HomeMy WebLinkAboutMiscellaneous - 171 LIBERTY STREET 4/30/2018 (3) LOT: 1
PARCEL:
STREET: LIBERTY STRE
APPLICANT: RICH
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MAP # 10 g LOT #
PARCEL # STREET LtP. L'ril -;T
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HAS- PLAN . REVIEW FEE BEEN PAID? YES . NO
r PLAN APPROVAL: DATE f APP. BY. Allt
DESIGNER: PLAN DATE. tZ01.
CONDITIONS i� t� `D- t � r►�sikr-.�I?—
to
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WATER SUPPLY: TOWN ,WELL
' .
WELL REKNIT �1 DRILLER.�.._.A.I - __...............__._.___. ._
WELL 'TESTS: CHEMICAL DATE APPROVED
BACTERIA I DATE APPROVED.,.,
BACTERIA II DATE APPROVED
COMMENTS:
FORM U APPROVAL: APPROVAL 1-0 IS" - Y S NO
DATE ISSUED BY
CONDITIONS:
FINAL APPROVAL:
ALL PERMITS PAID YES NO
WELL CONSTRUCTION APPROVAL YES NO
SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO
OTHER YES NO
ANY VARIANCE NEEDED YES NO
FINAL BOARD OF HEALTH APPROVAL: DATE:.___._.,----_._-_„__.,
1'
IS THE INSTALLER LICENSED? ES NO
TYPE OF CONSTRUCTION: NEW REPAIR
NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW YES NO
CONDITIONS OF APPROVAL YES NO
(FROM FORM U)
ISSUANCE OF DWC PERMIT YES NO
DWC PERMIT NO. INSTALLER: C JS
BEGIN INSPECTION YES
EXCAVATION INSPECTION: NEEDED:.._,__________
PASSED Py___ _
CO STRUCT I ON INSPECTION: NEEDED: _......._._.__........_..._._...............
AS BUILT PLAN SATISFACTORY: YES:
APPROVAL TO BACKFILL: DATE: ;^ BY�_..___.__..__._...._.._.___...__._......_._-_-._.._
FINAL .GRADING APPROVAL: DATE _--BY.__ __.__�..__-____:_ _
F I NAL CONSTRUCTION APPROVAL: DATE:
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Commonwealth of Massachusetts RECEIVED
_ Ci /Town of
I'.PR 2 9 2013
w° System Pumping Record
Form 4 T� r't:Tl`4M' 0
LVfE9�hr
DEP has provided this form for usez by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left kftfront of hou Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address 1- 17 (
L ( (�r � b
Citylrown state Zip Code
2. System Owner.
Name
Address(if different from location)
CitylTown Staten ��_f f � Zip Code
Telephone Number
B. Pumping Record _
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system. ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0'No If yes,was it cleaned? ❑ Yes ❑ No
S. Condition of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locaf where contents were disposed:
G L Lowell Waste Water
�-� S-_C�
Sign a I Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
j/'��
9 of
I V L
Town of North Andover
HEALTH DEPARTMENT
SACMUSf
CHECK#:S-6 3� DATE: I/ I
LOCATION: / L o ti G- S t u P.C-'
H/O NAME: ,HrtCs
CONTRACTOR NAME:
Type of Permit or License:(Check box)
❑ Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service-Type: $
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal(Septic)Hauler $
❑ Recreational Camp $
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ Trash/Solid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
f
C1 Title 5 Report $ Jl Q
❑ Other. (Indicate) $
P
Health Agent Initials
White-Applicant Yellow-Health Pink-Treasurer
v
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessment t G `uw'`S S
v �t
51 Long Pasture ,
Property Address
Derek Barbagallo
Owner Owner's Name
information is
required for North Andover MA 01845 10/23/2010
every page. Cityfrown State Zip Code Date of Inspection
Inspection results must be submitted on this form.Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important: A. General Information
When filling out
forms on the
computer,use 1. Inspector: ���
only the tab key
to move your Neil J. Bateson
cursor-dp,not Name of InspectorTOWN OF NORTH ANDOVER%-
use the return HEALTH DEPARTMENT
key. Bateson Enterprises Inc.
Company Name
111 Argilla Road
Company Address
Andover Ma 01810
Cityrrown State Zip Code
978-475-4786 S115
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
Need Furthe Evaluation b the Local Approving Authori
❑ Y PP 9 tY
10/23/2010
WorsSionatu'r 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 theconditions of
use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
51 Long Pasture
Property Address
Derek Barbagallo
Owner Owner's Name
information is
required for North Andover MA 01845 10/23/2010
every page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass. .
Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 51 Long Pasture
Property Address
Derek Barbagallo
Owner Owner's Name
information is
required for North Andover MA 01845 10/23/2010
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
U. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
51 Long Pasture
Property Address
P
Derek Barbagallo
Owner Owner's Name
information is
required for North Andover MA 01845 10/23/2010
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria 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:
Y pp Y
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ N Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
t5ins•09/08 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
51 Long Pasture
Property Address
Derek Barbagallo
Owner Owner's Name
information is
required for North Andover MA 01845 10/23/2010
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion',of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
'= tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion,of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. (This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.)
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•09/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
51 Long Pasture
Property Address
Derek Barbagallo
Owner Owners Name
information is
required for North Andover MA 01845 10/23/2010
every page. CitylTown 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
a ❑ ® 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?
® 0 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): 5 Number of bedrooms(actual): 5
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 550
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
51 Long Pasture
Property Address
Derek Barbagallo
Owner Owner's Name
information is
required for North Andover MA 01845 10/23/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 3
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
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d Yes
9 ( Y 9 (gp ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
51 Long Pasture
Property Address
Derek Barbagallo
Owner Owner's Name
information is
required for North Andover MA 01845 10/23/2010
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
i
Source of information: Pumped 2008, owner
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1500
gallons
How was quantity pumped determined? Measured tank
Reason for pumping: Inspect tank&tees
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
i
❑ 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
a Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
51 Long Pasture
Property Address
Derek Barbagallo
Owner Owner's Name
information is
required for North Andover MA 01845 10/23/2010
every page. Citylrown state Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
10 years old, 7/24/2000, as built plan
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1
feet
Material of construction:
® cast iron ❑40 PVC' ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
4"Cast iron thru wall, 3" PVC in house, no leaks visible
Septic Tank(locate on site plan):
Depth below grade: .05
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
10'x5'x4
Sludge depth:
1"
P
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
51 Long Pasture
Property Address
Derek Barbagallo
Owner Owner's Name
information is
required for North Andover MA 01845 10/23/2010
every page. Cityfrown 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
26"
Scum thickness
1"
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
19"
How were dimensions determined? Tape Measure
` Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Inlet tee ok. Outlet tee ok. Outlet filter clogged, clean same. Depth of liquid at outlet invert. No
evidence of leakage. Pumped septic tank.
I
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness °
I
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
51 Long Pasture
Property Address
Derek Barbagallo
Owner Owner's Name
information is
required for North Andover MA 01845 10/23/2010
every page. Cityrrown 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•09108 Title 5 Official Inspection Foam:Subsurface Sewage Disposal System-Page 11 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 51 Long Pasture
Property Address
Derek Barbagallo
Owner Owner's Name
information is
required for North Andover MA 01845 10/23/2010
every page. Cityrrown 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
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box level&distribution equal. No evidence of leakage. Evidence of light carryover. Pumped d-
box to clean.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09/08 Tifie 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 51 Long Pasture
Property Address
Derek Barbagallo
Owner Owner's Name
information is
required for North Andover MA 01845 10/23/2010
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 2 trenches 70'
long
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology: —
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soil ok. Vegetation ok. No evidence of ponding to surface.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•09/08 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
51 Long Pasture
Property Address
Derek Barbagallo
Owner Owner's Name
information is
required for North Andover MA_ 01845 10/23/2010
every 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•09/08 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
• Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 51 Long Pasture
Property Address
Derek Barbagallo
Owner Owner's Name
information is
required for North Andover MA 01845 10/23/2010
every 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
3
o
161
l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
• Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 51 Long Pasture
Property Address
Derek Barbagallo
Owner Owner's Name
information is
required for North Andover MA 01845 10/23/2010
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam-
ED Check Slope
® Surface water
r ® 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: Date 996
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
P
Design Ian
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Asper test pit data on design plan. '
Before filing this Inspectionection Report,Please see Report CompletenessChecklist on next page.
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
• Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
51 Long Pasture
Property Address
Derek Barbagallo
Owner Owner's Name
information is
required for North Andover MA 01845 10/23/2010
every 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Commonwealth of Massachusetts
City/Town of
a
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location:
Address
City[Town t State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
<R —(ng
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? es ❑ No If yes,was it cleaned? es ❑ No
5. Conditl ion ofd-c.��lSyst ✓� Ci��c'
6. System Pumped By:
P4.)
Name � Vehicle License Number
Company
7. Location where contents were disposed:
G.L.S.D. Aowell VyasW Water
Silfh#de Hauler Date
t5form4.doc•06/03 System Pumping Record•Pae 1 of 1
Y P 9 9
Summary Record Card generated on 10/22/20101:53:29 PM by Karen Hanlon Page 1
Town of North Andover
Tax Map # 210-106.B-0222-0000.0
Parcel Id 17617
51 LONG PASTURE ROAD
BARBAGALLO, DEREL &JANE
51 LONG PASTURE ROAD
NORTH ANDOVER, MA
01845
Class 101 Single Family Property Type 1 Residential
Size Total 2 Acres
FY 2011
UB Mailing Index
Name/Address Type Loan Number Active/Inact. From Until
BARBAGALLO,DEREL&JANE Payor
51 LONG PASTURE ROAD
NORTH ANDOVER,MA
01845
UB.Account Maint.
Account No Cycle Occupant Name Active/inactive
Bldg Id. 17899.0-51 LONG PASTURE ROAD Last Billing Date 10/7/2010
3170565 03 Cycle 03 Active
UB Services.Maint.
Account No.3170565
Service Code Rate Charge Multiplier/Users
MISCFEE ADMIN FEE 1 1 9.18 1/
WTR WATER 01 ALL METER SIZE 335.31 /1
UB Meter Maintenance
Account No.3170565
Serial No Status Location Brand. Type Size YTD Cons
16300908 a Active ERT METE METE w Water 1 1
Date Reading Code Consumption Posted Date Variance
9/10/2010 1684 a Actual 67 10/15/2010 132%
6/7/2010 1617 a Actual 27 7/15/2010 12%
3/10/2010 1590 a Actual 24 4/14/2010 -44%
12/11/2009 1566 a Actual 44 1/12/2010 112%
9/10/2009 1522 a Actual 21 10/15/2009 -5%
6/9/2009 1501 a Actual 21 7/20/2009 -8%
3/13/2009 1480 a Actual 24 4/29/2009 3%
12/10/2008 1456 a Actual 23 1/20/2009 33%
9/9/2008 1433 a Actual 18 10/10/2008 -10%
6/5/2008 1415 a Actual 18 7/16/2008 -12%
3/11/2008 1397 a Actual 22 4/11/2008 10%
12/10/2007 1375 a Actual 21 1/22/2008 -61%
9/4/2007 1354 a Actual 43 10/12/2007 7%
6/18/2007 1311 a Actual 50 7/20/2007 176%
17 4/16/2007 -7%
3/13/2007 1261 a Actual
19 1/19/2007 60%
12/12/2006 1244 a Actual
44%
9/8/2006 1225 a Actual 11 10/20/2006
6/12/2006 1214 a Actual 22 7/10/2006 0%
3/6/2006 1192 a Actual 18 4/17/2006 -9%
12/16/2005 1174 a Actual 23 1/17/2006 -83%
9/14/2005 1151 a Actual 144 10/14/2005 265%
Trouble Code:03
6/8/2005 1007 a Actual 31 7/15/2005 90%
3/23/2005 976 a Actual 22 4/5/2005 -50%
12/9/2004 954 a Actual 36 1/14/2005 -640/c
9/15/2004 918 a Actual 113 10/8/2004 391
Commonwealth of Massachusetts D
City/Town of NO. ANDOVER RECEIVE
a a� System Pumping Record DEC 0 8 2009
Form 4
' TOWEALLTH DEPARTMENJe
OF NORTH
DEP has provided this form for use by local Boards of Health. Other
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 170 LIBERTY ST.
only the tab key Address
to move your NO.ANDOVER MA 01845
cursor-do not Cityrrown State Zip Code
use the return
key. 2. System Owner:
LUIS CARRILLO
Name
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 11/6/09 2. uantity 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
11/6/09
atfurf uler Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of RECEIVED
System Pumping Record
Form 4 DEC 2 3 2GUJ
4�M ey`e�
DEP has provided this form for use by local Boards of Health. Ot er for bat the
information must be substantially the same as that provided here 69 tag T ck with your
local Board of Health to determine the form they use. The Syste ecord must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left side of house, Right side of house, Left front of hous , Right front of house
Left rear of house, Right rear of house. Left rear of building. Right rear of bul '
Address
Cityrrown State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State j_ j Zip 6 7,S.Telephone Number /
B. Pumping Record
1. Date of Pumping Date 2• Quantity Pumped: 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:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
.L Lowell Waste Water
g toe of Haul r Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts RECEIVE®
City/Town of `
a' System Pumping Record NOV 2 5 2008
Form 4
TOWN OF NORTH ANDOVER
- HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Oth , u e
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: Left front, left rear, left side of hour . Right fron , right rear, right sia of Nous .
forms on the
computer,use
only the tab key Address rr 7 ( l
to move your
cursor-do not
use the return CityfTown State Zip Code
Ij
key. 2. System Owner:
Name
Address(if different from location)
Cityrrown Stat Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: Q Cesspool(s) Q4eptic Tank [ Tight Tank
Other(describe):
4. Effluent Tee Filter present? Q Yes [j—tdo If yes, was it cleaned? Yes [ No
5. Condition of System:
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loc ' re contents were disposed:
.L.S.D Lowell Waste Water
ignaPureofur Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
C4' /Town of RECEIVED
System Pumping Record
Form 4
DEC 112007
DEP has provided this form for use by local Boards of Health.Othr forms e
information must be substantially the same as that provided here. ef�b' A� a4�-eh with your
local Board of Health to determine the form they use. The System r mu submitted to
the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the o4--
computer,use
only the tab key Address U Q� /
to move your �(�_
cursor-do not Citylrown State Zip Code
use the return
key. 2. System Owner:
Name
Address(if different from location)
City/Town S 1 � de
� f —
D
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) - eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Q-ig-o-- If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. Syste Pu�
Name �_ Vehicle License Number
Company
7. Locatio her conte s we
r isposed:
Signato a tr
Date
t5form4.doc-06/03 System Pumping Record.Page 1 of 1
TOWN OF
SYSTEM PUMPING RECO RECEIVED
DATE: JAN 13 2005
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
E SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example:left front of house)
a,
DATE OF PUMPING: QUANTITY PUMPED : c GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
' GOOD CONDITION FULL TO COVER
-HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste
TOWN OF l "
SYSTEM P ING RECO
RECEIVE®
DATE: SEP 14 2004
LW
N OF NORTH ANDOVER
EALTH DEPARTMENT
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example:left front of house)
I
Lise
DATE OF PUMPING. QUANTITY PUMPED : l GALLONS
CESSPOOL: NOYES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste
Add J't d A-)
FORM U - LOT RELEASE FORM
INSTRUCTIONS: This forgo is used.to verify that all-necessary approval/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve the
applicant and or landowner fromcomp a with any applicable requirements.
�sasasaraf��/��f�i'r�}rrrrr� •■ .r.r....lff...............................
APPLICANT .� �°'Sc'�e'f _...A:•re.44,.��- PHONE 7�
ASSESSORS MAP NUMBER -14 LOT NUMBER
SUBDIVISION LOT NUMBER
STREET L-i B fe-YY STREET NUMBER 7
I as son won'a:a■aa■'a'snow man a on as a raa'-a a as man sas ass as a ala■am WE a a a sea a a a as ass aw a■a■
OFFICIAL USE ONLY
.saa.saaaaaWESao a0awas asaWEanass's asses.stoaasaaaaa0aaweaaaa0aa0aasaaa0aaaaaaaaa
RECON VWISMATIONS OF TOWN AGENTS
Asa■ ■■su-sasawssasssassa�sau�susssa�ssssssaussasrassssssasaswamaaaasss■
DATE APPROVED O
CONSERVATION AD TRATOR
DATE REJECTED
CONyMENTS N1d71i S Q--4m re AgaaJ '4e 44 -m;,,e. f0) , 'Proga" Elsid¢. tol 6 Aw
w c
Ae- F.4Lr¢- �� I.Lr 2. 2Pda�iDa1 r'/Iih
1
DATE APPROVED .
TOWN PLANNER
DATE REJECTED
COMMENTS
DATE APPROVED
FOOD IN CT -B EALTTI DATE REJECTED f
r DATE APPROVED - /is'JT>'-r
S CTOR- �—
fJ DATE REJECTED
COMMENTS �c`r �?.�-� C 3 ,r �F-c�i �. d Com-• `]'C`.i
�� rd
PUBLIC WORKS-SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
DATE APPROVED
FIRE DEPARTMENT
DATE REJECTED
COMMENTS
. . ...... ....
RECEIVED BY BUILDING INSPECTOR DATE
TOWN OF NORTH ANDOVER f pOR7H
i Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT 49
27 CHARLES STREET '
NORTH ANDOVER,MASSACHUSETTS 01845 9SsncH�s�`
978.688.9540-Phone
Susan Sawyer,REHS/RS 978.688.9542-FAX
Public Health Director healthdept@townofnorthandover.com
www.townofnorthandover.coni
BW
TO: From:
i
Fax: / 4 Pages:
Phone: Date:
❑ Urgent ❑ For Review ❑Please Comment ❑ Please Reply ❑Please Recycle
Please contact the Health Department at the above numbers for further assistance.
I
i
HP Fax K 1220xi Log for
NORTH ANDOVER
9786889542
Sep 13 2004 12:21pm
Last 30 Transactions
Date Time Twe Identification Duration Pages Result
Sep 10 9:06am Fax Sent 89786836595 1:13 3 OK
Sep 10 9:15am Received 1:46 3 OK
Sep 10 10:31am Received 9786821646 1:05 2 OK
Sep 10 11:Barn Fax Sent 819787626434 2:00 3 OK
Sep 10 11:20am Fax Sent 816173380122 3:59 17 OK
Sep 10 1:29pm Received 819786889563 0:40 1 OK
Sep 10 1:31pm Received 819786889563 0:32 1 OK
Sep 10 1:33pm Received 0:20 1 OK
Sep 10 2:03pm Fax Sent 89786860755 1:35 7 OK
Sep 10 2:lOpm Fax Sent 89784751448 1:28 2 OK
Sep 10 2:14pm Fax Sent 89786851099 2:20 3 OK
Sep 10 3:01pm Received 0:19 1 OK
Sep 10 3:12pm Received 978 688 9556 0:26 1 OK
Sep 10 3:43pm Fax Sent 819782820012 2:56 3 OK
Sep 11 3:45pm Received 1:28 4 OK
Sep 13 8:27am Fax'Sent 89786641713 1:51 1 OK
Sep 13 8:37am Received 1978 649 3839 1:52 2 OK
Sep 13 8:40am Received 0:38 0 No fax
Sep 13 8:50am Received 1:46 5 OK
Sep 13 9:24am Received affordablehealthcare 0:37 1 OK
Sep 13 9:28am Fax Sent 819785447958 0:51 2 OK
Sep 13 9:45am Fax Sent 89786851099 2:14 3 OK
Sep 13 10:31am Received 9785312479 1.:e1? , 3 OK
Sep 13 11:18am Fax Sent 814088712228 0; 1 OK
Sep 13 11:19am Fax Sent 814088712228 WWI, : 1 OKI
Sep 13 11:22am Fax Sent 89787940107 2 OK
Sep 13 11:43am Fax Sent 89786 36163 2:28 5 OK
Sep 13 11:51am Received 9786400531 1:02 2 OK
Sep 13 11:52am Received 9786400531 0:57 2 OK
Sep 13 12:05pm Fax Sent 89782568648 2:11 3 OK
.,. v.
' ? BOARD OF III�AL'T11
Town of North Andover ,t•tass .
9 19
APPLICATION FOIL WELL & FUt•1P PERI-irr
ication is hereby made for permit to drill as well ('C ) Application
to install ( ) a pump system'.
3 S7` . . Lot
.tion: Address % �l i l _._
y Address
ic � �.�.�►
r i rd rc ss Z
Contractorv//�l,'�4 l C C) Ac -------- .-_�.
7d
Adress 1 , _- )
Contra ����►�;► ��,�� �c�-,� c ry _ lr ,��vc�.�<
ctor
CONTRACTOR (To be completed at time of puin1) test )
of Well - Well used for 1Cr ' Q1 4/V
.
neter of Well Size of Ca si.>>� �--- `' � -- --- _.....
Depth casiT19 i
-h of Bed Rock ?D
nto L'ecl flock C.
Q- NO Date of Testi-119-
Seal Tested? Yes (-)
th We 11 Cnded in Wl�:i.c
th to Water- �D
' I)elivers /e; Gals - Per Hill - for �► tr:�']r ,
GI't1
feet after pumping hours__ t;
wdown
e of Completion �3G� >'� --- i '>'�'�- n, ;I - -
. 'Sif;naCurc •1e �7 �o>>trr. rcC tor
` ;!-;; ,. .. .. .• .. .. .. .. .. .. .: .. .. ..'�;.���;,is�::L�':;:.� .. :�:�'.
P INSTALLER (To be- filled i.n before
Pump Type used& Name Pump - -
Size of ...._...._-.
er Pump Delivers GPM —
terial Used in Well : ,Cast Iron ( _) G;I ) V gni zed ( -) Plastic ( _{
,e Ma
i Pit (_) or Pitless •Adapter (^)
sleeve used top Pipe?ipe? Ycs (_) tJU( r) 'Type or lJell Seal__._._.- ........__
:e . .
.f(r ua1 tom- l A 4•h 1.4 - T,L
t .Lu -C.: 1..., 'J�r -' tt. rt � •i. Yl���l :�`d1�1
:e Water analysi's repor-t 'submitted to Board of Ilealth__ -
:e release given tD owner of record & Bldg- I11sp
_______.._i i�.� ]. c.i r---1 ►�,, I�,,c is r>�- -
V9ERA ARTESIAN WELL C01VI NY
253 Andover Street Route 133
F GEORGETOWN, MASSACHUSETTS 01833 o a C
!V2 2627
(508) 352-8586 !V
FAX: (508) 352-8586
TO
Mr. Joseph R. Rictr__....... DATE . .. ...... March 30 .109'JOB NO. ._._.
3938 Salem Street outer Well 1nstj:llat ioin
_. JOB NAME .
W i lminuton MA. 0 9 8 8 ? N.Andover tli�
___._.. ...._.. ......... .. . ......_.... .._ JOB LOCATION
TERMS
7L Wn67 l f7r I�?A� I PTY r TAV-1 I Zf v ro7' n!^ vp)•,�tr TSN l Awf"
DESCRIPTION PRICE AMOUNT
> 658196.33
+ _ ... ..
of_CtZg Stipp: 3129191
Location: 171 Liberty Street EI_Andover,Ha.
Pgwrr # 313
400' of well drilling_hole at $7.00,Per ft. _._ . $_. 2.600 Qf'
4n' of 6" diameter well casing gt,$7.b0 per ft. 00. 00
N.Andover Permit Fee
Driveshop__Sea.1rinSta,11_tfo �5Q ,00 Ni'
.. _. .
'__ _. _....... _. __TOTAL.__AMOUN_T.DCT,
E LL. FIA,'T:Lt._1Ar___11 Gals_Per, Flin_
,ser -i co fess of 1,71% r-a ..:ppT i ed to any wmas d..vverduzv bv.,14:K-o. . . .n l v.7,s ? trj Ar:�4a.r r+
� DUPLICATE ����IU1llU6tU
,d#A Al # kh ;
, A'wlt i1`o f a?3,.1 r ,rr Y .
%�ti }i,}+ t$aj; A"_• pry ,
L ,n
y1
. � 1ik, tea;{yrs sd�I�d4wwc.ay
yyDepartment of Environmental Management/Division of Water Resources
n
WATER WELL COMPLETION REPORT
p+ + GEOGRAPHIC DESCRIPTION
WELL LOCATION
y't - 1 7�l iF3f '%-'�/ 5%' _:�, - - N g E !W� of
Address (circle)
i. J3 ;ra.. .is - - (feet),
his 4+ .i City/Town 1 \ (road)
+. '; Well owner v ;
NS /E W of
r °°t r) iqil n
Address C�s P J>��/ i% �~ — /�— circle)
'4 (nu.in tenths) (
s r intersect. w/ (road)
Board of Health permit: yes 13 no
s WELL DATA
r ` WELL USE Total well depth Y—0 ft.
Domestic ® Public❑ Industrial ❑ r��, ft•
Monitoring C] Other Depth to bedrock---
f
Water-bearing rock/unconsolidated material:
Method drilled `�
Description
Date drilled Water-bearing zones:
CASING 1) From cl_ To
YP e >/t"i( � 2 From �.t To :;:
+; •c,c�
' I l
r Length f/ft.OWED.) in.: 3) From-----To
' Length into bedrock ft.ft' Gravel pack well: dia.
Protective well seal: Screen: dia.
Slog length from_to
Grout-0 Other
)°UMP TEST
J,U ft. Date l •.:.
Stlatic water level
below land surface min.at /U—gPrn
Drawdown
4 ft. after pumping
hr.
1 -��•( � 1(' ft. after hr, min.
How measured A Recovery
0
LOG of FORMATIONS COMMENTS
Materials From To
71e Driller h
Mass. Registrations
Firm
Address
v r
City/Town
Si nature of supervisin registered well driller
PI swprinrfirmly BOARD OF HEALTH COPY
; l
I
i
Y �
STEVENS ANALYTICAL LABORATORIES, INC.
` 3$ Montvale Avenue, Stoneham, MA 02184, (617) 438-6114
..... FAX (617) 438-0173
LABORATORY NUMBER: 12441 SAMPLE DATE: 4/02/91
DATE RECEIVED: 4/03/91
SUBMITTED BY: WILMINGTON PUMP SUPPLY
P. 0. Box 577
WILMINGTON, MA 01887
SAMPLE SOURCE: WATER SAMPLE
JOE RICK, 171 LIBERTXT NQ. ANDOVER MA
REFERENCES: 1) STANDARD METHODS - FOR THE TIO
AND WASTEWATER,' ION
2) METH S FOR CHEMTCAL OF WATER ,AND WASTES .
EPA/600/4-79.021983,
PARAMETER CON ENTRATZON
Total Coliform 0 per 100 ml
PH 7 . 58
Chlorides 9 . 0 mg/l
Hardness 81 mg/l
Manganese 0. 023 mg/1
Sodium 10 .8 mg/l
Iron 0. 028 mg/1
Nitrate <0. 1 mg/l
Nitrite <0 .01 mg/l
i
Authorized by: ..
i
Alan P. Stevens, Laboratory D,ireotor
C.OMMFNT: The results of these analyses meet the federal and state
standards for drinking water.
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
��--
SYSTEM OWNER&ADDRESS SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING: 7 QUANTITY PUMPED GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES /
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
~. ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM PUMPED BY: P2 c 0- k�
COMMENTS:
CONTENTS TRANSFERRED TO: '
COMMONWEALTH OF MASSACHUSETTS
Z F EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
A
F
4C.
I y�f
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:_171 Liberty Street
_North Andover_
Owner's Name:_Joe Rich_
Owner's Address:_171 Liberty Street
_North Andover,Ma.01845
Date of Inspection:5/18/2002_
Name of Inspector: Neil J.Bateson_
Company Name: Bateson Enterprises Inc._
Mailing Address:_111 Argilla Road_
_Andover,Ma.01810_
Telephone Number:_(978)4754786_
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
_X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fai
� 5/18/2002
Inspector's Signature: 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.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:_171 Liberty Street_
North Andover—
Owner: Rich
Date of Inspection:_5/18/2002_
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 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 I for the following statements.If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Page 3 of I 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:_171 Liberty Street_
North Andover
Owner: Rich
Date of Inspection: 5/18/2002_
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well".Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:_171 Liberty Street_
North Andover—
Owner: Rich
Date of Inspection:_5/18/2002
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or`no"to each of the following for all inspections:
Yes No
_ No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
_ _No_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_ _No_ Liquid depth in cesspool is less than 6"below invert or available volume is less than''/s day flow
No Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_ No Any portion of the SAS,cesspool or privy is below high ground water elevation.
No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_ _No_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ _No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ _No_ 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.]
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 following criteria apply to large systems in addition to the criteria above)
yes no
_ the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:_171 Liberty Street_
_North Andover—
Owner: Rich
Date of Inspection: 5/18/2002_
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
Yes _ Pumping information was provided by the owner,occupant,or Board of Health
No Were any of the system components pumped out in the previous two weeks?
Yes_ _ Has the system received normal flows in the previous two week period?
No Have large volumes of water been introduced to the system recently or as part of this inspection?
Yes _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Yes_ _ Was the facility or dwelling inspected for signs of sewage back up?
Yes _ Was the site inspected for signs of break out?
Yes_ _ Were all system components,excluding the SAS,located on site?
_Yes_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the
condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of
scum?
_Yes_ _ Was the facility owner(and occupants if different from owner)provided with information on the
proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
Yes_ _ Existing information.For example,a plan at the Board of Health.
_No_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable)[3 10 CMR 15.302(3)(b)]
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:_171 Liberty Street
_North Andover_
Owner: Rich
Date of Inspection: 5/18/2002_
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):_5_ Number of bedrooms(actual):_5_
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):_750
Number of current residents:_4
Does residence have a garbage grinder(yes or no):_No_
Is laundry on a separate sewage system(yes or no): Yes_ [if yes separate inspection required]
Laundry system inspected(yes or no): Yes_Camera drywell thru inlet pipe,water 12"to invert
Seasonal use:(yes or no): No_
Water meter readings: Well Water>100°to SAS_
Sump pump(yes or no):–NO--
Last
o_Last date of occupancy:_Current_
COMMERCIAUMUSTRIAL
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: Pumped every year,owner
Was system pumped as part of the inspection(yes or no): 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:_11 years old.8/5/1991.
As built plan.
Were sewage odors detected when arriving at the site(yes or no):_No
Page 7 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_171 Liberty Street_
North Andover—
Owner: Rich
Date of Inspection: 5/18/2002_
BUILDING SEWER(locate on site plan)X
jDepth below grade: 3'
Materials of construction:_cast iron _X_40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments( Jon condition of joints venting,evidence of leakage,etc.):_4"PVC thru wall.3"PVC in house.No
leaks.
SEPTIC TANK: X locate on site plan)
Depth below grade:_2'
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: 10'x 5'x 4'
Sludge depth: 0
Distance from top of sludge to bottom of outlet tee or baffle: 27"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or bale:_8"
Distance from bottom of scum to bottom of outlet tee or baffle:_20"_
How were dimensions determined:_Subtract scum&sludge depth to tee length._
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.): Inlet tee ok. Outlet tee ok.Depth of liquid at outlet invert.
No evidence of leakage.
GREASE TRAP:_(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_fiberglass polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_171 Liberty Street_
North Andover—
Owner: Rich
Date of Inspection: 5/18/2002
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: X_(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:_0_
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):—D-box level&distribution equal.No evidence of leakage.Evidence of solid
carryover,pumped d-box to clean._
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_171 Liberty Street_
_North Andover—
Owner: Rich
Date of Inspection: 5/18/2002_
SOIL ABSORPTION SYSTEM(SAS):_X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:_
leaching chambers,number:
leaching galleries,number:
_X leaching trenches,number,length:_3 trenches 39'long_
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,):
_Soil oL Vegetation oL No sign of ponding to surface.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
Page 10 of 11
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:_171 Liberty Street_
North Andover—
Owner: Rich
Date of Inspection: 5/18/2002_
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.
Garage
i
House To well
A B
A to Tank=67'
Septic A to D-Box=173'4"
Tank
® B to Tank=44'4"
B to D-Box=163'4"
D-
Box
39'
0
Page 11 of 11
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_171 Liberty Street_
_North Andover—
Owner: Rich
Date of Inspection: 5/18/2002_
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water_10'_feet
Please indicate(check)all methods used to determine'the high ground water elevation:
X Obtained from system design plans on record=If checked,date of design plan reviewed:_6/10/1988_
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:_Water 10'.As per design plan._
r
Tel: (978) 475-4786
Fax: (978) 475-5451
BATESON ENTERPRISES, INC.
Excavating-Water.& Sewer Lines-Septic Systems &Pumping Service
111 Argilla Road Andover, Mass. 01810
Title 5 inspection Report
Property Address: 171 Liberty Street, North Andover
Owner: Rich
Date of Inspection: 5/18/2002
My report contained herein does not constitute a guarantee of future usage and the functionality of the existing
septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further
operation of your current septic system.
ej J\
Neil J. Bateson
Bateson Enterprises, Inc.
Commo 'wealth of Massachusetts
Massacliusetts
System Pumping Record
System Owner System Location
}
17/ L
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Date of Pumping: �— U Quantity Pumped: gallons
Cesspool: No Yes L;l Septic Tank: No Yes «!
System Pumped by: Fett`¢44r6 fe&,O�ftia8a License#
Contents transferrred to : Greater Lawrence Sanitary District
Date: _ Inspector-
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