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Home My WebLink AboutMiscellaneous - 178 HAY MEADOW ROAD 4/30/2018AO. . . I, - 4 I -- y ✓� C-0 P O ��S n NAY ME A Do y✓ k'D ►A IPA �.+ i V ,48 E5uiL-r -Su2D1s 5Y5 -r E.M I Nj moo. A�,jpov�� MA. . F o cZ F RA1�11L G � Ei._.i N AS � A SSUG1 ETES ENG1NEEQS A52r-� lITe�GT'-,t, .4 Sl •a.►.lokO� lb -r fro. AN 1289 COMMONWEALTH OF MASSACHUSETTS North Andover Board of Health TARNOPILSKY, WALTER & JESSICA TARNOPILSKY --------------- - -------------------------------------NAME------------------------------- 178 HAY MEADOW ROAD -------------------------------------------------------------------------------------------------------------- ADDRESS IS HEREBY GRANTED A PERMIT Disposal Works Construction This permit is granted in conformity with the Statutes and ordinances relating thereto, and expires ---------------August 15, 2003--------------- unless sooner suspended or revoked. -------------------------------------------------------------- April 15, 2003 ------------------------------------------------------------ ----------------------------------------------------------------- FEE $1.75.00 Board Of Health APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: q— q— '�'3 CURRENT INSTALLER'S LICENSE# LOCATION: / � S/- M LICENSED INSTAL)Id$R: __ SIGNATURE: TELEPHONE# 9jF �15 - d �� CHECK ONE: REPAIR: NEW CONSTRRUCTION: q), 704 k e�� IF NEW CONSTRUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. Administrative Use Only $175.00 Fee Attached? Yes Z//No Foundation As -built? Yes No Floor plans on file? Yes No Approval Date: J , INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the property at �� 7�/�d�� ✓ relative to the application of 1 a1 B•41,6kAy dated for plans by and dated with revisions dated I understand the following obligations for management of this project: 1. As the installer I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer I must call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system is not ready then item three shall be applicable. 3. As the installer I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Tile 5 and the Board of Health Regulations may result in a $50.00 fine being levied against my company. a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As -built or verbal OK from engineer must be submitted to Board of Health, after which installer calls for inspection time. Installer must be present for this inspection. With pump system all electrical work must be ready and able to cause pump to work and alarm to function. c) Final Grade Installer must request inspection when all grading is complete. Does not have to be on site. 4. As the installer I understand that only I may perform the work (other than simple excavation) required to complete the installation of the system identified in the attached application for installation. I further understand that work by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system, and/or revocation or suspension of my license to operate in the Town of North Andover; significant fines to all persons involved are also possible. 5. As the Installer I understand that I must be on site during the performance of the following construction steps: a) Determination that the proper elevation of the excavation has been reached. b) Inspection of the sand and stone to be used. c) Final inspection by Board of Health staff or consultant. d) Installation of tank, D -box, pipes, stone, vent, pump chamber, retaining wall and other components. 6. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Undersignedj�censed Septic Installer Date: Works Construction Permit # COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 rn OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 178 Hay Meadow Road— North Andover Owner's Name: _Walter Tarnopilsky_ Owner's Address: _178 Hay Meadow Road_ North Andover, MA 01845_ ` MAY �� Date of Inspection: _4/25/2003 Name of Inspector: Neil J. Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address: _111 Argilla Road_ _Andover, Ma. 01810_ Telephone Number: _( 978 ) 475-4786_ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: _X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fai 9 Inspector's Signature: Date: _4/25/2003_ 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 DEF. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments: After permit from B.O.H. , install new leach pit, outlet tee in septic tank & replace pipe from house to septic tank, inspection from B.O.H., septic system now passes Title 5 Inspection. ****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. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: _178 Hay Meadow Road_ North Andover Owner's Name: Walter Tarnopilsky_ Owner's Address: 178 Hay Meadow Road_ North Andover, MA 01845_ Date of Inspection: _4/25/2003_ Name of Inspector: Neil J. Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address: _111 Argilla Road_ _Andover, Ma. 01810_ Telephone Number: _( 978 ) 475-4786_ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: _X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority s Inspector's Signature: "" Date: _4/25/2003_ 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: After permit from B.O.H. , install new leach pit, outlet tee in septic tank & replace pipe from house to septic tank, inspection from B.O.H., septic system now passes Title 5 Inspection. ****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. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: _178 Hay Meadow Road_ North Andover_ Owner's Name: Walter Tarnopilsky_ Owner's Address: 178 Hay Meadow Road_ North Andover, MA 01845_ Date of Inspection: _4/25/2003_ 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 Fails "`J Inspector's Signature: �" Date: _4/25/2003_ 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: After permit from B.O.H. , install new leach pit, outlet tee in septic tank & replace pipe from house to septic tank, inspection from B.O.H., septic system now passes Title 5 Inspection. ****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. Town of North Andover f ,,aserM q Office .of the Health Department Community Development and Services Division } 27 Charles Street x?i w4ssoy North Andover, Massachusetts 01845 'ss.�w,5eo Sandra Starr Public Health Director TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE 05/10]/03 Telephone (978) 688-9540 Fax (978) 6W-9542 This is to certify that the individual subsurface disposal system components (building sewer, baffle and drywell) were constructed () or repaired (X) by Todd Bateson at 178 Hay Meadow Road has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. 0anij-asse Health Inspector BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 .HEALTH 688-9540 PLANNING 68&9535 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: _178 Hay Meadow Road_ _North Andover_ Owner's Name: _Walter Tarnopilsky_ Owner's Address: _178 Hay Meadow Road_ _North Andover, MA. 01845_ Date of Inspection- 121172002_ Name of Inspector: Neil J. Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address: _111 Argilla Road_ _Andover, Ma. 01810_ Telephone Number: J978) 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: Passes Conditionally Passes X_ Needs F er Evaluation by the Local Approving Authority F Inspector's Signature: Date: _12/17/2002_ 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: Outlet tee in septic tank, collapsed side wall of pit # 1, & cracked cast iron pipe thru foundation wall. ****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: _178 Hay Meadow Road_ _North Andover_ Owner: Tarnopilsky_ Date of Inspection: _12/17/2002_ Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _178 Hay Meadow Road- - North oad__North Andover— Owner: Tarnopilsky_ Date of Inspection: _12/17/2002_ C. Further Evaluation is Required by the Board of Health: _X 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: Outlet tee in septic tank, collapsed wall of pit # 1, & cracked pipe thru foundation wall. — Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _178 Hay Meadow Road- - North oad__North Andover— Owner: Tarnopilsky_ Date of Inspection: _12/17/2002_ 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 1/2 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.] TNo _ (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 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 11 of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: _178 Hay Meadow Road_ _North Andover— Owner: _Tarnopilsky_ Date of Inspection: _12/17/2002_ 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 nor -nal 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: _178 Hay Meadow Road_ _North Andover–' Owner: inspection: Date of Inspection: _12/17/2002_ FLOW CONDMONS RESIDENTIAL Number of bedrooms (design): 4_ Number of bedrooms (actual): _4_ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): _600_ Number of current residents: _2 Does residence have a garbage grinder (yes or no): No Is laundry on a separate sewage system (yes or no): No_ [if yes separate inspection required] Laundry system inspected (yes or no): _ Seasonal use: (yes or no): No_ Water meter readings: Yes_ Sump pump (yes or no): No Last date of occupancy: _Current COMMEERCIAIJINDUSTRIAL 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 2002, 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: _21 years old. 4/1/1981 As built plan. Were sewage odors detected when arriving at the site (yes or no): _No_ Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _178 Hay Meadow Road_ North Andover— Owner: Tarnopilsky_ Date of Inspection: _12/17/2002_ BUELDING SEWER (locate on site plan) X Depth below grade: _24" Materials of construction: _X cast iron —X-40 PVC —other (explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): _4" Cast iron thru wall. 3" PVC in house. 4" Cast iron cracked, needs replaced thru wall. _ SEPTIC TANK: X locate on site plan) Depth below grade: _12" Material of construction: — — X concrete metal fiberglass _polyethylene _other(explain) — If tank is metal list age: — Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of certificate) Dimensions: 10' x 5' x 4' Sludge depth: _1"— Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: _1"_ Distance from top of scum to top of outlet tee or baffle: _N/A N/A = Outlet tee corroded off. Distance from bottom of scum to bottom of outlet tee or baffle: _N/A_ 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 croorded off, needs replaced. Outlet baffle ok. Depth of liquid above outlet invert, found blocked pipe. Snaked pipe level normal. 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: _178 Hay Meadow Road_ _North Andover_ Owner: Tarnopilsky_ Date of Inspection: _12/172002_ 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 not equal. More flow to pit # 2. Install speed levelers. Flow equal. PUMP CHAMBER: (locate on site plan) Pumps in working order (yes or no): Alarms in working order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _178 Hay Meadow Road_ _North Andover_ Owner: Tarnopilsky_ Date of Inspection: _12/17/2002_ SOIL ABSORPTION SYSTEM (SAS): X_ (locate on site plan, excavation not required) If SAS not located explain why: Type X leaching pits, number: _2_ leaching chambers, number: leaching galleries, number: leaching trenches, number, length: 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 sign of ponding to surface. Pit # 1 has collapsed side wall, Pit # 1 MT. Pit # 2 has 1" of liquid in same._ CESSPOOLS: (cesspool must be pumped as part of inspectionxlocate on site plan) Number and configuration: Depth — top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow (yes or no): Comments (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: _178 Hay Meadow Road_ North Andover— Owner: Tarnopilsky_ Date of Inspection: _12/17!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. I Pit#2 I Pit # 1 House C Driveway Garage A Water Meter D- Septic Tank Box 2 1 A to 1=11'3" Ato2=13'8" Bto1=30'2" Bto2=22'5" B to D -Box = 27'5" B to Pit # 1= 42' BtoPit #2=35' C to D -Box = 4219" C to Pit # 1= 5812" CtoPit #2=35'5" Page I I of 1 I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _178 Hay Meadow Road_ _North Andover_ Owner: Tarnopilsky_ Date of Inspection: _12/17/2002_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 4 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: _4/21/1979 _ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Checked with local excavators, installers- (attach documentation) Accessed USGS database -explain: You must describe how you established the high ground water elevation: As per design plan_ 12/19/02, THU 16:48 FAX 978 688 9573 NORTH ANDOVER DPW 0 w1.,�o.pm.lo•vlrwNj ; a ,.,, NNNNN1viNNWNNNN 0 CC Irm A l m', O O O O O O a 0 a o m m 0 0 0 0 0 0 0 0 0 0 0 D O Alm1 w N N N N •y J j 0 0 0 0 r' 1 m 1 ID � p �rWN-+rWN�rwNa WwwwW6r wwwww W w I r ~i00000 m .0p0. N.Op a � N •Oo•w.+0 V1 I C! \\\\\\\ \\\ m I m 1 SSE p .6 .1. = N O -+ N i""" 4-4w�iraw a, %n popw O1' H OOOS7o00000o0'0 M1 I m 000000000000'p N IV N N j J 0 0 0 0 0 Z m o $ NN W 0000 NNj W a.knC OID.��'J m O, '+ C ID Boor 'Ow•OJ V VIVV9 r m a� _ ova y ..1 Nh1WNN1V NN WA7NNN NNNN.1J.atJJJ ®C� 9ID� m yIDr009041f1G9.10�ti1 j p•OwOj-40 V Z= { { r m a t � j N..►J.l .i S ill � .Oia•r�py�p.yr0pg'NIDN O C9 x f 0 rm V1.p0J V wC)"w a0N�Or ;Q 6 n6 O.ifo-+N Ncc0wr�ao.+N�rNa�ra M m Fgni W m m a eemoovv000cvv � 0 0 0 0 0 0 0 0 G1 O O O O J J J J %M %M km %R %R . . . . a a =5 J m 6Zn7 IV'St1100000000 m 'i rm V Y9 V1 v1 %900000000 y -w .& -4 v,.+r*4&'%Mkn Owwri o ��t10-IN& V:OOaNaav 5 � ��aarN.+Nv.+o• m e�oftm.JNL Nm&O• _ Lgj UUl 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: 178 Hay Meadow Road, North Andover Owner: Tarnopilsky Date of Inspection: 12/17/2002 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. ONe'J. B son Bateson Enterprises, Inc. Town of North .Handover Office of the Health Department 21 Community Development and Services Division ; y 27 Charles Street too P'R North Andover, Massachusetts 01845 °Sss`F,,,$e� Sandra Starr Telephone (978) 688-9540 Public Health Director Fax (978) 688-9542 January 27, 2003 Re: Notice of Conditionally Passing Septic System at 178 Haymeadow Road Dear Mr. and Mrs. Tarnopilsky: The North Andover Health Department has received and reviewed the inspection report that resulted from the inspection of your septic system on December 17, 2002. The DEP approved system inspector has determined that your system was not deemed as "...failing to protect or threatening public health and safety or the environment..." as defined in Title 5 of the State Sanitary Code. However, he did determine that "One or more system components ... need to be replaced or repaired." After review of the inspection report, the Health Department has determined that you must: Retain the services of a licensed plumber to obtain a plumbing permit to: remove your garbage disposal re-route your laundry drain pipe to your septic system X Retain the services of a North Andover licensed septic system installer to obtain a disposal works construction permit and: X replace your septic tank outlet tee repair or replace the defective distribution box X repair or replace damaged piping X Replace pit #1 Other: Please have all work performed within 90 days of receipt of this notice. Should you have any questions, please call me at 978-688-9540. Sincerely, Sandra Starr, R.S., C.H.O. Health Director Cc: File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTIO,N., JAN - 2 2002 TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: "178 Hay Meadow Road_ _North Andover Owner's Name; _Walter Tarnopilsky_ Owner's Address: _178 Hay Meadow Road_ _North Andover, MA. 01845_ Date of Inspection: _12/17/2002_ Name of Inspector: Neil J Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address: _111 Argilla Road_ _Andover, Ma. 01810_ Telephone Number: _( 978 ) 475-4786_ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The _system: Passes Conditionally Passes X Nee Further Evaluation by the Local Approving Authority Fai Inspector's Signature: Date: _12/17/2002_ 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: Outlet tee in septic tank, collapsed side wall of pit # 1, & cracked cast iron pipe thru foundation wall. ****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: _178 Hay Meadow Road_ _North Andover— Owner: Tarnopilsky_ Date of Inspection: _12/17/2002_ Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _178 Hay Meadow Road_ _North Andover— Owner: Tarnopilsky_ Date of Inspection: _12/17/2002_ C. Further Evaluation is Required by the Board of Health: _X Conditions exist which require further evaluation by the Board of Health in order to determine if the system Fs 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 i 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: Outlet tee in septic tank, collapsed wall of pit # 1, & cracked pipe thru foundation wall. _ Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _178 Hay Meadow Road_ North Andover— Owner: _Tarnopilsky_ Date of Inspection: _12/17/2002_ 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 V2 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. NC 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 l l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 178 Hay Meadow Road` _North Andover— Owner: _Tarnopilsky_ Date of Inspection: _12/17/2002_ 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_ T 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: 178 Hay Meadow Road_ rNorth Andover_ Owner: _Tarnopilsky_ Date of Inspection: 12/17/2002_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): _4_ Number of bedrooms (actual): _4_ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): _600_ Number of current residents: _2 Does residence have a garbage grinder (yes or no): No_ Is laundry on a separate sewage system (yes or no): _No_ [if yes separate inspection required] Laundry system inspected (yes or no): _ Seasonal use: (yes or no): _No_ Water meter readings: Yes_ Sump pump (yes or no): No_ Last date of occupancy: _Current COMMERCIALANDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): , gpd Basis of design flow (seats/persons/sqft,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 2002, 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: _21 years old. 4/1/1981 As built plan. Were sewage odors detected when arriving at the site (yes or no): _No_ Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _178 Hay Meadow Road_ _North Andover_ Owner: Tarnopilsky_ Date of Inspection: _12/17/2002_ BUILDING SEWER (locate on site plan) X Depth below grade: _24" Materials of construction —X—cast iron —X-40 PVC other (explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): _4" Cast iron thru wall. 3" PVC in house. 4" Cast iron cracked, needs replaced thru wall. _ SEPTIC TANK: _X _locate on site plan) Depth below grade: _12" Material of construction: —X—concrete _metal _fiberglass __polyethylene —other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of certificate) Dimensions: 10' x 5' x 4' Sludge depth: _1"_ Distance from top of sludge to bottom of outlet tee or baffle: N/A Scum thickness: _1" Distance from top of scum to top of outlet tee or baffle: _N/A N/A = Outlet tee corroded off. Distance from bottom of scum to bottom of outlet tee or baffle: _N/A 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 croorded off, needs replaced. Outlet baffle ok. Depth of liquid above outlet invert, found blocked pipe. Snaked pipe level normal. 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: _178 Hay Meadow Road_ _North Andover - Owner: _Tarnopilsky_ Date of Inspection: _12/17/2002_ 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 not equal. More flow to pit # 2. Install speed levelers. Flow equal. PUMP CHAMBER: (locate on site plan) Pumps in working order (yes or no): Alarms in working order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 17$ Hay Meadow Road_ _North Andover— Owner: _Tarnopilsky_ Date of Inspection: _12/17/2002_ SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan, excavation not required) If SAS not located explain why: Type X leaching pits, number: 2_ leaching chambers, num_ber: leaching galleries, number: leaching trenches, number, length: 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 sign of ponding to surface. Pit # 1 has collapsed side wall, Pit # 1 MT. Pit # 2 has 1" of liquid in same._ 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: _178 Hay Meadow Road_ North Andover— Owner: _Tarnopilsky_ Date of Inspection: _12/17/2002_ 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. C I House Driveway Garage Pit # 2 D- I Septic Tank Box 1 2 1 I Pit # 1 I A Water Meter A to 1=11'3" Ato2=13'8" Bto1=30'2" Bto2=22'5" B to D -Box = 27'5" B to Pit # 1= 42' BtoPit #2=35' C to D -Box = 4219" C to Pit # 1= 5812" CtoPit #2=35'5" Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _178 Hay Meadow Road- - North oad__North Andover— Owner: _Tarnopilsky_ Date of Inspection: _12/17/2002_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 4 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: _4/21/1979 _ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Checked with local excavators, installers- (attach documentation) Accessed USGS database -explain: You must describe how you established the high ground water elevation: As per design plan_ • 12/19/02 THU 16:48 FAX 978 688 9573 NORTH ANDOVER DPW Ip�uul I A� 1: a �.� i �'. r4"�i•;'�f�. 'Ei4vti W Nsa■OOV Otvf='wN IV NNIV NT3h5NNNNNN C� I -i ©000CODCO2 aoeam '� I m', 0 0 0 0 0 0 0 0 0 O o ry l 0f. L�INNNN��Ja0a0 r 1 61 w N I I I I I I I l l m I m Jr WNj�t■�Ns wwwwwwwwwwwww I f� aoa0000"Cosom I s" 40 ■0 C2% jr 0 CK w —A m I �.►N � aNaiNiN �� O 1 21 NNNNNNNNNNNN�► l� I -�� oocpa 00ao0aod m I of pQO000o00aaGo-cc NNNNj-+ioo0a1 1: o w' N N N N N N N N N N N N N O m a S O, NN j OD o�inCJ-L0cc. -4%M—L w.✓r ajo'OW %0 N'f V V1 Lf n 1 , xva? NNNNNNNIVNNNNN Om�l NNNN■iJ.a,iJJ ®pp m &"""wo■f,RwdO�til�l1 yS� 11m j Q■�o■ -4 Wl V -4 "C r+ Ion F9�i Irl w -Cl ■OiT�Q wlot-1,;rW4- Q 111�0� A -4 W (2- CC 40 GCI OL � CO' y mi m z: 96M km e■wwt� Q �6r1a.IN.& V:OOmN■ov �1 i..... sz 3j, 'fcll tt .: Cn Kfl'_yi� ooe90000000000 a o a o 0 0 0 0 D 0 0 0 0 o ij ' D O O D 0 0 0 0 0 0 0 0 0 •• to Vm to 0 0 0 0 0 0 0 0 V %Mvj%nCn00i7o0oQQ m 96M km e■wwt� Q �6r1a.IN.& V:OOmN■ov �1 i..... sz 3j, 'fcll tt .: Cn Kfl'_yi� 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: 178 Hay Meadow Road, North Andover Owner: Tarnopilsky Date of Inspection: 12/17/2002 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. RC"4 Neil J. Bateson Bateson Enterprises, Inc. E Board North ' of Health WoverzMaas. BEPTIC SZSTEli IN:S'rALLATICK tHECg LIST LOT yl LIVED DATE III PFiOPE'D . EXCAVATION OK FAIL t $eaganst i i OK 1. Distance Tot a. Wetlands I+ b. Brains c. Well 2. Water Line Location 3. No PPC Pipe $. Septic Tank a. _Tees --Length & To Clean Oat Comers. b. Cement Pipe ..to Tank - On Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b All Lines Flowing Amounts c. No Back Flow j 6.- Leach Field or Trench a. Dimensions b. Stone Depth c. Capped Inds d. Clean Double Washed Stone' 7. Leach Pits a. Dimensions b. Stone Depth / c. Splash Pads L d. Tees S. Cement Pipe to Pit - Both Sides. f. Clean Double Washed Stone / 8. No Garbage Disposal 9. Final Grading Inspection '4 _10. Barricading Covered System 71. As Built Sabmitted - - a. Lot Location---- ocation-_-_.--b. b.Dimensions of System c. Location with Regard -to Pere Test / d. Elevations a e; Water Table 3 Board of Health North Andover,Mass SUBSURFACE DISPOSAL DESIGN CHECK LIST LOT #. '.APPROVED DATE DISAPPROVED --DATE,,,_, iProvided: Reasons % f 13, lRv f Title V // FAIL _0[ 'Reg 2.5 The submitted plan must show as a minimum: the lot to be served -area, dimensions lot #,abutters y/ I ocation and log deep observation dimensions to ties cation and results percolation tests -distance to ties esign calculations & calculations showing required leaching area j/ (e � cation and dimensions of system -including Eeserve area fa�� Listing and proposed contours r/ g) cation any wet areas within 1001 of sewage disposal system or disclaimer -check wetlands mapping L,I(h) face and subsurface drains within 100' of sewage disposal system or disclaimer (i"ocation any drainage easements within 1001 of sewage disposal system or disclaimer -Planning Board files (j) wn sources of water supply, within 2001 of sewage disposal . sten or disclaimer ( tion of anY proposed well. to serve lot -1001 from leaching facility n of water lines onproperty-101 from leaching facility 21 r tio tion of benchmark 'Loeways age disposals VC to be used in construction ile of system -elevations of basements plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and Other elevations maximum ground water elevation in area sewage disposal system s) plan must be prepared by a Professional Ragineer or other professional authorized by lax to prepare such plans Reg 6 Septic Tanks (&Y'capacities-l5D% of flows water table, tees, depth of tees, access, pumping leanout 10I from cellar wall or inground swimming Pool (d) 25+ from subsurface drains Reg 10.2 1 d%,Ds tribu tion Boxes s ope greater 0.08 Reg 10.4 b) sunP Desi FAIL eck List Page 2 ` 0K Leaching Pits jLeaching pits are preferred where the installation is possible calculations of leaching area -*d ni mm+ 500 eq ft b acing 04, surface drainage 2% I material v Rlx2'x4" splash pad tee at elbow g) no bends in pipe .Brom d -box to pipe a) no greater t 20 minutes/inch b area, 900 aq ft c cons=cedrainage c on of field d) surf2 % e) 201 A.5,Pm cellar wall or inground swimming pool Leaching Tri ches a)—calculati 's o eaching area -min 500 aq ft b) spacing -4 ft min 6 ft with reserve between C) =onstrsia d) tion e) stone drainage 2% a) sslope x _-_5o be shown b) y/x 150 = (to be shown Pun}�a )g 9.1 a) appifoval 9.6 b) stud -by power North AndoversX-a is 4 APPROM DATE Provided: r.JBS!T.FhCE Dl:§POSAL MILK US? DISAPPROVED DATE Reasons: LCYT #_J? ,47 2a r A, Title V FAII, OK Reg 2.5 The submitted Plan mat show as a minim=: a) the, lot to be served -areas dimensions lot #,abutters 7 b observation holes -distance to ties c11 location and log deep obr location and results Pemolati011 testa -distance to ties design calculations & calculations showing required leaching area e location and dimensions -of system -including -'reserve area-_ f) existing end proposed contours - g) location any-- vat areasulthin loot --of sewage --disPOsal b7sten or-- disclai=er-check watlands mapping:----- 1 - h) surface and subsurface wsewage within 1001 of sage disposal ssystemor disclaimer i) location any drainage easwtents ulthin 1001 of stege disposal 1 system or disclaimer-Mwxwing Board files (J) know sources of -ester swply vitbin 2001 of sewmge disposal -system or disclaimer (k) location of any proposed well to serve lot -1001 from leaching facility 7 (1) location of vater- lines on property -101 from leaching facility i7tm) location of benchmark drive ways A -11i 6) garbage disposals p) -no PVC -to be used in construction - q) profile of system -elevations of basement., plumb., pipe, septic tank., distribution box inlets and outlets, distribution field piping and oo Ether elevations (r) raxi=-a ground nater elevation in area sewage disposal system =Zs) plan rmst be prepared by a Professional Eagineer or other F-1 I professional authorized by law to prepare such plans Reg 6 otic Tanks (a) capacitie-i--T50% of flows vater table., teess depth of teess 10 access, ping (b) cleanout c 10 1 from cellar wall or inground si4=dzg pool d) 251 from subsurface drains Reg 10.2 Distribution Boxes I t-4 a) slope greater tian 0.08 Reg 10.4 b) mLV ►:.uiit141 �. eavrG Reg 11.2 3-1.4 11.10 11.11 Reg 15.1 15.4 15.8 3.7 - -.Reg 14.1 14.3 14.4 14.6 1-4.7 14.10 - Reg 9.1 9.6- af-i..r.i w;aA FAIL OR r _. W Leaching Pits + Leaching pits are ferred where the installation is possible a) calculations f leaching area-minim= 500 eq ft b) spacing c) sur face ainage 2% d) cove r terial e) 2+ x4" splash pad f) a at elbow �no bends in pipe from d-box to pipe Leaching Fields great t� 20 minutes/inch a-minium 900 aq ft struction of field face drainage 2 % from cellar wall or inground sw i.mving pool L eachin D=c a) cal culation o eaching area-min 506 oq ft- [b) spacing- t min 6 ft with reserve between- - -- s d) ion (c) 7arfacecdrainage e) f) 2% - DowihilT. -- f _gee..y x.�_ a) s o-to_ be shown) [b) y/x X 150 (to be shown) Punps a) aroval stand-by-power --- orb)