HomeMy WebLinkAboutMiscellaneous - 194 BOSTON STREET 4/30/2018 (2) 194 BOSTON STREET
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Lot & Street 1 5TO,U (D7 , Map/Parcel
CONSTRUCTION APPROVAL
Has plan review fee been paid: NO Permit# /L06
Plan Approval: Date: �/��9� Approved by: 7�
Designer: /116_14� 19 1'./°10,0%1 Plan Date:
Conditions:
Water Supply: Town Well
Well Per Driller:
Well Tests: Chemical Date Approved
Bacteria I Da roved
Bacteria II Date Approv
Plumbing Sign-Off: Wiring Sign-Off-
Comments:
Form"U" Approval: Approval to Issue: YES NO
Date Issued By:
Conditions:
Final Approval:
All Permits Paid? YES NO
Well Construction Approval? YES NO
Septic System Construction Approval? YES NO
Certification? YES NO
Other YES NO
Any Variance Needed? 3 To 6-4J YES NO
FINAL BOARD OF HEALTH APPROVAL:
DATE:
APPROVED BY:
SEPTIC SYSTEM INSTALLATION
Is the installer licensed? N
Type of Construction: NEWREPAIRR�
New Construction: I Certified Plot Plan Review YES NO
Floor Plan Review YES NO
Conditions of Approval from Form U YES NO
Issuance of DWC permit: NO
DWC Permit Paid? O
DWC Permit# Installer: p
Begin Inspection: NO
Excavation Inspection:
Needed:
Passed: 3a By:
Construction Inspection:
Needed: Flick
.S a•.�' �r�e--,�6 v� i� SSC'-�
As ilt Plan Satisfactory:
S.,i
Approval of Backfill: Date: 4, �Jb' By.
lo
Final Grading Approval: Date: By:
Final Construction Approval: Date: By:
Certificate of Compliance: Approval: Date:
Commonwealth of Massachusetts
= City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
Form 4
M
DEP has provided this form for use by local Boards of Health. The S steMYjunping,Record must
be submitted to the local Board of Health or other approvin u �odtv�
-EIVED
A. Facility Information
APR 1 12008
Important:
When filling out 1. System Location:
�Q TOV ,F NORTH ANDOVER
forms the "t` r LTH DEPARTMENT
computer,use H ' '
only the tab key �Addpress
to move your I V 6 E o
cursor- not
use the return City/Town State Zip Code
key. 2. System Owner:
k
A,D f1'1ce, bya aftw
Name
Address(if different from location)
City/Town Sta Zip Code
Telephone Num6er
B. Pumping Record `
1.. Date of Pumping 4 os 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) `�j Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes eJ No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. SyAtem Pumped By,
me Vehicle License Number
Company
7. o tion here c ntents were disposed:
Signature of Hauler Dates_
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
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PUBLIC HEALTH DEPARTMENT
(ommunity Development Division
Date: October 19,2009
Matthew and Jennifer Goodrow
194 Boston Road
North Andover, MA 01845
Re: Application for: home addition
Dear Mr. and Mrs. Goodrow,
Your application for a home addition at 194 Boston Road has been reviewed by the Health
Department. The application was denied on October 19, 2009 for multiple reasons. Details are
below; however,please contact me with any questions you may have.
1. Submit missing information
To properly review the application we must receive a complete floor plan showing all rooms in
the proposed home and the existing home. Please identify each room with common names. The
septic system servicing this property was installed in 1998. At time of plan approval, your
engineer requested a local upgrade approval (see attached). This request was granted at the
February 26, 1998 Board of Health meeting. The granting of this came with restrictions on this
property. One restriction found in 310. CMR 15.405 (4) (see attached) states there may be "no
increase in design flow". The design flow for your property is for a maximum 9-room home.
If the design flow is found acceptable, with no increase,then the following must be submitted
per the local Board of Health regulation.
2. A passing Title 5 inspection of septic system required per local N. Andover
regulations (BOH reg. 17.04)
Have a locally licensed system inspector conduct a Title V inspection to ascertain that the system
is working as designed.
3. The location of structure shown on same plan as the septic stem components
P Y �
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
` The septic system plan and the site plan must be combined to show that all system components
meet the state and local regulations.
Please feel free to call the Health Office at 978-688-9540 with any questions you may have.
Sincerely,
Susan Sawyer, REHS/RS
Public Health Director
Cc: Building Department
File
Encl. Feb. 26, 1998 minutes
Feb. 5, 1998 letter
310 CMR 15 section
Local BOH regulation excerpt
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8416 Web www.townofnorthandover.com
E=
1
16.03 Transfer of Septne: Transfer of septage from one truck or tanker to another for
transport except in cases of emergency shall be prohibited.
16.04 Equipment: No person or firm shall use equipment to remove or transport the
contents of privies, cesspools, septic tanks or tight tanks unless such equipment has
first been inspected and approved by the Board of Health. Inspections shall take place
annually in the fall prior to licensing, unless new or additional equipment is added
before this period. Also see 310 CMR 15.505 (2,3,4,5)
PART F . Title V System Inspectors
17.00 Title V System Inspector License: No person shall conduct a System Inspection
in the Town of North Andover without first obtaining a license with the Board of
Health. To be eligible to obtain the license the applicant must first be certified by
the MA Department of Environmental Protection (MA DEP). Inspections
performed by inspectors not licensed by the North Andover Board of Health will
not be accepted. A nonrefundable fee for annual licensure shall be paid to the Town
pursuant to the current fee schedule.
17.01 Application for licensing shall include a copy of the MA DEP's System Inspector
certification or equivalent documentation.
17.02 .There will be a fee for each Title 5 inspection submitted to the Health Department
by a system inspector licensed by the town. The amount of the fee shall be pursuant
to the current fee schedule.
17.03 All Title 5 inspection submittals must be completed and submitted in accordance
with MA DEP 310 CMR 15.301(10)
17.04 A Title 5 system inspection is required when an addition or renovation to an
existing building, excluding decks and screened in porches, is proposed that
increases the footprint of the building and requires a building permit from the
building inspector. The inspection requirement shall be waived if a Certificate of
Compliance was issued or a Title 5 System Inspection was completed within the
previous 5 years or if the system is under an operation and maintenance contract.
17.05 Any Title V inspection that identifies the septic tank, pump tank or distribution box
at an elevation of greater than 36 inches below grade, without an access riser, shall
have a riser and cover installed within 9 inches to grade, by a N. Andover licensed
installer. .
17.06 Any septic system that conditionally passes a Title 5 inspection due to a component
failure, which has resulted in the leaching area having not received usual effluent
flow, is required to have a second inspection conducted 6 months later. A MA
licensed septic inspector must conduct this inspection and a proper report must be
submitted to the Health Department.
17.07 Inspector License Revocation: The Board of Health may suspend or revoke for
cause any license as stated in 3.02 License Revocation of this regulation.
Septic Regulations TOWN OF NORTH ANDOVER, MA
a�
",Page 3
l '
Minutes: February 26, 1998
a
I '
f VARIANCE REQUEST— 12 FARNUM STREET—NEW ENGLAND
ENGINEERING:
Mr. Ben Osgood, Jr. requested to come before the Board for the following variances: Plt
a
1)Reduction in the offset between the ground water and the bottom of the trench from 4
feet to 3 feet which is a local upgrade approval for Title 5.
InA `
`2)Reduction in the distance between leach trenches from 10 feet to 6 feet, �\
A
3)70 feet from the isolated wetland instead of 100 feet.
W. Ben Osgood, Jr. stated that the Conservation Commission had seen this plan and
approved it subject to the Board of Health approval.
Ms. Starr would request another test pit to be done.
Ona motion by Dr. MacMillan, seconded b Dr. Rizza the Board
t Y � voted
unanimously to grant the variances as mentioned above.
1& Osgood resumed the meeting as Chairman. i
VARIANCE REQUEST— 194 BOSTON STREET NEVE ASSOCIATES
.Mr. John Morin, Neve Associates, was present representing Rick Beers for a local
}upgrade approval for a septic repair at 194 Boston.Street. Mr. Moran stated that he is
asking for a reduction in the.distance from the bottom of the leach bed to high
groundwater elevation to 3 feet as allowed in Title 5, Sec. 15404(2b). Mr. Morin stated
...
,�ahat the way the topography sloped, approximately 50% of the septic will still be greater
than 4 feet above the ground water, however, on the low side it will be approximately 3
feet above.
�r' g o
Mr. Osgood asked Ms. Starr, "Did you look at this"? Ms. Starr responded, "Yes". Ms.
t Starr stated that she has no problem with this variance request.
,On a motion by Dr. Rizza, seconded by Dr. MacMillan, the Board voted
unanimously to grant the variance to groundwater from 4 feet to 3 feet. NO
1'
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310 CMR: DEPARTMENT OF ENVIRONMENTAL PROTECTION
15.405: Contents of Local Upgrade Approval
(1) In granting local upgrade approvals pursuant to 310 CMR 15.404(2)where full compliance
as defined in 310 CMR 15.404(1)is not feasible,the local Approving Authority shall consider
the impact of the proposed system and shall vary to the least degree necessary the requirements
of 310 CMR 15.100 through 15.293 so as to allow for both the best feasible upgrade within the
borders of the lot,and have the least effect on public health,safety,welfare and the environment.
Under a local upgrade approval,the local Approving Authority is allowed to diverge from the
goal of full compliance only to the extent necessary to achieve a feasible upgrade and may allow
divergence only from those provisions,and to the extent,as specified in 310 CMR 15.404(2)and
15.405(1). In determining whether full compliance is feasible,the Approving Authority should
appropriately consider not only physical possibility as dictated by the conditions of the site,but
also the economic feasibility of the upgrade costs, The Approving Authority should emphasize
protection of water resources and treatment of the sanitary sewage. Absent conditions which
would result in a different outcome based on best professional judgment,the options set forth
below should be considered in the order in which they appear with 310 CMR 15.405(1')(a)being
the first option to be considered and rejected or adopted and 310 CMR 15.405(1)(k)being the
last option to be considered and rejected or adopted:
(a) Reduction of system location setbacks otherwise established in 310 CMR 15.211 for
property lines provided that the system is within the property lines,a survey of the property
line is required if a component is to be placed within five feet of the property line,and no
such reduction shall result in the soil absorption system being located less than ten feet from
a soil absorption system on an abutting property;
(b) Reductions of system location setbacks from cellar wall,crawl space,swimming pool,
or slab foundations;,an increase in the maximum allowable depth of system components
required by 310 CMR 15.221(7),from 36"to 72"below finish grade,provided that adequate
venting and adequate access are provided and H-20 loading is provided for all system
components;a decrease in the liquid depth of the septic tank required by-3 10 CMR 15.223(2)
from four feet to three feet;
(c) Up to a 25%reduction in the required subsurface disposal area design requirements;
(d) Where upgrade is required pursuant to 310 CMR 15.303(1)because it is within Zone
I of public well or within 100 feet of private well,relocation of the well. Any relocation of
a public well shall be performed pursuant to 310 CMR 22.00(water supply source approval);
(e) Reduction of system location setbacks from bordering vegetated wetlands;
(f) Reduction of system location setbacks from surface waters,salt marshes, inland and
coastal banks,certified vernal pools in accordance with 310 CMR 15.211(1)[2],leaching '
catch basins,dry wells,or surface or subsurface drains other than those which discharge to
surface water supplies or tributaries thereto;
(g) Reduction of system location setbacks from water supply lines,private water supply
wells(but not within 50 feet of the well),tributaries to surface water supplies,surface water
supplies,but not within 100 feet of the surface water supply or tributary thereto or open,
surface or subsurface drains which discharge to surface water supplies or tributaries thereto;
(h) the local Approving Authority may reduce the required four foot separation(in soils
with a recorded percolation rate of more than two minutes per inch)or the required five foot
separation(in soils with a recorded percolation rate of two minutes or less per inch)between
the bottom of the soil absorption system and the high groundwater elevation only if all of the
following conditions are met:
1. An approved Soil Evaluator who is a member or agent of the local Approving
Authority determines the high groundwater elevation.
2. A minimum three foot separation(in soils with a recorded percolation rate of more
than two minutes per inch)or a minimum four foot separation(in soils with a recorded
percolation rate of two minutes or less per inch) between the bottom of the soil
absorption system and the high groundwater elevation is maintained.
3. The system is a failed or non-conforming system serving an existing building with
a design flow of less than 2,000 gpd.
4. No increase in design flow is allowed.
5. No reduction in required soil absorption system size or setbacks from public or
private wells,bordering vegetated wetlands,surface waters,salt marshes,coastal banks,
certified vernal pools,water supply lines,surface water supplies or tributaries to surface
water supplies,or drains which discharge to surface water supplies or their tributaries,
is allowed.
9/22/06 (Effective 4/21/06)-corrected 310 CMR-563
3
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ASS fC1ATLFN, INN
February 5, 1998
Ms. Sandy Starr
Board of Health
30 School Street
North Andover, MA 01845
Re: 194 Boston Street- Rick Beers, Owner
Dear Sandy:
Please find enclosed 3 prints of the sanitary disposal system repair design for the
above-referenced property.
We are proposing a reduction in the distance from the bottom of the leach bed to high
groundwater elevation to 3' as allowed in Title 5, Section 15.404 (2.b.). If the system
was to be designed 4' above the water table the necessary grading for the construction of
the system would create a ponding area on the upstream (east) side of the system at the
property line. In order to eliminate the problem we would either have to pump up to the
system and swale the surface runoff in front of the system, creating a mound in the back
yard, or we would have to perform major earth work along the existing fence to the rear
of the property in order to swale the surface runoff around the system. Even with a 3'
separation to groundwater I still had to propose a swale on the upstream (east) side of the
system in order to prevent ponding along the property line.
By examing the existing topography and the soil log information you can see that
approximately 50% of the system is located 4' above the high groundwater elevation.
Please schedule us for the February 26, 1998 meeting so that we may discuss this issue
with the Board of Health. As you are aware, my client is under critical time constraints, I
hope that you will be able to review the design prior to the meeting so that we may
address any issues you may have prior to the meeting.
Please call our office to confirm that we are on thea agenda for the February 26th meeting.
g rY g
• ENGINEERS LAND SURVEYORS LAND USE PLANNERS
447 Old Boston Road U.S. Route#1
(978)887-8586 Topsfield, MA 01983
FAX(978)887-3480
i
� r �
Ms. Sandy Starr Page 2
February 5, 1998
I thank you, in advance, for your anticipated cooperation.
Very Y trul yours,
THOMAS E. NEVE ASSOCIATES, INC.
y�
John M. Morin, P.E.
Executive Vice President
JMM/kmm
Enclosures
cc: Rick Beers
#1723-Beersmps
Commonwealth of Massachusetts RECEIVE®
W Title 5 Official Inspection Form
J _ Subsurface Sewage Disposal System Form -Not for Voluntary Assess ents��O V 209
�,Odn `f' TOWN OF NORTH ANDOVER
SIM SV'y`v
Property Address " "' '
'j-Q-n C,GL)d tZ e4 L)
Owner Owner's Na e
information is y�O� r t4odOv-q(L �I�+ I, - �O ��•�
required for ' 1 ,iyyy D� I
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form_ lnQn0.-+inn f-- any
way. Please see completeness checklist at th
Important:
When filling out A. General Information
forms on the l //
computer,use 1. Inspector:
only the tab key .��� �
to move our VA L)n V �1
cursor-do not
Name Inspecto
kuse ey.the return
`S (1 l C
CompanyName
�
Compa?y ress
(A ill n C
III�/� II
City/Town
Telephone 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 MR 15.000).The system:
Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
Inspe tor' Ignature 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•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal Syste Form -Not for Voluntary Assessments
GSM 6V' I � V'� v-
Propert1V ' I Go od uI`f t
Owner Owner's Name
information is NA D 9�6
required for
every page. Anyown 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:
4have 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:
60 <�- 10
C
-Pv - t Lvat S m
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
repla ed or repaired. The system, upon completion of the replacement or repair, as approved by
the Bo rd of Health,will pass.
Check the box r"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," plea explain.
The septic tank is metal a over 20 years old*or the septic tank (whether metal or not) is
structurally unsound, exhibits bstantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing nk is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if s structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less tha 0 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts RECEIVED
Title 5 Official Inspection Form
J �' 2
Subsurface Sewage Disposal System Form -Not for Voluntary Assess entsNO V u 0Q9
I qF
' TOWN O NORTH ANDOVER
N
C �on f .
AI -1
Property Address " """
7F n A i trz C,o,) t e4 L)
Owner Owner's Na e
information is y� v1n /',tom+ VS-
every
required for 1 `diz-� t4�)0Uq(— rAa . ojl
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:
When filling out A. General Information
forms on the
computer,use 1. Inspector:
only the tab key
to move your J CJh n VA`J rp�1Ll
cursor-do not NameInspecto (1
key.use the return Oha`S J 4, ,�4('C, C to
"II—V Company' Name
-�� Cpi2�n
Compa y Iddress
City/Town State Zip Code
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 MR 15.000). The system:
Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
Z� /6;` — a�
Inspe tor' Ignature 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal Syste Form - Not for Voluntary Assessments
Property-ress
LA ' 1 t vrz
Owner Owner's Name
information is
required for A) ,01Q+h lq(OrxA.C - MA
every page. Ci y own 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:
h � �
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a s
Lu YZ 2�1�- S M
B) System Conditionally Passes:
❑ one or more system components as described in the"Conditional Pass" section need to be
replaed or repaired. The system, upon completion of the replacement or repair, as approved by
the Bo rd of Health,will pass.
Check the box r"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," plea explain.
The septic tank is metal a over 20 years old*or the septic tank (whether metal or not) is
structurally unsound, exhibits bstantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing nk is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if s structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less tha 0 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
• Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41M �V• 4 ���
Propert Address t /1 Goac) A qb
Owner Owner's Name
information is nG ay\ A n�r1 c- m a O t S�\ to ,
�
required for CC���'C L �.I CJ pC
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) S\E-1
tCditionally Passes (cont.):
❑ f sewage backup or break out or high static water level in the distribution box due
bstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
on if(with approval of Board of Health):
n pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
uction is removed ❑ Y ❑ N ❑ ND (Explain below):
ution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pum\irepled
an 4 times a year due to broken or obstructed pipe(s). The
system will pass inspectioroval of the Board of Health):
❑ broken pipe(s)are ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is rem ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of alth:
❑ Conditions exist which require further evaluation by the card of Health in order to determine if
the system is failing to protect public health, safety or the nvironment.
1. System will pass unless Board of Health determine in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a man r 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•09/08 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
V
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
_ I160
S�
Prop--,y Address
Owner Owngr's Name
information is Yl��-t-� 4 r)OL ci2Z � (3rW� 10 . �7 a V
required for `�
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,
s ty and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet a surface water supply or tributary to a surface water supply.
❑ The stem has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The syst has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a sep ' tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private wate upply well*".
Method used to determine ' tance:
**This system passes if the well water a alysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presenc f ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failur 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
❑ PK 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-09/08 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
r
Property Address GO�
1/�t I Itl/}
Owner Owner's N m
information is )D 11�. V\ O J�� fM �� to -
every
Q �-
required for i� ' ` V�t
every page. City/Town 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.
❑ 1 Any portion of cesspool or privy is within 100 feet of a surface water supply or
�J tributary to a surface water supply.
❑ � Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ Lj� 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
question�r� .
Yes
❑ ❑ the syster?ras within 400 feet of a surface drinking water supply
❑ ❑ the system is within z 0 feet of a tributary to a surface drinking water supply
the system is located in nitr en sensitive area Interim Wellhead Protection
❑ ❑
Y 9
Area— IWPA)or a mapped Zo II of a public water supply well
If you have answered "yes"to any question in Section E th stem is considered a significant threat,
or answered "yes" in Section D above the large system has fat . The owner or operator of any large
Y
system considered a significant threat under Section E or failed u r Section D shall upgrade the
Y 9
P9
system in accordance with 310 CMR 15.304. The system owner sho contact the appropriate
regional office of the Department.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System F rm -Not for Voluntary Assessments
Propertv N—gess
i) c f4 ►2 eloo �—�
Owner Owner's Name �� G
information is fvc,kf(_t �� ��/A�- a�g 7
required for r y"f
every page. City/Town 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 o
❑ 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 sign's of sewage back up?
E " ❑ Was the site inspected for signs of break out?
❑ Were all system components, excluding the SAS, located on site?
Rje ❑ 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:
15/ ❑ 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)]
i
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Z7 �
I
t5ins-09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Owner Owner'll Name
information is `� _rn ,/� �j/ S /
required for re)4 L �y�'C `�` & _ A9 `O -d 7o
every page. City/Town `Std ip`Ctde Date of Inspection
D. System Information
Description:
d v L�� bq/K r n Z,f
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes R' No
Laundry system inspected? es No
Seasonaluse? o
Water meter readings, if available (last 2 years usage (gpd)):
Detail: AT[0,0
10
Sump pump? ❑ Yes A—ITo
coza4✓tT
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Elishment:
Design flow (bas on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow (sea ersons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 syste ❑ Yes ❑ No
Water meter readings, if available:
t5ins-09/08 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
Property Address ^ �O P"q A
��4VI �l rz�
Owner Owner's Namg (�
information is 1 l UD1 f-�lh�0v�'� Pk A. Q/✓ey(}
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date u ancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? es ❑ No
If yes, volume pumped: d cy 1-4(,,c,gallons
How wasuantit
q y 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•09/08 Tile 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
(4 f-�o 2:6
Propert Address
zna (�Q
Owner p,nr�,p 6TV�
n KJ�JV`e? �/� Q[�
information is 1'V•- ''7 I'1 O�� T' /0 ' ' Q C
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
bSnI 0 LA) �
Were sewage odors detected when arriving at the site? ❑ Yes [ a No
Building Sewer(locate on site plan): ! /
Depth below grade: i
feet
Material of construction:
cast iron ❑40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet /V A—
Comments (on condition of joints, venting, evidence of leakage, etc.):
la � � oln*s q ✓1, WQW-q-- t'-)2 Odd 4(24&1
tilt+ s a -P
Septic Tank (locate on site plan):
Depth below grade: l�
feet
Material of construction:
�ncrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
Li �-
U
VM- g-s
If tank is metal, list age: years
Is age confirmed by a Certificate of Complianc attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
a ' )
tins•09/08 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
rg
Property Address
rzQ
Owner Owner's Nam
information is 1/1 U� � � n �n /i 1D 6 e _1
required for r ` �, (1(_ /•` V C% o i
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
Scum thickness
S
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
v rA C)Y.c�� Ll AA,
.70A IL
Grease Trap (locate on site plan):
Depth below de: feet
Material of constructs
❑ concrete ❑ met ❑ 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 \
15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage�°isposal System Form -Not for Voluntary Assessments
Property Addres
ann t � Coukg,4L)
Owner Owwn,er'sme
information required for y �VL �,doUel� AA 4(9WS /0
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 leve s related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank tank must be pumped at time of inspection) locate on site
9 9 ( P P P ) (
D th below grade:
Mated of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
i
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: ate
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
u W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M �O(0 • ` !
Pr rty Addres
�4n►1i
Owner Owner's Uame ` /,�
information is I _ � ,�1J/! A� �1 � C(J " 7, v required for L WV `t
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened)(locate on site plan): J S r
Depth of liquid level above outlet invert n)
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.):
k Ta iLCt
c,) t+k to s 14 O.s a `� C44z c-cr, �S
V�o I as o -' L4�4U
Pump Chamber(locate on site plan):
Pumps in ing order: ❑ Yes ❑ No
Alarms in working or ❑ Yes ❑ No
Comments (note condition of pu chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Lo c4iOVA � c
-�� -7 kgaCk I fi n�
a� �C Z�U
t5ins•09/08 Tide 5 Official Inspection Forth: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
, M
Property Address
Owner Owner's Name
information is
required for
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:
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.):
ydrz4vlfc Nlclkq
d U4, c� no o,,Ld c"11c, "
l Ino i-D 4Vq SO1 L
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top ' uid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
N W Title 5 Official Inspection Form
Subsurface Sewage Di posal Sys m Form - Not for Voluntary Assessments
M l �
�G S,0A- .
PropMqat
dress
o U h �'14v
Owner Owner's Ninformationa , /� (.• l
required forts he) ��'U�- t m,4- a ��J LO - X7 -05
every page. City own 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 onstruction:
Dimensions
Depth of solids
Comments (note on
of so , signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-09108 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 �o S ✓L
Propddress
0 d ne, qL)
Owner Owner's Name
information is �J6 [� 01&' b
required for r�
every page. ity/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:
❑ h -sketch in the area below
yawing attached separately
I
t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Prop�e vv Address
Janvt,t ,2 6o(JQ�t� rq-(/
Owner Owner's N e ._ 1
information is 0,0 / /tJ / (�� /Ips �7 � 0
required for every page. own State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
heck Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
Obtained from system design plans on record
.? ° 05� ° S�
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:
Cv
v hod
� S � G �
t/J14-k 51ga-C, d
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Prop
ert V1n -K rt- �oc '^
Owner Owner's Nanle
information is �1 __�,L�ezr
required for LO 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
Sy tem Information—Estimated depth to high groundwater
ketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 194 Boston Street
North Andover,MA 01845
Owner's Name:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the buidding.
r -
i
A —C
► , - D
Iq'\
h�Js�
v`
'a,\4
J
i
•., OFFICE HOURS PAYMENT ON OR BEFORE
Town of North Andover
• 120 Main Street Monday to Friday 09/11/2009 $111.57
�
North Andover, MA 01845g;30am to 4:30 m ACCOUNT ` BILLING'DATE;`
(978)688-9550 p
1090376 08/12/2009
Billing Information: SERVICE DATES *`_'DUE.DATE
JENNIFER GOODROW (978)688-9550 104/24/2009-07/23/20091 09/11/2009
MATTHEW GOODROW Reading Information: "'SERVICE ADDRESS
194 BOSTON STREET (978)688-9570 194 BOSTON STREET
NORTH ANDOVER,MA 01845 q41
,1k TRANSACTIONS THIS PERIOD = AMOUNT a;
PREVIOUS BALANCE $100.42
PAYMENTS THROUGH 08/12/2009 ($100.42)
ADJUSTMENTS THROUGH 08/12/2009 $0.00
RETAIN THIS PORTION FOR YOUR RECORDS INTEREST AS OF 09/11/2009 $0.00
MOVING? PLEASE CALL(978)688-9570 IN ADVANCE BALANCE FORWARD $0.00
SERIAL# READINGS USAGE NB OF CURRENT BILL DETAIL USAGE/UNIT AMOUNT
Current Type Date DAYS
32939012 329 Actual 07/23/2009 25 90 WATER USAGE 25 $103.75 j
ADMINISTRATIVE FEE $7.82
$0.00
$0.00
SERIAL# READINGS USAGE NB OF $0.00
Previous Type Date DAYS
32939012 304 Actual 04/24/2009 25 91 Sub-Total $111.57
32939012 279 Actual 01/23/2009 25 93 TOTAL
MESSAGES
*NOTE" PAYMENTS SHOULD BE MADE:TOWN HALL @ 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX @ P.O.BOX 184,MEDFORD,MA 02155
WATER RATE: FIRST 20 UNITS @$3.80 OVER 20 UNITS @$5.55
SEWER RATE: FIRST 20 UNITS @$5.83 OVER 20 UNITS @$8.22
BYPASS METER WATER RATE: ALL UNITS @$5.55
Town of North Andover OFFICE HOURS •- BEFORE
120 Main Street Monda to Frida 06/12/2009 ; $100.42
North ANdover, MA 01845 y y
(978)688-9550 8:30am to 4:30pm ' ACCOUNT BILLING DATE'; = 1
1090376 1 05/13/2009 i
Billing Information SERVICE DATES DUE DATE
JENNIFER GOODROW �l (978)688-9550 101/23/2009-04/24/20091 06/12/2009
MATTHEW GOODROW Reading Information: SERVICE ADDRESS
194 BOSTON STREET (978)688-9570 194 BOSTON STREET
NORTH ANDOVER, MA 01845
`I .TRANSACTIONS THIS PERIOD T. AMOUNT-
.,
PREVIOUS BALANCE $99.73
PAYMENTS THROUGH 05/13/2009 ($99.73)
ADJUSTMENTS THROUGH 05/13/2009 $0.00
RETAIN THIS PORTION FOR YOUR RECORDS INTEREST AS OF 06/12/2009 $0.00
MOVING? PLEASE CALL(978)688-9570 IN ADVANCE BALANCE FORWARD $0.00
SERIAL# READINGS USAGE NB OF CURRENT BILL DETAIL USAGE/UNIT AMOUNT 1
_---_-Current Type Date DAYS
32939012 304 Actual 04/24/2009 25 91 WATER USAGE 25 $92.60
ADMINISTRATIVE FEE $7.82
$0.00
$0.00
SERIAL# READINGS USAGE NB OF $0.00
Previous Type Date DAYS
Sub-Total $100.42
32939012 279 Actual 01/23/2009 25 93
32939012 254 Actual 10/22/2008 27 92 TOTAL 1 1
I
MESSAGES
' NOTE* PAYMENTS SHOULD BE MADE:TOWN HALL @ 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX @ P.O.BOX 184,MEDFORD,MA 02155
WATER RATE: FIRST 20 UNITS @$3.39 OVER 20 UNITS @$4.96
SEWER RATE: FIRST 20 UNITS @$4.96 OVER 20 UNITS @$7.07 1
I
;BYPASS METER WATER RATE: ALL UNITS @$4.96
AKE PAYMENTS TO Billing
Information
TOWN OF NORTH ANDOVER
_ c (978)688-9570 =BEFORE
Fp120 MAIN STREET NORTH ANDOVER MA 01845 Reading Information 03/12/09 , $99.73
978-688-9550 (978)688-9570
5A[N1I OFFICE HOURS - ACCOUNT NO. BILLING DATE
Mon to Fri.
8:30am to 4:30pm 1090376-416471605 2/10/2009
SERVICE DATES DUE DATE
RETAIN THIS PORTION FOR YOUR RECORDS 11/1/2008- 1/31/2009 03/12/09
MOVING?PLEASE CALL 978-688-9570 IN ADVANCE
SERVICE-
ADDRESS
194 BOSTON STREET
JENNIFER GOODROW V�/ TRANSACTION THIS PERIOD ' AMOUNT
MATTHEW GOODROW Previous Balance 110.00
194 BOSTON STREET Payments Through 02/10/2009 (110.00)
NORTH ANDOVER MA 01845 Adjustments/Late Charges
Interest as of: 3/12/2009 -
Balance Forward -
Previous,. Current, Consumption Nb of Current Bill Detail Usage/Umt Amount
Rea,;„' xCaumg llay5
WATER USAGE WATER 25 91.91
3 );Y 1/23/09 ADMIN FEE 7.82
_1.54 279 25 Actual 93
Sub-Total 99.73
Total
MESSAGE
PAYMENTS SHOULD BE MADE: TOWN HALL @ 120 MAIN STREET OR BY MAIL TO OUR LOCKBOX @ P.O. BOX
184 , MEDFORD, MA 02155
Water rate : First 20 units $3 . 39 Over 20 units u $4 . 96
Sewer rate : First 20 units $4 . 96 Over 20• units $7 . 07
Bypass Meter Water rate : all units @ $4 . 96
..... TT T`A TTT Tn T.T TT TTO n/ "TTI NT TT TTTTT"A ATA XTTTTC'
i
tT
l
i
COMMONWEALTH OF MASSACHUSETTS
A
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
F
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
Sy0
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FCWM
PART A
CERTIFICATION
OF NORTH APlt�a,
Property Address: 194 Boston Street BOF ID OF HE) L -1_ ,
North Andover,MA 01845
Owner's Name: Lisa Durivage t,�n
Owner's Address: Same 1'� R { 6
Date of Inspection: 03-05-2004
Name of Inspector:(please print)John Soucy
Company Name: Soucy Sewer Service,Inc.
Mailing Address: 830 Livingston Street
Tewksbury,MA 01876
Telephone Number: 978-851-8839
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that tihe 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 syssems.I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The;system:
X_ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approvimg Authority
Fails
Inspector's Signature: Date: 3- 'Oq
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 dlesign 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 applicab0e,and the approving
authority.
Notes and Comments
****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 time same or different
conditions of use.
f t
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 194 Boston Street
North Andover,MA 01845
Owner's Name: Lisa Durivage
Date of Inspection: 03-05-2004
Inspection Summary:Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X I have not found any information which indicates that any of the failure criteria descrilbed 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 t®be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or nott)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distributiom box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND a lain:
xp
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 194 Boston Street
North Andover,MA 01845
Owner's Name: Lisa Durivaee
Date of Inspection: 03-05-2004
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to dettermine 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 andl the environment:
_Cesspool or privy is within 50 feet of surface water
_Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marslh
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 witlhin 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 feat 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 laboratorcy,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A co of the analysis must be attached to this form.
8€ PY Y
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 194 Boston Street
North Andover,MA 01845
Owner's Name: Lisa Durivage
Date of Inspection: 03-05-2004
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged DSAS or cesspool
-5F Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded cu clogged SAS or
cesspool
_ X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet froun a private water
supply well with no acceptable water quality analysis. [This system passes if the;well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that n®other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,11100 gpd to 15,000'
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significantt threat,or answered
"yes"in Section D above the large system has failed.The owner or operator of any large systeun considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 194 Boston Street
North Andover,MA 01845
Owner's Name: Lisa Durivaae
Date of Inspection: 03-05-2004
Check if the following have been done.You must indicate"yes"or"no"as to each of the folllowing:
Yes No
x _ Pumping information was provided by the owner,occupant,or Board of Health
x Were any of the system components pumped out in the previous two weeks?
x _ Has the system received normal flows in the previous two week period?
x Have large volumes of water been introduced to the system recently or as part of t6hiis inspor ien?
x _ Were as built plans of the system obtained and examined?(If they were not availlnble note as N/A)
x _ Was the facility or dwelling inspected for signs of sewage back up?
x i Was the site inspected for signs of break out?
.�x — Were all system components,excluding the SAS,
located on site?
x _ Were the septic tank manholes uncovered,opened,and the interior of the tank insipected for the
condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of
scum?
x Was the facility owner(and occupants if different from owner)provided with infk matiun an the prkaper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been deitermined based on:
Yes No
x _ Existing information.For example,a plan at the Board of Health.
x Determined in the field(if any of the failure criteria related to Part C is at issue a1pproximation of
distance is unacceptable)[3 10 CMR 15.302(3)(b)]
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIOPW FORM
PART C
SYSTEM INFORMATION
Property Address: 194 Boston Street
North Andover,MA 01845
Owner's Name: Lisa Durivne
Date of Inspection: 03-05-2004
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440
Number of current residents: 2
Does residence have a garbage grinder(yes or no):no
Is laundry on a separate sewage system(yes or no): no [if yes separate inspection requiredT
Laundry system inspected(yes or no): no
Seasonal use:(yes or no): no
Water meter readings,if available(last 2 years usage(gpd)):see attached
Sump pump(yes or no): no
Last date of occupancy:_recent
COMMERCIAL/INDUSTRIAL N/A
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):—
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Home Owner
Was system pumped as part of the inspection(yes or no):yes
If yes,volume pumped:_1500_gallons--How was quantity pumped determined?N/A
Reason for pumping:Maintenance and inspection of tank interior.
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if known)and source of information:
6 nears
Were sewage odors detected when arriving at the site(yes or no):No
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 194 Boston Street
North Andover,MA 01845
Owner's Name: Lisa Durivagg
Date of Inspection: 03-05-2004
BUILDING SEWER(locate on site plan)
Depth below grade: 18"
Materials of construction: X_cast iron _40 PVC_other(explain):
Distance from private water supply well or suction line: N/A
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: x (locate on site plan)
Depth below grade: 10"
Material of construction: X concrete_metal_fiberglass_polyethylene_other
(explain)
If tank is metal list age:_Is age confirmed by a Certificate of Compliance(yes or no): ((attach a copy of
certificate)
Dimensions: 6'x 11'
Sludge depth: 6"
Distance from top of sludge to bottom of outlet tee or baffle: 35"
Scum thickness: 4"
Distance from top of scum to top of outlet tee or baffle: 5"
Distance from bottom of scum to bottom of outlet tee or baffle: 15^_'_ _
How were dimensions determined: Tape&Sludge Tool
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural iintegrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
GREASE TRAP: (locate on site plan) N/A
Depth below grade:_
Material of construction: concrete metal fiberglass_polyethylene_other(expidain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural iintegrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 194 Boston Street
North Andover,MA 01845
Owner's Name: Lisa Durivage
Date of Inspection: 03-05-2004
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)N/A
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: X (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: equal_
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryower,any evidence of
leakage into or out of box,etc.): Flow Checked Okay
PUMP CHAMBER: (locate on site plan)N/A
Pumps in working order(yes or no): N/A
Alarms in working order(yes or no): N/A
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 194 Boston Street
North Andover,MA 01845
Owner's Name: Lisa Duriva2e
Date of Inspection: 03-05-2004
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
X leaching fields,number,dimensions:_Leaching Field 28'x40'
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,convilition of vegetation,
etc.): No Sign of Hydraulic Failure.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)N/A
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vcgetation,etc.):
PRIVY: (locate on site plan)N/A
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vei„getation,etc.):
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 194 Boston Street
North Andover,MA 01845
Owner's Name: Lisa Durivage
Date of Inspection: 03-05-2004
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent referemce landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
S
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Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 194 Boston Street
North Andover,MA 01845
Owner's Name: Lisa Durivape
Date of Inspection: 03-05-2004
SITE EXAM
Slope
Surface water
Check cellar x
Shallow wells
Estimated depth to ground water 3 feet plus.
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed::
X 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:
Obtained from designs plans dated 2-05-1998,and test pit date 2-04-1998.
Govenn Sarver-1£1.1-7I-4.- Demote Desk-top =_- _
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WATER BILLINC HISTORY 1090376-DURIUAGE, LISA DIETER 41: 1090376 -
---------------------- 194 BOSTON ST '
# CYCLE SERUICE PRIOR CURRENT USE WATER SEWER FEES TOTAL- -
_ 1 1999-100 07/15/1999 0.00 0-00 . 0.00 0-8 ' -
2 1999-130 05/15/1999 0.00 0.00 0-00 0.6 T
3 1999-160 82/8611999 54.60 A.AO 0.00 54_6
4 1999-190 12/29/1998 117.13 0.00 8.80 117.13`
5 2000-1 07/01/1999 136 152 16 43.68 8.09 8.08 43_68
6 2000-21 11/02/1999 8 3 32 87.36 0.00 0.80 87.36 =
7 2000-31 03/02/2080 3 28 25 68-25 0.00 8.00 68-25. ;
8 2000-41 05/10/2800 28 43 15 48.95 8.00 8.00 40_95
9 2000-1-R 18/01/1999 136 152 16 43_68 0.80 0.00 43.68 =-
18 2081-11 07/31/2600 43 60 17 46.41 0_00 11.08 57_41
11 2801-21 11/U6/2000 60 111 51 139.23 B-00 11.00 150.23
` 12 2001-31 02/09/2801 111 191 20 54.68 0.00 11.00 65.6 -_
-13 2001-41 85/07/2001 131 150 19 51_87 0.00 11.80 62.87:
14 28A2--11 07/24/2001 158 172 22 56.58 8.00 5.55 62.13
15 2802-21 11/16/2081 172 201 29 81.71 8.80 5.55 87.26:
16 2082-31 03/11/2002 281 227 26 64.22 0.08 5.55 69.77
17 -2082-41 U5/10/2002 227 240 13 32.11 0.08 5.55 37.66
r 18 2082-CRD 11/17/2001 201 201 8 -7.84 O.OU 0.08 -7-8ti
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WATER DILL INC HISTORY `1090376-DURIURGE, LISA HETER #1: 1090376
--------------------- 194 BOSTON ST
L
8 CYCLE SERVICE PRIOR CURRENT USE WATER SEWER FEES TOTAL
Modeml
2003-11 07124!2002 240 257 17 40.46 0_DO 5.97 46-431
r` 2 2003-21 10/28/2002 257 278 21 49.98 0.00 5.97 55.91; _
3 2003-31 0`1128/2003 278 292 14 33.32 0.00 5.97 39.24 F b`
4 2003-41 04/18/2003 292 301 9 21.42 D.DD 5.97 27.39 -
Del S�
'I' 5 2004--11 fl7/18J20O3 30i 349 4R 148.36 0.00 7.42 155.78 - �- _: •� -:__
6 2004-21 i0/??/'r 003 349 368 19 43.32 O.00 7.42 50.74
_ : ..
_ _ 7 2004--31 02/62/2004 368 377 9 20.52 0.00 7.42 27.94.:..,
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FORM - U - LOT RELEASE FORK[
INSTRUCTIONS: This form is used to verify that all-necessary approval/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve the
applicant and or landowner from compliance with any applicable requirements.
APPLICANT .tip �9� /J{<I'l t/a .� HONE
ASSESSORS MAP NUMBER /07d KOT NUMBER 63
SUBDIVISION LOT NUMBER
STREET &4/� 6L �---TREET NUMBER
OFFICIAL USE ONLY
RECOMMENDATIONS OF TOWN AGENTS
DATE APPROVED
CONSERVATION ADMINISTRATOR
DATE REJECTED
COMMENTS
DATE APPROVED
TOWN PLANNER
DATE REJECTED
CON04ENTS
DATE APPROVED
FOOD INSP R-HEAL DATE REJECTED
�— DATE APPROVED
CTOR-HEALTH
DATE REJECTED n
COIy1MENT'S z e'
PUBLIC WORKS–SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
DATE APPROVED
FIRE DEPARTMENT
DATE REJECTED
COMMENTS
RECEIVED BY BUILDING INSPECTOR DATE
i
Area = 44,050 S.F. +/--
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Form No.4
Town of North Andover, Massachusetts
BOARD OF HEALTH
>� 19
CERTIFICATE OF COMPLIANCE
This is to certify that
the Individual Soil Absorption Sewage Disposal System constructed ( ) or repaired ()C)
b y �
INSTAL ER
n
at 1 q ���
SITE LOCATION
has been installed in accordance with Board of Health Regulations as described in the Design
Approval Site System Permit No. /C0(61) dated U5 19 q.�
The issuance of this certificate shall not be construed as a guarantee that the system will
function satisfactorily.
BOARD OF HEALTH
I .
it
4
Town of North Andover, Massachusetts For No.3
NORTH BOARD OF HEALTH
19
O A
�,"°•;::o�•at DISPOSAL WORKS CONSTRUCTION PERMIT
SS SE
ACNU
Applicant % K� �e-�`/11v�
NAME ADDRE 5 TELEPHONE
r
Site Location _ `T Y /-- y S /'-11' t` .
Permission is hereby granted to Construct ( ) or Repair (Van Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S. No. 1 0
CHAIRMAN,BOARD OF HEALTH
J/ s p>
Fee D.W.C. No.
( �S
I
TOWN OF NORTH ANDOVER
SEWAGE DISPOSAL SYSTEM
INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System( )constructed; ( repaired;
- located at
was installed in conformance with the North Andover Board of Health approved plan, System
Design Permit#1,06f dated -:2- S I'JV ,with an approved design flow of -4141c
gallons per day. The materials used were in conformance with those specified on the approved
plan;the system was-installed in accordance with the provisions of 310 CMR 15.000, Title 5 and - -
- — local regulations, and the final grading agrees substantially with the approved plan. All work is -
_. -accurately represented on the As-built which has been submitted to the Board of Health.
Installer: Lic. #: Date: S-4 j.
Design Engineer: Q,iL Date: S- �'
w `
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f
Town of North Andover, Massachusetts Form No.3
BOARD OF HEALTH
kORTN
19
F 9
�. `�•,,, °`� DISPOSAL WORKS CONSTRUCTION PERMIT
,SS�CNUS�S
Applicant
NAME ADDRE S TELEPHONE
Site Location
Permission is hereby granted to Construct ( ' ) or Repair an Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No.
CHAIRMAN,BOARD OF HEALTH
Fee 7 s D.W.C. No. 9�s
s
a
♦ 1 I
TOWN OF NORTH ANDOVER
SEWAGE DISPOSAL SYSTEM
INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System( ) constructed; ( repaired;
by 4-2K
_. located at "--
was installed in conformance with the North Andover Board of Health approved plan, System
_ I
Design Permit#XQG,, dated 21519,P with an approved design flow of yQ
gallons per day. The materials used were in conformance with those specified on the approved
- plan;the system was.installed in accordance with the provisions of 310 CMR 15.000, Title 5 and
_ - local regulations, and the final grading agrees substantially with the approved plan. All work is -
_- accurately represented on the As-built which has been submitted to the Board of Health.
Installer: Lic. #: Date:
Design Engineer: Date:
' I
' I
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE: T g-� �' CURRENT INSTALLER'S LICENSE#
LOCATION: Rcc A
LICENSED INSTALLER:
SIGNATURE: TELEPHONE#
CHECK ONE:
REPAIR: ✓ NEW CONSTRUCTION:
IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUILT.
i
Administrative Use Only
$75.00_Fee Attached? Yes_ No
oundation As-Built? Yes No
loor Plans? Yes No
Approval
Date:
.�L /a/V I�j�,GDVA�-
Town Form No.2
f MORTot
0 00
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E v
7-0
SSACMUSft SOIL ABSOR
AppIicah � �
Site Location
Reference Plans and Specs.
ENGIN DATE
Permission is granted for an indivi3ual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
CHAIRMAN,BOARD OF HEALTH
(7-J
: Fee Site System Permit No./ dy d
Town of North Andover, Massachusetts Form No.2
NORrti BOARD OF HEALTH
ltLo•,.�.e •,yo 19
o �
F w
A
DESIGN APPROVAL FOR
�SSACMUSf�ty SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
A p p I i c a � noir n—/ Test No.
Site Location
Reference Plans and Specs.
ENGINEER DESIGN DATE
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
��G U 3,10
CHAIRMAN,BOARD OF HEALTH
: Fee d, `— Site System Permit No./ ��
Town of North Andover NORTH
OFFICE OF 3�°y °,�o�
COMMUNITY DEVELOPMENT AND SERVICES ° . A
30 School Street X *
North Andover,Massachusetts 01845
WILLIAM J. SCOTT 9SSAC►+uS
Director
March 2, 1998
Mr. John Morin
Neve Associates
447 Old Boston Rd.
Topsfield, MA 01983
Re: 194 Boston St.
N. Andover, MA 01845
Dear Mr. Morin:
This is to inform you that the proposed plans for the site referenced above have been
approved.
If you have any questions, please do not hesitate to call the Board of Health Office at the
number below.
Sincerely,
Sandra Starr, R.S.
Health Administrator
SS/rel
cc: Richard Beers
File
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
PLAN REVIEW CHECKLIST
ADDRESS I�� /j/� ENGINEER
GENERAL /
3 COPIES STAMP ✓ LOCUS �� NORTH ARROW SCALE
CONTOURS L,-' PROFILE Ll/' (Sc) SECTION L-� BENCHMARK V SOIL &
PERCS ELEVATIONS__Q�- f ETS . DISCLAIMER t-' WELLS & WETS
WATERSHED?�D DRIVEWAY WATER LINE FDN DRAIN M&P
SCH40 �� TESTS CURRENT? ` t/ SOIL EVAL
SEPTIC TANK /
MIN 1500G ✓� . 17 INVERT DROP GARB. GRINDER �/O (2 comps +200 )
10 ' TO FDN MANHOLE(/ ELEV GW # COMPS . GB V.
D-BOX
SIZE # LINES---/— FIRST 2 ' LEVEL STATEMENT
INLETOUTLET _ 7 (2" OR . 17 FT) TEE REQ' D? S
Z�I
q
EACHING
�
MIN 440 GPD? RESERVE AREA -- 4 ' FROM PRIMARY? Q(
20 ELOPE
100 TO WETLANDS 100 TO WELLS 4 � >TO S .H.GW ~ 5 2M/IN)
20 ' TO FND & INTRCPTR DRAINS `' 400 ' TO SURFACE H2O SUPP
74
4 ' PERM. SOIL BELOW FACILITY MIN 12" COVER FILL? t- ( 15 ' )
BREAKOUT MET)
TRENCHES
MIN 440 gpd SLOPE (min .005 or 6"/100 ' ) SIDEWALL DIST. 3X EFF.
W OR D (MIN 6 ' ) RESERVE BETWEEN TRENCHES? IN FILL? MUST
BE 10 ' MIN. 4" PEA STONE? VENT? ( >3 ' COVER; LINES >501 )
BOT + SIDE - X LDNG = TOT
( L x W x #) (DxLx2x#) (G/ft2 )
Copyright @ 1996 by S.L. Starr
PITS
MIN 440 LEACHING MIN 1 ( 13 'x16 ' ) PIT MANHOLE/PIT
GW MIN 4 ' BELOW BOTTOM EXC 2x EFF W OR D 12"-48" STONE
BOT + SIDE x LOAD = TOTAL
( L x W x #) (2x(L+W)xD x #) (G/ft2)
CHAMBERS
MIN 440 LEACHING GW MIN 4" BELOW COVER >3 FT - VENT
MANHOLES 12"-48" STONE SPLASH PADS SLOPE . 005
BED/TRENCH (Bed max. 60 ' X 60 ' ) MIN 13 ' X 16 ' PIT
BOT + SIDE X LOAD = TOTAL
( L x W x #) (2 x (L+W)xD x #) (G/ft2)
FIELDS
MIN 440 GPD 900 ft2 BED GW MIN 4 ' BELOW BOTTOM OF FIELD
PIPE ENDS JOINED? 4" PEA STONE? v DIST LINE SLOPE .005? V
>3 'COVER-VENT SCH 40 ✓ MIN 12" COVER
RATE (~�� ---X—a 0 ) X TOTAL
L W LDG
DOSING TANKS AND PUMPS
DIMENSIONS X X = PUMP CAPACITY gpm
L W D Vol .
DISCHARGE SIZE DISCHARGE RATE DISCHARGE TIME
gpm
MANHOLES TO GRADE ALARM SEP . CIRC. GW (Min. 1 ' below
inlet) HWL LWL CHECK VALVE BLEEDER HOLE MANUAL
OP. SWITCH ENUF STORAGE?
Copyright Q 1996 by S.L. Starr
TH® ; NEVE
ASS CIATE INC.
January 14, 1998
Sandy Starr
Board of Health
30 School Street
North Andover, MA 01845
Re: 194 Boston Street, North Andover
Dear Sandy:
As you may recall, I had called you on Monday, January 5, 1998 regarding the failure of
a septic system at the above-referenced lot and I expressed my client's wishes to conduct
out of season testing. Our client is going through a corporate relocation and will be
moving out of state soon.
As you and I had discussed the Board of Health will only allow out of season soil testing
if the septic system is backing into the house or failing onto the ground. All other
requests would require the approval of the Board. The current system does not meet the
above referenced criteria.
Based on my clients situation, he wishes to test now. Therefore, please schedule us for
the January 22, 1998 Board of Health meeting so that we may ask permission from the
Board to conduct soil testing now for the repair of the system.
Please call our office to confirm that we have been put on the agenda. If you should
have any questions regarding this please do not hesitate to contact our office.
Very truly yours,
THOMAS E. NEVE ASSOCIATES, INC.
rq. P(&U/n
John M. Morin, P.E.
Executive Vice President
JMM/kmm #1723 BEERS.WPS
• ENGINEERS • • LAND SURVEYORS • • LAND USE PLANNERS
447 Old Boston Road U.S. Route#1 Topsfield, MA 01983
(978)887-8586 FAX(978) 887-3480
FEB 9 :qUl
THO NEVE
ASS LATE , ING
February 5, 1998
Ms. Sandy Starr
Board of Health
30 School Street
North Andover, MA 01845
Re: 194 Boston Street- Rick Beers, Owner
Dear Sandy:
Please find enclosed 3 prints of the sanitary disposal system repair design for the
above-referenced property.
We are proposing a reduction in the distance from the bottom of the leach bed to high
groundwater elevation to 3' as allowed in Title 5, Section 15.404 (2.b.). If the system
was to be designed 4' above the water table the necessary grading for the construction of
the system would create a ponding area on the upstream (east) side of the system at the
property line. In order to eliminate the problem we would either have to pump up to the
system and swale the surface runoff in front of the system, creating a mound in the back
yard, or we would have to perform major earth work along the existing fence to the rear
of the property in order to swale the surface runoff around the system. Even with a 3'
separation to groundwater I still had to propose a swale on the upstream (east) side of the
system in order to prevent ponding along the property line.
By examing the existing topography and the soil log information you can see that
approximately 50% of the system is located 4' above the high groundwater elevation.
Please schedule us for the February 26, 1998 meeting so that we may discuss this issue
with the Board of Health. As you are aware, my client is under critical time constraints, I
hope that you will be able to review the design prior to the meeting so that we may
address any issues you may have prior to the meeting.
Please call our office to confirm that we are on the agenda for the February 26th meeting.
• ENGINEERS LAND SURVEYORS • • LAND USE PLANNERS
447 Old Boston Road U.S. Route#1 Topsfield, MA 01983
(978)887-8586 FAX(978)887-3480
Ms. Sandy Starr Page 2
February 5, 1998
I thank you, in advance, for your anticipated cooperation.
Very truly yours,
THOMAS E.NEVE ASSOCIATES, INC.
John M. Morin, P.E.
Executive Vice President
JMM/kmm
Enclosures
cc: Rick Beers
#1723-Beersmps
,ORTIy
3?�'`�� • ~�� BO-ARD OF HEALTH
w ia
' '• 146 MAIN STREET TEL. 688-9 540
SA US NORTH ANDOVER, MASS. 01845
APPLICATION FOR SOIL TESTS
DATE:
LOCATION ` F SOIL TESTS:
Assessor's map & parcel number: /,Q 17 6 63
OWNER: ��C�jQrG�! SUSS TEL. NO.: 6&
ADDRESS: KA)
ENGINEER:--/ 1 V-e TEL. NO.:
CERTIFIED SOIL EVALUATOR:
Intended use of land: residential subdivision, single family home, commercial
THE FOLLOWING MUST BE INCLUDED WITH THIS FORM:
1. Proof of land ownership (Tax bill, deed, or letter from owner permitting
tests)
2. Plot plan
3. Fee of $175.00 per lot for-new construction. This covers the two deep holes
and two percolation tests required for each lot. Fee of$75.00 per lot for
repairs or upgrades.
GENERAL INFORMATION
1. Only Certified Soil Evaluators may perform deep hole inspections.
2. Only Mass. Registered Sanitarians and Professional Engineers can design
septic plans.
3. At least two deep holes and two percolation tests are required for each septic
system.
4. Repairs require at least two deep holes and at least one percolation test, at
the discretion of the BOH representative.
5. Full payment will be required for all additional tests within two weeks of
testing.
6. Within 45 days of testing, a scaled plan (no smaller than 1"-100') shall be
submitted to the Board of Health showing the location of all tests (including
aborted tests).
7. Within 60 days of testing soil evaluation forms shall be submitted.
DATE: 3 Z
LOCATION:
ENGINEER:
u
BOH WITNESS.-
PERCOLATION
ITNESS:PERCOLATION TEST#
BOTTOM DEPTH OF PERC TEST: 1
TIME OF SOAK: , [ .� (At least 15 minutes long)
TIME AT 12"
TIME AT 9" ��,� ,_ j�
.. 1
TIME AT f: E. � 3 L �.
� ' Y
OVERNIGHT SOAK —
. '
TIME STARTED
NEXT DAY SOAK: _ (At least;15 minutes)
TIME AT 12" t 1 _ y
TIME AT 9" — c ✓WL-�,�
TIME AT 6" /, b �~
1111111111111111111111111111111111 ����
1111111111111111111111111111111111
1111111111111111111111111111111111 '. ����
1111111111111111111111111111111111 � ���� w
1111111111111111111111111111111111 ��. ��.�,;���� .
1111111111111111111111111111111111 ����•�,�-
1111111111111111111111111111111111
1111111111111111111111111111111111 ; . .,.
1111111111111111111111111111111111
111MEN 1MINE 111111111111111111 �},
1111111111111111111111111111111111
1111111111111111111111111111111111 ����p - • a
1111111111111111111111111111111111
111111111111111111III 1NINE 1MEN
111111111 MEN � �•�� —
111 111111111111111111111111111111
111 1111111111111111 1111111111111 , -� ��/� �ZJ, - ,
11111111111111111111 1111111111111 � -- � .� - �� . :
l 1111111111111111 1 111111111111111
1111111111111111 111111111111111 ;
111111111111111 1 1111111111111111 ®��
111111111111 11 1111 1 1111111111 ���� ,(
111111111111 111 1111 1 111111111 : _ ,��;� A ••
1111111111111111 111 111 11111//11 —
1111111/1/ 11111 111 11111 1111111 ,.,, �:,���
%P.1
161 --
�j', We, Jay A. Farrell and Theresa K. Farrell, husband and wife, and bothI� �C�$
of North Andover, Essex County,Massachsctts,
be/nglfxsatarr/ed,forconsideration Paid,and In fuirconslderationof One Hundred Eighty Nine!
t,. Thousand Five Hundred and 00/100 (fl89t500.00) Dollars
grant to Richard D. Beers and Susan M. Beers 10S0,A10 -0 Wrf'( �s 7"f, I'$its xfi"
Q. , . G /
of 194 Boston Street, North Andover, MA with q tttlalmtoo ants
Nx�mlllr>rax °� tj'�.
IDescrlptlon and encumbrances.If■nyl r
�• The land with the --- — -- - - - - - I
town on tars of
' land entitled: "PI 6 Walt r
` Woodburn, Stowers Stsoun ded Wit Eealx Ir'
North District Reg antic tart F fI _
f bounded and descri r P ' y
NORTHEASTERLY, thr
and no
w;or
formerly of Marcor p � v-�
'-� •��' � SOUTHEASTERLY, six i � � J�� } ;•i;�
{, 0 6 Doris H. Solomon a y of Sem G.
l"1
SOUTHERLY, follawl n , /Y /1
as shown on said p
0,- L/ .60; T. 30.051
cSOUTHWESTERLY, one , f J
a: �IF�,f10wC) �/( ow or formerly
>, of said Solomone, �Q 1,� �f S S
nd 15/100 1
t• r?; (175.15) feet by e.
oe
� Jk&h eco �I�►e e, �l-e ed, k
' N NORTHWESTERLY, n 1
a Said Parcel coattail
0 i Plan. •
r' w 'Being the same prat n
l' vin J. Comeau '1
dated December 11, of Deeds,
Book 3040, Page 52. jI
r ail
V1
i,
in
IMIMUCLL,EI)
ipso■ our hands and seals this da of December 19-93—
re 1
9-93—rel
�—
resa Q Vl , lil�l
,?;;•, K. arra i
ape Gotnmonwealth of Maseachuattta
ESSEX ss. December ,10 199
Then personally appeared the above named g f'4
Pe Y PPe Jay A. Farre harass K. Farrell SL
,i and acknowledged the foregoing Instrument to be their ��' a act and or
1
Charlotte Veit Notary Public-X iBHdExtlf 111WK �+
My commission cxpirn January 7 04
('Individual—JoInlTemnts—Tenants in Common.)
e Z
�. CIIAPrER I83 SEC.6 AS AMENDED BY CHAPTER 497 of 1969 }
I 1
Every deed preserved for record shall contain or have endorsed upon it the full name,residence and rk.
t office addms of the p/amer 'q1
•.f� �: and a reclul of the amount of the full consideration thereof In dollars or the nature of the other cunddcra on thtr.
ror,If nut dellverclt for a 1�}
F specific tmmcury sum.The full consideration shall mean the total price for the conveyance without deduction for any liens or encurobtanm
i' wutned by the grantee or remaining thereon.All such endorsements and recitals shall be recorded as pan of thedeed.Pallure to epmply ;
a., with this section shall not affect the validity of any deed.No register of deeds shall accept a deed for recording unless It Is In compUnc
lt with
�I the requirements of thio srctson, l , e
t t �
t
i
A.
,. , BR3966
i01�0A
We, Jay A. Farrell and Theresa K. Farrell, husband and wife, end both i!
of North Andover, Essex County,M2382Chl setts,
befnginwarrled,for consideration paid,and infulrconsidcratlonof One Hundred Eighty Nine[ j
}, !^ Thousand Five Hundred and 00/100 (j189r500.00) Dollars
i
r• grant to Richard D. Beers and Susan M. Beers NusB9�b Y W�ar� �s 7��# 3*
' ii, . YSl r� r�►°'�� 1 ' �
of with q WNW COUi anti 1 I
c.... 194 Boston Street, North Andover, MA 1.
't (Description and encumbrances,if anyl
f, The land with the buildings theteon situated in North Andover, being shown on len of �"
land entitled: "Plat! of Land in North Andover, Maes., owned by Marjorie 6 Walt r
!+' , Woodburn, Stowers Associates, Reg. Land Surveyors," which plan is recorded w}t Essex
II'4
North District Registry of Deeds as Plan No. 5020. Said parcel ie more panic laxly' j
`r bounded and described as follows;
t. a' NORTHEASTERLY, three hundred seventy-five and 58/100 (375.58) feet by land now,or
formerly of Marjorie b Walker Woodburn, as shown on said plan; j d
SOUTHEASTERLY, sixty-two and 95/100 '(62.95) feet by land now or formerly of Sam 0.
0 6 Doris N. Solomon, as shown on said plan; '
�'' t• SOUTHERLY, following a curve having the dimensions of: Arc 48.05; R 31.60; T. 30.051
h� n as shown on said plan;
0 SOUTHWESTERLY, one hundred sixty-two and 93/100 (162.93) feet by land now orformerly
to of said Solomons, as shown on said plan; and one hundred seventy-five and 15/100 a
(175.15) feet by said land of Solomon; and {
NORTHWESTERLY, one hundred fifty and 0/10 (150,0) feet by Boston Street. Ip t�
N
a
Said parcel contains 44,050 square feet( more or less, according to'sald plan.
1, o
m 'Being the same premises conveyed to us by deed of mart' T. Comeau and Kevin J. Comeau I!
dated December 11, 1989 and recorded with North Ease' District Registry of Deeds,
•� v Book 3040, Page 52. Ij1
m
M;. Q r Q �► CELL j
14 �� .M•l• ' II
';f � �. `n a 9p n) ` t,"�`e�•^i: � I Il,
���.If� lP� � 3.fJ .H �•' � f_ '� t
'.' �„ f• �, Sec: ! i
/ttneaa our hands and seat a this � da of December 19g3—/04
?.'
iA. arrel
ce ,
,E
regia erre a
rr ry
she Oletntnenweslth of Massachusetts
a „
ESSEX ss.
December JJ� 1993
Then personally appeared the above named ?
3 6.{ Pe Y PPe Jay A. Farre harass K. Farrell
I�
and acknowledged the foregoing Instrument to be their a act and or
1p s Charlotte Veit VouryPublic-XyjLX&i(1 llEilK
Mycommissloncapirea January 7
.lr tlh.
("Individual—joint Tcnants—Tenants In Common.) ,
CHAPTER 18 SEC.6 AS AMENDED BY UTA FTER 197..1 1969 Y
Every dad presented for record shalt contain or have entb,rsed upon it the full name,residence and p iso office address of the 0anter
Il „, ands recital of the amount of the full consideration thermolln dollar. r the nature of the other wnslderatlon Yhereror.If nos dcuvereil(ora �}
spectac monetary sum.The full consideration shall mean the tall price for the n.nveyance whbout deducthm for any liensor encumbrances ,
assumed by the grantee of remaining thereon.All such endorsements and recitals sccept a eed for recordlna unless It U in rnmhall be recorded as part of the deed.failure to cpmply �
with this section shall not a
affect the validity of any dd.No register of deeds shall adllanck with �
the requirements of this section. p
t•
f.�t
.S
a„
PETER F. REILLY
AFFILIATED WITH F.P. REILLY AND SONS, IN.G.yFri F�, � ..
6 STIRLING STREET
ANDOVER, MA 01810
(978) 475-4370 'PIAN 2 2 1998
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION
Property Address: 194 Boston Street, North Andover, MA 01845
Address of Owner (if different): N/A
Name of Inspector: Peter F. Reilly
(I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name, Address, Phone #: F.P. Reilly & Sons, c/o Peter Reilly, 6 Stirling Street
Andover, MA 01810 (978) 475-1237 / (978) 475-4370
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the
information is true, accurate and complete as of the time of inspection. The inspection was performed
based on my training and experience in the proper function and maintenance of on-site sewage disposal
systems. The system:
N/A Passes
N/A Conditionally Passes
N/A Needs Further Evaluation By the Local Approving Authority
✓ Fails
WXX_
Inspector's Signature: Date: January 10, 1998
Peter F. Reilly
The system inspector shall submit a copy of this inspection report to the approving authority within thirty
(30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the regional office of the
Department of Environmental Protection. The original should be sent to the system owner and copies sent
to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
A. SYSTEM PASSES: Check A, B, C or D
N/A I have not found any information which indicates that the system violates any of the failure criteria
as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
f
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION (continued)
Property Address: 194 Boston Street, North Andover, MA
Owners Name: Richard Beers
Date of Inspection: 1/10/98
B. SYSTEM CONDITIONALLY PASSES:
N/A One or more system components need to be replaced or repaired. The system, upon completion of the
replacement or repair, passes inspection.
Indicate yes, no, or not determined (Y, N, ND). Describe basis of determination in all instances. If "not determined",
explain why not)
N The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming
septic tank as approved by the Board of Health.
N Sewage backup or breakout or static high water level observed in the distribution box is due to broken or
obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if
(with approval of the Board of Health):
N/A broken pipe(s) are replaced
N/A obstruction is removed
N/A distribution box is leveled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will
pass inspection if (with approval of the Board of Health):
N/A broken pipe(s) are replaced
N/A obstruction is removed
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is
failing to protect the public health, safety and environment.
1. SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT
FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
N/A Cesspool of privy is within 50 feet of a surface water
N/A Cesspool or privy is within 50 feet of a bordering vegetated wetland or salt marsh.
2. SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF
APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT
THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
N/A The system has a septic tank and soil absorption system and is within 100 feet to a surface water
supply or tributary to a surface water supply.
N/A The system has a septic tank and soil absorption and is within a Zone I of a public water supply well.
N/A The system has a septic tank and soil absorption and is less than 100 feet but 50 feet or more from a
private water supply well, unless a water well water analysis for coliform bacteria and volatile organic
compounds indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance N/A
(approximation not valid).
f
1
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION (continued)
Property Address: 194 Boston Street, North Andover, MA
Owner's Name: Richard Beers
Date of Inspection: 1/10/98
D. SYSTEM FAILS:
✓ I have determined that the system violates one or more of the following failure criteria as defined in
310 CMR 15.303. The basis for this determination is identified below. The Board of Health should
be contacted to determine what will be necessary to correct the failure.
N Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
N Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool.
N Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool.
Y Liquid depth in cesspool <6" below invert or available volume <'/z day flow.
N required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped: none
N Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
N Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
N Any portion of a cesspool or privy is within a Zone I of a private water supply well.
N Any portion of a cesspool or privy is within 50 feet of a private water supply well.
N Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,
attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
The following criteria apply to a large system in addition to the criteria above.
N/A The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
N The system is within 400 feet of a surface drinking water supply
N The system is within 200 feet of a tributary to a surface drinking water supply
Y Y 9 pP Y
N The system is located in a nitrogen sensitive area (Interim Wellhead Area (IWPA) or a mapped Zone II of
a public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater
treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the DEP for
further information.
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART B - CHECKLIST
Property Address: 194 Boston Street, North Andover, MA
Owner's Name: Richard Beers
Date of Inspection: 1/10/98
Check if the following have been done:
✓ Pumping information was requested of the owner, occupant and Board of Health.
✓ None of the system components have been pumped for at least two weeks and the system has been receiving
normal flow rates during that period. Large volumes of water have not been introduced into the system
recently or as part of this inspection.
N/A As built plans have been obtained and examined. Note they are not available with N/A.
✓ The facility or dwelling was inspected for signs of sewage backup.
✓ The system does not receive non-sanitary or industrial waste flow.
✓ The site was inspected for signs of breakout.
✓ All system components, excluding the SAS, have been located on the site.
✓ The septic tank manholes were uncovered, opened and the interior of the septic tank was inspected for
condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of
SCUM.
✓ The facility owner land occupants, if different from owner) were provided with information on the proper
maintenance of SSDS.
The size and location of the SAS on the site has been determined based on:
N/A Existing information (Example: Plan at BOH).
N/A Determined in the field if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable Ill 5.302(3)(b)].
PART C - SYSTEM INFORMATION
FLOW CONDITIONS
RESIDENTIAL:
Design Flow (gpd/bedroom for SAS): not applicable
Number of bedrooms: 3
Current residents: 4
Garbage grinder: no
Laundry connected to system: yes
Seasonal use: no
Water meter readings, if available: est. 112,500 gal. 1996-97 / 154 gpd
Sump Pump (yes or no): no
Last date of occupancy: current
COMMERCIAL/INDUSTRIAL:
Type of Establishment: N/A
Design Flow: N/A
Grease trap present: N/A
Industrial waste holding tank N/A
Non-sanitary waste discharged the Title 5 system N/A
Water meter readings, if available: N/A
Last date of occupancy: N/A
OTHER:
Describe: N/A
Last date of occupancy: N/A
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 194 Boston Street, North Andover, MA
Owner's Name: Richard Beers
Date of Inspection: 1/10/98
GENERAL INFORMATION
PUMPING RECORDS and source of information:
last pumping: November 1997 years according to owner
System pumped as part of inspection: no - cesspool failed prior to pumping
if yes, volume pumped: N/A gallons
Reason for pumping: N/A
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
✓ Single cesspool
Overflow cesspool
Privy
NO Shared system (yes or no - if yes, attach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other (explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Believed to be Y
original system, house constructed in 1882
9
Sewage odors detected when arriving at the site NO
BUILDING SEWER: (locate on site plan)
Depth below grade: 4"-12"
material of construction: ✓ cast iron 40 PVC other (explain)
Distance from private water supply well or suction line N/A
Diameter: 4"
Comments: Condition of joints, venting, evidence of leakage, etc.)
Building sewer was watertight and appeared sound.
SEPTIC TANK: N/A (locate on site plan)
Depth below grade: N/A
material of construction: concrete metal FRP other (explain)
Dimensions:
N/A sludge depth
N/A distance from top of sludge to bottom of outlet tee or baffle
N/A scum thickness
N/A distance from top of scum to top of outlet tee or baffle
N/A distance from bottom of scum to bottom of outlet tee or baffle
Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation
to outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc.)
N/A
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 194 Boston Street, North Andover, MA
Owner's Name: Richard Beers
Date of Inspection: 1/10/98
GREASE TRAP: N/A (locate on site plan)
Depth below grade:
material of construction: concrete metal FRP 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
Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation
to outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc.)
N/A
TIGHT OR HOLDING TANK: N/A (locate on site plan)
Depth below grade:
material of construction: concrete metal FRP other (explain)
Dimensions: N/A
Capacity: N/A gallons per day
Design Flow: N/A gallons per day
Alarm level: N/A Alarm in working order N/A
Date of previous pumping: N/A
Comments: (condition of inlet tee, condition of alarm and float switches, etc.)
N/A
DISTRIBUTION BOX: N/A (locate on site plan)
N/A depth of liquid above outlet invert
Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box,
recommendation for repairs, etc.)
N/A
PUMP CHAMBER: N/A (locate on site plan)
N/A Pumps in working order (yes or no)
N/A Alarms in working order (yes or no)
Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for
maintenance or repairs, etc.)
N/A
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 194 Boston Street, North Andover, MA
Owner's Name: Richard Beers
Date of Inspection: 1/10/98
SOIL ABSORPTION SYSTEM (SAS): N/A (locate on site plan, if possible; excavation not required, but
may be approximated by non-intrusive methods)
If not determined to be present, explain: not applicable
Type
leaching pits and number N/A
leaching chambers and number N/A
leaching galleries and number N/A
leaching trenches, number, length N/A
leaching fields, number, dimensions N/A
overflow cesspool, number N/A
alternative system (name of technology) N/A
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
recommendations for maintenance, repairs, etc.)
N/A
CESSPOOLS: ✓ (locate on site plan)
number and configuration one - about 475 gallons capacity
depth-top of liquid to inlet invert liquid about inlet pipe
depth of solids layer <1"
depth of scum layer <1"
dimensions of cesspool cylindrical about eight (8) feet in diameter
materials of construction fieldstone
indication of groundwater inflow (cesspool
must be pumped as part of inspection) N/A
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
recommendations for maintenance or repairs, etc.)
Single cesspool believed to be original. Was pumped in November 1997. Not pumped during this inspection due to
failure criteria of liquid being above inlet pipe.
PRIVY: N/A (locate on site plan)
materials of construction N/A
dimensions N/A
depth of solids N/A
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
recommendations for maintenance or repairs, etc.)
N/A
y SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
,i
{ Property Address: 194 Boston Street, North Andover, MA
Owner's Name: Richard Beers
Date of Inspection: 1/10/98
SKETCH OF SEWAGE DISPOSAL SYSTEM:
indicate at least two permanent references, landmarks, or benchmarks
locate where public water system enters house
locate all wells within 100' N/A
li
Wow svC.
p B
gu,ld;�y
Sewer
r3R��
G C¢SSpool
SEPTIC TANK TIES: A to Inlet (1) N/A B to Inlet N/A
A to Center (C) 70'0" B to Center 65'4"
A to Outlet (0) N/A B to Outlet N/A
D-BOX TIES: A to Box N/A B to Box N/A
NOTE: The cesspool is in the rear yard.
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 194 Boston Street, North Andover, MA
Owner's Name: Richard Beers
Date of Inspection: 1/10/98
DEPTH TO GROUNDWATER
Depth to Groundwater unknown (below bottom of SAS)
Indicate all methods used to determine High Groundwater Elevation:
N Obtained from Design Plans on record
Y Observation of Site (abutting property, observation hole, basement sump, etc.)
Y Determined from local conditions
N Check with Local BOH
N Check FEMA Maps
N Check pumping records
Y Check local excavators, installers
N Use USGS Data
Describe in words how High Groundwater Elevation was established:
Grade changes in the area appeared to indicate no groundwater in the SAS.