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HomeMy WebLinkAboutMiscellaneous - 1929 SALEM STREET 4/30/2018 (2) Health Department 210/106.6-0042-0000.0 1929 Salem Street North Andover, MA 01845 i I i I Residential Property Record Card Parcel ID: 210/106.13-0042-0000.0 MAP: 106.8 BLOCK: 0042 LOT: 0000.0 Parcel Address: 1929 SALEM STREET FY: 2017 PARCEL INFORMATION Use-Code: 101 Sale Price: 1 Book: 14335 Road Type: T Inspect Date: 05122/2013 Owner: Tax Class: T Sale Date: 08/10/2015 Page: 0056 Rd Condition: P Meas Date: 05/22/2013 BESSETTE,STEPHEN,L. Tot Fin Area: 1888 Sale Type: P Cert/Doc: Traffic: M Entrance: C Address: Tot Land Area: 1.240 Sale Valid: A Water: Collect Id: SGC 1929 SALEM STREET Sewer: Grantor: BESSETTE Sewer: Inspect Reas: M NORTH ANDOVER MA 01845 Exempt-B/L% 0/0 Resid-B/L% 100/100 Comm-B/L% 0/0 Indust-B/L% 0/0 Open Sp-B/L% 0/0 RESIDENCE INFORMATION LAND INFORMATION Style: SL Tot Rooms: 6 Main Fn Area: 1888 Attic: NBHD CODE: 6 NBHD CLASS: 6 ZONE: R2 Story Height: 1.00 Bedrooms: 3 Up Fn Area: Bsmt Area: 840 Seg Type Code Method Sq-Ft Acres Influ-Y/N Value Class Roof: G Full Baths: 2 Add Fn Area: Fn Bsmt Area: 648 1 P 101 S 43560 1.000 N 213,444 Ext Wall: WS Half Baths: 1 Unfin Area: Bsmt Grade: A 2 R 101 A 10454 0.240 N 1,824 Masonry Trim: Ext Bath Fix: Tot Fin Area: 1888 Foundation: CN DETACHED STRUCTURE INFORMATION Bath Qual: T RCNLD: 188352 Kitch Qual: T Eff Yr Built: 1976 Str Unit Msr-1 Msr-2 E-YR-Blt Grade Cond %Good PIF/E/R Cost Class Mkt Adj: Heat Type: HW Ext Kitch: Year Built: 1970 PV S 512 1988 A A /50//42 11,900 1 Sound Value: Fuel Type: O Grade: A Cost Bldg: 188,400 G2 S 26 24.00 1988 A A 50///50 12,900 1 Fireplace: 1 Bsmt Gar Cap: Condition: A Att Str Val 1: SE S 240 1988 A A 50///50 2,100 1 Central AC: N Bsmt Gar SF: Pct Complete: Att Str Va12: CB S 24 32.00 1975 A A 50///50 26,800 1 Att Gar SF: %Good P/F/E/R: 1100/100/76 VALUATION INFORMATION Porch Type Porch Area Porch Grade Factor Current Total: 457,400 Bldg: 242,100 Land: 215,300 MktLnd: 215,300 P 120 Prior Total: 488,800 Bldg: 274,800 Land: 214,000 MktLnd: 214,000 Sketch Photo 16 8 24 32 0 B 2 840 Sti R 35 35 1808 94R 1 R 2 1 R 48 4 4 5 48 %R 1202 R 1929 SALEM STREET ~ Commonwealth of Massachusetts �Q Title 5 Official Inspection Form ZlG ., s Subsurface Sewage Disposal System Form- Not for Voluntary Assessments k 1929 Salem St. t/ Property Address Barbara Bessette / Owner Owner's Name PW information is required for North Andover MA 01845 8/11/17 every page. City/Town State Zip Code Date of Inspection -/l .S i 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. `ID ImpoWhen filling A. General Information When filling out VO forms on the �013 computer,use 1. Inspector: P only theetab key NO to move yourMike Fisher � 0� cursor-do not use the return Name of Inspector key. M.D.F. Septic Company Name P.O. Box 601 Company Address Rowley MA 01969 City/Town State Zip Code (603)401-6493 S113820 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 Further Evaluation by the Local Approving Authority i/11/17 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•3/13 Title 5 Official Ins pection Form:Subsurface Sewage Disposal System•Page 1 of 17 4 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments " 1929 Salem St. I Property Address Barbara Bessette Owner Owner's Name information is required for North Andover MA 01845 8/11/17 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: 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 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments rY 1929 Salem St. Property Address Barbara Bessette Owner Owner's Name information is required for North Andover MA 01845 8/11/17 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ 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 w 1929 Salem St. Property Address Barbara Bessette Owner Owner's Name information is required for North Andover MA 01845 8/11/17 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than'/2 day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .'t 1929 Salem St. Property Address Barbara Bessette Owner Owner's Name information is required for North Andover MA 01845 8/11/17 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 either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered"yes" to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w r 1929 Salem St. Property Address Barbara Bessette Owner Owner's Name information is required for North Andover MA 01845 8/11/17 every page. Cityrrown 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 been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 GPD 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 r 1929 Salem St. Property Address Barbara Bessette Owner Owner's Name information is required for North Andover MA 01845 8/11/17 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 5 Does residence have a garbage grinder? ❑ Yes ® No Is laundryon a separate sewage system?stem? Include laundry system inspection information in this report.) El Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): 204 Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Still Occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Tide 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 w " 1929 Salem St. Property Address Barbara Bessette Owner Owner's Name information is required for North Andover MA 01845 8/11/17 every page. CityrFown 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: Last pumped 2 months ago, information from 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 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 Foran: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 w " 1929 Salem St. Property Address Barbara Bessette Owner Owner's Name information is required for North Andover MA 01845 8/11/17 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: Approximately 51 years old, information from plans Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: in. feeee t Material of construction: cast iron 40 PVC El other(explain): Town Water Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 10 in. 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: 8 ft. by 5 ft. and 5 ft. deep Sludge depth: 1 in. j t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments µ r 1929 Salem St. Property Address Barbara Bessette Owner Owner's Name information is required for North Andover MA 01845 8/11/17 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 28 in. Scum thickness 1 in. Distance from top of scum to top of outlet tee or baffle 6 in. Distance from bottom of scum to bottom of outlet tee or baffle 22 In. How were dimensions determined? rulers and measuring rod Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): *tank has effluent filter in rear tee, recommend cleaning every 6 months"tank does not need to be pumped, inlet tee and outlet tee are in good condtion, liquid is at invert of outlet pipe, no sign of leakage into or out of the tank. Grease Trap(locate on site plan): Depth below grade: feet 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: Date t5ins•3113 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 w " 1929 Salem St. Property Address Barbara Bessette Owner Owner's Name information is required for North Andover MA 01845 8/11/17 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 System Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �. 1929 Salem St. Property Address Barbara Bessette Owner Owner's Name information is North Andover MA 01845 8/11/17 required for 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 N/A 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Foam-Not for Voluntary Assessments ,a"~ 1929 Salem St. Property Address Barbara Bessette Owner Owner's Name information is required for North Andover MA 01845 8/11/17 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: 2, 32 ft. leaching trenches ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SAS contains 2 leaching trenches that are 32 ft. each. Dry gravel, no signs of hydraulic failure, no ponding. 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1929 Salem St. Property Address Barbara Bessette Owner Owner's Name information is required for North Andover MA 01845 8/11/17 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 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.): i 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 r 1929 Salem St. Property Address Barbara Bessette Owner Owner's Name information is required for North Andover MA 01845 8/11/17 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately A - L /),T ' 7B-C, W13 // A- Y , � In t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pago 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1929 Salem St. Property Address Barbara Bessette Owner Owner's Name information is required for North Andover MA 01845 8/11/17 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: 8 ft. feet Please indicate all methods used to determine the 9 high round water elevation: ® Obtained from system design plans on record 1966 If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: from plans in 1966, groundwater in TP1 at 8 ft. 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 w Commonwealth of Massachusetts x v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1929 Salem St. Property Address Barbara Bessette Owner Owner's Name information is North Andover MA 01845 8/11/17 required for i every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 i o<NORTh, 7986 • Town of North Andover HEALTH DEPARTMENT SACMUSt CHECK#: DATE: LOCATION: /9,2,2 �- H/O NAME: 6 e.S S E Ee_ CONTRACTOR NAME: s�� 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 $ xTitle 5 Report pa-55 $50 - 1:1 50 —❑ Other. (Indicate) $ Hea ent Initials White-Applicant Yellow-Health Pink-Treasurer Ot NOR7N 1ti I 6264 F? Lp • Town of North Andover HEALTH DEPARTMENT S�cMust CHECK#: DA v� LOCATION: • H/O NAME: CONTRACTO NAM d� 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 $ ❑ TrashlSolid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Ti X5 Inspector $ Title 5 Report $ ❑ Other. (Indicate) $ 1 Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 1929 Salem St Property Address Richard Ringdahl Owner Owner's Name information is required for North Andover Ma 01845 8-10-12 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 any way. Please see completeness checklist at the end of the form. Important: A. General Information �t When filling out RECEIVED forms on the computer, use 1. Inspector: only the tab key AUGC )fl�� to move your N. TimothyAU White J LU cursor-do not Name of Inspector use the return TOWN OF NORTH ANDOVER key. N.T. White Enterprises HEALTH DEPARTMENT Company Name P.o. Box 101 Company Address Rowley Ma 0 City/Town State Zipp Code 978-948-8428 S12015 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 Further Evaluation by the Local Approving Authority Inspectors 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-11/10 Title 5 Official Inspection Forth: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 ;M 1929 Salem St Property Address Richard Ringdahl Owner Owner's Name information is required for North Andover Ma 01845 8-10-12 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: 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): na t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1929 Salem St 'M Property Address Richard Ringdahl Owner Owner's Name information is required for North Andover Ma 01845 8-10-12 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 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): na ❑ 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): na 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 1929 Salem St Property Address Richard Ringdahl Owner Owner's Name information is required for North Andover Ma 01845 8-10-12 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: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•11/10 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 ,M 1929 Salem St Property Address Richard Ringdahl Owner Owner's Name information is required for North Andover Ma 01845 8-10-12 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 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•11/10 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 �M 1929 Salem St Property Address Richard Ringdahl Owner Owner's Name information is required for North Andover Ma 01845 8-10-12 every page. Cityrrown 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 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): na Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): na t5ins-11110 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 �M 1929 Salem St Property Address Richard Ringdahl Owner Owner's Name information is required for North Andover Ma 01845 8-10-12 every page. Cityfrown 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? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ® Yes ❑ No ' Water meter readings, if available(last 2 years usage (gpd)): 10 & 11 47,600 gal =65 gpd Detail: Sump pump? ® Yes ® No Last date of occupancy: still occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 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 1929 Salem St Property Address Richard Ringdahl Owner Owner's Name information is required for North Andover Ma 01845 8-10-12 every page. Cityfrown 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: last pumped 3 months information from 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 I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 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 1929 Salem St Property Address Richard Ringdahl Owner Owner's Name information is required for North Andover Ma 01845 8-10-12 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 46 years old infromation owner [system appears newer than its listed age] Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 16 in feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 28 ft from incoming water line to out going sewer line Comments(on condition of joints, venting, evidence of leakage, etc.): jointts &venting good condition no evidence of leakage Septic Tank(locate on site plan): Depth below grade: 10 in 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: 8 ft long 5ft deep 5ft wide 1000 gal Sludge depth: lin t5ins-11/10 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 1929 Salem St Property Address Richard Ringdahl Owner Owner's Name information is required for North Andover Ma 01845 8-10-12 every page. Citylrown 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 32 in Scum thickness 1 in Distance from top of scum to top of outlet tee or baffle 8 in Distance from bottom of scum to bottom of outlet tee or baffle 18 in How were dimensions determined? rulers&measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): tank does not need to be pumped -inlet baffle&outlet baffle in place-liquid at bottom of outlet invert-no sign of leakage in or out of tank-septic tank appears to be in good condition Grease Trap(locate on site plan): Depth below grade: feet 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: Date t5ins•11110 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 ;M 1929 Salem St Property Address Richard Ringdahl Owner Owner's Name information is required for North Andover Ma 01845 8-10-12 every page. CitylFown 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.): na *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 'M 1929 Salem St Property Address Richard Ringdahl Owner Owner's Name information is required for North Andover Ma 01845 8-10-12 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 na 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.): no d-box 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.): na Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 1929 Salem St Property Address Richard Ringdahl Owner Owner's Name information is required for North Andover Ma 01845 8-10-12 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2 trenches 32 ftlong each ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): dry sandy soil-no hydraulic failure-no ponding -system was under back lawn 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1929 Salem St �M Property Address Richard Ringdahl Owner Owner's Name information is required for North Andover Ma 01845 8-10-12 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11110 Title 5 Official Inspection Forth: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 °M 1929 Salem St Property Address Richard Ringdahl Owner Owner's Name information is required for North Andover Ma 01845 8-10-12 every page. Citir own 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 ❑ drawing attached separately G I 1 'j s, t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 s ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M 1929 Salem St Property Address Richard Ringdahl Owner Owner's Name information is required for North Andover Ma 01845 8-10-12 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: 8+ft 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: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: no information this lot - 1925 Salem st next door much lower elevation showes groundwater at 5 ft - 2009 Salem next door also much lower elevation showes eshgw 60 in -this lot stis on top of a hill Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11/10 Title 5 Official Inspection Form: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 ;M 1929 Salem St Property Address Richard Ringdahl Owner Owner's Name information is required for North Andover Ma 01845 8-10-12 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information—Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 OF NONTH, OFFICES OF: o m Town of 120 Nlain Strcct AI'I't=�\1_S North Anclorc�r. NORTH ANDOVER •" ;' 'a W)SSF)C,hLISCIiS()184 i BUILDING CONSERVATION e"QH 5� DIVISION OF ((i 1 7)685-4775 HEALTH PLANNING PLANNING & COMMUNITY DEVELOPMENT KAREN H.P. NEL.SQN, DIRECTOR February .23 1987 Building Inspector. re Proposed Addition 1929 Salem St. On Feb. 20 1987 I visited this site while the house owner, Richard Ringdahl explained his plans for addition. Since the. Septic System appeared to be functioning adequately and there is room for repairs if they ever prove. necessary; I have no objection to the addition which will be a one bedroom apartement above the garage as currently proposed. Sincerly Inspector Board of Health cc-R.Ringdahl 1929 Salem St. mg, Donohoe, John Giot 173 Campbell Rd. � %'APPLICATION FOR SEWAGE DISPOSAL INSTALLATION Z HEALTH DEPARTMENT - NORTH ANDOVER, MASS. , I hereb . make application for a permit for a sewage disposal installation at Campbell EA. I will install this system in ac- cordance with all the laws of the Commonwealth of Massachusetts and regulations of the Board of Health of the Town of North Andover. Further, I will construct the house sewer of bell and spigot pipe, the minimum diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre- ceding the septic tank, where the grade shall not exceed 2/. I will install a con- crete septic tank of 1000 gal. in size. A manhole (s) permitting easy cleaning will be provided with removable cover (s) of iron or concrete within 12 inches of the ground surface. I will provide subsurface disposal field with 4 inch perforated or open jointed pipe and laid in a series of trenches, the bottom of which will pro- vide a minimum of 200 lineal ( g.Xg) feet of effective absorption area. The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar material to a height of 2 inches above the crown of the pipe. The joints of these pipes will be protected from clogging and before filling the trench, 2 inches of gravel or stone 1/8" to 1/4" (dia. ) will be placed over the course gravel or stone. The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single tile line will exceed 100 feet in length and in any case, two lines of tile will be installed. A minimum of 6 feet will be maintained between the center lines of the disposal field trenches and the average depth of trench shall not exceed 36 inches. No part of the installation will be less than 100 feet from any private water supply, 25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line. I further agree not to cover any portion of this installation until approved by the inspection officer, as provided below, and to incorporate any additional requirements that may be attached to the permit. Plot Plans must bei sublEtted with application. DATE �.� Signature of Applicant I hereby issue the above permit for a Board of Health of the Town of North Andover, Massachusetts. DATE70�5 eze Signature of Health Agent I have inspected the uncovered system indicated above and find everything done as described. 1 DATE - �� .F-c_� � I c1 J l - 1 Q Signature of Inspecting Offic Percolation Test 6 min. Soil: Sandy-clay Garbage Grinder No A 1' BOARD OF HEALTH TOWN OF NORTH ANDOVER, MASS. t u L r ►.N r,- 1 /yo / - - 1. NAME—j A �V {.'c'? L�3 DATE I C. Ai)u RESS / l/f'IIf �! IiS�.^I� I1 lAJT NO. 3. NO. OF BEDROOMSDEN YES NO 4. GARBAGE GRINDER YES N0__ 5. SHOW DIMENSIONS OF HOUSE 6. SHOW DISTANCES OF HOUaE TO ALL PROPERTY LINES 7. SHOW' DIMENSIONS OF LOT 8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL 9. NO-LE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM / r 0 � 10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, EIC. f z 11. SHOW DISTANC ; OF c;',PTIC TANK OR CESSPOOL FROM HOUSE NOTE: Lf-)CAI: REGULATIONS SHOULD BE READ CAREFULLY. 4 J v BOARD OF HEALTH TOWN OF NORTH ANDOVER, MASS. r ,�--�-- j - 70 --- Boo 6—o , 1. NAME DATE `� J" 2. ADDRESS 1� f-4 r,B f-L L_ _ LOT NO. ��/' TELL7-4 3. NO. OF BEDROOMS DEN YES N0__ 4. GARBAGE GRINDER YES NO X- 5. SHOW DIMENSIONS OF HOUSE 6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES 7. SHOW DIMENSIONS OF LOT 8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL 9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM (J (� 10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC. 11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY. 44 BOARD OF HEALTH OF NORTH ANDOVER, MASSACHUSETTS SEWAGE DISPOSAL DATE kpril 22, 1966 NAME OF APPLICANT John Donohoe LOCATION Lot #17, Cain-pbell Rd. Address of lot no. BUILDING: Dwelling X Other SYSTEM: New x Repair GENERAL DESCRIPTION OF LAND High SUBSOIL: Clay Gravel Sand Y-ClaY X PERCOLATION TEST 6 minutes per inch. I . v MINIMUM INSTALLATION RECOMMENDATIONS CONCRETE SEPTIC TANK 1000 gallon capacity. LEACH FIELD 200 lineal feet of drain pipe. William J. Dr' s oll , Engineer Board of HealtbJ