HomeMy WebLinkAboutMiscellaneous - 18 STEVENS STREET 4/30/2018 (2)Name_
Address
BOARD OF HEALTH
14. '.MMAIN STREET
TELEPHONE# (508) 688-9540
APPL ICA TION FOR ABANDOMVENT
OF SUBSURFACE DISPOSAL SYSTEM
(SEPTIC SYSTEM)
Pursuant to Section. 310 CMR 15.354
of the State Environmental Code, Title V
Contractor hired for work:
Name
—
Phone
e Z7 – -25
Address qF2 Z-9, L)4'I
Date for scheduled abandonment
The septic system at the above address has been abandoned according to
Title V specifications.
Signature of Contractor
Method of septic tank abandonment (check one). () removal () sandfill
(�C) crush O other
Name of Offal Hauler Q
This form must be returned 'to the North Andover Board of Health.
PLEASE DO NOT WRITE IN THE SPACE BELOW FOR HEALTH
REPRESENTATIVE'S USE ONLY.
Inspecting Agent Date '
107 Forest St.
Middleton, MA 01949
(508) 774-2772
FILE# 1.201197
C�"�� SEPS RVICEAIN
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 4
PROPERTY OWNER'S NAME: ---).t 16par m A n ,
PROPERTY ADDRESS: i $ Ste► r, r AJ Andy, ler
ADDRESS OF OWNER:.' QW1
(if different)
DATE OF INSPECTION:.44 1)e c I c�
NAME OF INSPECTOR: 7G n vim, w e, T t -L . e^. v
0 THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY 0
FILE# I ,20c1 f
orest St.
leton MA 01949
(508) 774-2772
SEPTIC & DRAIN
SERVICE
ff4q�A E r `111 W 1111111111F
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: I$ Jt%2.Vt� T iJ, AndoVer Address of Owner:
Date of Inspection: .4 D c 1�9`� (If different) Sam e.
Name of Inspector: 1 %Cart to S SczLi
�4 Q
I am a DEP approved system inspector�ursuant to Section 15.340 of Title 5 (310 CMR 15.000)
r
Company Name: Currier-Se
i Service-
Mailing
e. iMailing Address: FQr e ( 4leto
Telephone Number: -7—/4/-A7-7 2 -
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below it true, accurate
and complete as of the time of inspection. The insPection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
_ Passes
_ Conditionally Passes
,Needs Further Evaluation By the Local Approving Authority
Fads .
Inspector's Signature: g Date: r C_ qqd
The Svstem Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmenta! Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, OrDO:
AJ SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR` 1.5.:303"
Any failure criteria not evaluated are indicated below.
COMMENTS:
B] SYSTEM CONDITIONALLY PASSES:
///
l� 6 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.
Indicate ye,�,ino, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; of
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
DEP on the World Wide Web: http.11www.m2pnet.5tate ma.uslder
ti..
io Printed on Recycled Pater
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: /8 STe vet) sr
Owner: SILL erMAr)
Date of Inspection: --1 C- X997
BI SYSTEM CONDITIONALLY PASSES (continued)
FILE# 12 4/ 9�7
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed.; .
pipets) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval
Board of Health). Describe observations:
E9broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass,
inspection if (wi h approval of the Board of Health):
broken pipets) are replaced
obstruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
• WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
AdCesspool or pri%N. is within 50 feet of a surface water
Cesspool or prK--. 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 APPROPRIATE) DETERMINES;THAT
THE SYSTEM 15 FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
.The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supolv'well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid).
3) OTHER
f-�
(revised 04/25/97) Yaps 2 of 10
FILE# fZ 0T
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO% FORM
PART A
CERTIFICATION (continued)
Property Address: /8 STev,�jg 67-
Owner: self er,>7a,�
Date of Inspection:
D) SYSTEM FAILS: �C 97
1'o mus; indicate ether "Yes" or "No' as to each of the following:
► have determined that the system violates one or more of the following failure cri r
for this determination is identified below. The Board of Health should be contin 310
the failure. actedto detia asderfmine what wC.lvtbe necessary to corm
Yes
LC Backup of sewage into facilitysystem or
component due to an overloaded or clogged SAS or cesspool.
LY Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded
cesspool. oaed or dogged SAS o=
Ts _. Stant liquid level in the distribution boa above outlet invert due to an overloaded or clogged SA
gg _ S
or cesspool.
A/ Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flo%%.
ARequired pumping more than 4 times in the last year NOT due to clogged or obstructed pi ;s;.
Number of times pumped pe
-- L� Any portion of the. Soil Absorption System, cesspool or privy P p vy is below the high groundwater elevation.
/.fA Am• porton of a cesspool or privy is within 100 feet of a surface water supply or tributary t
o a surface water supply.
�1'LI Any portion of a cesspool or prey is within a Zone I of a public well.
/YA Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Anv porton of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water su
PpIv weacceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysishfor
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E) LARGE SYSTEM FAILS:
You ust indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in drtion to the criteria above:
_,,
e system serves a facility with a desi n w Of
pu lic health and safety and the en g ent because on a pd or greater orr more of the following condiarge System) tions exist:system is a significant threat to
Yes Xe
em is w• in 400 feet of a surface drinking water supply
j
e is within 200 feet of a tributary to a surface drinking water supply
i
is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a
a r supply well)
The owthe
ny su system shall bring the system and facilirequirem.00 an 6.00. Please consult the local regional fficety into foflcompliance the Departments orhfurther infortmation treatment program
(s*via*d 0{/25/97)
Pag* 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:ly�I/e`J $r
OwnedDate of Inspection: J U�
4 7lec j7
FILE 1, 9
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Ye!vo
_
Z Pumping information was provided by the owner, occupant, or Board of Health.
Vol ._ None of the system components have beenum
flow rates P Ped for at least two weeks and the system has been receiving normal
during that period. Large volumes of wat
as part of this inspection. er have not been introduced into the system recently or
�/�
-- IY— As built plans have been obtained and examined. Note if they are not available with N,'A.
_ The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non -sanitary or industrial waste flow.
_• The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
✓ The size and location of the Soil Absorption System on the site has been determined based on:
_- The facility owner (and occupants, if difierent irom owneri were provided with information on the proper maintenance of
Sub -Surface Disposal System.
-_ Existing information. Ex. Plan at B.O.H.
-_. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation
of distanunacceptable) [15.302(3)(b)J ce is
(sav11116d 09/25/97)
Paye 9 of 10
j. .
�I
i'
(sav11116d 09/25/97)
Paye 9 of 10
j. .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECT10% FORM
PART C
SYSTEM INFORMATION
Propert% Address:h?
Owner: f/�•'�.�-•�
Date of Inspection:
�17ec 97
RESIDENTIAL:FLOW CONDITIONS
Design fioN _ t/ 4 e•p.cl/bedroom for S.A.S.
Number of bedrooms:
Number of current residents:
Garbage 9, -;-der (yes or no!:$
Laundry cor'-ectad to sysvestem or no):
Seasonal use ryes or no): `--
Water meter readings, if available (last two (2) year usage (gpd):
Sump Pump Ives or no):,w
Last date of occupancy:/ff
Ty of establikii
Oast flow:_/d
Crease ap prno:
Industrial tastnk oresent: Ives or not
'Non -Non . wed to the Title i system: Ives or no)
b1`ater meter ril bl —"
Last da;ems o
IER: (Describe:
date of occuoancv
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: ryes or nolo„
If yes, volume pumped: � ¢allons
Reason for pumping —
----
TyPf OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Pricy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Other VA Technology etc. Copy of up to date contracts'
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no) ,
(revised 04/23/97)
Page S of 20
� r
FILE#
00000000,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO% FORM
PART C
p SYSTEM INFORMATION (continued)
Property Address: JO s-l—ew %s S%
Owner: S//Aerlmy
Date of Inspection: "/ 1 /
/ c -
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction: Zcast
40 PVC _, othey(explain)
FILE#
-.
Distance from rivate water supply well or suction lief
Diameter
Comments: (condition of 'tints, venting, evidence o leakage, etc. ,
"Y"
d 4
P
SEPTIC TANK: -665
(locate on site plan) , ?
Depth below grade: �J �
Material of construction: ✓concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank it metal. Inst age — Is age confirmed by Certificate of Compliance (Yes/rvoi
r
Dimensions:_'�D X Ott �/ TQwk
Sludge depth- jr
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: j
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bonorp of utlet tee or anile:
Now dimensions were determined:
i
Comments:
(recommendation for pumping, condition of }n�let and oytle} tee or baffles, dept of liquid level in rel ion to outlet invert, structural '
int�e�gnty, eyjge, o. Ie_#age, etc.) hK nPPa✓ fid . n,.h4.,�� .� _
I
I-----------------
GREASE TRAP:
(locate on site plan)
D th below grade:
Mat ial of construction: _co rete _metal _Fiberglass _Polyethylene ,_other(explain)
Dimens ns:
Scum thi Hess: i.
Distance fr m top o cum to top of outlet tee or baffle:
Distance fro bo m. of scum to
bottom of outlet tee or baffle: 'I
Date of last p ing:
Comments
(re•com ndation f pumping, condition of inlet and outlet tees or baffles, depth of liquid level in r I
integri , evidence of akage, etc.) 4 elation'to outlet invert, structural
I
(revised 04/2S/97)
Paye i of 10
• I
f .
000
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1O j/C'!�E°/7,$' �pf
Owner: �i,�dcr�lcrrr�
Date of Inspection: �fDec 9'
TIGHT OR HOLDING TANK:/ Tank must be pumped prior to, or at time, of inspection)
\Ma
lon site plan;
elow grade:
of constructton: _concrete met _ Polyethylene
—other(explain)
Dimensions:
Capacm-: gal
Design flow: g�
Alarm level.
Date of previous Pum ng
Comments:
(condition of in tee, cond
rm in working order _ Yes; _ No
alarm and float switches, etc.)
DISTRIBUTION BOX:yS
(locate on site plan;
N
Depth of liquid level above outlet invert:
Comments:
• r
FILE#
PMP CHAMBER:/
(lo to on site plan!
i
Pumps � working or r: (Yes or Not
Alarms i working rder (Yes or Not
Comments. .
(note candid of pump chamber, condition of pumps and appurtenances, etc.)
-------------------
r
I FILE# g
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: l0 skevem S7
Owner: IS f Lberm k f)
Date of Inspection:
C
SOIL ABSORPTION SYSTEM (SAS):S
(locate on site plan, if possible; excavation not. required, but may be approximated by non -intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:_
leaching chambers, number:
leaching galleries, number: /
leaching trenches, number,length:Sd
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(n5w cofdition of soil, sigrys of hydraul)c failure, level of,pondinq, condition of veeetation_
-Lr11er'V—P�4?re
s � AR�
'
P
OOLS: L !
(I to on site plan)
Num be and configuration: _
Depth -to of liquid to inlet en:
Depth of ids layer:
Depth of scu layer:
Dimensions of esspo
Materials of cons ion:_
Indication of gr n water:
infl (cess ool must be pumped as pan of inspection)
condition of soil, signs
tulic failure, level of ponding, condition of vegetation, etc.)
P IVY:
(I to on site plan)
Materia of co ruction: Dimensions:
Depth of s s:
Commen .
(note c clition soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04/25/97) page a of to
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
y SYSTEM IN -FORMATION (continued)
Property Address:�0Y�/�
O%ner:
Date of Inspection: �fxc 97
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (locate where public water supply comes into house)
G �i SeVS T
x
FILE#
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
p� SYSTEM INFORMATION (continued)
Property Address:/? Sreee4x ,
Owner:/���
Date of Inspection: �04?�
y_D9,
Depth to Groundwater _L Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
/
✓ Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
/Check FEMA maps
_ZCheck pumping records
Check local excavators, installers
Use USGS Data
FILE#
Describe in your own words how you established the High Groundwater Elev tion. Must be completed
f1Gkf /%d ;SUsr7�o �l/yLl�7.��'�'S
p V
��. f .'
ark o t We Q w,? a,/,vf
(swissd.04/25/97)
Days 10 of 10
I-IHI, 1c - 14n L=HV
tDUID (41:MW44 1 U:
DEPARTMENT OF PUBLIC HEALTH/DEPARTMENT OF LABOR A INDUSTRIES
NOTIFICATION OF DELEADING WOR)(
All sections of t� is form must be cofaPleted in order to comply with
the notifteation requirements of X.G.L. C. 111 1197
Y I L E NIJ MB F R—
M, be r I V E C 0 t", t e Date of Inspection 4-22-92
Lead Paint —
i. Ranscn License # DI -000912
Contractor po fo'rM-4A9 P 01
Addreai of ?ro�ac�t
Building Name (if 1 2
Street Addrobs IF ste-krens St. Apt. No.
L
7
CitMA Lip PC�,
_ _-F-'
Y�-
SLILATIC, DEMOLITIOn
Deleadirig
(Oi-101Q all that apply
<fEEPLACV11IT-��> OTHER
A 5
if "Other" 881C.0tel, ple4ae explain
Whem wi-Ll 'Pork be donel. am 8.00 pm 5:00 weekands? ves
Project Sup:�r;isor riama,.LiE�unis J. Ranson License # DC1300912
Property Ovner. _pAX1 �IPinar
Addreso—,
Z4
Ci ty___ iug� �A
-;- ;k� State
Tole P'hdouc
D a r! In i S J c3 n S 0 fl 0 r
In 0ase of g-0
ergency, onta-,41 what person, Sco-�t A. Xnightly
Phone; Area coda raq,vir,--4 day 1'603) 749_927 4 av en i n (603', '743-3246
0030/3
rev !2/05/90
11
d WS 11.41 rg
I PIx u I t i - Ira M�, Y
X
aheak
one:
Start
i9i 9 2
complation
Dsto—
Whem wi-Ll 'Pork be donel. am 8.00 pm 5:00 weekands? ves
Project Sup:�r;isor riama,.LiE�unis J. Ranson License # DC1300912
Property Ovner. _pAX1 �IPinar
Addreso—,
Z4
Ci ty___ iug� �A
-;- ;k� State
Tole P'hdouc
D a r! In i S J c3 n S 0 fl 0 r
In 0ase of g-0
ergency, onta-,41 what person, Sco-�t A. Xnightly
Phone; Area coda raq,vir,--4 day 1'603) 749_927 4 av en i n (603', '743-3246
0030/3
rev !2/05/90
11
MAYS F �J2 12:47 LEAD SOURCE 6037425044 T0: 5056839391 P03
in aacordanoe with Chapter 773 of the Acta .of 1997, MattsFtchusotts General Laws
C. 111 1197, 454 "CMR ?,?..j00 and 105 CMR 460.000, nati.cri of the date and met}lod (s ) of
.removal or covering; of mint, plaeter soil or ether acceneihle material containing
dangerous levels of 1nad;, is to be provided to the following persona at least five
days prior to the beginn�ing of deleSding.
1. Occupants of the dwpiling unit
2. All other occunarta of the residential premises, if any
3. Direotor, CN.1ehood Lead Praiaaning provention Program
Depar"V, e?nt cvf Nblic Heal th, '05 ;south Street, Jamaica Plain, ?U 02130
4. Li�-&i Remov.q; ?`c� ase, ti^ 6� :b ir�crnica . aor.;r c e
Depar° ment of liab."r,and rk : aGrias, iivi.sion of ?rdustrial Safety
100 (;atTi ;}r.R .'l ee S:•if}Pt,C/Q°i�, 1101. .uU$vo T:i MA 0 2... 4'2
5. Loeal. Board of Hpa;T4h; Oode ftforoemen.t Agency
6, Masoachuset4s xistorioa! "omnission
(if pry ,tisan in lialed on the State Register of Historic Places)
The undersigned hereby slates, under the penalties of perdu*, that s/he has read
and understood the r7o=#wealth of Massschusstts Deleading Regulations, 454 CM?
22.00, and Lead Poison.in# Prevention and Coat,�al Regulat�ans, 105 CMR 460,00, .end
that th4 conjsined in this noti icati.on is td correct to tate beat
of his/her :•.,,.vw" vdge and belief.
Date 5.Y�'> S:gt;8d.1�_'��
wcmpany e'acoast r versified inn
Ad3resa: 4J Mopbe St. Dover? PIH 03820
Office ?1s Only
0034B/6 rev 12/05/90
i
0
PAGE II STEWART'S SEPTIC TANK SERVICE
04-22-96
A
31
STONE CLEAVE ROAD
201
BRADFORD STREET
04-23-96
585
BOXFO.RD STREET
A
175
GREAT. POND ROAD
04-24-96
1615
OSGOOD STREET
A
122
OLYMPIC LANE
A
1116
SALEM STREET
04-25-96
A
75
FORREST STREET
04-26-96
550
BOSTON STREET
04-27-96
A
1015
JOHNSON STREET
175
FOREST STREET
350.SHARPNERIS
POND ROAD
04-29-96
A
18_
STEVENS_ STREET)
A
100
FOREST.STREET
A
82
PADDOCK LANE
04-30-96
A
133
SUMMER STREET
A
347
HILLSIDE ROAD
1�
(CONT'D)
1,800
1,000
1,500 HEAVY
2,000
500 FLOODED
1,500
750
1,000
2,000 2-1,000 TANKS
1,000
1,000
1,500
1,250
1,500
1,500
1,000
1,000