- North Andover, Mass. ' SITE LOCATION The grades and construction are as specified in my plans and specifications dated 19 a�vNds iV)VO/. o- Vti 'U eg. f". tlgSneer/ g anitarian NORTH ANDOVER SUBSURFACE DISPOSAL SYSTEM CHECK LIST I. General Information Reg. 2. 5 The submitted plan must show as a minimum: (a the lot to be served (b� ocation and dimensions of the system (including reserve area) (c) design calculations (d) calculations showing required leaching area (e existing and proposed contours (f),V location and log of deep observation holes - V'distance to ties (g)V �ocation and results of percolation tests - distance to-,ties (h)tlocation of any wet areas within 100 ' of the sewage disposal system or disclaimer P (i )64su rf ace and subsurface drains within 100 ' of the sewage disposal system or disclaimer (j ) location of any drainage easements wit ' 100 ' of the sewage disposal system or disclaime (k) known sources of water supply wi o the sewage disposal system o disclaimer MK location of any proposed well --serve the lot (m)y-location of water lines on the property (nX maximum ground water elevation in the area of the sewage disposal system (o a profile of the system (pVo PVC is to be used in construction (q [location of benchmark (r�L Plan must be prepared by a Professional Engineerineer or other professional authorized by law to prepare such plans. II. Garbage Disposers III. Septic Tanks Reg. 6.1 (a)5zCapacities - 150% of flow Reg. 6. 7 (b)L)4Water table Reg. 6.8 (c)/yTees Reg. 6.9 (d`"_t Depth of tees Reg. 6. 12 (e l" Access Reg. 6. 18 (f)lok Pumping (g) KCleanout IV. Pumps Reg. 9. 1 (a) Approval Reg. 9.6 (b) Stand-by power i V. Distribution Boxes Reg. 10.2 (a) Slope greater than 0.0804 Reg. 10.4 (b) Sump (�J VI. Leaching Pits Leaching pits are preferred where the installation is possible. Reg. 11.2 (a) Calculations of leaching area (minimum 500 S.F. ) Reg. 11.4 (b). Spacing Reg. 11.10 (c) Surface drainage 2% Reg. 11.11 (d) Cover material VII. Leaching Fields Reg. 15. 1 (a) Greater than 20 minutes/inch Reg. 15.1 (b) Area (minimum 900 S.F. ),pe Reg. 15.4 (c) Construction of field Reg: 15.8 (d) Surface drainage 2% IX. Downhill Slope (a) Slope y/x = (to be shown) (b) y/x X 150 = (to be shown) i t SOIL PROFILE & PERCOLATION TEST DATA Town/Cit � No.&Street.Cc Lot No, 42 Loc./Subdiv. Plan-�� Owner � �� Investigator Observer SOIL PROFILES-DATE 1' Elev. lev. 3" Elev. 4'Elev. �4 p 0 2 7 p p 1 1 1 1 i� 2 2 2 2 3 3 3 3 4 4 4 4 ` 5 5 5 5 �j6 6 6 6 y7 7 7 7 ..... -- -- 8 8 8 9 9 9 9 10 10 10 10 Benchmark Location Elevation Datum Percol ti n Tests-Date 2 l� Pit Number 1 2 3 4 5 Start Saturation Soak-Mins. 7 r Start Test-Time Dro of 3"-Time Dro of 6"-Time Mins.lst 3"Dro Mins. 2nd 3"Dro Notes & SketcPes n 9ack Frank VCelinas ssociates, North And. ✓�/elf o AREA -- , ,4 8,. 4/45 79 O 15z10 � J. �9,Q f0�1 • .. 'L �c r tj -77 'z ' � �se�� .off�� v � � �'9` �`�� '•L.��z.� ;� 5z 00 tx ��• �. � �o,s, ./sem � 1 ► '� . . r� � �� o- t o 3 J � /OC% Jc.. i� �N111W^Q woNddil a Ln fdo. 464 O Z Yl F6 C f F6 I � i 4 iyp "u i t, NORTH ANDOVER BOApL OF HEALTH INSTALLATION CHECK LIST APPROVED DATE DISAPPROVED DATE' EXCAVATION OK FAIL OK 1. Distance To: Wetlands Drains Well 2� W r Line Location 3. Td C P i �-- 4. Septic Tank e ength & To Clean A�ot ement Pipe to Tank - Sides of 5. Distribution Box _ Cover & Box - No rack' •-- 411— --nes Flowing qual Amounts T' Flow 6. LeachField r Trench Dimen ' ons St :_e Depth Aped Ends Glean Double Washed Stone 7. Leach Pits Dimensions Stone Depth Splash Pads Tees Cement Pipe to Pit - Both Sides Clean Double Washed Stone 8. Pio Garbage Disposal Q. Final Grading Inspection -� 'IO: rac ding' !'1syr�ra� � *c� O l �t/ 11-7e 11 . As - Built Submitted 1G. Lot Location Dimensions of System Location lith Regard to Ferc Test Elevations Water Table F; 190 D /,tri ,;"��;y . {/ �fJC1SE D.GA-/N5 40 0 - o f'ko p&-A 7/A=- . IJVC . LOT 12 A ZC-r-41770V= L�q�'.� a7: � 1. 17.8 A / AlynoV -p -w C eZZ C 6r *-A /��th1 X1,4 a/gG�l X983 '~ . • / • • � �4rA- VG • L.'= / �L � &�4 � G�'LL.6,e f-[11M,b✓c/� G1YE1.1/N6 • / - , S�1 Y, ' aD!v�T�M4rs: Ca a n G/'v � � - ' ' � � - of � � A� ra✓x: /aov ",,�.1� ��:a,E,q� !¢�� Ale=;Y J92AU4 70s/ ! - qG,, 75Av -- 101 HW MIMI r - I"�aY \ Taj q AZ i J -74 451 �oc , -1a / _Nrac,o 4-14.7 �Xlj/Y�i E / E4 f I9x Pail �� ` " j �► 40,,, rr c .ovo r : E � IV ( 76 /1.4 I - l - ` > r: �- �� „w y , j MM,71-f: - oy VAA MW 400 Swa ro ..b wT '�0wp a F intP'� oe mal.. 00 p p f �1 o GAPS .IDS ---- - o '. _ '-0” 2'•�° 404 PIPE M RJAL 201 rAFzTI4L. 1�,W L JP 6; cp low i~ '" FiG4T10NS S S=1oN AT {=t6NT) ARF.o► Q� �� SEE t7t:'TW L .SET L� . rl�1STR.t1y13T10W rlOX � j /OPO GAL.G MCUTG fff tiG TANK ------------------ - ,. _ - -_{ }«+ eAs�r I Row / 4"'cp 'Sa�►i p �� s EAt..a:D J�. I F I N/s y 6tZAc6 too rV4 rim de a #R c WU4t.' s ~To 511�M51 _ e o D w 64N0 UND�Q QED. „ 4¢pE PATH . c3: rim at OIA t- -- -- a a °a° ^�1 1YASNGO lv Hlaf I.A. a ` ' ;` Flo. gPIGGS• T-tt-4o Z . as . . . z 41GI LM • MoKRWTdL=," tiq L: Ab y�c.E ''� '' �'coTr �'�P��s /•SrG. t -- l1.� A��orJ P. pt�tJ "' Or•15 �' S! ! 2 of .3 �GGESS /WAA.IHOC.ES R 7o 6RAVE &e4DE 0/oi. oe Less) LicQU,o LEVEL ° A c` o THE DE TA/L S SHOWN /�� LE✓E� ON Ti4ls PLAN SHEET A�eE TYP/CAL 06 XILS • � "��,�sr T�2DN TEE "� '• ••' F A Cee7-,4/ti/ /t`4AI- 4• 4,V C4sr,-reo.v TEE a ° 11FAC TG/,E'O.e• �QV ✓A- LeA/r ,Dk+oouc rs M4Y SuB,Sri r-41 rL-O a. 4 o Get/G Y W1 rN TSE n iYI�P.20!/AG DF 45907,1/THE �ARd OP NE4 4" •: a ` AND Tf lE DES1,!iwe e. 12` /flAl. GRAVEL SUB-BASE - � /Z` M/N. �� AVE SUB-BAL Sep 7-1c- TAti/k - cSKT/oAi 4-A S .voT- ro sn4c.E SEPT/C TA^-o< - SECT/oti! B-B Al-07- 770 c5'C4e-E 8' a,i 8 - , q '. 4. 'q _� ,u} u _ ._c�, _•.0 . a'.- :4'. �C,. 't�•• J.. Q. . C '. •� .A' 0 ' ,�. ,o p,e o � , i 4' 0-0 O -� � -- ,, -. .,,.- '�_ �" Mid: • •,. '. _ • - '� '• GRA!/EL ' GRAvEG SUB-BAs ScIB-eA5E re rloAj 3 4t Box DISTR/SUT/OAJ N BOX SECT/O�lS cSEP T/G TANK PG A N ' DETAILS FoR /ODO C,44- Cavc. SEPr/C TA,uk Co�vC. D/SrR16wr�,ov Box cSHEE7- 2 oF3 Cal- 8� o e, t� 1 Town of North Andover f M°R*M Office of the Health Department ° °p Community Development and Services Division +� , 400 OSGOOD STREET s" <.<s North Andover,Massachusetts 01845 �s"CH�E Arlo Susan Y. Sawyer,REHS/RS 978.688.9540-Phone I Public Health Director 978.688.8476-Fax CEqWq'ICAgtF OT COQ T- f- r 9197 E As of: December 29, 2005 This is to certify that j the individual subsurface disposal system was a Repaired10-(Box, e� 1Tipe Completed by: .Mike Reilly At: 170 .Lacy Street North Andover, -11A 01845 Yfas been installed in accordance with the provisions of Title v of the State Sanitary Code and with the Noah Andover Ooard of Yleafth regulations. die Issuance of this certzcate shall not be construed as a guarantee that the system will function satisfactorily. r o� Susan 2:Sawyer, RE34S/1R5 Public 9fealth Director BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 7 0 U6 . O Town of North Andover HEALTH DEPARTMENT S�cHuse CHECK#: DATE: 1, 1*4 -� LOCATION: 1 � � fll H/O NAME: v QY4 CONTRACTOR N E: 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 $ Title 5 Report $A0 ❑ Other. (Indicate) $ ( 2 Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer Commonwealth of Massachusetts RECEIVED Title 5 Official Inspection Form i; Subsurface Sewage Disposal System Form-Not for Voluntary Assessm nts SIL 2 4 TOVVN Uh NUK I H A ER y 170 Lacy Street HEALTH DEPART Property Address Robert Rainville Owner Owner's Name information is required for North Andover MA 01845 9/11/2014 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important= A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Neil J. Bateson cursor-do not Name of Inspector use the return key. Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover MA 01810 City/Town State Zip Code 978-475-4786 S116 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 ❑ Needsf urther aluation by the Local Approving Authority Ila1 9/11/2014 Insp r s ignature 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 170 Lacy Street Property Address Robert Rainville Owner Owner's Name information is required for North Andover MA 01845 9/11/2014 every page. Cityrrown 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•3/13 Title 5 Official Inspection Forth: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 170 Lacy Street Property Address Robert Rainville Owner Owner's Name information is required for North Andover MA 01845 9/11/2014 every page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 170 Lacy Street Property Address Robert Rainville Owner Owner's Name information is North Andover MA 01845 9/11/2014 required for every page. Citylrown 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: I 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 EJ ® 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 day flow t5ins•3113 Title 5 Official Inspection Forth: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 170 Lacy Street Property Address Robert Rainville Owner Owner's Name information is required for North Andover MA 01845 9/11/2014 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality.analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large. Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection 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•3113 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 170 Lacy Street Property Address Robert Rainville Owner Owner's Name information is required for North Andover MA 01845 9/11/2014 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ 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): 600 t5ins•3/13 Tide 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 170 Lacy Street Property Address Robert Rainville Owner Owner's Name information is required for North Andover MA 01845 9/11/2014 every page. Cityrrown 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?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): on well water Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 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 170 Lacy Street Property Address Robert Rainville Owner Owner's Name information is required for North Andover MA 01845 9/11/2014 every page. Cityfrown 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: Pumped 2005, owner Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Measured 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 bta ned from system owner and d a co of la Y ) copy test inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Tithe 5 Official Inspection Form rUAV; Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 170 Lacy Street Property Address Robert Rainville Owner Owner's Name information is required for North Andover MA 01845 9/11/2014 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Tank&field 36 years old, d-box was replaced in 2005, 10/21/1978, as built plan & info at B.O.H. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ® cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >100' Comments(on condition of joints, venting, evidence of leakage, etc.): 4" PVC through wall, 3"PVC in house, No leaks visible Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: Tx 5'x 4' Sludge depth: 6" t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �< 170 Lacy Street Property Address Robert Rainville Owner Owners Name information is required for North Andover MA 01845 9/11/2014 every page. CityrTown 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 27" Scum thickness 6.. 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 9 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 ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of Ieakage.Outlet cover broken, replaced with steel frame&cover 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-3/13 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 170 Lacy Street Property Address Robert Rainville Owner Owner's Name information is required for North Andover MA 01845 9/11/2014 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(onpumping recommendations, inlet and outlet tee or bafflecondition, structural Integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): i 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-3113 Title 5 Official Inspection Forth: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 "< 170 Lacy Street Property Address Robert Rainville Owner Owner's Name information is North Andover MA 01845 9/11/2014 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): i Depth of liquid level above outlet invert 0 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 level &distribution equal, has flow levelers. No evidence of leakage. Evidence of q g 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.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 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 170 Lacy Street Property Address Robert Rainville Owner Owner's Name information is required for North Andover MA 01845 9/11/2014 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: 1 field 20'x 45' ❑ 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.): _Soil ok. Vegetation ok. 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•3/13 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 170 Lacy Street Property Address Robert Rainville Owner Owner's Name information is required for North Andover MA 01845 9/11/2014 every page. Citylrown 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: I Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i I i I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 170 Lacy Street Property Address Robert Rainville Owner Owner's Name information is required for North Andover MA 01845 9/11/2014 every page. Cityffown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately C +3. to p.r �� `�GZn�.�'�-- fir(C�, ►t t5ins•3/13 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 170 Lacy Street ,p Property Address Robert Rainville Owner Owner's Name information is required for North Andover MA 01845 9/11/2014 every page. Cityrrown 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: 4/14/1977 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: P Design Ian ❑ 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 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 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 170 Lacy Street Property Address Robert Rainville Owner Owner's Name information is required for. North Andover MA 01845 9/11/2014 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked E Inspection Summary D (System Failure Criteria Applicable to All Systems)completed E System Information—Estimated depth to high groundwater E' Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i t5ins•3/13 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 Locatio eft/ 'gh ro of house eft/Right near of house, Left/right side of house, Left/ Right side of bui • , Left/Right nt o uildin , Left/Right rear of buil 9 g building, Under deck Address D � CdY/Town state Trp Code 2. System Owner. Name Address(if different from location) I Cdyrrown state Zip Code Telephone Number f B. Pumping Record 1. Date of Pumping Date2. ntity Pumped: Gallons 3. Type of system: ElCesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yep No If,yes, was it cleaned? ❑ Yes ❑ No ' 5. Condition of System: oA `. M"6. System Pumped By: Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc- Company 7. Location where contents.were disposed: O• S• Lowell Waste Water Sig Haul p ate t5fonn4:doc-O8/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts Map-Block-Lot r .• 0 105.C-0019- Board of Health Permit No > 2 North Andover BHP-2005-0577 P.I. F.I. FEE: $125.00 Disposal Works Construction Permit Permission is hereby granted Mike Reilly to(Repair-D-BOX&PIPE)an Individual Sewage Disposal System. at No 170 LACY STREET as shown on the application for Disposal Works Construction Permit No. BHP-2005-057 Dated October 19,2005 Issued On: Oct-19-2005 Board of Health ............................................................................................................................................................................... o•," "�ti� Commonwealth of Massachusetts Map-Block-Lot t 105.C-0019- i Board of Health North Andover Certificate of Compliance THIS IS TO CERTIFY,That the Individual Sewage Disposal System (Repair-D-BOX& PIPE) by Mike Reilly Installer at No 170 LACY STREET has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. BHP-2005-057 Dated October 19,2005 Printed On: Oct-19-2005 Board of Health Town of North Andover /D/� Health Department Date: Location: (Indicate Address,if R siderttial,orl1`fame of Business) Check#: �� Type of Permit or License: (Circle) ➢ Animal $ ➢ Dumpster $ ➢ Food Service-Type: $ ➢ Funeral Directors $ ➢ Massage Establishment $ ➢ Massage Practice $ ➢ Offal(Septic)Hauler $ ➢ Recreational Camp $ ➢ SEPTIC PERMITS: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ,} e��Septic Disposal Works Construction(DWC)$ ❑ Septic Disposal Works Installers(DWI) $ ➢ Sun tanning $ ➢ Swimming Pool $ ➢ Tobacco $ ➢ TrashlSolid Waste Hauler $ ➢ Well Construction $ ➢ OTHER;(Indicate) r A o �� 7 Health Agent Initials 7 f•: White-Applicant Yellow-Health Pink-Treasurer Application for Septic Disposal System �S'Dcs' J O°`t ..eo e'96 3? �40 TODAY'S DATE ° pConstruction Permit - TOS OF NORTH ANDOVER, MA 01845 $250.00—Frail-Repair x "Ao x �4S A,..o r,�� 125.00 -Component SACHU`<'k' Important: Application is hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on the computer, use ❑ Repair or replace an existing on-site sewage disposal system* only the tab key to move your VRepair or replace an existing system component cursor-do not use the return key. A. Facility Information Address or Lot#�--- �ie2c'''iT `i � ice✓) !ltd�+�� c�.;�s.`�.✓ City/Town 2.- *TYPE OF SEPTIC SYSTEM*: ❑ Pump ❑ Gravity (choose one) ***If pump system, attach copy of electrical permit to application*** ❑ Conventional System (pipe and stone system) ❑ Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D-Box) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D-Box Present)S.A.S. 2. Owner Information Name 17o Locq s�-. Address(if different from above) At 01^fit 14 'A ✓ce City/Town State Zip Code Telephone Number 3. Installer Information M/64cQ/ fie l?l� F P �1i//ti Sa�tf Name Name of Company Address ��z D/f/0 City own State Zip Code -7 Telephone Telephone Number(Cell Phone#if possible please) a. Designer Information Nl/AA Name Name of Company Address City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 N°R,k Application for Septic Disposal System TODAY'S DATE Construction Permit — TOWN OF t�� $ 250.00-Full Repair 9.°a �.�. ORTH ANDOVER, MA 01845 4SS^�HUSEi $125.00 -Component PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: residential Dwelling or ❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place the system in operation until a Certificate of Compliance has been issued OX this Board of Health. Name Date Applica Approved By: goard of Health Representative) m Date Application Disapproved for the following reasons: For Office Use Only: L Fee Attached? Yes No 2. Project Manager Obligation Form Attached? Yes_ No r/ �w 3. Pump System? If so,Attach copy of Electrical Permit Yes , No 4. Foundation As-Built?(new construction ronly): Yes No (Same scale as approved plan) S. Floor Plans?(new construction only): Yes_ No Application for Disposal System Construction Permit°Page 2 of 2 COMMONWEALTH OF MASSACHUSETTS Z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS p DEPARTMENT OF ENVIRONMENTAL PROTECTION F t I TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:_170 lacy Street_ _North Andover E Owner's Name: Robert Rainville_ EID Owner's Address: 170 Lacy Street rNorth Andover,MA 01845_ Date of Inspection_101612005_ OCT 1 4 2005 TOWN OF NORTH ANDOVER Name of Inspector: Neil J.Bateson_ HEALTH DEPARTMENT Company Name:_Bateson Enterprisesrises Inc._ Mailing Address:_111 Argilla Road_ _Andover,Ma.01810 Telephone Number:_(978)475-4786 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15340 of Title 5 310 CMR 15.000). The system: PP Y P P ( Passes _X_ Conditionally Passes Needs Further Evaluation by the Local Approving Authority ils Inspector's Signature: f Date: _10/13/2005_ 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. Page 2 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:_170 Lacy Street_ _North Andover— Owner:_Rainville Date of Inspection_10/6/2005_ 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: X 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.Replace d-bog&collapsed section of outlet pipe. N 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: N 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: N 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 Y OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_170 Lacy Street- -North Andover — Owner:_Rainville_ Date of Inspection 10/6/2005_ 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 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) Property Address:_170 Lacy Street_ _North Andover— Owner: Rainville_ Date of Inspection_ 10/6/2005 D. System Failure Criteria applicable to all systems: You must indicate"yes"or`ono"to each of the following for all inspections: _ _No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool No Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool No Liquid depth in cesspool is less than 6"below invert or available volume is'/z day flow. _No_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _No Any portion of the SAS,cesspool or privy is below high ground water elevation. _No_ Any portion of cesspool or privy is within 100 fat of a surface water supply or tributary to a surface water supply. No Any portion of a cesspool or privy is within a Zone 1 of a public well. No Any portion of a cesspool or privy is within 50 fat of a private water supply well. No Any portion of a cesspool or privy is less than 100 fat 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.] No (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 gild. You must indicate either"yes"or`ono"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no T _ 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. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:_170 Lacy Street_ _North Andover_ Owner:_Rainville Date of Inspection_10/6/2005_ Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No Yes _ Pumping information was provided by the owner,occupant,or Board of Health No Were any of the system components pumped out in the previous two weeks? _Yes_ — Has the system received normal flows in the previous two week period? _ _No_ Have large volumes of water been introduced to the system recently or as part of this inspection? _Yes_ _ Were as built plans of the system obtained and examined? Yes_ _ Was the facility or dwelling inspected for signs of sewage back up? Yes _ Was the site inspected for signs of break out? Yes _ Were all system components,excluding the SAS,located on site? _Yes_ _ 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? _Yes_ _ 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 _Yes _ Existing information. Yes_ _ 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:_170 Lacy Street _North Andover– Owner:_Rainville_ Date of Inspection: 10/6/2005_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_4 Number of bedrooms(actual):_4 DESIGN flow based on 310 CMR 15.203_600_ Number of current residents:_2 Does residence have a garbage grinder(yes or no): No_ Is laundry on a separate sewage system(yes or no): No_ Laundry system inspected(yes or no): _ Seasonal use:(yes or no):_No Water meter reading:_On well water_ Sump pump(yes or no):_No Last date of occupancy:_Current COMMERCIAL/INDUSTRIAL Type of establishment:_ Design flow(based on 310 CMR 15.203):`Md 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: Never pumped,owner_ Was system pumped as part of the inspection(yes or no): Yes_ If yes,volume pumped:_1000_gallons--How was quantity pumped determined?_Measured tank Reason for pumping: Never pumped_ 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) _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: 27 years old, 10/21/1978,as built plan_ Were sewage odors detected when arriving at the site(yes or no):_No i Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_170 Lacy Street_ _North Andover_ Owner:_Rainville Date of Inspection_T 10/6/2005_ BUILDING SEWER_X_ (locate on site plan) Depth below grade:_24 Materials of construction: X cast iron X 40 PVC_other Distance from private water supply well or suction line:_>100'_ Comments(on condition of joints,venting,evidence of leakage,etc.) 4"Cast iron thur wall.3"PVC in house, no leaks visible SEPTIC TANKS: X Depth below grade:_12" Material of construction: X concrete—metal_fiberglass polyethylene _other(explain) If tank is metal list age:_.__ Is age confirmed by a Certificate of Compliance(yes or no):`(attach a copy of certificate) Dimensions:_7'x 5'x 4'_ Sludge depth: 20"_ Distance from top of sludge to bottom of outlet tee or baffle:—7"— Scum thickness:_15" 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: 611 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.Outlet tee ok.Depth of liquid above outlet invert.Found collapsed outlet pipe.No evidence of leakage._ 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.): i I Page 8 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_170 Lacy Street _North Andover_ Owner:_Rainville_ Date of Inspection:_10/6/2005_ TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: ex Material of construction: concrete metal fiberglass__polyethylene oth er( plain): 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 BOXES: X Depth of liquid level above outlet invert: —0 — 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 badly corroded. Needs replaced.Evidence of leakage.Evidence of carryover PUMP CHAMBER: (locate on site plan) Pump in working order(yes or no):— Alarm 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:_170 Lacy Street _North Andover_ Owner:_Rainville_ Date of Inspection: 10/6/2005_ SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number:_ leaching galleries,number: _ leaching trenches,number,length:_ X leaching field,number,dimensions:_1 field 20'x 451 _ 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.):_Soil ok.Vegetation ok.No sign of ponding to surface_ CESSPOOLS: Number and configuration: Depth—top of liquid to inlet invert: Depth of sludge 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.): i Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_170 Lacy Street _North Audover_ Owner: Rainville_ Date of Inspection:_10/6/2005 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. Porch Garage *--To Well A to Tank=17'9" A to D-Boz=49'4" House B to Tank 19'10" B to D-Boz=32'8" A Driveway Septic Tank D-Boz Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_170 Lacy Street_ _North Andover— Owner:_Rainville_ Date of Inspection: 10/6/2005_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water _4'_ Please indicate(check)all methods used to determine the high ground water elevation: _X Obtained from system design plans on record-If checked,date of design plan reviewed:_4/14/1977 Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain:_ Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain:_ You must describe how you established the high ground water elevation: As per design plan_ I Tel: (978) 475-4786 Fax: (978)475-5451 BATESON ENTERPRISES, INC. Excavating-Water.& Sewer Lines-Septic Systems&Pumping Service 111 Argilla Road Andover,Mass. 01810 Title 5 Inspection Report Property Address: 170 Lacy Street, North Andover Owner: Rainville Date of Inspection: 10/6/2005 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. Neil J. Bateson Bateson Enterprises, Inc. I I'I