HomeMy WebLinkAboutMiscellaneous - 187 STONECLEAVE ROAD 4/30/2018A�
a
Grant, Michele
From: Gaffney, Heidi
Sent: Thursday, January 07, 2016 4:23 PM
To: KURE29@gmail.com'
Cc: Grant, Michele
Subject: 187 Stonecleave
Attachments: 187 Stonecleave. pdf, 201601071605.pdf, 20'
Nam ("�'
i
Hi, Attached are two scans of plans from the health department file and a GIS � J
Overlay. All information is publicly available. You are welcome to visit the Cc
any information in the file for this property. I did not find a previous plan she
area as well as Riverfront Area appears to exist on the property and would
work. As far as the question of the feasibility of a pool on the property, You
evaluate and delineate the wetlands and Riverfront Area and distances to determine itworK-yua .Wa
comply with the rules & regulations of the Wetlands Protection Act and the Town of North Andover Wetland Protection
Bylaw, as well as any other applicable laws/rules including but not limited to setback from septic system/tank and lot
lines and then proceed with filing requirements for obtaining a permit. I have copied Michele in the health department
so she will be able to help if you come into review the health file.
Sincerely,
Heidi Gaffney
Conservation Field Inspector
Town of North Andover
1600 Osgood Street, Suite 2035
North Andover, MA 01845
Phone 978-688-9530
Fax 978-688-9542
Email hgaffney@townofnorthandover.com
Web www.TownofNorthAndover.com
1
Grant, Michele
From: Gaffney, Heidi
Sent: Thursday, January 07, 2016 4:23 PM
To: 'KURE29@gmail.com'
Cc: Grant, Michele
Subject: 187 Stonecleave
Attachments: 187 Stonecleave.pdf, 201601071605.pdf, 201601071605.pdf
Hi, Attached are two scans of plans from the health department file and a GIS image showing the FEMA Flood
Overlay. All information is publicly available. You are welcome to visit the Community Development offices and review
any information in the file for this property. I did not find a previous plan showing wetland areas, but wetland resource
area as well as Riverfront Area appears to exist on the property and would be required to be evaluated for any proposed
work. As far as the question of the feasibility of a pool on the property, you would need to have a wetland scientist
evaluate and delineate the wetlands and Riverfront Area and distances to determine if work you wanted to do would
comply with the rules & regulations of the Wetlands Protection Act and the Town of North Andover Wetland Protection
Bylaw, as well as any other applicable laws/rules including but not limited to setback from septic system/tank and lot
lines and then proceed with filing requirements for obtaining a permit. I have copied Michele in the health department
so she will be able to help if you come into review the health file.
Sincerely,
Heidi Gaffney
Conservation Field Inspector
Town of North Andover
1600 Osgood Street, Suite 2035
North Andover, MA 01845
Phone 978-688-9530
Fax 978-688-9542
Email hgaffney@townofnorthandover.com
Web www.TownofNorthAndover.com
North Andover MIMAP 187 Stonecleave -GIS with FEMA Flood Overlay January 7, 2016
r
A S s A cue ,q A y F '•i" `� i
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eave Roa y
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E3 MVPC Bo
Interstates Horizontal Datum: MA Stateplane Coordinate System, Datum NAD83,
— I - Meters Data Sources: The data for this map was produced by Merrimack
— SR 14ORTM Valley Planning Commission (MVPC) using data provided by the Town of
Roads pf t�tn qNorth Andover. Additional data provided by the Executive Office of
r Easements 1, +t� - ��� �� Environmental Affairs/MassGIS. The information depicted on this map is
_ Parcels .; G for planning purposes only. It may not be adequate for legal boundary
Q— ' "` R' definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER
Floodplain k' MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING
100 Year Floodplain � THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY
500 Year Floodplain y + * OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT
ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF
THISINFORMATION
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Fmcul45
of .Commonwealth of Massachusetts Map -Block -Lot
104.$0132..,
• ------------------------
BOARD OF HEALTH Permit No
North Andover BHP -2015-0235
-----------------------
P.I. FEE
F.I. $125.00
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Todd -B -ate -son -------------------------------------------------------------------------------------------
to. (Repair) an Individual Sewage Disposal System.
at No 187 STONECLEAVE ROAD N�'__ Q__�� ----------------
-- ------------------------------------------------- WW
as shown on the application for Disposal Works Construction Permit No. -BIP--201-5---023--- Dated --- May -28-,-20-1-5 --------
---- -- --------- --- - -- -
OF
Issued On: May -28-20-15 ------------------------------------------------
------------------------
4+
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
VI!t:A
a�
Application for Septic Disposal System
Construction Permit -TOWN OF
NORTH ANDOVER, MA 01845
Application is hereby made for a permit to:
❑ Construct a new on-site sewage disposal system*
TODAY'S DATE
$ 2501.00 - Full Repair
$425.00 - Component
❑ Repair or replace an existing. on-site sewage disposal' system* _
MM -Pair or replace an existing system component- What? Q+ -c 6
A. Facility Information "7Address or Lot #
MAY 2 8 2015
2: *TYPE OF SEPTIC SYSTEM*: TOWN OF NORTH ANDOVER
➢ ❑ Pumpravity (choose one) HEALTH DEPARTMENT
***If pump syste ach copy of electrical permit to application*"
9 onventional System (pipe and stone system)
➢ ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system.)
❑ Pressure Distribution S.A.S. (No D -Box)
➢ ❑ Pressure Dosed (D -Box Present) S.A.S.
➢ ❑ Does the system require an effluent filter? Yes No,
If yes, does plan specify make and model of filter? YES = (no further info. needed)
NO = (installer must specify brand of filter before DWC issuance)
WAatis the Make?
2. Owner Information
Address (if ci ferent from above)
Cityrrown
3. Installer Information
What is the Moder'
2 94"tJ_
/114 -
State
Q 1 P /"/6r
Zip Code
410 3
Telephone Number
Name Name of Company
�ATE:ON ENTERPRISES. INa _
TROAD
Address n ANDOVER, MA otalo
Cityrrown
4. Designer Information
Name
Address
Cityrrown
State Zip Code
97r S -/s ---v7-3
Telephone Number (Cell Phone # if possible please)
Name of Company
State
Zip Code
Telephone Number (Best # to Reach)
Application for Disposal System Construction Permit • Page 1 of 2
TODAY'S DATE
$.250.00 - Full Repair
$125.00.- Component
PAGE 2OF2
A. Facility. Information continued....
S. Type* of Building:esidential Dwelling or ❑Commercial
B. Agreement
The undersigned agrees to ensure the constructlon and maintenance of the afore -described
on-site sewage disposal system In accordance with the provision of Title 5 of the
Environmental Code, as well as the Local Subsurface Disposal Regulatlons for the Town of
North Andover, and not to place the system In operation until a Certificate of Compliance has
been Issue y this Board of Health.
Name Date
pp�lcation Approve Board of Health Representative)
Name J
Date
Application Disapprovedl. fob the following g reaso rts.
For Office Use Only:
1
-Fee Attached.
Yes
No
Z.-
ProjectManager Obligation Foam Attached?
YesNo
'
.3.:
PM LSnstem? IfsoJ Attach�oy ofElectrical
No
4.
FoundatianAs Built.? (hew construction -ronly).-
(Same scale as approvedplan)
Yes
No
—
5.
F1oorNws? (hew construction only).
Yes_
No
4-plf�tl0n fior-pjsppsal Systerii:C�onmmcuoh Permft' Page 2 of 2
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Under *d-U=wdSop ft.bWWS=_ (Epi I is -'�`�_ /S
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.
_ 1d
Commonwealth of Massachusetts
�'R E C%1 E
Title.5 Official Inspection Form JUN 08 2015
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
187 Stonecleave Road
Property Address
Roger Gauld
Owners Name
North Andover
Cityrrown
MA 01845
State Zip Code
TOWN OF NORTH AN
HEALTH DEPARTN
5/5/2015
Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be
way. Please see completeness checklist at the end of the form.
A. General Information
1. Inspector:
Neil J. Bateson
edi any t
G
Name of Inspector �6"
Bateson Enterprises Inc. y,
Company Name v9 v
111 Arailla Road
Company Address
Andover
Cityrrown
978-475-4786
Telephone Number
B. Certification
MA
State
S115
License Number
01810
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 E Conditionally Passes ❑ Fails
❑ Needs rthervaluation by the Local Approving Authority
! 5/5/2015
Insp ct s fijnature 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 - 3113 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
187 Stonecleave Road
Property Address
Roger Gauld
Owner's Name
North Andover MA 01845 5/5/2015
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
Owner
information is
required for
every page.
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Forth - Not for Voluntary Assessments
187 Stonecleave Road
Property Address
Roger Gauld
Owner's Name
North Andover
City/rown
B. Certification (cont.)
MA 01845
State Zip Code
5/5/2015
Date of Inspection
❑ 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 • 3113 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
187 Stonecleave Road
Property Address
Roger Gauld
Owners Name
North Andover MA 01845 5/5/2015
Citylrown 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:
Outlet tee & Outlet Cover needs to be replaced.
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 % day flow
t5ins • 3113
idle 5 official Inspection Form: Subsurface Sewage Disposal System •Page 4 of 17
Commonwealth of Massachusetts
Title 5
Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
187 Stonecleave Road
Property Address
Roger Gauld
Owner owner's Name
information is
required for North Andover
MA 01845 5/5/2015
every page. Cityrrown
State Zip Code Date of Inspection
B. Certification
(cont.)
Yes
No
❑
® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑
® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑
® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑
® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑
® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑
® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.] '
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15;000 gpd.
For large systems, you must indicate eithLr "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
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
187 Stonecleave Road
Property Address
Roger Gauld
Owners Name
North Andover
Cityrrown
C. Checklist
MA
State
n1AAA
-'N vvuc
5/5/2015
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
this inspection?
® ❑
Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑
Was the facility or dwelling inspected for signs of sewage back up?
® ❑
Was the site inspected for signs of break out?
® ❑
Were all system components, excluding the SAS, located on site?
® ❑
Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑
Was the facility owner (and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑
Existing information. For example, a plan at the Board of Health.
® ❑
Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms):
A
M.
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
187 Stonecleave Road
Property Address
Roger Gauld
Owner Owner's Name
information is
required for North Andover MA 01845 5/5/2015
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents:
Does residence have a garbage grinder?
Is laundry on a separate sewage system? (Include laundry system inspection
information in this report.)
Laundry system inspected?
Seasonal use?
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump?
Last date of occupancy:
CommerciaUlndustrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present?
Industrial waste holding tank present?
Non -sanitary waste discharged to the Title 5 system?
Water meter readings, if available:
Gallons per day (gpd)
® Yes ❑ No
❑ Yes ® No
❑ Yes ❑ No
❑ Yes ® No
On well water
❑ Yes ® No
Current
Date
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 7 of 17
'& Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
' 187 Stonecleave Road
Property Address
Roger Gauld
Owner owner's Name
information is
required for North Andover MA 01845 5/5/2015
every page. Cityrrown state Zip Code Date of Inspection
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:
Type of System:
Date
Pumped 2014, owner
gallons
® 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 • 3113 Title 5 Official Inspection Form: Subsurface Sawage Disposal System • Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
187 Stonecleave Road
Property Address
Roger Gauld
Owner Owner's Name
information is
required for North Andover MA 01845
every page. City/Town State Zip Code
D. System Information (cont.)
5/5/2015
Date of Inspection
Approximate age of all components, date installed (if known) and source of information:
31 years old, 10/2/1984, as built plan
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer (locate on site plan):
Depth below grade: 1.8
feet
Material of construction:
® cast iron ® 40 PVC ❑ other (explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
4" cast iron through wall, 3" PVC in house, no leaks visible
Septic Tank (locate on site plan):
Depth below grade: '6
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate)
Dimensions: 10'x 5'x 4'
Sludge depth:
2"
❑ Yes ❑ No
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 9 of 17
'&\. Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
187 Stonecleave Road
Property Address
Roger Gauld
Owner Owner's Name
information is
required for North Andover MA 01845 5/5/2015
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle N/A
Scum thickness
2"
Distance from top of scum to top of outlet tee or baffle N/A = Outlet tee corroded off.
Distance from bottom of scum to bottom of outlet tee or baffle N/A
How were dimensions determined? Tape Measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Inlet tee & baffle ok. Outlet tee corroded off, needs to be replaced. Depth of liquid at outlet invert.
No evidence of leakage.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal El fiberglass ❑ polyethylene ❑ other (explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins • 3/13 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
' 187 Stonecleave Road
Property Address
Roger Gauld
Owner Owner's Name
information is
required for North Andover MA 01845
every page. City/Town State Zip Code
t5ins . 3113
5/5/2015
Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain):
Dimensions:
Capacity:
Design Flow:
Alarm present:
Alarm level:
gallons
gallons per day
❑ Yes ❑ No
Alarm in working order:
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
❑ Yes ❑ No
* Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17
Owner
information is
required for
every page.
l5ins • 3113
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
187 Stonecleave Road
Property Address
Roger Gauld
Owner's Name
North Andover MA 01845 5/5/2015
Cityrrown state Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D -box level & distribution equal. No evidence of carryover. No evidence of leakage.
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:
We 5 official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17
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JOSEPH
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BARBAGALLO
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PUBLIC HEALTH DEPARTMENT
Town of North Andover
Community Development Division
CERTIFICATE OF
COMPLIANCE
As of 8/14/15
This is to certify that the individual subsurface disposal system received a
SATISFACTORY INSPECTION of the:
Repair Tank Cover & outlet tee
By: Todd Bateson
At:
187 Stonedeave Rd
Map 104B Lot 132
No
h Andover, MA 01845
of this certrt�ate ot be c6nstrued as aguarantee that the system will function satisfactorily.
Michele Grant
Public Health Agent
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fox 978.688.8476 Web www.townofnorthandover.com
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Foram - Not for Voluntary Assessments
187 Stonecleave Road
Property Address
Roger Gauld
Owner Owners Name
information is
required for North Andover MA 01845 5/5/2015
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 4
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 10/2/1984
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health - explain:
Design plan
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
Test pit data on design plan
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins • 3/13 Tdle 5 Official Inspection Foran: Subsurface Sewage Disposal System •Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
187 Stonecleave Road
v . Property Address
Roger Gauld
Owner Owner's Name
information is
required for North Andover MA 01845 5/5/2015
every page. Cityfrown 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 Forth: Subsurface Sewage Disposal System •Page 17 of 17
1
Town of Yorth Andover,Mass.
Permit n
Date --
19
APPLICATION FOR WELL & PUMP PERMIT
Application is he'reby made for permit to drill a well ( ). Application is
made to install (_) a pump system". -
Location: Addres%
Lot # -Z
Owner Address
Well Contractors Address�� / Tel. --------
Pump Contractor _Address �� 1:�! ay
WELL CONTRACTOR (To be completed at time of pump test)
Type of Well �j\//�� Well- used for. ���� -------
` L /
Diameter of Well / _Size'of Casing
Depth of Bed Rock_ Depth casing -into Bed Rock,��
Was Seal Tested?. Yes (� No (If Date -of Testing rJ
Depth of Well Well Ended in I%Tha Material
Depth to Water Q. Delivers Cals . Per Min . f r h =ur
Drawdown_feet- after- umping_ -`¢'/ hours at _GPM--
Date of Completion
- Sign -t e .el _ n racto=
,.i.i... SIC iii:. ii�_�9.rinri�"�_il.. ^_t_�.�+�-i-i��i���.^.�ni.��i1.=i^..._.:l.i.:�iii'.i.iit--i-�-��:: :: i�.. i:-i.��-i.i���-:... _•i_��-�-i"w w.
PUMP- INSTALLER_+T6 -be--filled-i-n-before -i.nst-ali.afion)=- -
Size & Fume- Pump Pump Type Used
1,7ater Pump -Delivers GPM = Size - of _Tank---- -
Pipe Material Used --in Well: Cast Iron ( ) Calvanized- C ) Plastic'( )-
1.1el_l Pit _(. -) or Pitles7s--=Adapter
t?as=sleeve_ used- to =protect pipe- 1'es- {_): N0(_� T3,pe -or-Dane elT
Date
.t .t.• .�. �.� • ,� J t.l- -�, i,,. „ �ii� U��11 11[-Pl
.•-,.. :�:�...'a"�C�iY'...''Y�"�7SY'�.`.-i'i�:�i.-7i .ZYi•..�YTi'i':�(i..:.� 'iTiir:.;Y�;--57i::.::...:;:,-....:::........:..,::.;...;iat�i�,ri�.��t;. .a;.
Date, Mater-. analy-sis -repor=t - submitted to" -Board- of -Health=
Date 'release -given iD oi:-ner of record & Bldg: .-Insp. _
Health -Inspector
-4-
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5. Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
187 Stonecleave Road
Property Address
Roger Gauld
Owner's Name
North Andover
MA 01845
5/5/2015
City/rown 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
n rtrnutinn -n4hnrhgaA cannrotaiv
—tv ti Z36
3 QWVNI
s
�--� t =3 1
D-�0Y = 5+
a $ I w 11
t5ins • 3113 Title 5 official Inspection Form: Subsurface Sewage Disposal System •Page 15 of 17
,Ai
��)L A-6
CM
North Andover Health Department
[ommunity and Economic Development Division
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: 187 Stonecleave
INSTALLER: Todd Bateson
DESIGNER:
PLAN DATE:
BOH APPROVAL DATE ON PLAN:
MAP: 104.13 LOT: 0132
INSPECTIONS
Outlet T and tank cover INSPECTION:
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
Comments:
SEPTIC TANK
❑ Contractor reports any changes to design plan
❑ (Existing septic tank properly abandoned
❑ Internal plumbing all to one building sewer
❑ Topography not appreciably altered
❑ Building sewer in continuous grade, on
compacted firm base
❑ Cleanouts per plan
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ 1500 gallon tank has been installed
H-10 loading
❑ Monolithic tank construction
❑ Water tightness of tank has been achieved by
visual testing
❑ Inlet tee installed, centered under access port
Comments:
PUMP CHAMBER
Comments:
CONTROL PANEL
Comments:
DISTRIBUTION -BOX
Comments:
❑ Outlet tee installed, centered under access port
(gas baffle/effluent filter)
❑ inch cover to within 6" of finish grade
installed over one access port
❑ Hydraulic cement around inlet & outlet
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ 1500 gallon Pump Chamber installed
❑ H-10 loading
❑ Monolithic tank construction
❑ Inlet tee installed, centered under access port
❑ Pump(s) installed on stable base
❑ Alarm float working
❑ Pump On/Off floats working
❑ Separate on/off floats
❑ Drain hole in pressure line
❑ cover at final grade installed over pump
access port
❑ Water tightness of tank has been achieved by
testing
❑ Hydraulic cement around inlet & outlet
❑ Alarm & Pump are on separate circuits
❑ Alarm sounds when float is tripped
❑ Location of control panel: basement
❑ Alarm signal located inside: basement
❑ Installed on stable stone base
❑ H-20 D -Box
❑ Inlet tee (if pumped or >0.08'/foot)
❑ Hydraulic cement around inlet & outlets
❑ Observed even distribution
❑ Speed levelers provided (not required)
❑ Schedule 40 PVC Pipe
" Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Forth - Not for Voluntary Assessments
187 Stonecleave Road
Property Address
Roger Gauld
Owner Owner's Name
information is
required for North Andover
MA
01845 5/5/2015
every page. Citylrown
State
Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑
leaching pits
number:
❑
leaching chambers
number:
❑
leaching galleries
number:
❑
leaching trenches
number, length:
®
leaching fields
1 field 20'x.45'
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.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth — top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 13 of 17
Jl
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
187 Stonecleave Road
Property Address
Roger Gauld
Owner's Name
North Andover
MA 01845
Cityrrown 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.):
5/5/2015
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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 17
BURLINGTON WATER TRFATMIT PLANT -August. „R„ 984 --
WATER SUPPLY ANALYSIS (mg. per liter)
Collector: r Rooney
Source A Private,Water Supply C. Rooney
Source B
Source C
Source D
Source E
Source F B C D E F
A
Sample No.
Date of Collection
8-2-84
Date of Receipt
8-2-84
TURBIDITY
8
SEDIMENT
0
COLOR
0
ODOR
0
pH
6.80
ALKALINITY -Total (CaCO3)
42
HARDNESS (CaCO3)
119.7
CALCIUM (Ca)
MAGNESIUM (Mg)
SODIUM (Na)
POTASSIUM (K)
.03
IRON (Fe)
0.00
MANGANESE (Mn)
SILICA (Si02)
SULFATE (SOO
CHLORIDE (CI)
12.5.
SPEC. COND.(micromhos%cm
240
'
NITROGEN (AMMONIA)
NITROGEN (NITRATE)
I
NITROGEN (NITRITE)
Wat r Manager
Watei Manager
TOWN OF .BURLINGTON
Department of Vubiie Works
BACTERIAL EXA?HIAATION OF VATNF
Collected
8-1-84,�
Ny._-C. Rooney
Recieved
8-1-84
Reported W.D.
Keene
w
.Location
Sample fcolllwtar
Analyst
Coll.ectLon
Analysis
Coliform bacteria
Number
time
Time
per 100 ml
Membrane Filter
Private Well
650
Rooney
Haynes
Spm
Spm
o
Watei Manager
L:()jj, I :-,U: 11,_". CC
orth 1-ndo Vert Nass. Street No Sra A -Ag d 46 -*V Lot No
I.Oc/Subdi-v. Pland Ouner :�71
I Observer tzor-Az
Investi6ator- Y-1
SOIL PROFILE DATES
ev 2.Elev 3. El ev_
0
2
3
4
0
2
3
4
0
2
3
4
0
2-
3
4
5
6
/c/o
9
id-
Ernch
nark
Mevation
5 ---
67
8
5
6
7
8
5
6
7
8
9 9 9
10 10 10
Location
Datum
DAT,Er,3
Pit Number 4
Start "Saturation
Soa) �'-,i-n-u-t- -e —s
prop of 6"-'lijne
crop
is T,q.�nd
nn
4. Elev_
Ti -es to Te,,
Pits
I'VELL DATAIASE
Ai0FEES:
ACE of W jet A v' W r -T; D E; ;
`P==c�L �� �i:-7 i LOC.�.i-SON:
DA= DEPT OF W E? L.: —
T�LE_OF ! .' DRILLED b. DLC C uNKNO v
ELIffG'N Y 0�CQ��rll�+��� is Y N
D A'LA3AEE
�r
ADDRESS: /J(
A_CE OF
DIY _`.1 L- DRLLl
F�"rLL LO.CA? ON 1 U t V
"LL P\ DA _ l -. Cis DEP7',-T OF WELL.
:
TYrE OF TEE -L: a li7EL�D b. DI uC
TYPE OF WA E 12, ITG ROCK:
-wA1LRAji�L'YS?SDA.TL= rEGr��rL���iGA�!rSE: Y N
EGA LRON: `` T+ 01 CONT tiC, qAyTS: Y y
ROA
COMMONNN-EALT14 OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON. AIA 02108 617-292-5W
WILLIAM F. WELD�j TRUDY CORE
Govemo: 13 Secmtan
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Lt. Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICATION
Property Address: ���1Kb cAAA ess
of Owner.
Date of Inspection:I - df different)
Name of Inspector: �t?'t llak_414N
I am a DEP approved system inspector pursuant to.Section 15.340 of Title S (310 CMR. 15.000)
Company Name: `epi` �r-V� �� _.l.✓ -
Mailing Address: (i I An' ' 1 .4rhJ q . 0 0a 1 O
Telephone Number: t -i r7 P=,Ce)
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete'as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Ll Passes
_ Conditionally Passes
— Needs Further Evaluation By the Local Approving Authority
_Fas )�
Inspector's Signature: ' `�T Date:
The System 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 Environmental 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, or d
A] SYSTEM PA
I have not found any information which indicates that the system violaies any of the failure criteria as defined in 310 CMR 15.303.
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.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances, If "not determined") 0010i why hot.
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; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltiatiah, of 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. A.
(revised 04/25/97) Page i of io
DEP on the World Wide Web: http:/h~.m9gnetsWe.ma.uiVde0
0 Printed on Reeyejed Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATIQN (continued)
Property Address: I Q)N s6v,cl-ave- RA
Owner: tit_) I
Ci -
Date of Inspection: h
B} SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the
Board of Health). Describe observations:
broken 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 (with approval of the Board of Health):
brokem pipe(&.) AP ratsla01d
obstruction is removed
CJ 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
4 WHICH WILL, PROTECT THE PUBLIC HEALTH AND 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 (ANDPUBLIC WATER SUPPLIER, It ES THE PUBLIC HEALTH AND SAFETY AND
DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PRO
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.is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and the SAS
_ 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 i00 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliforrn 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
xiniation .hot valitil).
less than 5 ppm. Method used to determine distance (�ppro
3) OTHER
--------------
(revised 04/25/97) page 2 ei 10
•
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: i SNOY"g—r—A2Gc Wt2
Owner: G
Date of Inspection:
., (I_tj
Dj SYSTEM FAILS:
You must indicate .either "Yes" or "No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
Backup of sewage into facility or system component due to an 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 1/2 day flow.
_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped _.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliiorm bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E) LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(rgviaad 04/25/97) pag* 3 of 10
ft
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: ( �5 4 Siler_ CA24ke- IUO�' 44A.A.a-f
Owner: el
Date of Inspection: L f _#I
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes o
Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection. •'
As built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage bads -up.
The system does not receive non -sanitary or industrial waste flow.
t/ 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.
/f The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants,,if different from owner) were provided with information on the proper maintenance of
/ Sub -Surface Disposal System.
v� Existing information. Ex. Plan at B.O.H.
..0 y Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) (15.302(3)(b))
(revised 04/25/97) page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: �G ! 5�CS��xZ. J�1Qt'�tk fX)
Owner:
Date of Inspection: tC�
q6
FLOW CONDITIONS
RESIDENTIAL:
Design flow: l bi D e.p.d./bedroom for S.A.S.
Number of bedrooms:
Number of current residents:
Garbage grinder (yes or no):`
Laundry connected to systgm�(yes or no):S
Seasonal use tyes or no):
Water meter readings, if available (last two (2) year usage (gpd): CIA u_Vil Lk&r-
Sump Pump (yes or no): No
Last date of occupancy: "M- A—
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flow:__gallons/day
Grease trap present: lyes 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:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no) LAO
If yes, volume pumped: I 00 _ gallons
Reason for pumping: kvVSClo t. ��nn,)►c_ � '%-C`�-{, �l %� ��"
TYPE OF S
„�/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)
VA Technology etc. Copy of up to date contract?
Other
(:)-)OCVV\e�f-
Jt-1
APPR XfMATE AGE of all components, date installed (if known) and source of information:
G. I iA-Vka'--
Sewage odors detected when arriving at the site: (yes or no) %%O
(rwiaed 04/25/97) Pago 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 16 l S -m e. c.Ap�Q.
Ower: 60.A 1(
Date of Inspection:
BUILDING SEWERk/
flocate on site plan)
kc —,, k�— AvAouar
Depth below grade:
Material of constr cd?n:,r1 ca. iron 4Z0 PyC other (exp�ai
. � y� Ltas'��t cv-+�.ti�- 3 G °t �� kv
Distance from water supply well or suction line
Diameter a
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:
(locate on site plan)
/f�
Depth below grader
Material of construction. _concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance (Yes/No)
Dimensions:
Sludge depth: ! "r(
Distance from top of�sludge to bottom of outlet tee or baffle: 9`t_
Scum thiIt
ckness: _ ti
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bon m f outlet tee or baffle: I a " ��a��
How dimensions were determined:
ae A SL vv�
Comments:
(recommendation for pumping, condit of inlet and outlet tees or baffles, depth of liquidiepvel in relation
GREASE TRAP:_SW\
(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:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structura
integrity, evidence of leakage, etc.)
(sevimed 01/25/97) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address; 16`131 p�G��� Q/j -���U
Owner: /'�'`ti-c ,
pate of Inspection: Go ` t -�
< <- q-90
TIGHT OR hIOLDING TANK:�0 jank must be pumped prior to, or 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/da�
Alarm level: Alarm in working order _ Yes; _ No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: D
Comments:
(np�e if level ar�d distrib tion is eq al, videnge pf solids carryover, evidence of leakage i to or out of box, etc.)
M!11 � l.2vC � SWr. �'��'ar� 4P—a l,Y -_' -:-, r, ,Q- I.tCO (">�' `� c
PUMP CHAMBER: J&1W —�(Y
(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.)
(revised 04/25/97)
?aye 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 6"1 �.oy\e- Cl2aujQ_ PA- . W -A tl 1► -1 �� (('
Owner:) .
Date of Inspection: `I _ t j �q d
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excavation bot 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:I
leaching fields, number, dimensions: `e , c -)O X 4S
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(not condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
ov\ o tc .
CESSPOOLS: 29Ae
(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 (cesspool must be pumped as pan of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, levelof ponding, condition of vegetation, etc.)
PRIVY; —cove -
(locate on site plan)
Materials of construction:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(rovieed 0{/15/91) Page 0 of 10
Dimensions:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:,
Owner:
Date of Inspection: 6D ekV I C
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"LI�-1 of ,\j(".\)ja
a- 3
(3-9VVIL
ac
v
1ys' ---�7
( t,
PAO = a3 3
=�C)
3 (O't4
DL,-,L- 3I
(revised 04/25/97) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address r] `UVllQ C �.�.� Q, �U (� ku—&—kVA-
Owner: _
Date of Inspection:
Depth to Groundwater H Feet
Please indi all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
L< ' Observation of Site (Abutting property, observation hole, basement sump etc.)
GDetermine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
�SGS
Check local excavators, installers
Data
Describe in your own words how you established the High Groundwater Elevation. (Must be completed)
�,, f
ISO V�7�k-�O Ll'
Y 1e l(A -)
GLSUP_`� C(v� 0.M
(roviaed 04/25/97) ?age 10 of 10
C
Tel: (978) 475 - 4786
Fax: (978) 475 - 5451
TIATRS ENTPRISES, INC.
A w#00§ m W*ff t Sawa I W4 - Septic systems & Pumping service
1 l 1 MOW Road + Andover, Mass. 01810
Title 5 Inspection Report
Fto gty Address; kk) rA-t�- (6"hma4 .
Owner;
date of Inspection: —
S
My report Gogtalned hereindoes not constitute a guarantee of future
psa�e ani the funegouatity of the existing septic system. Such report issued
berowith is merely based upon my observations, and I hereby disclaim any
fu-rftr operation of your current septic system.
Page 11 of 11
Neil J. Bateson
Bateson Enter)rises, Inc.
i*
Commonwealth of Massachusetts
City/Town of
System Pumping Record RECEIVED
Form 4
JAL 31 LU14
DEP has provided this form for use -by local Boards of Health. Other formsvvmay_be used, but the
information must be substantially the same as that provided here. Before iQjs tg;th s �rR rafieck M ith your
local Board of Health to determine the form they use. The System Pumpngr 1nus��esub/nitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left / Right front of house, Left /OjErear ofhouse eft / right side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
Address /� C, / ,e- � 1 `•' � "� �
City/Town ` State Trp Code
2. System Owner.
Name
Address (d different from location)
Cityrrown
State Zjv Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped
3. Type of system: ❑ Cesspool(s)eptic Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑Yes LK No If yes, was It cleaned? ❑ Yes ❑ Na
5. Condition of s m:
.. CMGs V\_
Gallons
❑ Tight Tank
6. System Pumped By:
Neil. Bateson
Name
Bateson Entemrises Inc -
Company
7. Locatio ere contents were disposed:
a S. Lowell Waste Water
l
F5821
Vehicle License Number
—a-& —c -Lr
or
Date
t5form4.doc.- 06/03 System Pumping Record • Page 1 of 1