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Miscellaneous - 192 LACY STREET 4/30/2018
192 LACY STREET- 210/105.C-0020-0000.0 i Commonwealth of Massachusetts City/Town of System Pumping-Record Form 4 DEP has provided this form for use;by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left/Right front of house, Left *ei��of , Left/right side of house, Left/ Right side of building, Left/Right front of building, building, Under deck Address City/Town State Trp Code 2. System Owner. Name Address(if d'e from location) MWOM , State _Zip Code H" Telephone Number = r I � B. Pumping Record 1. Date of Pumping Date �eptluc tity Pum Gallons 3. Type of system: ❑ Cesspool(s) ank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No, ' 5. Condition fYstem-��`-GC/� 6. System Pumped By. Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Lova' ere contents were disposed: O S. Lowell Waste Water Signitufa,qt Haule Date tftrm4.doc-06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 192 Lacy Street Property Address Nathan Smith Owner Owner's Name information is required for North Andover MA 01845 12/16/2014 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in an P P Y Y way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer,use 1. Inspector: t, ''{�5 c��5 only the tab key N to move your Neil J. Batesonp►1EN, cursor-do not use the return Name of Inspector I ltukk I, I, "i t r key. Bateson Enterprises Inc. Hof Company Name ffi 111 Argilla Road Company Address Andover MA 01810 ' Citylrown State Zip.Code 978-475-4786 S115 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs urther Evaluation by the Local Approving Authority 12/16/2014 lnsfeorsilzignature i 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 addr p ess how the system will perform in the future under the same or different conditions of use. ii t5ins•3/13 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspe6tion Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 192 Lacy Street Property Address Nathan Smith Owner Owner's Name information is required for North Andover MA 01845 12/16/2014 every page. Cityrrown 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: After permit from B.O.H., remove drop box , pipe outlet pipe to d-box, inspection from B.O.H. septic system now passes Title 5 inspection. I I i B) System Conditionally Passes: i ❑ 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 infiltation 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 i 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): I i t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 l J--`�!' 4iTIM) North Andover Health Department Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 192 Lacy St. MAP: LOT: INSTALLER: Todd Bateson DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS D Box INSPECTION: 12/16/14 DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ 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 ❑ 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 Comments: PUMP CHAMBER ❑ 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 Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION-BOX ❑ 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) ®i Schedule 40 PVC Pipe n � Comments: �}( �y � P.A- 4-e�5 • Commonwealth of Massachusetts Map-Block-Lot °'. 105.C0020 BOARD OF HEALTH ----------------------- Permit North Andover BHP-2014-1300 --------------- -- P.I. FEE F.I. $125.00 DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd-Bateson to(Repair)an Individual Sewage Disposal System. at No 192 LACY STREET - - PPDisposal _ X4=130 ``Dated December 15 2014 as shown on thea application for Works Construction Pen-nit No. BHP-20 — --------------- Issued --- ---------Issued On:Dec-15-2014 BOARD OF HEALTH FT 7188 Of HORT:,� 0 F P Town of North Andover HEALTH DEPARTMENT ,SSACMU`+t4 CHECK#: DATE: . LOCATION: PQ H/O NAME: CONTRACTOR NAME: Tyne of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ 12�Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other. (Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer f _ Application for Septic Disposal Svstem _f 0-DAYS DATE Construction Permit — TOWN OF $250.00—Full Repair NORTH ANDOVER, MA 01845 $125.00-Component Important Application is herebv made for a permit to: When filling out ❑Construct a new on-site sewage disposal system* forms on the computer,use ❑Repair or replace an existing onsite sewage disposal system* tory the tab key to move yourLg-lllepair or replace an existing system component-What? cursor-do not K use the return A. Facility Information J�r key. / / Q_ f-A La-11 5� Address or Lot# -- - Cityr town Z01/ 2.- TYPE OF SEPTA SYSTEM ► ➢ ❑ Pump gravity(choose one) ***If pump system,attach copy of electrical permit to application— T4vf,N ➢ ©'conventional System (pipe and stone system) -. 4F, ➢ ❑Infiltrator or Biodiffuser(Gravel-Less)(Attach a copy of yourcerti6cafion 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 /f yes, does plan specify make and model of filter? YES=(no further info. needed) NO=(installer must specify brand of filter before DWC issuance) Wbatis die Make? What is the Modck 2. Owner Information Y / Name A4 CSS/ Sd• - Address(if different from above) p(/a Al- l�I�►- r `fS City/Town State / p Zip Code &<3 — O Sq3 Telephone Number 3. installer Information Name 1� Name of ComWE''ON ENTE:RPRnE.S INC. 1 /zo-CA 111 ARC!L.U. (,QAD Addressn `T � ru,400VER, Iv[A 01810 City rTown State Zip Code %'/-� - Telephone Number(Cell Phone#if possible please) 4. Desi. ner Info tio. N __V ame Name of Company Address Cityrrown State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 ; :T1y Appiicati-oh..for Septic Disposal 3r.:�� •.�:.°�- �—^ TODAY'S DATE ` pConstruction Permit - TOWN OF ' -ORTH ANDOVER, MA 01845 $.250.00-Full Repair CHUS $725.00,-Component SAMUS PAGE 2OF2 A. Facility.Information continued.... 5. Type-of Building: Residential Dwelling or❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system/n accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place the system in operation until a Certificate of Compliance has been issue y thiq Board of Health. Name Date jpGcat n Appro By oard of ealth Representative) Date Application Disapproved the following reasons: For Office Use Only: 1 Fee Attached? Yes No 2.- ProjectMariager Obligation Form Attached. Yes . No ' 3,: F=12,SM ? Ifso,Attach copy ofElectrrcal Permit' �'es No 4. Foundation As Bur'It?(hew construction ronly, Yes (Same scale as approved plan) NO 5. FloorMws?(new construction only). Yes_ No Appifc�tion for•pisppsal Systemonstracfton Permft Page 2 of 2 SL7il`l YC :g;yJR'i+.0pa LTiL7!1Yi]bi43li OM As die.Ngnh Aadovar HCemaed dbststter fomite tdwW4, Aft•-theaeg •tic eyetexn•£or.thc•prapc�tyati (Adsmr of teric iyttem) Far peau by R;htina to the.apAmd*n cf (i�aataYYet'a na�ste} Acid daW Dated _ c a a rioua d4�lmwviw4 ) I undwtand the follot+ tv oiiligatiom for management of4tis project: i. As the iaswffer,I ata.oblig, w t-*abtain•nitpermits and Board ofHeseith approved plane to erfomtiag any:�orh oa a site. I rntt$t hie thtrrov1ei,3�lthe � t on site �.g ' { 2. As&�ink dlrs�,J.*I sst'4a$for, any sad teg4asp Bam t£ho teoamei,coatractQr,,ptoject maugger,of any Qihcr peraoa riot taz{ocisted with my ca:apaay echOttN=inapce d=sad the apatctn is n©t rcaclj4 then item tbzee•s�11.h�;tt�plicsbte, - '- . ' . Ae in sada f a rm to. ttie yet' r •p o to the spplPaeb�C*icdpo as • �• alter b�•;d�� �� , ����`6j#wpon-mss -is a`retAiavag tva�l,�liiclx b• t- Ise�t C�f&t#0 ecdor�but dgea•net have W bG grtsait: . A+•b• lho vacua_ tart moa for . t a �rbiill DK-(ar e�d1•tor A � ��'e . -be ttibaiitt�ed•to4w Bvserd OfReakk aikt6v •= the etfgiaeer mist be pretaqt fa-rt cue tipne. Istnitc=insist eat>ad tiingp.#ts - { Pqttft ile t 4' must be tesdj and able to c. — sett tier mtsat a+oque�t asap tvhe i i grAftg3 -Complete'. InsftUea does not • hava#o bt rnsfa�te.• - .4. As•the iastaliet'I uatt3float only I 026=did-* c'(exbr"x ,(e anJ azti regwred to casupiete tliaitis mucin of the aystrtp idetYt4f iu#titstt, etc pplt` •s QA&Z n 4 p MN Seaanni for denial of A&a�arern endlnr: r„Y. ffii�4i eii forth Ando+ve*�Mnficatit iin����• ��—•'' � ���"'�`�`�•�a�n 5. Aa tltP-imt311Ie:y.I xttcdertt t tI muaii a omitth .. it p tx of tfi faJicswittg coas"Coon- A: Det�rnlaa�to�i�iat.theprr�pe�tler�et�ton attlie e�e�,��•bcr.�scachedL - b. I Pc& 'aa of&eA=d=d ache- v Gr used a 'Ffasl aspeetfoa 8oau�tiut.�Ye 'OrcostsaAwt. d Infl�lla�ta ofmak,D�- avrj pY 4�i gee, �reat�P brr rt a waffsQd atlrrr b. As thr.ic,Wlcc: cofmpaaaat�r. � - ' . hnsibl � vh�a; Ns taatr*setiona$v�e � �.�i } ensan enQ"3bao��•e . M&2fflillbblinfign. UndemigaedUceaaed S etn�c_?�tstnfier: ,,�_ r*.• v` ;:. . e Of Ma oTN 7175 00 Town of North Andover HEALTH DEPARTMENT ,SSACHU`+tt CHECK#: &20— TE: LOCATIO : ' f • to l H/O NAM 9 CONTRACTOR NAME: Au Type of Permit or License:(Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ � I --M Title 5 Report a LJ � $ ❑ Other. (Indicate) $ i Health'Xg'ent Initials White-Applicant Yellow-Health Pink-Treasurer • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 't 192 Lacy Street Property Address Nathan Smith Owner Owner's Name information is required for North Andover MA 01845 11/21/2014 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information ozr, When filling out RE- forms on the computer,use 1. Inspector: only the tab key rj Z014 to move your Neil J. Bateson DEC1J _ cursor-do not Name of Inspector use the return TOWN uF NUR h AN key. Bateson Enterprises Inc. HEALTH DEPARTMENT Company Name ffi 111 Argilla Road Company Address Andover MA 01810 City/Town State Zip Code 978-475-4786 S115 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approve&system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Fu her Evaluation by the Local Approving Authority. 11/21/2014 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****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 Oficial Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 192 Lacy Street Property Address Nathan Smith Owner Owner's Name information is North Andover MA 01845 11/21/2014 required for every page. 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 192 Lacy Street Property Address Nathan Smith Owner Owner's Name information is required for North Andover MA 01845 11/21/2014 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ® N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 192 Lacy Street Property Address Nathan Smith Owner Owners Name information is required for North Andover MA 01845 11/21/2014 every page. 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: Drop D-box needs to be remove&install clean out 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-3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 192 Lacy Street Property Address Nathan Smith Owner Owner's Name information is required for North Andover MA 01845 11/21/2014 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. [Phis 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. El ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 192 Lacy Street Property Address Nathan Smith Owner Owner's Name information is required for North Andover MA 01845 11/21/2014 every page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® 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 beendetermined 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): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 600 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 192 Lacy Street Property Address Nathan Smith Owner Owner's Name information is required for North Andover MA 01845 11/21/2014 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): On well water Detail: Sump pump? El Yes ® No Last date of occupancy: Current Date Commercial/industrial Flow Conditions: I Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 192 Lacy Street Property Address Nathan Smith Owner Owner's Name information is required for North Andover MA 01845 11/21/2014 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pumped 2012, owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® 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) and a copy of latest inspection of the UA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ° 192 Lacy Street Property Address Nathan Smith Owner Owner's Name information is required for North Andover MA 01845 11/21/2014 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 21 years old, 10/24/1983, 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.): i 4"Cast iron through wall, 3" PVC in house, no leaks visible I Septic Tank(locate on site plan): Depth below grade: .8 feet Material of construction: ® concrete ❑ metal ❑.fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'x 5'x 4' Sludge depth: 2" t5ins•3113 Title 5 Oficial 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 192 Lacy Street Property Address Nathan Smith Owner Owner's Name information is required for North Andover `MA 01845 11/21/2014 every page. Cityrrown 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 31" Scum thickness 3„ Distance from top of scum to top of outlet tee'or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Tape Measure Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet tee ok. Outlet tee ok. 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 ❑;fiberglass El 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 ,Ii a Commonwealth of Massachusetts 3 `title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 192 Lacy Street Property Address Nathan Smith Owner Owner's Name information is North Andover MA 01845 11/21/2014 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? - ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal pact g p System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 192 Lacy Street Property Address Nathan Smith Owner Owners Name information is required for North Andover MA 01845 11/21/2014 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box level&distribution equal. No evidence of leakage. Evidence of carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No" Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): " If pumps or alarms are not in working order,::system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17 3i� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments 192 Lacy Street Property Address Nathan Smith Owner Owner's Name information is North Andover MA 01845 11/21/2014 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 21'x 45 ❑ 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 Commonwealth of Massachusetts y Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Foam-Not for Voluntary Assessments r< 192 Lacy Street Property Address Nathan Smith Owner Owner's Name information is North Andover MA 01845 11/21/2014 required for every page. 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.): Privy(locate on plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, i etc.): t5ins•3/13 Title.5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 ,, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 192 Lacy Street Property Address Nathan Smith Owner Owner's Name information is required for North Andover MA 01845 11/21/2014 every page. Cityrrown 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: Z hand-sketch in the area below ❑ drawing attached separately 131( _a f Or�p� oco �E61 o O W� t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts 3 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a 192 Lacy Street Property Address Nathan Smith Owner Owner's Name information is required for North Andover MA 01845 11/21/2014 every page. Cityrrown 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: 5/15/1981 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: As per design plan test pit data Before filing this Inspection Report, please"see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 r: f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 192 Lacy Street Property Address Nathan Smith Owner Owners Name information is required for North Andover MA 01845 11/21/2014 every page. Cityrrown 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 i i I t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 i I 1 i 1 s o� L ci-r 22 LACY ST. �..o T F KJ Oc --r. 2y , 1883 i s t S �• �h.3 `..OT. FtE�p woR�'� ay Ga0 .7�L- �'►tr� ys � So � 1 Yp '°NSS� I ti ^• a- Il , NJ L �! EX t Ste'• �'� ! S ID w Et. t_I t-ACa , S(,,3-7 1 - (AO 1 h1 �. C3.�1 = 1 3Z •g(p 137••9 1 OT s1.1 o. o>r PAPE = 131 .5(0 r � ny;h ' t�✓+�•'t, � ,xJl?t' tc'. .1 aL J � ! �. ,�' t�1r,µ1 � � a,{y1 t ,}{�r t b. ... •• � '• .. I � +' i�{ 'r �. � ..r r' ^� ;�- 7�, t a �+ 1 "'777 •., f, ;t�r vS�� �S�.'y�i��•gt'iti IiM')t•,��'♦ � • •r��if'!�r r' ,. 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Z �'.:1• Al ., r '��� \'r�1 ` Ni y f,Y�r.•. R t i ' //•'r✓ yv�•,•+f �t .�•Y., it�f t hrix F'4�"!Y rt 771� y� ,. tom• �.Jt. I t � i" , � �r� 1yp �. •p7+.i Y41.-t*`-., '�a.S• fir.♦, 1 �.�:,sv • t` !' �...- S��. /Lu � r if2✓ ✓•., K:-.� i : 37lFat Yft'• ti > LwT� `- ..�Y k4 4♦ar4:�j a � Cfn v� � •• � V $ NAL "}ry 7 ' M,w1 gi•� Rf'� ? T� ��/` i t '4'jtr"c}�•. - .. sl �.. N �-.•�C t � ,�Y , �•J"'r Com' i •.� � i..� f pry '• ( '1!T r- �•• 1.1`• 1- A � 7; S til T1 1 jet t� w �� `� ��• . �• �'� :•: ��' . �e � �° X11 � b •O '•'' Asir: � � ���% � � . •,° . . � -�icy �yQ,-� ' ��/o°� �► - t.• �,�.�� ti ,x'8949, a ��._, ✓. 1 �,- �� � >� �1 � � � �.- gt i r ,..... Commonwealth of Massachusetts W City/Town of No.Andover System Pumping Record Form 4 M y.y`• DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. _ A. Facility Information IRECEIVED Important: U81 When filling out 1. System Location: forms tor, use the compute _ TOWN OF NORTH ANDOVER only the tab key Address to move your No.Andover Ma 01810 cursor-do not City/Town State Zip Code use the return key. 2. System Owner: ,� i t� Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping �tV 2. Quantity Pumped: Gallons �� 3. Type of system: ❑ Cesspool(s) Lk_Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: , A/ Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Ste rt' 'Pre re ment Plant, 20 So. Mill Bradford, Ma 01835 ignat Hauler Date /0 3 JJ Si ure Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 \: �.���'�1��1��•��' K•k�'�•ry1•:� iW,�'(}��s`�ppy��F I�'i'I'::�'ri3�r:.•,.;,;• • � tfN w7�)r.i�,p,rt,•�liy\�1�ii��JY ��t`�'�` t`'I,• , v�ti EYE ✓tt ��i•��•��i '' 4'�iti.�,�'y.N't h41i!��ly Y�:av'� t.. , RECEIVED COWN DEC 0 UA I't / 4Y9T-E&' PoMPINU 6 2��5 TOHEAL HOF DEP RTMENTTH ANDOVER iYsreM 0 QRADDi�3s 'erEM'i.:� 6�4 OM OF P U1 �'t��POpLc Np Y N� rvo . xUV'rIN . . _ . OnIGKui:tvl '. 4000 COt�pl'PIVN YVLL rU RXAYY $30 � Cfprl�l 0 KVNa�,�'�• P oom �oLiDcA Y9Y�X ONER•eXPLAm �vNl'�N1'y tX�Nyt�xKbU J1' • TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD � > > TEM OWNER & ADDRESS SYSTEM LOCATION �Ar (example: left front of house) u" t Oc eorck U 0 E OF PUMPINC: QUANTITY PUMPEDA G,� LLO)-,> i.)SPOOL: NO YES SEPTIC TANK : NO YES _ ATURE OF SERVICE: ROUTINE EMERGENCY I i �.� 13�r�zv :�TloNs: GOOD CONDITION FULL TO COVER HEAVY CREASE BAFFLES IN PLACI,' ROOTS LEACHFIELD RUNBACK . EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER 01�HER (EXPLAIN) i >1 )TL M PUMP ED BY: UmmENTS: U�' I f:'.NI S 7'1ZANSFEIZIZLD TO: NORTH BOARD OF HEALTH 120 MAIN STREET S�CMUSEt�y NORTH ANDOVER, MASS. 01845 TEL. 682-6400 Ivr 2Z Lc� 1 i I� T Scownmipool 1S (►)'�?Tc� �L' er �-vv►n rine 4!!�vvOctrcvk) �S pru()oSec) SrH I T�)5 . i 53Ivo �a i ' Te e-xt!5t-t, `��zl� Board of Health North Andover,Kass WBSURFACE DISPOSAL DESIGN CHBCB LIST LOT 7 APPROVED DATE DISAPPROVED DATEl+ Provided; Reasonss l o Title V V FAIL OE Reg 2.5 The submitted plan must show as a minimum; a the lot to be served-area,dimensions lot # abutters �� location and log deep observation hoes-distance to ties location and results percolation tests-distance to ties design calculations & calculations showing required leaching area )" location and dimensions of system-including reserve area existing and proposed contours g) cation any wet areas within 100' of sewage disposal system or disclaimer-check wetlands mapping (h) face and subsurface drains within 100' of sewage disposal system or disclaimer (i) ,location any drainage easements within 100' of sewage disposal system or disclairer-Planning Board files (3 known sources of water supply within 200' of sewage disposal g system or disclaimer location of any proposed well to serve lot-100' Brom leaching facility location of water lines on property-10' from leaching facility location of benchmark (a'r driveways garbage disposals W'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 Otter elevations r)- maximum ground water elevation in area sewage disposal system (s) plan must be prepared by a Professional Engineer or other professional authorized by lax to prepare such plans Reg 6 Septic Tanks (a) capacities-150$ of flow, water table, tees, depth of Mees, access, pumping (b) cleanout nb) c) 10' from cellar wall or inground swimming pool - d) 25+ from subsurface drains Reg 10.2 Distribution Boxes a) slope greater than 0.08 Reg 10.1 sump Subsurface Design Check List Page 2 FAIL €K Leaching Pits Leaching pits are preferred where the installation is possible Reg 11.2 a) calculations of leaching area-ni.nimam 500 sq ft 11.4 b) spacing dxe 11.10 c) surface a 2% 11.11 d) cover imfierial e} +x2 t`40 splash pad f) at elbow g��no beads in pipe from d-box to pipe Leaching Fields Reg 15.1 no greater than 20 minutes/inch } area-mini mum 900 aq ft 15.4 'construction of field 15.8 V surface drainage 2 % 3.7 e) 201 from cellar wall or inground swimming pool Leachin ftep4ss Reg 14.1 a)—Cqaculatlonoreaching area-min 500 sq ft 14.3 b) spacing-4 ft min 6 ft with reserve between 14.4 c) d3 mansion 14.6 d) constrac on 111.7 e) stone 14.10 f) surfs drainage 2% Do Slope a) slope x = to be shown) b) y/x 50 = (to be shown) s Reg 9.1a) app val 9.6 b) s d-by power Board of Health BFMC SISTEM North An ver Maas. INSTALLATION CHECK LIST LOT i (NED DAT g DI SA PROV M AVATI EXCON OK FAIL OK 1. Distance Tot a. Wetlands b. Drains c. we]1. 2. Water Line Location 3. No PVC Pipe Septic Tank a. _Tess --Length do To Clean Ont Covers. Tank .-to T b. Cement Pipe .- On Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Lines Flowing Equal Amounts c. No Back Flow b. Leach Field or Trench a. Dimensions b. Stone Depth 4' c. Capped I7id.s 1 d. Clean Double Washed Stone 7. Leach Pits a. Dimensio s b. Stone 'epth C. Sp sh Pads d. s e Cement Pipe to Pit - Both Sides f. Clean Double Washed Stone 8. No Garbage Disposal 9. Final adisgInspection lA. Barricading Covered System 11. As Built Submitted a. Lot Location b. Dimensions of System c. Location with Regard-to Pere Test d. Elevations es Water Table