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Miscellaneous - 1701 SALEM STREET 4/30/2018 (2)
1701 SALEM STREET _ 210/106.B-0154-0000.,o i f North Andover Board of Assessors Public Access Page 1 of 1 $1 ` Parcel ID: 210/106.11-0154-0000.0 Community: North Andover SKETCH PHOTO Click on Sketch to Enlarge No "Picture Aval ' Location: 1701L-50B SALEM STREET Owner Name: DUFFY,MARTIN J& JUDITH B Owner Address: 1701 SALEM STREET City: NORTH ANDOVER State: MA ZIP: 01845 Neighborhood: 6 - 6 Land Area: 1.14 acres Use Code: 101 - SNGL-FAM-RES Total Finished Area: 2264 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 503,700 470,300 Building Value: 293,100 275,400 Land Value: 210,600 194,900 Market Land Value: 210,600 Chapter Land Value: LATESTSALE Sale Price: 435,000 Sale Date: 07/25/2002 Arms Length Sale Code: Y-YES-VALID Grantor: SIPLE, GEORGE Cert Doc: Book: 06968 Page: 0206 http://csc-ma.us/NandoverPubAcc/jsp/Home.jsp?Page=3&Linkld=808952 11/20/2006 Residential Property Record Card PARCEL ID:210/106.B-0154-0000.0 MAP:106.113 BLOCK:0154 LOT:0000.0 PARCEL ADDRESS:1701 L-50B SALEM STREET PARCEL INFORMATION Use-Code: 101 Sale Price: 435,000 Book: 06968 Road Type: T Inspect Date: 05/28/2002 Tax Class: T Sale Date: 07/25/2002 Page: 0206 Rd Condition: P Meas Date: 05/28/2002 Owner: Tot Fin Area: 2264 Sale Type: P Cert/Doc: Traffic: M Entrance: C DUFFY,MARTIN J &JUDITH B Tot Land Area: 1.14 Sale Valid: Y Water: Collect Id: RRC Address: 1701 SALEM STREET Grantor: SIPLE,GEORGE Sewer: Inspect Reas: C NORTH ANDOVER MA 01845 Exempt-B/L% / Resid-B/L% 100/100 Comm-B/LOW Indust-B/L% 0/0 Open Sp-B/L% 0/0 RESIDENCE INFORMATION LAND INFORMATION Style: CP Tot Rooms: 7 Main Fn Area: 1328 Attic: NBHD CODE: 6 NBHD CLASS: 6 ZONE: R2 Story Height: 1.75 Bedrooms: 4 Up Fn Area: 936 Bsmt Area: 1328 Seg Type Code Method Sq-Ft Acres Influ-Y/N Value Class Roof: G Full Baths: 2 Add Fn Area: Fn Bsmt Area: 1 P 101 S 43560 1 209,959 Ext Wall: FB Half Baths: 1 Unfin Area: Bsmt Grade: 2 R 101 A 0.14 658 Masonry Trim: Ext Bath Fix: Tot Fin Area: 2264 VALUATION INFORMATION Foundation: CN Bath Qual: T RCNLD: 244288 Current Total: 503,700 Bldg: 293,100 Land: 210,600 MktLnd: 210,600 Kitch Qual: T Eff Yr Built: 1987 Mkt Adj: 1.2 Prior Total: 470,300 Bldg: 275,400 Land: 194,900 MktLnd: 194,900 Heat Type: FA Ext Kitch: Year Built: 1984 Sound Value: Fuel Type: O Grade: G Cost Bldg: 293,100 Fireplace: 1 Bsmt Gar Cap: Condition: A Att Str Val 11: Central AC: N Bsmt Gar SF: 624 Pct Complete: Att Str Va12: Att Gar SF: %Good P/F/E/R: /100/100/91 Porch Type Porch Area Porch Grade Factor P 112 S 192 SKETCH PHOTO 16 12 192 Sq.R. 12 No Picture 92 AS Available } Ma: : 26 26 30 a zR 4Q 4 112 .R. 4 Parcel ID:210/106.B-0154-0000.0 as of 11/20/06 Page 1 of 1 vi.,r\c\ Rcco-\ ��=�"�x ice`-o`< �3 jr� <<X �3���;, �ob- 4'-Cy A C R<s , 1-701 rT—jt—je-T r5+ IScale : Drwn by : pg 1 of Commonwealth of Massachusetts w W City/Town of NORTH ANDOVER } System Pumping Record Form 4 M 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 within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, use only the tab 1701 SALEM STREET key to move your Address cursor-do not NORTH ANDOVER MA 01845 use the return key. City/Town State Zip Code 2. System Owner: 39 COTUIT LLC. ILA Name seam Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 11/18/13 2. Quantity Pumped: 1500 Date Gallons 3. Component: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Observed condition of component pumped: GOOD CONDITION 6. System Pumped By: JAMES H CURRIER II H79 406 Name Vehicle License Number X SEPTIC & DRAIN RECEIVED Company 7. Location where contents were disposed: rnr^ 0013 L�v GLSD ^ HEALTH DEPARTMENT 11/18/13 Signature of Hauler Date Signature of Receiving Facility(or attach facility receipt) Date t5form4.doc•11/12 System Pumping Record•Page 1 of 1 MORT16664 O aidgdk p Town of North Andover HEALTH DEPARTMENT CYIUSE` CHECK#: DATE: l 3 LOCATION: 1 I V I LAbA—S�7- H/ NAME: A rob A 1,4 ILC,� CONTRACTOR NAME<NL (Q (.�)ff UA'- 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 $ ❑ TrashlSolid 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 $� ❑ Other. (Indicate) $ (,e-2 Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer 6664 Town of North Andover HEALTH DEPARTMENT ,sSACMUS CHECK#: ' DATE: LOCATION: SA H/O NAME: WiA G y CONTRACTOR NAME" ' ) _ Y r 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 $ J.s ❑ Sun tanning $ ❑ Swimming Pool ❑ Tobacco $ i3 ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Sustems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $� Cr Title 5 Report $� t Y ❑ Other:(Indicate) $ r v Health Agent Initials.. White-Applicant Yellow-Health Pink-Treasurer 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I�/ 1701 SALEM STREET Property Address 39 COTUIT STREET LLC Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 12/4/13 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not JAMES H CURRIER use the return Name of Inspector key. J'S SEPTIC & DRAIN Company Name 131 FOREST ST Company Address MIDDLETON MA 01949 City/Town State Zip Code 978-774-6685 S12327 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: 91=r,EIVE® ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority DEC 0 9 2013 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 12/4/13 t pector's Signa ure 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 inspection does not address how the system will perform in the future under that time.This ins Y at a p the same or different conditions of use. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts w . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 1701 SALEM STREET Property Address 39 COTUIT STREET LLC Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 12/4/13 page, City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM WORKING PROPERLY B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts w . Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'wM 1701 SALEM STREET Property Address 39 COTUIT STREET LLC Owner Owner's Name information is NORTH ANDOVER MA 01845 12/4/13 required for every State Zip Code Date of Inspection page. City/Town B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due 9 p 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): F1 distribution box i leveled or re 'laced ❑ 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 bithe Board of Health: ❑ Conditions exist which require furthLr 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 Cess y Cesspool privy is within 50 feet of a bordering vegetated wetland or a salt marsh p or p t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1701 SALEM STREET Property Address 39 COTUIT STREET LLC Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 12/4/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ' The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank d SAS a d the SAS is less than 100 feet but 50 feet or more from a private water supply II**. Method used to determine distance: ** This system passes if the well water an lysis, p ormed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and th presence ammonia nitrogen and nitrate nitrogen is equal no her failure criteria are tri triggered. A cop of the analysis must to or less than 5 m, provided that g9 Y pp p be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ❑0 Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 1701 SALEM STREET Property Address 39 COTUIT STREET LLC Owner Owner's Name information is NORTH ANDOVER MA 01845 12/4/13 required for 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. ❑ ❑,�\k� Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary ryto a surface water supply.. ❑ ❑4 Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ❑�0 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ❑V\� 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 feet of a surface drinking water supply ❑ ❑ the system is within 20 fee f a tributary to a surface drinking water supply El El Area 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. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 t5ins•11110 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1701 SALEM STREET Property Address 39 COTUIT STREET LLC Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 12/4/13 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the 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): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 600 GPD t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts N W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1701 SALEM STREET Property Address 39 COTUIT STREET LLC Owner Owners Name information is required for every NORTH ANDOVER MA 01845 12/4/13 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 269.48 9 ( Y 9 (gPd))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: CURRENT Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 C 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/s etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank presen . ❑ Yes ❑ No Non-sanitary waste discharged to t e Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1701 SALEM STREET Property Address 39 COTUIT STREET LLC Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 12/4/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: LPD 11/18/13 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1701 SALEM STREET Property Address 39 COTUIT STREET LLC Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 12/4/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: AS BUILT DATED 12/5/84 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 18" Depth below grade: feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: NA feet Comments (on condition of joints, venting, evidence of leakage, etc.): PLUMBING IN GOOD CONDITION Septic Tank (locate on site plan): 9" Depth below grade: 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 10'6 X 5'8" 1500 GALLONS Dimensions: Sludge depth: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Q 1701 SALEM STREET Property Address 39 COTUIT STREET LLC _ Owner Owner's Name information is NORTH ANDOVER MA 01845 12/4/13 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 18" 0 Scum thickness 11 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 2'6" SLUDGE JUDGE &TAPE How were dimensions determined? 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.): TANK DOES NOT NEED PUMPING AT THIS TIME, LIQUID LEVEL CORRECT. INLET AND OUTLET BAFFLES IN PLACE IN GOOD CONDITION (CONCRETE). Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ eta/ ❑ fiberglass El polyethylene El other(explain): Dimensions: Scum thickness Distance from top of scum to to of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments >. 1701 SALEM STREET Property Address 39 COTUIT STREET LLC Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 12/4/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1701 SALEM STREET Property Address 39 COTUIT STREET LLC Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 12/4/13 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comm entsno ( to if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): BOX LEVEL AND WORKING PROPERLY, LIQUID LEVEL CORRECT. NO EVIDENCE OF SOLIDS CARRYOVER. BOX 17" BELOW GRADE. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, co dition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate o site plan, excavation not required): If SAS not located, explain why: t5ins•1 Ill0 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 1701 SALEM STREET Property Address 39 COTUIT STREET LLC Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 12/4/13 page. City/Town 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: 32'X25' ❑ 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.): SOILS DRY, NO SIGN OF HYDRAULIC FAILURE, VEGITATION NORMAL. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1701 SALEM STREET Property Address 39 COTUIT STREET LLC Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 12/4/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts H r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1701 SALEM STREET Property Address 39 COTUIT STREET LLC _ Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 12/4/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately LA- N CeS TRNt4, q3 U 3 r f 3 I i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 1701 SALEM STREET Property Address 39 COTUIT STREET LLC Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 12/4/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 4 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 12/13/82 Date - ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) Accessed USGS database-explain: p You must describe how you established the high ground water elevation: TEST PIT DATA ON FILE WITH BOARD OF HEALTH SHOWS A FOUR FOOT SEPERATION BETWEEN BOTTOM OF BED AND SEASONAL HIGH WATER TABLE. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1701 SALEM STREET Property Address 39 COTUIT STREET LLC Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 12/4/13 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 FORM 4- SYSTEM PL1iPV�G RECORD Commonwealth of Massachusetts Massachusetts System Pumping Record 'stem Uwner bvstern Location 01 &� Date of Pumping: �-g — �� Quantity Pumped: /`j-W gallons Cesspool: N0 ® Yes ❑ Septic Tank: No ❑ Yes Q System Pumped bv: � License #: Contents transferred to: � S Date Inspector Form 4 -- System Pumping Record Commonwealth of Mossachusetss Massachusetts System Pumping Record System Owner System Location 1'].�i*�r- Ytrnu• 1 ;u:..�ta,i3n- i .+C ,t gni 1,�.,, r'tts� i ti•�'! .9 w.t, r,togtnn rt 7111 sal"M 2t. H.' 01,!84 R,rhb Ands v«?£ MA f)Id4`± 'tgnr h,�mn Inspeot.ttin Type: Emergency Routine Cesspool: W Yes. Septic tank: W Yes Date of Pumping: Quantity Pumped: Gallons System Pumped By: Wind River Environmental, LLC Permit#: Contents transferred to: Contents Disposed at: Date: Pumper signature: Condition Sy Other Comments Lep Approved from - 12/07/95 I \oSEPTIC STSTEK alth. ' INSTA?.LATICK CHECK LISP LOT ' SAP c OVID DAT$ DI SU Q DAT X AVA1fS(S21 CK ''AIL e� aR-Dn5` i OK s FA1Z I. DTic:tance Tot a. Wetlands b. brains c.. Well 2. Water Line Location 3. No PPC Pip e 4. Septic Tank a. _Tees -_Length k To Clean Out Covers b. , Cement Pipe .to Tank On Both Sides of Tank 5. Distribution Box a. Covers & Box No Cracks All Lines Flo wing Equal Amounts c. No Back Flow 6. Le ich Field or Trench a. Dimensions b. Stone Depth c. Capped Inds d. Clean Double Washed Stone ?. Le ich Pits a. Dimensions. b. Stone Depth c. Splash Pads d. Tess e. Cenant Pipe to Pit - Both Sides f. Clean Double Washed Stone 8. No Garbage Disposal 9. Final Grading Inspection 10. Barricading Covered System 11. As Built Submitted a. Low Location b. R. •pensions of System c. Location with.Regard_to Pere Test d. Elevations Water'Table r i r_..x .• r.r: :ns---�.rsa�-nrt�•a+:::rr..:^n r..:.�sr•r�++c e ! IJ t j �OQ�' H Ai...iDO E bz elcwz,2D P. 'd1.Ay1INSKI ZkQP ASSOCI OTF S,I-JC. 110�T1-t A►.1DOvCx2. MA. ' . S A L E M 5 T Q E ET . 150.00' — 0 ucW � [" E G1d1.lD� ppwE 2 CoiT .EASEi t A!T LOT 51 L ,$ LOT A15 8 Ta?g^G+ �G5•1proX76 .1 to 'I • 31.x'3 � =='"�' •'°'` � p K pLo-r 50 e E d � T i • I I I I i i I I i �o 8d : Aq • uNup o x O.� Z� H-1109. V � COMMONWEALTH OF MASSACHUSETTS HUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS N W DEPARTMENT OF ENVIRONMENTAL.PROTECTIOR"^ _ r.'. i f ratted 0. ••�++„.„ ' TITLE 5 - F ' OFFICIAL INSPECTION FORM-NOT FOR.V,OLUNTARY ASS.E , SSMENTSt,) .. SUBSURFACE SEWAGE DISPOSALSYSTEM.FORM,$, � PART.A s �uUL CERTIFICATION 76! SALEM Property Address:-_ ST"" Name of Owner: (�eUNE Sr'"(PZ Address of Owner: S� Date of Inspection: Z- Name of Inspector: 6'Aw!N t A- Company Name: Tiger Environmental Engineering Mailing Address: 969 Washington Street, Braintree, MA 02184 Telephone Number: 781-849-0088 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 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(CMR 15.000).The system: X Passes Conditionally Passes Needs Further Evaluation By The Local Approving Authority Fails Inspector's Signature: Date: 4-1 i—Q z- The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gdp or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies to the buyer, if applicable, and the approving authority.. NOTES AND COMMENTS "�►-tE __7_)+5T,4 8L r 0AJ 94�k i tIR-S Ar WIT-;4 f reAuu c_ Com — T U22rI& ` 7)6 CWgSE OF. t hS, W,51PUTI oral. ****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. revised 6/15/2000 Page 1 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARYrASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: �'7C3r1 sT. �.. �V�YZ IVA r; { Owner: �Jfpl.I` 1 . 1(- Date of Inspection: 4- d2``" ' INSPECTION SUMMARY: Check A, B, C, D or E/ALWAYS complete all of Section D A. SYSTEM PASSES: X _ I have not found any information which indicates that any of the failure conditions 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 i pass. 1 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*o r 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. s "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): y 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: revised 6/15/2000 Page 2 of 11 R ' �i F'# �. may...• i ���� OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.A l CERTIFICATION (continued) E' Property Address: Owner: S I PC E Date of Inspection: 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 the 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,�ENVIRONME-Af. 4s. 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, Y== SAFETY AND THE 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 Zone 1 of a public.water supply. s� 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;analysisnust.be.aftached to..this form. ,r .. r 6 I 3. OTHER `w revised 6/15/2000 Page 3 of 11 pf 4 .. w OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 7D� 1 S`" A1« . 6L_, Owner: :SkPL r 02- Date Date of Inspection: D. SYSTEM FAILURE CRITERIA APPLICABLE TO ALL SYSTEMS: " r`.`no"to each of the following for all inspections: N A ' P�Ia7• / \' ' u�� must indicate es o You u t g _ Y � , Yes No Backup of sewage into facility orrsystem component due to an.overloaded or clogged SAS or cesspool. VDischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged :z SAS Or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. N�A Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ZAny portion of the SAS, cesspool or privy is below the high groundwater elevation. Any portion of a 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. i6la Any portion of a cesspool or privy is within 50 feet of a private water supply well. s 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.] �a (Yes/No)The systems fails. I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303,.therefore the system fails. The system owner should contact the Board of Health to.determine�what W.ill,be necessary-to correct the failure �. .._- . M �.. ."�+..�... ++'T.MA-", r'rr.r.nns',sr.'*^�,•'i d�fi v.E,l:T ,il--n w -.,a+., ?I."+F ,....,.g W.. ---.E. LARGE SYSTEM: 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 t:. 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 f 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 tt 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. revised 6/15/2000 Page 4 of 11. • F' O FI CIAL INSPECTION�r C ON FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Nr Property Address:J Ib ISA'tEM S-r-, a�+ lxitlE)'Z, .Iqw� Owner: 1`` ,. ys Date of Inspection: ^11-0 Z^' Check if the following have been done.You must indicate either"Yes"or"Nd'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? r' 1 ,. v y r reCe� d no riiai flo is in fli-e p- iktlV o weei pbriod°.� / / Have large volumes of water been-introduced to thesystem 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? IA 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 in for the condition of the.baffles or tees;:materialof construction,dimensions,depth of liquid,.depth of rt sludge and depth of scum:? a Was the facility owner(and occupants if different from owner)provided with information on the proper . maintenance of subsurface sewage,.disposal systems? ;14 The size and location of the Soil Absorption System(SAS)on the site has been determined based on: sf 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) [310 CMR 15.302(3)(b)] :"^^'"` ..,,',� .,�„"_" c �±-�+wu.+!c,+,'�- K'ar� `•}.ps.�:-.�,.,ey�q r a. ir-�n..a..�,. .s...� t.,-t.+v a.� «...es . 1. ,7 revised 6/15/2000 Page 5 of 11 ik: OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFOARMATION Property: Property Address: : X701 SAr( T S' N« p� f'' l� . Owner; Date of Inspection: +� D ' RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): 4— Number of bedrooms(actual):_ / //++��,, DESIGN flow based on 310 CMR 15.203(for example110 gpd x#of bedrooms): X 15o = 6oa & > Number of current residents: 21 Does residence have a garbage grinder(yes or.no) ►SID Is laundry on.a separate sys em:(ye :or no rt O :.; �r [If yes;separate rnspecfion required] `1 Laundry system inspected (yes or no): • Ip�O �•¢�0 / ��D( 15a Seasonal use(yes or no): N6 /�� 1411 / / .Water meter readings, if available(last two year's usage(gpd)): I QL $5, � /�foz ��C�� Sump Pump(yes or no): ?10 Last date of occupancy: (AJ.�000ufla� COMM ERCIAL/INDUSTRIAL Type.of Establishment: ` ' Design flow(based on 31.0 CMR 15.203):. gpd Basis of design flow(seats/persons/sq ft" etc): *s: 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 �.A .PWPJAI(s (6 77 ,4(" ... ..fir . :�+rca.-.�'+^,ye of 3 `° ,ey��7 t..�c:`4 Was system pumped as part"off inspection(yes or )o): � *. ,� , $` �r'°:'.`' : ,;"`,. 7 4 , If yes, volume pumped. 1500 gallons-- How was quantity pumped determined? Reason for pumping: Auil f/P of Sou16 id"TANG TYPE OF SYSTEM X Septic tank, distribution box, soil absorption system Single cesspool Overflow cesspool Privy P!p Shared system (yes or no)(if yes, attach previous inspection records,.if any) Innovative/Alternative technology.Attach a copy of current operation and maintenance contract(to be obtained from system owner) R 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): Nd revised 6/15/2000 Page 6 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 1? ► ter, . N >' Property-Address: '� 'Owner' pLr- Date of Inspection: ' t, ©2^" BUILDING SEWER(locate on site plan) Depth below grade: r� Material of construction:0 cast iron O 40 PVC O other. (explain) Distance from private watersupply well or suction line: VIA — MUNIUML, u4tQ2- Comments (on condition of joints venting widence oleakage,etc.): Otn�s 't SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: 0 concrete O metal O Fiberglass O Polyethylene O other(explain) -- -- --- "---- ------- -::i If tank is metal, list age:. Is."age confirmed by Certificate of Compliance(yes or.no): (attach a copy of certi#icate) ,I Dimensions: !, }SQA Sludge depth: 0 2j�a yr Distance from top of sludge to bottom of outlet tee or baffle: Q" .'.Scum thickness: rt Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: � t, How dimensions were determined: M iW £t h Comments(on pumping recommendations, inlet and outlet tees or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): / GREASE TRAP: (locate on site plan) '' v� -v OVTIA---r Depth below grade: Material of construction: O concrete O metal O Fiberglass O Polyethylene O other(explain) Aimensions: Scum thickness: 71 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee of baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tees or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): f revised 6/15/2000 Page 7 of 11 At f OFFICIAL.INSPECTION FORM-'NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM'INSPECTION FORM PART C . SYSTEM INFORMATION (continued) } . :Property Address., Owner: Date of Inspection: " ' 0 ' TIGHT OR HOLDING TANK: NO (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Materials of construction:10 concrete O metal O.F'berglass 10 Polyethylene ,O:other_(explain) a r Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): s Alarm level: Alarm in working order. (Yes or No) Date of last pumping: Comments(condition.of alarm and float'switches.etc:): y, _ a } DISTRIBUTION BOX: ► (if present must be opened)(locate on site plan) (/j M4 01-_S Depth of liquid level above outlet invert: 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.): t2Qtl "�..�'f�, _ PUMP CHAMBER: Na (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Eomments(note condition of pump chamber, condition of pumps and appurtenances, etc.): J revised 6/15/2000 Page 8 of 11 OFFICIAL INSPECTION FORM,-NOT-FOR VOLUNTARY ASSESSMENTS'. SUBSURFACE SEWAGE DISPOSAL SYSTEM•INSPECTION FORM: y PART.C SYSTEM INFORMATION(continued) 3 I1 Property Address. Q 'V Owner: t PUS r Date of Inspection: '"r 0 "' SOIL ABSORPTION SYSTEM(SAS): (locate on site plan, excavation not required) If SAS not located explain why: w . Type - _ �J*j 15, t96Z. leaching pits, number: (-11 r K MtN$1<) U>R(A5 leaching chambers, number: I �,, leaching galleries, number: No. , `"f VGZ, T , ensions: �,.�: leaching trenches;number, length: y ':. No. 7 > .. � leaching fields,.number,dim' overflow cesspool number a i innovative/alternative.aystem Type/name of technology rrComments(note condition of soil signs of hydraulic failure, level of ponding•damp soil,"condition of vegetation etc.):' s v Q. t ` ��+c_ : u:►�rs: ��'t�?t79-! tVd �Ils�S c� . fur: �rw� 12. n(�1 �: �1 -ro�r /s AfML_ s CESSPOOLS:A0 (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 layerl t; @ �. > r t - ,� a ; �a >; � .,_~y e = s ) G t 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 onsite plan) TM. Materials'of construction: i s, Dimensions: Depth of solids: f Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 6/15/2000 Page 9 of.11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS; SUBSURFACE SEWAGE_DISPOSAL SYSTEM INSPECTION FORM x i' 'PART C Y t. y' SYSTEM INFORMATION (continued) Property Address. t�?ol Ayly f12MA Owner: Date of Inspection: 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. A.ra AM— :ZX-5VUSUr&J a r 7} 4 ate i l5ao C7j`„S � t . . . . . . . . . . . . . . . . .: . it .. • _ .•. ��. ,. k. .•. 4 � r • a • :•: lei i .,.v. � • •-. •E:. .•i �. � -• pr • , + r �, -y; s C rr� ! Y ."�fi�j`i ��'S*��a,+ ��'(S� � � �'��t�,����i��i� �� '�x� �. i ! ';.��� • . . . .. . ' . . rj .:i { 1 revised 6/15/2000 Page 10 of 11 so- " r OFFICIAL INSPECTION FOY�M-VNOT FOR.VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL-SYSTEM INSPECTION FORM ` PART C SYSTEM INF..ORMATION,(continued),, ' Property Address r7l ► , YA r Owner: 51" Le Date of Inspection: + o2— SITE EXAM Slope . Surface water" .f Check,Cellar Shallow wells l , Estimated depth to ground water 'feet . Please indicate(check)all the methods used to determine the high groundwater elev6tion: X Obtained from system design plans on record- If checked,date of design plan reviewed: Observed site(abutting property/obsenraUon Bole within 150 feet of-SAS) :Checked with local Board of Wealth=:explain: ` r .. F.. 7 a :Checked local excavators installers 4`(attach documentation) r Accessed USGS database-explain: You must describe how you established the high groundwater elevation: POZ X164 _D Uj See --------------------- 117- S r &71 �m OF lam" r 4 . revised 6/15/2000 Page 11 of 11 TO: NORTH ANDOVER, MASS. December 5, 19 84 BOARD OF HEALTH FROM: DESIGN ENGINEER Re: Soil Absorption Sewage Disposal System This is to certify that I have reviewed the construction materials of said disposal system at Lot 50B Salem Street Site Location North Andover, Mass . The grades and .construction materials are in ,general conformance- ,to the specifications dated December 13 19 82 and AAs-Built December 5 19 84 . Reg.Prof. Rggxl� e Sanitarian I PLACE to cz CIVIL �No.31)12® /STE�kr �'� ��`���MAL TOWNgQAt4()Of Is l %5 APR 11 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSP Address of property f°70 1 Ql�, SA- 00'� , � Owner's name 14 C. e BCD W-y\ Date of Inspection PART A CHECKLIST Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently''or as part of this inspection. As built plans have been obtained and examined. Note if they are not aavv ilable with N/A. y The facility or dwelling was .inspected for signs of sewage back-up. � T site was inspected for signs of breakout. All system components, excluding the SAS, have been located on the The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of . baffles or tees material of construction,-r tion, dimensions, depth of liquid, depth of q P udge, depth of scum. The size and location of the SAS on the site has been determined based oo existing information or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential number of bedrooms number of current residents O garbage grinder, yes or no laundry connected to system, yes or no _ 'No seasonal use, yes. or no ; If nonresidential, ' calculated flow: Water meter readings, if available: ....� vailable: Ra..� X `1.5 �s ts-Li Last date of occupancy P�jq r1 GENERAL INFORMATION Pumping records and sou rce of information: �-wo L� CSV\ --)k, System pumped as part of inspection, yes or no if yes, volume pumped lsOb Reason for_ pumping: fD � Type 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) Other (explain) Approximate age of all components. Date installed, if known. Source of information: 4vU Sewage odors detected when arrivingat the site es o y r no f 9 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B / SYSTEM INFORMAATION continued v SEPTIC TANK: (locate on site plan) depth below grade• material of construction: �` concrete metal FRP other(explain) dimensions: c� rr j sludge depth o distance from top of sludge to bottom of outlet tee or baffle .9 " scum thickness = distance from top of scum to top of outlet tee or baffle IWI distance from bottom of scum to bottom of outlet tee or baffle Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, r commendations for re airs etc. ) DISTRIBUTION BOX: `�� (locate on site plan) depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evi ence of le kage into or out�qfx, recomipendation f r repair etc. ) t �C . 81 &20 Q r t ox U O t (UCA PUMP CHAMBER: (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumila and appurtenances, recommendations for maintenance or repairs,etc. ) 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type leaching pits and number leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions 1 cmc e- overflow cesspool, number Comments: (note condition of soil , signs of hydraulic 'failure, level of ponding, co dition o v etation, recom end ions for-: mainten nce or repai et . ) o�\ ti" � c� Wi o S;�' w I iL �v�� CESSPOOLS (locate on site plan) : QbV\i2. 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 (cesspool must be ,pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) PRIVY: N�P'.' (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, recommendations for maintenance or repairs,etc. ) 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' S 4o S:3 LI ,Ll � ® o C- DEPTH TO GROUNDWATER depth to groundwater kec method of determination or approximation: �C. ��•, ` 1 Irl 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined", explain why not) Backup of sewage into facility? NDischarge or ponding of effluent to the surface of the ground or surface waters? N Static liquid level in the distribution box above outlet invert? Liquid depth in cesspool <6" below invert or available volume< 1/2 day flow? ,V Required pumping 4 times or more in„the last year? number of times pumped AJ Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial,mexfiltration? tank failure imminent? ; NIs any portion of the SAS, cesspool or privy: below the. high groundwater elevation? N within 50 feet of a surface water? within 100 feet of a surface water supply or tributary to a surface water supply? Nwithin a Zone I of a public .well? within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, fit, the SAS) ? N � within 50 feet of a private water supply well? less than 100 feet but greater than 50 feet from aP rivate water supply well with no acceptable water quality analysis? If the well has been analyzed to be acceptable, attach copy of well water analysi for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. R 13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector Company Name Company Address Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and manitenance of on-site sewage disposal systems. Chec e: I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15. 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15. 303 . The basis for this determination is 7prv 'ded n the FAILURE CRITERIA section of this form. Inspector' s Signature Date r _C?s Original to system owner Copies to: Buyer (if applicable) Approving authority I of 11 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION r TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION RED Property Address: 1701 Salem Street North Andover,MA 01845 Owner's Name: Judy Duffy Owner's Address: 1701 Salem Street North Andover,MA 01845 NOV 2 0 2006 Date of Inspection: August 23,2005eOR' dmf TOW HANDOVER Name of Inspector:(please print) Benjamin C.Osgood,Jr.Certified Title 5 Inspector HEALTH DEPARTMENT Company Name: New England Engineering Services Inc. Mailing Address: 60 Beechwood Drive North Andover,MA 01845 Telephone Number: 978-686-1768 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of the on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15340 of Title 5(3 10 CMR 15.000).The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: z 3 S The system inspection shall submit a copy of this inspecti /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. 2of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1701 Salem Street North Andover,MA 01845 Owner's Name: Judy Duffy Date of Inspection: August 23,2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: N� 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: APO v 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: V 3of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1701 Salem Street North Andover,MA 01845 Owner's Name: Judy Duffy Date of Inspection: August 23,2005 C. Further Evaluation is Required by the Board of Health: nro Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and (SAS)Soil Absorption System and the(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organize compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 4of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1701 Salem Street North Andover,MA 01845 Owner's Name: Judy Duffy Date of Inspection: August 23,2005 D. System Criteria applicable to all systems: You must indicate"yes or No"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overload or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overload or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped ✓ Any Portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (this system passes if the well water analysis,performed at a DEP certified laboratory for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrogen is equal to or less than 5ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) Arm (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 follo criteria apply to large systems in addition to the criteria above) Yes No The system is within 40 of a surface drinking r supply The system is within 200 feet of a trib to a surface drinking water supply The system is located' rtrogen sensitive area(Irate ' Wellhead Protection Area—IWPA)or a mapped Zone II of a public w upply well If you answ yes"to any question in Section E the system is considered a significant t or answered`yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant thr at 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. i y 5of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1701 Salem Street North Andover,MA 01845 Owner's Name: Judy Duffy Date of Inspection: August 23,2005 Check if the following have been done. You must indicate"Yes"or°Gno"as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health V Were any of the system components pumped out in the previous two weeks-? Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of an inspection? 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? v Was the site inspected for sign of break out? V Were all system components,excluding the SAS,located on site? Were all the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if difference from owner)provided with information on the proper maintenance of the subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] 6of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1701 Salem Street North Andover,MA 01845 Owner's Name: Judy Duffy Date of Inspection: August 23,2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design) Number of bedrooms(actual): 3 DESIGN flow based in 310 CMR 15.203(for example: 110 gpd x 4 of bedrooms): C U Number of current residents: Z Does residence have a garbage grinder(yes or no): A.10 Is laundry on a separate sewage system(yes or no): /v D [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): IV J . Water meter readings,if available(last 2 years usage(gpd): la ,J Sump Pump (yes or no): Last date of occupancy--5-., COMMERCIALA NDUSTRUL 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: Z o D r ?e2 O uu Was system pumped as part of the inspection(y9 or no): If yes,volume pumped: gallons-How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank, distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Altemative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attached a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: �ec"Q Qe2 130 K RGco 2+>S Were sewage odors detected wen arriving at the site(yes or no): AID . 7of11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1701 Salem Street North Andover,MA 01845 Owner's Name: Judy Duffy Date of Inspection: August 23,2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction _;�_cast iron 40 PVC other(explain) Distance from private water supply well or suction line: V)A Comments(on condition of joints,venting,evidence of leakage,etc.): tF WE Cry.,DD' 1ti 3fl-,-,P"/,-e SEPTIC TANK: (locate on site plan) Depth below grade: q 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: 1 �) N Sludge depth: Z-z Distance from top of sludge to bot of outlet tee or baffle: Z Z Scum thickness: <t Distance from top of scum to top of outlet tee or baffle: Distance from botAt#EFUMM of scum to bot of outlet tee or bathe z3 How were dimensions determined: /,,gj_+s- 2 e s C I I- Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): KININ C-CoD, Co,. D(-T)0 1 Ce j cr-eC 0 s 13�r=tee i GREASE TRAP: /'Y`11- (locate on site plan) Depth below grade: Materials of construction: concrete metal fiberglass polyethylene other (explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from botAugust 23,2005 of sludge to botAugust 23,2005 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. 8of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1701 Salem Street North Andover,MA 01845 Owner's Name: Judy Duffy Date of Inspection: August 23,2005 TIGHT OR HOLDING TANK:__14 (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Materials of construction: concrete metal fiberglass polyethylene other (explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: D Comments(note if box is level and distribution to outlets equal,any evidnence of solids carryover,any evidence of leakage into or out of box,etc.): C��NJtllp✓L- /1/J i=ytoeYiy� ��:.fi1��+6E NCS C,taay C)U ,P Sr;ZJ) /U0 i C-QkjPq L- fZeconte e v PUMP CHAMBER: NVI, (locate on sire 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.): 9of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1701 Salem Street North Andover,MA 01845 Owner's Name: Judy Duffy Date of Inspection: August 23,2005 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required If SAS not located explain why TYPE leaching pits number leaching chambers, number leaching galleries number leaching trenches,number in length _ ( leaching fields,number,dimensions: 1 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) CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of Construction Indication of groundwater inflow(yes or no) Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: locate on site plan) Material of construction: Dimensions: Depth of solids Comments(note condition of soil signs of hydraulic failure,level of ponding,condition of vegetation,etc. 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1701 Salem Street North Andover,MA 01845 Owner's Name: Judy Duffy Date of Inspection: August 23,2005 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. A- 9 qiS i?q"i ccs /� -T Z z L } .3 t�-13��% 3 11 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1701 Salem Street North Andover,MA 01845 Owner's Name: Judy Duffy Date of Inspection: August 23,2005 SITE EXAM Slope Surface water AIC N c Check cellar v 12") /,-0 -60"? ro,v ? Shallow wells n;e Estimated depth to ground water 9 _feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: —3L Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavator,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: X115 k�jS�ec-q�R R.� Feq_f tZ l-D 5°" i i NEW ENGLAND ENGINEERING SERVICES INC RECEIVED August 23, 2005 AUG 5 2b05 TOWN OF NORTH ANDOVER HEALTH DEPARTMET North Andover Board of Health 400 Osgood Street North Andover, MA 01845 RE: TITLE V REPORT: RE: 1701 Salem Street, North Andover Dear Sir or Madam: Enclosed is a copy of the Title V report for the above referenced property. The system PASSED our inspection. If there are any questions please call me at my office, 686-1768. Sincerely, Bene C. Osgoo , Jr. Certified Title 5 Inspector 60 BEECHWOOD DRIVE-.NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 I f FORM - U - LOT RELEASE FORM f IN TR CTIONS: This form is used to verify that all-necessary approval/permits from Bo' ds d Departments having jurisdiction have been obtained. This does not relieve the i app 'can and or landowner from compliance with any applicable requirements. !_ *�� •� ,APPLICANT ..�.�.a ...5'e i .I-e--...........PHONE ■• � .�.......... ASSESSORS MAP NUMBER'LI 6 LOT NUMBER / SUBDIVISION LOT NUMBER 0 STREET STREET NUMBER 7 .......................... OFFICIAL USE ONLY.........................ro RECOMMENDATIONS OF TOWN AGENTS DATE APPROVED CONSERVATION ADMINISTRATOR DATE REJECTED COMMENTS 6 DATE APPROVED TOWN PLANNER DATE REJECTED COMMENT'S i DATE APPROVED FOOD INSPECTOR-HEALTH DATE REJECTED ` :�=�f~R_.►dl._ DATE APPROVED SEPTICI NSPECTOR-HEALTH DATE REJECTED COMMENTS PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED FIRE DEPARTMENT DATE REJECTED COMMENTS RECEIVED BY BUILDING INSPECTOR DATE Septic System Information 1701 SALEM STREET Printed On: Thursday,July 05, 2007 System ID: BHS-2002-1332 General System Information Latest Permit Information Calcaluted Design Flow: Test Pits Septic Tank Disposal Trench Design Flow: One TWO Capacity: Number: Design Flow Provided: Minutes per inch: Width: Width: Total Flow: Depth: Length: Length: Seasonal: No No Depth to Water: Diameter: Leaching: Grinder: No No Soil Type: Depth: Laundry: No No HaulinaTumping Listin Quantity Type System Type Pumped Pumped By Transferred To Disposed At Date Pumped allons Routine Septic Tank STEWARTS SEPTIC GLSD 08/17/2005 1000 Inspections: Inspected: Expires: Inspector: Status: 06/28/2007 Benjamin C.Osgood,Jr. Passes Comments: Title 5 GeoTMSO 2007 Des Lauriers Municipal Solutions, Inc. Page 1 of 1 3 NORT" y F p � . Town of North Andover 'tia ::•t�,' HEALTH DEPARTMENT SACHU4t CHECK#: �C�! DATE: LOCATION: --®/ /�iC H/O NAME: CONTRACTOR NAME: d 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 $ y SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ l i ❑ Septic Disposal Works Installers(DWI) $ { ❑ Title 5 Inspector $ fitle 5 Report $�� ❑ Other. (Indicate) $ 2505 - Health Agent Initials t White-Applicant Yellow-Health Pink-Treasurer Ku.. 1 Commonwealth of Massacht et+s• r RECEIVE E� • ��i �6 r7 v Title 5 Official Inspection Form �uL 0 5 2007 Subsurface Sewage Disposal System Form - Not for Voluntary Assessme s TOWN OF NORTH ANDOVE 1701 Salem Street HEALTH DEPARTMENT Property Address Judy And Martin Duffy Owner Owner's Name information is required for No.Andover MA 01845 06/26/07 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Benjamin C. Osgood Jr. cursor-do not Name of Inspector use the return key. New England Engineering Services, Inc. Company Name VQ 1600 Osgood Street Suite 2-64 Company Address No.Andover MA 01845 n City/Town State Zip Code 978-686-1768 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: []Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority - Inspector 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. TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1701 Salem Street Property Address Judy And Martin Duffy Owner Owner's Name information is required for No. Andover MA 01845 06/26/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ave 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 TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1701 Salem Street Property Address Judy And Martin Duffy Owner Owner's Name information is required for No. Andover MA 01845 06/26/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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: 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. TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1701 Salem Street Property Address Judy And Martin Duffy Owner owner's Name information is required for No.Andover MA 01845 06/26/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ❑. Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ 9 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ 2' Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ L2` Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1701 Salem Street Property Address Judy And Martin Duffy Owner Owner's Name information is required for No.Andover MA 01845 06/26/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ 2' Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ a Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 0' 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.] ❑ Ege The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ 01*`� 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 ❑ 2"' the system is within 400 feet of a surface drinking water supply ❑ 2" the system is within 200 feet of a tributary to a surface drinking water supply ❑ E2,,- 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. TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1701 Salem Street Property Address Judy And Martin Duffy Owner Owner's Name information is required for No. Andover MA 01845 06/26/07 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 ❑ 2"" Pumping information was provided by the owner, occupant, or Board of Health ❑ IK Were any of the system components pumped out in the previous two weeks? 2'*- ❑ 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? LIQ ❑ Were all system components, excluding the SAS, located on site? I� ❑ 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. El g---- (if an Determined in the field of the failure Y c ri terra related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1701 Salem Street Property Address Judy And Martin Duffy Owner Owner's Name information is required for No. Andover MA 01845 06/26/07 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 6,90 Number of current residents: Z Does residence have a garbage grinder? ❑ Yes [2 No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes W No Water meter readings, if available last 2 ears usage cf 2 G.PP 9 ( Y 9 (gpd)): 31t►s' 1.0 3/07 Sump pump? ❑ Yes © No Last date of occupancy: G rr4,.,7— 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: Last date of occupancy/use: Date Other(describe): TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1701 Salem Street Property Address Judy And Martin Duffy Owner Owner's Name information is required for No. Andover MA 01845 06/26/07 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: —7 ,L� 2,&05- ?4FA 0w,..�2 Was system pumped as part of the inspection? ❑ Yes No 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 ❑ 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: ; 6 _ + dc-,—As oe2. 4?7 a R (L.cc43 2fl,s Were sewage odors detected when arriving at the site? ❑ Yes [0, No TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1701 Salem Street Property Address Judy And Martin Duffy Owner Owner's Name information is required for No. Andover MA 01845 06/26/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: AJ feet Comments (on condition of joints, venting, evidence of leakage, etc.): 1n•�'�t l✓� G-e O P Go a.��i1�/�- l N P fk��^tet.ems✓ll Septic Tank(locate on site plan): Depth below grade: feet Material of construction: fA concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Z Z Scum thickness 41 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? TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts d Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'GSM 5v 1701 Salem Street Property Address Judy And Martin Duffy Owner Owner's Name information is required for No. Andover MA 01845 06/26/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): T'A,N V, t,V (soap caND1-llo1-j. c4Fr ' r> CrOSS B tA7V- L(- L.v o CJ -;3p IiTonJ 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): TITLE 5 FORM2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1701 Salem Street Property Address Judy And Martin Duffy Owner Owner's Name information is required for No. Andover MA 01845 06/26/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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 Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): 13 X (ti+ !r O J cd,.,0 L-'1ory• No c,c A-K4&Z- I N o2 DuT 0R- SbLA p.S COtIggy Dye-C_ .PcS i XtB4-)74.--J 6-G2..4 44 Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1701 Salem Street Property Address Judy And Martin Duffy Owner Owner's Name information is required for No. Andover MA 01845 06/26/07 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: leaching fields number, dimensions: tx,4c� size ❑ overflow cesspool number: U AJ 9'N/b ❑ 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.): 1A-IL W 0 14-A NO jZ.A j4-(__ AJ.D 6%.-1 t 0 e.4 C,� C1� QaN ptNG D � So« „ 02 ys,,,,+L. LJ " WD TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 1701 Salem Street Property Address Judy And Martin Duffy Owner Owners Name information is No. Andover MA 01845 06/26/07 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 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.): TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 1701 Salem Street Property Address Judy And Martin Duffy Owner Owner's Name information is required for No. Andover MA 01845 06/26/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. 3 TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 1701 Salem Street Property Address Judy And Martin Duffy Owner Owner's Name information is required for No. Andover MA 01845 06/26/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: [Check Slope [Surface water 0d_pc N t-j Rer-2- E Check cellar No S,,M p ['"Shallow wells/i �✓� Estimated depth to ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: / t S -r s TC✓N1 ( ✓� Gt G/� w l.i L i-5 a �►d f`r°J �//�D p w Al-;E.2 t G-e-A�al�� =C-C7- R eco w C,-,=�Jd AJD 'F QA M G Yt2 L 2l�wJC rj ori- �NsPcc-�2. TITLE 5 FORM 2007.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 I of 11 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION RECEIVED Property Address: 1701 Salem Street North Andover,MA 01845 Owner's Name: Judy Duffy AUG 2 5 2005 Owner's Address: 1701 Salem Street North Andover,MA 01845 Date of Inspection: August 23,2005 TOHEA�FHQRrH DEpqRTMAND OVER Name of Inspector:(please print) Benjamin C.Osgood,Jr.Certified Title 5 Inspector Company Name: New EnglanaEngineering Services Inc. Mailing Address: 60 Beechwood Drive North Andover,MA 01845 Telephone Number: 978-686-1768 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 the 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: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: The system inspection shall submit a copy of this inspecti report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1701 Salem Street North Andover,MA 01845 Owner's Name: Judy Duffy Date of Inspection: August 23,2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: E5 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: AtO 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: I ' 3of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1701 Salem Street North Andover,MA 01845 Owner's Name: Judy Duffy Date of Inspection: August 23,2005 C. Further Evaluation is Required by the Board of Health: 1\TO Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and (SAS)Soil Absorption System and the(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within a p pp y The system has a septic tank and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Methal used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organize compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5ppm,provided that no other failure criteria are triggered A copy of the analysis must be attached to this form. 3. Other: 4of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1701 Salem Street North Andover,MA 01845 Owner's Name: Judy Duffy Date of Inspection: August 23,2005 D. System Criteria applicable to all systems: You must indicate"yes or No"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overload or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overload or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than'/s day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped ✓ Any Portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (this system passes if the well water analysis,performed at a DEP certified laboratory for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrogen is equal to or less than 5ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) 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 gpd. You must indicate either"yes"or"no"to each of the following: (The follo criteria apply to large systems in addition to the criteria above) Yes No The system is within 40 of a surface drinking r supply The system is within 200 feet of a trib o a surface drinking water supply The system is located' trogen sensitive area(Int ' Wellhead Protection Area—IWPA)or a mapped Zone Il of a public w upply well If you answ es"to any question in Section E the system is considered a significant or answered"yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant thr t 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. 5of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1701 Salem Street North Andover,MA 01845 Owner's Name: Judy Duffy Date of Inspection: August 23,2005 Check if the following have been done. You must indicate"Yes"or"no"as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks-? ✓ Has the system received normal flows in the previous two week period? .✓ Have large volumes of water been introduced to the system recently or as part of an inspection? ✓ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for sign of break out? ✓ Were all system components,excluding the SAS,located on site? ✓ Were all the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if difference from owner)provided with information on the proper maintenance of the subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] 6of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1701 Salem Street North Andover,MA 01845 Owner's Name: Judy Duffy Date of Inspection: August 23,2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design)__!j_Number of bedrooms(actual): 3 DESIGN flow based in 310 CMR 15.203(for example: 110 gpd x #of bedrooms) e o &-e D Number of current residents:_ Does residence have a garbage grinder(yes or no): A)o . Is laundry on a separate sewage system(yes or no): /y D [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): N'0 . Water meter readings,if available(last 2 years usage(gpd): ?o�,,J Sump Pump (yes or no): /IV 0 Last date of occupancy c. ,r e✓C COAMERCIALANDUSTRIAL 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(yb6 or no): If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank, distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative(Alternative technology. Attach a copy of the currant operation and maintenance contract(to be obtained from system owner) Tight tank Attached a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: a .1ec.2s �P/L 13D K (ZEcm 29S Were sewage odors detected wen arriving at the site(yes or no): Al 0 . 7of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1701 Salem Street North Andover,MA 01845 Owner's Name: Judy Duffy Date of Inspection: August 23,2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:__X_cast iron 40 PVC other(explain) Distance from private water supply well or suction line: iv)A Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: (locate on site plan) Depth below grade: Q Material of construction: ,e 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: 160 c-,A�L10 N Sludge depth: 1-2 4 Distance from top of sludge to botARVffi&23j=ft of outlet tee or baffle: Z Z Scum thickness: <l Distance from top of scum to top of outlet tee or baffle: Distance from bot of scum to bot of outlet tee or baffle Z3 How were dimensions determined: /-"eA-s-Q 0 s T��I I- 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 n TK}N� ►n1 C-0 CS c�,jtc> o,�. Ga �C�e�- }e.e� a-a� C-fLoS.s 34-F-r=tee coM ,7" � r✓ . GREASE TRAP:N (locate on site plan) Depth below grade: Materials of construction: concrete metal fiberglass polyethylene other (explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from botAugust 23,2005 of sludge to botAugust 23,2005 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. 8of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1701 Salem Street North Andover,MA 01845 Owner's Name: Judy Duffy Date of Inspection: August 23,2005 TIGHT OR HOLDING TANK:—L 4 (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Materials of construction: concrete metal fiberglass polyethylene other (explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: D Comments(note if box is level and distribution to outlets equal,any evidnence of solids carryover,any evidence of leakage into or out of box,etc.): i;oX L^iyl4-. GolNDriIZ�✓t- /V0 FUIDe -F91AiA-(,E tAJ r�i2- DVT NCS SOLI DS .6 ita1Z oUC 1s-r2, 6c)J)0VN 4t fZeco,�-G.�� I"oST4Uu 6-7)0N d F� ,, I.00cc-&2s PUMP CHAMBER: N114 (locate on sire 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.): 9of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1701 Salem Street North Andover,MA 01845 Owner's Name: Judy Duffy Date of Inspection: August 23,2005 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required If SAS not located explain why TYPE leaching pits number leaching chambers, number leaching galleries number leaching trenches,number in length leaching fields,number,dimensions: lo - 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) CESSPOOLS: N (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of Construction Indication of groundwater inflow(yes or no) Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIW:--4�(locate on site plan) Material of construction: Dimensions: Depth of solids Comments(note condition of soil signs of hydraulic failure,level of ponding,condition of vegetation,etc. 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1701 Salem Street North Andover,MA 01845 Owner's Name: Judy Duffy Date of Inspection: August 23,2005 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. A- T]is 1?qN C65 A--I ZZ L ,a 9-ga,r 3 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1701 Salem Street North Andover,MA 01845 Owner's Name: Judy Duffy Date of Inspection: August 23,2005 SITE EXAM Slope Surface water c Check cellar v27 1,va co—? Shallow wells A•6 NC- Estimated depth to ground waterfeet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record—If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health—explain: Checked with local excavator,installers—(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: T''�IS -%�ec-vbR KSS '?c--Rr PrP 5C- 1, �lN I M l c A-12Ff} i f l-Eh TA--9,ue3 '� �� �L'f.I! {�C(L-q 0*- i 2 f 14t3c7J� OCA pxis i2, G- (r(�,.4"iof �LN Commonwealth of Massachusetts RECEIVED W City/Town of NO. ANDOVER System Pumping Record DEC 10 2007 Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 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 Important: When filling out 1. System Location: forms the 1701 SALEM ST. computer,use only the tab key Address to move your NO. ANDOVER MA 01845 cursor-do not City/Town state Zip Code use the return key. 2. System Owner: QRENEE NICOLOSI Name Address(if different from location) Citylrown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 1119/07 2. Quantity Pumped: 1500 Date Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present. ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Benjamin Shute H79 406 Name Vehicle License Number J's Septic& Drain Company 7. Location where contents were disposed: GLSD 11/9/07 6gnaturf Hauler Date t5form4.doc-06103 System Pumping Record-Page 1 of 1 Commonwealth of Massachusetts RECEIVED City/Town of NO. ANDOVER Nnv -- 8 Z010 System Pumping Record I TOWN OF NORTH ANDOVER Form 4 1 HEALTH DEPARTMENT nM Sve OV 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 Important: When filling out 1. System Location: forms on the computer,use 1701 SALEM ST. only the tab key Address to move your NO. ANDOVER MA 01845 cursor-do not City/Town State Zip Code use the return key. 2. System Owner: f� RENEE NICOLOSI Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 10/7/10 � ti anty Pumped: 1500 Date Gallons 3. Type of system: ElCesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter resent? ❑ Yes No If es,was it cleaned? ❑ Yes ❑ No P Y 5. Condition of System: 6. System Pumped By: James H. Currier H79 406 Name Vehicle License Number J's Septic& Drain Company 7. Location where contents were disposed: GLSD .4 141 10/7!10 Signature of Hauler Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1