HomeMy WebLinkAboutMiscellaneous - 970 FOREST STREET 4/30/2018 (3)MOR7N
* Town of North Andover
HEALTH DEPARTMENT
s�CHust
JJ
CHECK
LOCATION:
H/O NAME:
CONTRACT(
7238
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 (DW) } $
1
[� Title 5 Inspector �..�P}�'1 A $
c ' Title 5 Report , �`^ $ v
❑ Other: (Indicate) $
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 970 Forest Street
Property Address
Thomas & Jane Gunn
Owner
information is
required for every
page.
Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
Owner's Name
North Andover
City/Town
MA 01845
State Zip Code
Ue
4/29/2015 C/
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.
A. General Information RECEIVED
Inspector:
MAY 2 9 2015
Anthony R Mottolo TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Name of Inspector
John Zanni Pumoino Co.
Company Name
5 Hallberg Park
Company Address
North Reading
City/Town
781.944.0149
Telephone Number
B. Certification
MA
State
S15018
License Number
01864
Zip Code
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
&-Ak� R -
Inspector's Sig ure
5/1/15
Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
970 Forest Street
Property Address
Thomas & Jane Gunn
Owner's Name
North Andover MA 01845 4/29/2015
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins • 3/13 Title 5 Official Inspection 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 970 Forest Street
Property Address
Thomas & Jane Gunn
Owner Owner's Name
information is
required for every North Andover MA 01845 4/29/2015
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if (with approval of Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
❑ Y ❑ N ❑ ND (Explain below):
❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if (with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
970 Forest Street
Property Address
Thomas & Jane Gunn
Owner's Name
North Andover MA 01845 4/29/2015
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 fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
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 '/2 day flow
t5ins - 3113
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 970 Forest Street
Property Address
Thomas & Jane Gunn
Owner Owner's Name
information is
required for every North Andover
page. City/Town
MA 01845 4/29/2015
State Zip Code Date of Inspection
B. Certification
(cont.)
Yes No
❑ ®
Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ®
Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ®
Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ®
Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ®
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ®
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ®
The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ®
The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area — IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins • 3113 Title 5 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
970 Forest Street
Property Address
Thomas & Jane Gunn
Owner Owner's Name
information is
required for every North Andover
page. City/Town
C. Checklist
MA 01845 4/29/2015
State Zip Code Date of Inspection
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
N /A EJ
/
ElWere
this inspection?
as built plans of the system obtained and exa ined? (If they were not
available N/A) I 7
note as on
I P�- o p() s e
P 1 4, 5
®
❑
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): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 450 gpd
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Insp
o Subsurface Sewage Disposal System Fo
M
970 Forest Street
Property Address
Thomas & Jane Gunn
Owner Owner's Name
information is
required for every North Andover
page. City/Town
D. System Information
Description:
Number of current residents:
Does residence have a garbage grinder?
❑
ection
Form
No
rm - Not for Voluntary Assessments
❑
Yes
®
No
information in this report.)
Laundry system inspected?
❑
Yes
®
No
Seasonal use?
❑
Yes
®
MA
01845 4/29/2015
N/A
State
Zip Code Date of Inspection
Detail:
Property has private well.
Does residence have a garbage grinder?
❑
Yes
®
No
Is laundry on a separate sewage system? (Include laundry system inspection
❑
Yes
®
No
information in this report.)
Laundry system inspected?
❑
Yes
®
No
Seasonal use?
❑
Yes
®
No
Water meter readings, if available last 2 ears usage
9 ( Y 9 (gPd))�
N/A
Detail:
Property has private well.
Sump pump?
❑
Yes
®
No
Last date of occupancy:
currentDate
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Gallons per day (gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
970 Forest Street
Property Address
Thomas & Jane Gunn
Owner Owner's Name
information is
required for every North Andover MA 01845
page. City/Town State Zip Code
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Date
4/29/2015
Date of Inspection
John Zanni Pumping Co.
1250
gallons
gauge on truck
requested by owner
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
® Yes ❑ No
❑ 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
970 Forest Street
Property Address
Thomas & Jane Gunn
Owner Owner's Name
information is
required for every North Andover
page. City/Town
D. System Information (cont.)
State Zip Code
4/29/2015
Date of inspection
Approximate age of all components, date installed (if known) and source of information:
1984, per system design plans provided by owner.
Were sewage odors detected when arriving at the site?
Building Sewer (locate on site plan)
Depth below grade: 20 inches
feet
Material of construction:
® cast iron ❑ 40 PVC4" diameter
❑ other (explain):
Distance from private water supply well or suction line. over 100
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
All ok. No leakage.
Septic Tank (locate on site plan):
❑ Yes ® No
Depth below grade: 1
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene
1250 gallon single compartment tank with concrete baffles and 3 access covers.
❑ 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'L x 5'W x 68" H
Sludge depth:
2"
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17
Commonwealth of Massachusetts
u u Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 970 Forest Street
Property Address
Thomas & Jane Gunn
Owner Owner's Name
information is
required for every North Andover MA 01845
page. City/Town State Zip Code
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
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
20"
ill
10"
36"
4/29/2015
Date of Inspection
How were dimensions determined? measuring tape
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 should be pumped ANNUALLY. Inlet baffle is in good condition. Outlet baffle is good, but is
showing typical signs of corrosion. Structural integrity of tank is very good. Liquid level is at outlet
invert. No evidence of leakage into or out of tank.
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal
Dimensions:
Scum thickness
feet
❑ fiberglass ❑ polyethylene ❑ other (explain):
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:
t5ins • 3/13
Date
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
970 Forest Street
Property Address
Thomas & Jane Gunn
Owner Owner's Name
information is
required for every North Andover MA 01845 4/29/2015
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
Dimensions:
Capacity:
Design Flow:
Alarm present:
Alarm level:
Date of last pumping:
❑ polyethylene ❑ other (explain):
gallons
gallons per day
❑ Yes ❑ No
Alarm in working order: ❑ Yes ❑ No
Date
Comments (condition of alarm and float switches, etc.):
* Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
970 Forest Street
Property Address
Thomas & Jane Gunn
Owner Owner's Name
information is
required for every North Andover MA 01845 4/29/2015
page. City/Town 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 at outlet inverts
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.):
This system has 2 distribution boxes. Both are ok. The first one is just for effluent to pass through.
The second one distributues the effluent to the two leaching trenches. Little evidence of solids
carryover. No leakage. Distribution to outlets is equal.
Pump Chamber (locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins • 3/13 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
970 Forest Street
Property Address
Thomas & Jane Gunn
Owner Owner's Name
information is
required for every North Andover
page. Cityrrown
D. System Information (cont.)
Type:
❑
leaching pits
❑
leaching chambers
❑
leaching galleries
®
leaching trenches
❑
leaching fields
❑
overflow cesspool
❑ innovative/alternative system
State Zip Code
4/29/2015
Date of Inspection
number:
number:
number:
number, length: 2, 50' each
number, dimensions:
number:
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soil is dry with ledqe. No siqns of hvdraulic failure.
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
t5ins • 3/13
❑ Yes ❑ No
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17
Ig�
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
970 Forest Street
Property Address
Thomas & Jane Gunn
Owner's Name
North Andover MA 01845 4/29/2015
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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17
WI
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
970 Forest Street
Property Address
Thomas & Jane Gunn
Owner Owner's Name
information is
required for every North Andover MA 01845 4/29/2015
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 X
r, _--- - - — .r
t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
GSM
970 Forest Street
Property Address
Thomas & Jane Gunn
Owner Owner's Name
information is North Andover
required for every
page. Cityfrown
t5ins • 3/13
D. System Information (cont.)
Site Exam:
® Check Slope
®
Surface water
®
Check cellar
®
Shallow wells
Estimated de th to hi In round water
MA 01845
State Zip Code
over 10
4/29/2015
Date of Inspection
p g g feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked date of desi n Ian reviewed
4/30/1984
g p 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:
Perc test data dated 4/30/1984 show no groundwater at 10.5 feet. The well in the front of the house
goes down over 300 feet.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 970 Forest Street
Property Address
Thomas & Jane Gunn
Owner Owner's Name
information is
required for every North Andover MA 01845 4/29/2015
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 - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17
Commonwealth of Massachusetts
Town of North Andover
System Pumping Record
System Owner & Address:
Thomas Gunn
970 Forest Street
North Andover, Ma
Date of Pumping:
Type of System:
01845
June 12, 2013
Septic tank
Location of System: Rear yard
Gallons Pumped: 1250 gallons
System Pumped By:
John Zanni Pumping Co. LLC
5 Hallberg Park
North Reading, Ma 01864
License #: BHP -2013-0067
JUL 0 8 2013
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Contents Transferred to: Greater Lawrence Sanitary District
._..._..
Date: June 12, 2013 Pumping Technician. DD
This is proprietary and confidential information that may be used only by the
Board of Health for regulatory purposes
Commonwealth of Massachusetts
Town of North Andover
System Pumping Record
System Owner & Address:
Thomas Gunn
970 Forest Street
North Andover, Ma 01845
Date of Pumping: May 10, 2011
Type of System: Septic tank
Location of System: Rear
Gallons Pumped: 1250
System Pumped By:
John Zanni Pumping Co. LLC
5 Hallberg Park
North Reading, Ma 01864
License #: BHP -2012-0343
RECE'p
hAY 8 ZU12
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Contents Transferred to: Greater Lawrence Sanitary District
Date: May 10, 2011 Pumping Technician: PD
This is proprietary and confidential information that may be used only by the
Board of Health for regulatory purposes
R
T
In
0
0
U
L
I
c
c
m
c
0
o
�
D
�
o
�
m
to
f
E
Q.
L
r
CL
1
c
c
(D
o ++ o
z
fY
s:
'c
c
R
a
_
o c
Eu o .o
Q
D O
=
4-
c
cp
c
m
H
v
c
C
❑
II
Q
Q
o
o
m
0
U
O
O
C,
in to Z
Board of Health SEP�'IC S15TEK
North A.ndove�rZHaaa. ALLArrTCW CHFYIg Li3f'
• • ;KTI-7021i
�v ►�l�ll
LOT_.
XCAVA1TI03i OK EUL
1. Distance Tot
a. Wetlands
b. Drains
C.. Well
2, Water Line Location
3. No PPC Pipe
4. Septic Tank
a. .Tees -_Length & To Clean Out Covers
b. Cement Pipe.to Tank On Both Sides of Tank
5. Distribution Box
a. Covers & Box - No Cracks
b. All Lines Flowing Equal- Amounts
c. No Back Flow
6.- Leach Field or Trench
a. Dimensions
b. Stone Depth
c. Capped Ends
d. Clean Double Washed Stone
7. Leach Pits
a. Dimensions
b. Stone Depth
c. Splash Pads
d. Tess
e. Cement Pipe to Pit - Both Sides
f. Clean Double Washed Stone
8. No Garbage Disposal
9. Final Grading Inspection
10. Barricading Covered System
11. A.s.Built Submitted
a. Lot Location
b. Dimensions of System
c. Location with Regard -to Pere Test
d. Elevations
e: Water Table
# 2097
I3ANCOCK SURVEY ASSOCIATES, INC.
69 HOLTEN STREET DANVERS, MA 01923 (617) 777.3050 / 662-9659
1 November 1984
Board of Health
120 Main Street
North Andover, MA 01845
ATI'N: Michael J. Rosati
In Re: Subsurface Sewage Disposal System
.970 Forest.Street
Dear Michael:
I hereby certify that the subject.system was installed as shown
on the enclosed as -built sketch.
Please call Chuck Johnson if you have any questions.
FCH/mec
cc: Jane & Thomas Gunn
970 Forest Street
North Andover, MA. 01845
Very truly yours,
F-00OCK SURVEY
HANCOCK SURVEY ASSOCIATES, INC.
69 Holten Street
DANVERS, MASSACHUSETTS 01923
(617) 777-3050
JOB 2oQ
SHEET NO. ' OF- 1 q
CALCWLATED BY 6: DATE •'yy ����
CHECKED BY
DATE
,f Health
,,ndover,%Bs
y
APPROM
Provi, ned:
DATE—
SUBSURFACE DISPOSAL DESIGN CHECK LIST ',`j�t/// C�r'.9
-LCT # G� 57
DISAPPRGM
Reasons:
DATE
'title V FAIL
Reg 2.5 The submitted plan must show as a mi] a I
Aa) the lot to be served-area,dimensions lot #2abutters
location and log deep observation holes -distance to ties
c location and results percolation tests -distance to ties
design calculations & calculations showing required leaching area
location and dimensions of system -including reserve area
existing and proposed contours
g) location any fret areas -Athin 100' of sewage disposal system or
disclaimer -check wetlands crapping
face and subsurface drains within 1001 of sewage disposal
system or disclaimer
)/location any drainage easements vithin 100' of stege disposal
/ffstem or disclaiirer-Planning Board files
j) kno= sources of tater supply within 2001 of wage disposal o _
stem or discl.ainar
Z, ation-of -vW proposed we to serve lot -100 from leaching foci:
cation of nater lines on property -101 from leaching Sacili —
tion of benchmark
ivekays
garbage disposals _
no PDC to be used in construction
profile of system -elevations of basement, plumb, pipe, septic tank..
distribution box inlets and outlets, distribution field piping and
ctLer elevations
ma d.=am ground mater elevation in area ser;, -age disposal system
s) plan must be prepared by a Professional Eagineer or other
professional autborized by law to prepare such plans
Reg 6 Septic Tanks
(a) capacities -150$- of flog, nater table, tees, depth of tees,
access, pumping
(b cleanout
c 10t from cellar wall or inground s --ng pool
251 from subsurface drains
Reg 10.2 Distribution Foxes
(a) slope greater than 0.08
Reg 10.4 ( b)
SOIL PROFILE & PERCOLATION TEST DATA
North Andover, Mass. Street No -` Lot.No
I;,oe/Subdiv.
Pland Owner
Investigator f�#'� �j Tae Observer
4 SOIL PROFILE DATES
1.Elev r 2.Elev 3.Elev 4.Elev
1
L
1
__- 7
8
9
— 10
2
3
4
f
f
-
Start Saturation
Ali/
6
7
8
9
i
-
=
Soak -Minutes
lo�--
-
2
3
.9
5
6
0
1
2
3
4
5
6
0
1
3
4
5
6
Ties Pts est
7
8
9.
10
1
__- 7
8
9
— 10
3
7
_ 8
9
_ to =
-
Start Saturation
Ali/
=
Soak -Minutes
Benchmark=— j �g/A��� Location-==-
Elevation r Datum -
NZ PERCO TION TESTS
DATES`;' �� 7
Pit Number
1
2
3
4
Start Saturation
Ali/
Soak -Minutes
5 -tart a
Drop of Y -Time
Drop of 6" -Time
VA • I,,
Mains-lst 3" drop
•�
1 ,
Mins.2nd 311 -Dro --
Percolation
ca
1 C2
I
r t�71
•_
Tazdtmean .eaevzatarg, Ate.
66 LITTLETON RD. - WESTFORD, MA 01886
Report Number: C-081-7359
Client:
Report Date:
Sample Taken at:
(617) 692-8395
May 24, 1984
B & H Drilling .J G-9 Gunn
P.O. Box 307 Lot #2 Forest ST.
Windham, NH No. Andover, MA
03087
On: May 23, 1984
CERTIFICATE OF ANALYSIS
------------------------
Test Parameter:
Results:
UNITS
Sample 1
Coliform Bacteria
per 100cc
0
Sodium (Salt)
mg/l
NT
Soap(MBAS)
mg/l
NT
Benzene(Toluene)
mg/l
NT
Lead
mg/l
NT
Acidity Value
SU
NT
Arsenic
mg/l
NT
Barium
mg/l
NT
Cadmium
mg/l
NT
Chromium
mg/l
NT
Color
CPU
NT
Copper
mg/l
NT
Cyanide
mg/l
NT
Flouride
mg/l
NT
Grease(Total)
mg/l
NT
Hardness
mg/l
NT
Iron
mg/l
X0.62
Manganese
mg/l
0.038
Mercury
mg/l
NT
Nitrates(as N)
mg/l
NT
Odor
TON
NT
Phenols(Total)
mg/l
NT
Phosphates(as P)
mg/l
NT
Selenium
mg/l
NT
Sulfide
mg/l
NT
Turbidity
NTU
NT
NT = Not -Tested
Massachusetts State Certified
Microbiological Drinking Water
Laboratory 033051
-4-
Ater. T. Thor.stensen, for
Thorstensen Laboratory, Inc.
Health Inspector
f
GREATER LAWRENCE SANITARY DISTRICT
CHARLES STREET NORTH ANDOVER MASS. 01845
TRUCKED WASTEWATER DISCHARGE SLIP
opt Al
TOWN
Company Name: V
Hauler's Name: o i
Address: /a 0 , A 0 y
Telephone: P 9l 1- 7w-41 / Y/,50
SOURCE #1 Date Pumped:lr� 6
Name: ,,J
Address: % O %F° ,, ej r 5 %
Telephone: 7' 8 - P t'P'Y- 7r0-,)
Signature: /y ,q " OO&/o,Z
SOURCE #2 Date Pumped: S,` 6
Name: 10V 9 //
Address: 1.2 V700V fJ e
Telephone: %% �' -� ` t�- 09 0 Y
Signature:
SOURCE #3 Date Pumped:. -is)
Name: /77 9 n/ pr 09C ti, A
Address: If /7 -Z"r* /--
Telephone:
tTelephone: O c y— 0 i' s*,,O
Signature: "I le.-
001
Slip No. 2? �
Date: �G
Tank Size: /Oy o
Tank Size: ' O 4
Tank Size: / Oy o
To the best of my knowledge the above information is true and correct.
Hauler's Signature
Tank Size: o? 0
•.t.1 lli t. _ S ,r �:�Ml, .ti's. 1.' ,-.vr+:•t.•1i1t I:1.��.'•'- '
' ' �•"'t; t;:np ,\�.{''{.'1.,.41r�•A:)Aj.yi:
1l�f ,J1`jr; j'„o• i.o,,•.Ir,'.Ji:;�•'. t; :,,.�••.i bl.
DEP as �.�'.. J'.�;. .. . • . , .. '
h provided this form for use by local Boards of Health. The S ste tern
be submitted 6 theroving aurity.local'Board of Health or other'app tho y Record mus,
,
.A. Facility lnform�tion " n�
knko
hOVR
n� out . System Location; ,J NT
.r.Y,tiulW use�• f...0 ---- .
only the tab key Address C -')r
to move your:: /%? • 'i7" `� % /G'c-N .
.auxor • do dot
tasat the.rotum':.%' .0 r. own State771�
aY�y�11114 'SiJ th ar; ��(;; :`•: :,,':ia+�Jl�:,,�r,7 :''�..,'';�'�.'y� -��; 4p
•,�. J •�•jt�.f��'{If:f;��,•,:. I:. I. r.• Vode'.
:...,;r.' :;',,; •;.:.p}i,2'.' .Systemowner,'.:..r-
•, �..{.. 'J�''\;J. ,'I. VI'!'I N•.. .�.L :,.,'+•',/i;l •�'' :: i.. N'.'i/A�l+.: }�, ��Y�
•s.'.+, i : ,. Name • . ,..,.:.� .;•, •i fs.i ;' .',�; I:'..,
`Address I( different from locatlon G
CWJITown. State ZJD Cod
Telephone Number
Y Pum.Ping.�NeQord. N ...,. .
114., 9iC)
gat00of Pumpinga'
Dat 2• Quantity Pumped:
1 .:;:';;',::..:,' • : Gallons
:Type Pf,system: ; Q ' Cesspool(s) eptic Tank
: ❑ Tight Tank
( Other (describe ,
Effluen.t TeB Filter resent?
p... Q Yes o If yes, was It cleaned? ❑ Yes ❑ N
Cot►ditlon`of:S
..�•..rn :it'•' a•. i•,�'fl" V�l•.•tr i:r.r.i.1, i...1., 1: li••J:�.• '•:i':: � �
':a'' :�!'�,+� 'r„) R^M'!iii�'tr!'' � r•t;•,•1.'+;%y:' n ��' •/'1'�••' t.
Ocbu
umped
_ ;�,; •r .�i, :fit>i=,:),"''''ia ..Irl• •...•1 •'v+��-,%ai�::;:'�::
,�VehicJeUcen*eNumber
.'�7i•'_.a_.•iP[Vt:•`tih�i�._..n.Y.�i Il.: t i.:'::. 1.'�i�•/l�',':•\ � � // 1•: '�/
.._f.: i.ti r i:)��.,f: y,'.'.;- r����(r'�J••v+V��. �t:8` . Ii<X ''' :`%I
.'^:•:;.. .,•':�•�:Y;.�i.. •ki:::. .U7••�:';ti,'.f' ,. v.., j, I'.�`�! L�� •,.y1,,j�•r.
`�''� v'�,',,•�yri !� Tt yyT �"1+1�t!l,F•1�::'''•:• i':'i S
7;. Locabon.whera Contents yvere dl;;posed;
.s••.:::::<l.•�::}•.'.,:�,3'�,;�':: �' f'��^I','1•.,,.:i:;fy,•;• �•c'' •':t:,'•.4'i:G♦ 4. 1;1 i
:,;::,:��r•:.�'�a';:;�"�..��;.�;....... SbnaGue of Hauler;; •
�ti�: http:/Irvww.mass,9oWdeawater/apprCvaJs/t5formsrhtm#Inspect
.: •x .:.
t5forrn4.doa!08I03
J
System Pumping Record • Page T of T
Commonwealth of Massachusetts
Town of North Andover
System Pumping Record
System Owner & Address:
Thomas Gunn
970 Forest Street
North Andover, MA
Date of Pumping: August 17, 2009
Type of System: Septic
Location of System: Rear
Gallons Pumped: 1250
System Pumped By:
John Zanni Pumping Co. LLC
P.O. Box 4
Reading, MA 01867
License #: BHF -2003-000159
RECEIVEDED
AUG 3 1 2009
TOWN OF NORTH
ER
HEALTH DEPARTMENT
Contents Transferred to: Greater Lawrence Sanitary District
_....... ._.. _ ..... ........ ... ..... 111.
Date: August, 17, 2009
Pumping Technician: BL
This is proprietary and confidential information that may be used only by the Board of
Health for regulatory purposes
Commonwealth of Massachusetts
Town of North Andover
System Pumping Record
System Owner & Address:
Thomas Gunn
970 Forest Street
North Andover, Ma 01845
Date of Pumping: May 17, 2010 1 my ,
Type of System: Septic
Location of System: Rear
Gallons Pumped: 1250
System Pumped By:
John Zanni Pumping Co. LLC
P.O. Box 4
Reading, MA 01867
License #: BHP -2010-0359
yOWN OF NORTH ANDOVER
Contents Transferred to: Greater Lawrence Sanitary District
Date: May 17, 2010
I
j Pumping Technician: PD
This is proprietary and confidential information that may be used only by the
Board of Health for regulatory purposes
Commonwealth of Massachusetts
Town of North Andover
System Pumping Record
System Owner & Address:
Thomas Gunn
970 Forest Street
North Andover, Ma 01845
Date of Pumping: May 02, 2011
Type of System: Septic tank
Location of System: Rear
Gallons Pumped: 1250
System Pumped By:
John Zanni Pumping Co. LLC
5 Hallberg Park
North Reading, Ma 01864
License #: BHP -2010-0359
Contents Transferred to: Greater Lawrence Sanitary District
Date: May 02, 2011
Pumping Technician: MW
This is proprietary and confidential information that may be used only by the
Board of Health for regulatory purposes