HomeMy WebLinkAboutMiscellaneous - 194 RALEIGH TAVERN LANE 4/30/2018 (2) 194 RALEIGH TAVERN LANE i Lane 210/106-C-0101-0000-0 ` l ty I l ,r r� TOWN OF SYSTEM PUMPING RECORD DATE: 1_ 0 SYSTEM OWNER&ADDRESS SYSTEM LOCATION (example:left front of house) DATE OF PUMPING: I q" b 5 QUANTITY PUMPED : GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. I COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste I ti ' s • y. 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T'+.�T f�'l !• y r R •_ 4 i.... :I •III ���j •� ���A; ti 13JV. P]Pr---aUT OF H 5 E. i "�t :o l5ulLOT �.. �5 t►��v �pE©t,rT of-r-'.�.►'1� '�� { !'� u� ��.... 1F [my, PIPE INTO D e>ox {�a ti;; - C ` INV. 21 PEE QUI �N4V. EIrlU 0P� .«��l' •'.. .{f.;.'-,:.._t"«..�_.._._n,-»..1:4.�.�_�.t,... � t� .. �.�lla � iii i✓�! �.7 �F... � � _ j GAL 1 .amu TO: Vo, A UDOVr;::2 L3OA/W ot'PE/-1L714 NOR"-':: ANDOVER, iiASS / _'-9 BOARD OF FROM: IJ/�ArU� l_ �EL/,VAS �SSG�; G DESIGN ENGINEER Re : Soil Absorption. FRO • Sewage Disposal System This is to certify that I have inspected the construction materials of said disposal system atSITE LOCATION 1-4 >� North Andover, Class . The grades and construction materials are as specified in my plans and specifications dated19 ��• Reg. Prof-. Engineer/-__F Sanitarian - ; r.7 ON ?r U1 E C ;, . J T SAPP'- VED DATE _, '_apt'�_1'i.Ui`T OK UU ?E4 ��S FA OK 1 Distance To: • e-la ncis Well f- ?, grater Line Location 3. No PITC Pipe 4. Septic Tank Tees - Length I),. To Clean Out Covers x � Cement, Pipe to Tank - On Both Sides of Tank c;. Distribution Box Cover x Box - No Cracks All Lines Flolaing Equal Amounts Uo Back Flora r. Leach -+field or Trench Di.r:^ens ons L D..,p _,h Capped Ends Clean Double Washed Sone 7. Leach Pits Dimealsions Stone Depth Splash Pads Tees Cement Pipe to Pit - Both Sides Clean Do11bl e Washed Stene R. Ido Gar'_ afe Disposal q. Final "a.dpL, Tnspec l.i_on 10- O. Ce-:�ered 11 . As - Ru i_l t Submitted Lot Location D-i i'eZ7s1o2-Is o1 Sys lem Local; -on -41-th Regard to T:rc 7-c.st Elevati-on.s I'j -e_ ;:�_"er Table H. _ rd-f of Health , NO` ` .indov ar,Y,"!O s &UBMHT'`ACE D1EP®SAI+ M81MI CHWK LIST LOT # 4V APPROVED DATEDISAPPROVED DATE Provider: Reasons: �? Title PAIL '. Reg 2.5 a submitted plan mwt show as a ndmi m: the lot to be served-area,dimensions lot ,#,abutters location and log deep observation hoes-distance to ties location and rets pewolation tests-distance to ties design calculations & calculations showing mired leaching area, -ocation and dimensions of system-including reserve area existing and proposed contours (g location any wt areas ulthin. 1001 of sewage- disposal system or disclaimer-check wetlands mapping P_ (h) smrface and w-bs dace des %1th n 3,001 of sewage disposal sf(. i or di scl location say dna?Aaage easew nts cdthin loot of stege disposal �yutcm or Fbard files ��systein civ cos of tater Sl�ppl.y vitakin 2601 of se ge di,sgocal or d'l sel!aimer location of &hav p5coposed rAl to serve lot-1001 from leaching facility . _. iocatto.,n of -:titter llaes on p1 pgrty-101 from leaching facility w-seaa a disposals Kno PVC to be used in construction q) P110file of system-elutions of basement, plumb, pipe, septic tic, distribution box inlots and outlets, distribution field piping and Ofber elevations ( maximum ground water elevation in area sewage di.oposal system S) plan must be prepare=d by a Professional Engineer or other professional authorized by law to Pre-pare such plans Reg 6MCI Tis (a) capac t e�-15D% of flow, water table, tees, depth of tees, access, ming le.-Mout, l01 from collar wall or inground swig pool (d) 251 from subsurface drams Peg 10.2 Di aLl-ibution Boxes y slope greater than 0.®8 Reg to-4 (b) samp a Sub.-ui°face Lewfm Check List Page 2 FAIL OK Leaching Leaching pits are preferred where the installation is possible Reg 31.2 ) calculations of leaching area-Rinimm 500 sq ft J 11.4 ) spacing 7.7..10 ) surface drainage 2% 11.13 ) ccver.material 2'x2fx4" splash pad tee at elbow g) no bends in pipe from d-box to pipe f Lescl xs ne . Reg 15.1 a) no Brea or an 20 montes/inch y b� ana- � aq ft 1.5.4 a ccnstru an of field 15.8 d) mwfac drainage 2 % 3.7 ®) 20 m cellar 7 or ingrd sg pal I.eachin48-0=eaching Caches Reg 1.4,3 a) -c area-min 500 sq ft 14.3 b) spat g©4 ft v&n 6 ft with reserve betvee 14.E 3J,-.6 d) etMetion 14.7 e 34.10 f) Surface dr .age 2% i DoWe7. 51® e cPtO be s ) Yj b) x 150 = (t® be shown) fPunds 3 Reg 9.1 a) Tsziod'-by 7"l R 9.6 b) pager i k 1 ,f f i r 1 f t SOIL PROFILE & PERCOLATION TEST PATA. North Andwer,llass. No.&Street /A- 0y �` L. t No. ,oc. /Subdiv. Plan Owner Investi-gator F1 V - Observer. SOIL PROFILES-DATE 1. Elev. `.2. Elev. El 4-Eley. �' . 0 0 0 0 1 1 1 1 Ties to Test Fits 2 2 2 2 3 3 3 3 - — 4 4 4 4 SV 5 5 5 6 6 6 6 7 7 7 7 8 8 - g g 9 9 9 g - 10 10 10 10 Benchmark Location Elevation Datum Percolation Tests-Date— bate—;- Pit ests-Datebate----Pit Number 1 2 3 4 5 Start Saturation Start , Test-Time =_- __- Dro of 311-Time - Drop '•-Time -Dro of 6"-Time I•iins . lst. 3"Dro Mins .-2nd 31'Dro - Percolation Rate - I 8E NEW ENGLAND ENGINEERING SERVICES INC TOWN OF NORTH ANDQ�E BOARD QF HEALTH NOV 7 2001 November 6,2001 North Andover Board of Health Town Hall Annex 27 Charles Street North Andover, MA 01845 RE: TITLE V REPORT: 194 Raleigh Tavern Lane,North Andover, MA Dear Sirs: Enclosed is a copy of the Title V report for the above referenced property. The system PASSED our inspection. If there are any questions please call me at my office,686-1768. Sincerely C-.. 27) Benjamitl C. Osgood, Jr. 60 BEECHWOOD DRIVE-NORTH ANDOVER, MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 w auaa COMMONWEALTH OF MASSACHUSETTSID EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS �'" ._;> DEPARTMENT OF ENVIRONMENTAL PROTECTION V TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: /9y R AL f I LVA TAru,12A L Owner's Name: Q tZ$ ca6i- '''`o m g Eg Owner's Address: f GI Ll 2 A i-g 64-1 Tr&C_ & _wr WoO14 Am R oues__ M A Date of inspection: 1012 y ®i Name of Inspector:(please print) F2e,,S_AA41A.1 C16 0 0 0 Company Name: M c-w iF0 G-L_4 Ajp GN(sw eMailing.Address:Co to iP3EFc he w v c�7 ®f2i o� . w. Telephone Number: `770- 606-17&9 CERTIFICATION STATEMENT I certify0,it,�I haye..personally,inspected the sewage disposal;system at this address and that theinformation reported below ;accurate,and>complete as of the time of the inspection.The inspection'was performed based on my training and;elcperienpe,in tti proper Ainction and maintenance of on site sewage`disposal systems.I am a DEP approved--system inspeEtor:pursuant to Section 15.340 of Title 5(310 CMR 15:000). The'system: V Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date:--42 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. Notes and Comments ****Thisreport 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. Page 2 of 11 4, OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A PERTIFICATION(continued) 'ROPERTY ADDRESS:194 Raleigh Tavern Lane. North Andover,MA OWNER Barbara Tomkins DATE OF INSPECTION: 10/24/01. Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: V I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: e of more system components as described in the"Conditional Pass'sectiori,:need to be replaced or repaired. e'system,upon completion of the'replacement or repair,as approved by the:B of Health;will pass. Answer yes,no-.otnot ermined(Y,N,ND)in the for the following stater If`riot determined"please explain. The septiatank is metal an ver 20 years old*or the septic tank'( ether metal or=not)is structurally -unsound,.exhibits�substantial infiltra or exfiltration or tank failure i A irient.System will pass inspection if the existing tank is4eplaced with a complyin septic tank as approved b e Board of Health- *A metal septic:tank will pass inspection if i ' structurally soun of leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old vailable. ND explain: Observation of sewage backup or break o a high sta' water level in the distribution box due to broken or obstructed pipe(s).or due to a broken,settled o even distributio x.System will pass inspection if(with approval of Board of Health): br en pipe(s)are replaced lion is removed distribution box is leveled or replaced ND explain: - The cyst equired pumping more than 4 times a year due to broken or obstructed pi .The system will pass inspecti f(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 x' OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 'ROPERTY ADDRESS: 194 Raleigh Tavern CERTIFICATION(continued) Lane. North Andover,MA OWNER Barbara Tomkins DATE OF INSPECTION: 10/24/01 _ C. Further Evaluation is Required by the Board of Health: Conditions exist wt'ich require fiuther evaluation by the Board of Health in order to determine' the system is failing to protect public health,safety or the environment. 1. Sy m will pass unless Board of Health determines in accordance with 310 C 5.303(1)(b)that the syste ' not functioning in a manner which will protect public health,safety d the environment: _ Cess 00 r privy is within 50 feet of a surface water Cesspool or ivy is within 50 feet of a bordering vegetated wetland a salt marsh System will fail unless the=Bpai d of alth(and Publi ater2Sunnlier,if any)determines that the system is:functioning in a manner that pro is the On c health,.=safety and environment: The system has a septic tank and soil abso on system(SAS).and the SAS is within 100 feet of a surface water supply or tributaryto a surface ter ply. The system has a septic tank and S and the SAS is thiri:`a Zone 1 of a public water supply. The system has a septic d SAS and the SAS is within- Ozfeet of a private water supply well. The system has a sept* tank and SAS and the SAS isless than='10 eet but 50 feet or more from a private water supply we *.Method used to determine distance **This system p es if the well water analysis,performed at a DEP certified la tory,for coliform bacteria and v the organic compounds indicates that the well is free from polluti from that facility and the presen of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,p vided that no other failure teria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 �* Y y <'y lav r t. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS .° SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) ?ROPERTY ADDRESS: 194 Raleigh Tavern Lane. North Andover,MA OWNER Barbara Tomkins DATE OF INSPECTION: 1.0/24/01 D. System Failure Criteria applicable to all systems: You must indicate`yes"or"no"to each of the following for all inspections: Yes No _Z Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 1. o/ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool f Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow f Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet'of surface water supply or tributary to-a surface water supply. V Any portion of a cesspool or privy is within a Zone '„of,a public well. ✓' Any portion of a cesspool or privy is within 50 feet of a private water'supply well. _ � Any portion of a cesspool or privy is less than 100 feet-but eater 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 coliform bacteria and volatile organic compounds dkll, indicates that the well is free from pollution from-aliat facility and the presence of ammonia nitrogen and nitrate nitrogen is equal--to or less thaw$ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NQ (Yes/No)The system fails.I have determined that oneor 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: considered a large system the system must serve a facility with a design flow of 10 gpd to 15,000 You must indi either"yes”or`no"to each of the following: (The following crit ly to large systems in addition to the criteria a e yes no the system is within 400 f a surface g water supply the system is within 200 feet of a . u a surface drinking water supply the system is located' nitrogen sensitive area(Int Wellhead Protection Area—IWPA)or a mapped Zone II of a pub' water supply well If you have an ed"yes"to any question in Section E the system is considered a si t threat,or answered "yes"in ion D above the large system has failed.The owner or operator of any large syst sidered a si cant threat under Section E or failed under Section D shall upgrade the system in accordance ' 310 CMR .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 Raleigh Tavern Lane. North Andover,MA OWNER Barbara Tomkins DATE OF INSPECTION: 10/24/01 Cheek if the following have been done.You must indicate`des"or"no"as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health _/ ✓ Were any of the system components pumped out in the previous two weeks? ✓ _ Has.the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) _✓_ Was the facility or dwelling inspected for signs of sewage back up? .' Was the site inspected for signs of break out? v,**' all system components,.excluding the SAS, located on site? _ Were,the septic tank manholes-uncovered,opened,and the interior of the tank:inspected for the condition .. of the baffles br tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum'? Was the facility owner(and occupants iMifferent 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: Yes no _ Existing information.For example,a plan at the Board of Health. _Z�etecmined 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(3)(b)j Page 6 of 11 + OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS s r F SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM A r PART C SYSTEM INFORMATION PROPERTY ADDRESS: 194 Raleigh Tavern Lane. North Andover,MA OWNER Barbara Tomkins DATE OF INSPECTION: 10/24/01 •--- -- ----— — — -T_ i FLOW CONDPIIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 for example:i ( p . 110 gpd x#of bedrooms): Number of current residents: _ Does residence have a garbage grinder(yes or no): �� Is laundry on a separate sewage system(yes or no):_ [if yes separate inspection required] Laundry system inspected.(yes or no):_ Seasonal use:(yes or no): Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): Last date of occupancy: L,u r rit yvt COMMERCIA A NDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203):,.. :. _gpd Basis of design flow(seats/persons/sgf,dt0,.): 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: OT 1ER(describe): GENERAL INFORMATION Pumping Records Source of information: Ae 1 CJL P�,)M P C 9 Was system pumped as part of the inspection(yes or no):jQ If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping:. 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/Altcmative technology.Attach a copy of the current operation and maintenance contract(to be obtained fromstem 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: gut) - lal31 Were sewage odors detected when arriving at the site(yes or no):jALD i a a Page 7 of 11 } OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS b3 s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PROPERTY ADDRESS: 194 Raleigh Tavern Lane. North Andover,MA OWNER Barbara Tomkins DATE OF INSPECTION: 10/24/01 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:—/cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: /Vyo j Comments(on condition of joints,venting,evidence of leakage,etc.): P-PLF 1Ai 6-CodP 6-k9DcT1(�1�1 SEPTIC TANK:_(locate on site plan) Depth below grade: (� Material of construction: ✓concrete metal_fiberglass_polyethylene _other(explain) { If tank is metal list age. Is;ageconfirmed by a>Certificate of,Compliance(yes or no):_(attach-4°copy of certificate) Dimensions: i5 o o &- tw-O N C. Sludge depth: 10" Distance from top of sludge to bottom of outlet tee or baffle: D" Scum thickness: / K Distance from top of scum to top:of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: /qN How were dimensions determined: Comments on pumping recommendations inlet ( and outlet t P P g et ee or baffle condition,>ho stru n, aural mtegnty,liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAP:&&Oocate on site plan) Depth below grade:_ Material of construction:_concrete metal fiberglass polyethylene_other (explain): _ Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 ¢5i I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS rn°F" w5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM :m.n: PART C : t �4 ::. .::n SYSTEM INFORMATION(continued) f PROPERTY ADDRESS: 194 Raleigh Tavern a;<<> Lane. North Andover,MA OWNER Barbara Tomkins — s ; DATE OF INSPECTION: 10/24/01 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons , Design Flow: allons/da g y 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.): DISTRIBUTIONBOX- (if present must be opened)(locate on site plan) f Depth of liquid level above outlet invert: Comments,;(note.if box is level and.distribution to outlets equal;any evidence o£solids carryover'any evidence of leakage into or out of box,etc.): Fou"0 PUMP CHAMBER: IVA(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): •c i d*� Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS _ x,r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C r' rvQnM INFORMATION(continued) t "` ROPERTY ADDRESS: 194 Raleigh Tavern Lane. North Andover,MA OWNER Barbara Tomkins DATE OF INSPECTION: 10/24/01 SOIL ABSORPTION SYSTEM(SAS): (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: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: T<_Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): 4aet Dr- P•i5 '1-ooKs ND2mCaj.. 3v P='C7)vnS vt= ®Y4E � �' �,••�,L �� it 4 ��t"r ►.S EM PTY. P 'T tliNG- l-'L-civ✓, '.'CESSPO,ULS: IM (cesspool must be pumped,as part of inspectionxlocate on site;plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:&&(locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 :q>` OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PROPERTY ADDRESS: 194 Raleigh Tavern Lane. North Andover,MA OWNER Barbara Tomkins DATE OF INSPECTION: 10/24/01 i 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 1.00 feet.Locate where public water supply enters the building. i H pv5t= 1 Soo G-At,.�o� TR+V K T pts}An�GrS t A Hs•s z -A -1 wo C., 1 - 6 51. 5 5 2 -G H3'S Page 11 of 11 , m xrr OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS .: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'ROPERTY ADDRESS: 194 Raleigh Tavern Lane. North Andover,MA OWNER Barbara Tomkins DATE OF INSPECTION: 10/24/01 SM EXAM - — -- Slope Surface water Check cellar Shallow wells Estimated depth to groundwater_�o feet 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: _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: _1) S 170 hus h€e^ aeL(st. D iAj 6 R Ef} LSF sV's7F n Z). u s G-5 ,� R Ps INjD,c Wim w�4-7E12 ^ c7 TOWN OF J� SYSTEM PUMPING RECORD DATE: 4- a -C-0 APR 14 20M .. A SYSTEM OWNER& ADDRESS SYSTEM LOCATION (example: left front of house) 1 is �A t � ac "� w-f- DATE OF PUMPING: ( QUANTITY PUMPED : 506 GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES i NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACIOULD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc, COMMENTS: I s CONTENTS TRANSFERRED TO: NEW ENGLANq ENGINEERING SERVICES INC RECEIVED NOV - 9 2004 TOWN OF NORTH ANDOVER HEALTH DEPARTM�E November 5, 2004 North Andover Board of Health Town Hall Annex 27 Charles Street North Andover, MA 01845 RE: TITLE V REPORT: 194 Raleigh Tavern Lane, North Andover, MA Dear Sir or Madam: Enclosed is a copy of the Title V report for the above referenced property. The system PASSED our inspection. If there are an questions lease call me at m office 686-1768. Y9 p Y Sincerely i G w Benja C. Osgoodr. Certified Title 5 inspector 60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645'-FAX(978)685-1099 _ a COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 7 5� TITLE 'OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 1 q`i 04,ctr� IUo RT11 lNti 0 ny e2 AAA Owner's Name: Pro u n `c �At l Owner's Address:- 1114 -4ALFI&H Too ,2J) 1_ns NoLIE A" o ZOO Date of Inspection: Name of Inspector.(please print) Benjamin C. Osgood, Jr. Company Name:New England Engineering Services Inc. Mailing Address:60 Beechwood Drive North Andover, MA 01845 Telephone Number. 978-686-1768 CERTIFICATION STATEMENT I certify that I have.personally inspected the sewage.disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience m the proper function and maintenance of on site sewage disposal systems.T am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000 The system lasses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: /i I o 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 ad or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be seam to the system owner and copies sent to the buyer,if applicable,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 systemwill perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: I -1' `l 1,3 0 2T1-f A^ ��L �lL ✓�az9 Owner: PA,)L c t_fkt Q Date of Inspection: !1 a Inspection Summary: Check A B C D or E/ALWAYS complete all of Section D A. System Passes: V 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 indicatedbe low. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or . repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N�0)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 not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or W&static water level in the distribution box diueto 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 pipc(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3.of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) PropertyAddress: tei 9 (Z4FL-r--L&, t Owner: Date of Inspection: C. Farther Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: I 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 I System will fail unless the Board of Health(and Public Water Supplier,lier if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water suppler. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _.The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well: The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**.Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the rrv11 is free from pollution from that facility aqd the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached tothis form. 3. Other: Pag e4of11 OFFICIAL,INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_H y Owner: A n`C L-vk-(0- Date of inspection: D. System Failure Criteria applicable to all systems: You must indicate`W or`Sno"to each of the following for aIl inspections: Ye$ No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ = Liquid depth in cesspool is less than ti below invest or available volume is less than Ys day flow — ¢ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. -t:L Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. � Any portion of a cesspool or privy is within a Zone 1 of a public well. — Any portion of a cesspool or privy is within 50 feet of a private water supply well. . Any portion of a cesspool or privy is less than 100 feet but greater than 50 fed from a private water supply well with no acceptable water quality analysis.[This system passes if the well water analysis, performed at.aDEP certified Pe laborato for coliform bacteria and volatile�� atrle 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 copy of the analysis must be attached to this form. ) 11/0 (YeslNo)The system&L&I have determined that one or more of the above failure criteria exist as described in 310 CMR 15303,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 hPth You must indicate either"yes"or"no"to each of the following: (the following criteria apply to large systems m 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 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large lar system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of l l OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: i c 9 R AL E I Owner: Date of Inspection: Check if the following have been done.You must indicate es"or"no"as to each of the following: Yes No +� _ Pumping information was provided by the owner,occupant,or Board of Health _ Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? _ Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the syr obtained and examined?(If they were not available note as WA) Was the facility or dwelling inspected for signs of sewage back up? — Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? f _ Were the 'c tank manholes uncover and the — ed,opened, 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 scam?. _ J:� 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: Yes no �— Existing information.For a example, plan at the Board of Health. P — Determined in the field(if any of the failure criteria related to Part C is at issue approximation 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 INSPECTION FORM PART C SYSTEM INFORMATION Property Address:-A j (RAS ELC-� ly 0 2 iw /�nJ G�ve2 it Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example:110 gpd x#of bedrooms): Number of current residents: 2- Does Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage 7- stem(yes or no):,A/D (if yes separate inspection required] Laundry system inspected(yes or no): — Seasonal use:(yes or no): vv o Water meter readings,if available(last 2 years usage(gpd)): - Sump Pump(yes;or no):�}o Last date of ocYY c-,-) r 1COIVIlVIERCIA1JMUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Rpd Basis of design flow(seats/persons/sq%etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):T Non-sanitary waste discharged to the Title 5 system(yes or no):— Water meta readings,if available Last date of occupancyluse: OTHER(descdbe): GF.NF.i?'yA i.INFORMATION Pumping Records Source of information: prG er r 1 . A C 2 o N r(L Was system pumped as part of the inspection(yes or no): If yes,volume pumped. gallons--How was quantityumped 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 cement 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: Were sewage odors detected when arriving at the site(yes or 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- I ti 2 o L-Et c-K �(Z-T"e 0 out ""A Owner: POO L- Date of Inspection: BURDING SEWER(locate on site plan) IF Depth below grade: Materials of construction: Last iron_40 PVC other(explain): Distance from private water supply well ar suction line: y A Comments(on condition of joints,venting,evidence of leakage,etc.): F( PC t N &1DO CO P --%l 0,4j SEPTIC TANK:_(locate on site plan) Depth below grade: Material of construction:—concrete metal fiberglass_polyethylene other(exphdn) Tf tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):_(attach a Dopy of certificate) Dimensions: )5-0 L') ns S Sludge depth: y u Distance from top of sludge to bottom of outlet tee or baffle; 2 Scum tludmess; Distance from top of scum to top of outlet tee or baffle: I/ Distance from bottom of scum to bottom of outlet tee or baffle- How were dimensions determined: ,4 ems ,, e s Il� Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): S (-A-1 6-L-09 co ,D -'n O ill C u Gre-Z tTl0I3 GREASE TRAP:A� ocate on site plan) Depth below grade:_ Material of construction: concrete metal fiberglass polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping- Comments umpingComments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 0 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: (c6 Ll (2- E P A-A 7 CQ n,+a Owner• J2 - Date of Inspection: )1 I. 1 C9y TIGHT or HOLDING TANK: a(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity-. Lgallons Design Flow: �allons/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: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: I!f - (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: L CI�K Tl�t�e1L✓� ,�,�,� N 0 til i A N v out .vi r� Owner: P►4�� ��c.��Y1f� Date of Inspection; 0'f SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why. Type s�leaching Pits,number:2 c,e jq-c K P T-5 leaching chambers,number: leading galleries,number: leading trenches,number,length: leading fields,number,dimensions: overflow cesspool,number: innovativelalternative system Typelname of technology: Comments(note condition of sod,sips of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): Y�1✓►R d� Pr 75 Rm0ic. mssP6-C P'T (A.) 9c�A�y� Trtr' T QIT 15 F,/14P19 , CESSPOOLS: (cesspool must be pumped as part of inspectionXlocateon site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): .PRIVY:A)A (locate on site plan) Materials of construction: Dimensions- Depth of solids- Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY`ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1,r.� Ra4-Ft&H `n4oe2 A t-Atic u D 2-r N. lana 0 oua, "."A Owner: Flu t-- cmc. L-A-u2 Date of Inspection: i i , 0 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 building. Pt5i ACES 7l-o z-3 l-c 7lj0 c- Page 11 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: tel 9 (2,4(,e►&-H -r-A 0 e4,() 1--A&)6- F010 --Rti6ILS 0-TN Owner: P)4La L aC L f+,(L Date of Inspection: m I b SITE EXAM Slope Surface water Check cellar Shallow wells i Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from systm design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach docrmentation) Accessed USGS database explain: You mast describe how you established the high ground water elevation: N►q'S B,CIP Q+4 lS C'DIry f�(Z�✓t c�%— e'er Zl V S "'o A-?-.S' 1 ti A r C �9-?6,2- Commonwealth of Massachusetts RECEIVEMOW p City/Town of System Pumping Record NOV 2 5 2008 Form 4 TOWN OF NORTH ANDOVER " HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Ot se , 0 the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: ; When filling out 1. System Location: Left front, left rear, left side of house. Right fron right rear, 'ght si a of house forms on the computer, use only the tab key Address to move your ! �J\ S1.•� 1(�, �, cursor-do not use the return City/Town State Zip Code key' _____ 2. System Owner: a=A Name Address(if different from location) City/TownSt i ode Stn -- I �` Telephone Number B. Pumping Record 1. Date of Pumping2. Quantity Pumped: Date Gallons 3. Type of system: Ej Cesspool(s) [i-Septic Tank Tight Tank p Other(describe): 4. Effluent Tee Filter present? 0 Yes M40-- If yes, was it cleaned? p Yes No 5. Condition of System: U�JC v� -- ti 6. System Pumped By: Neil Bateson F 5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: L.S. Lowell Waste Water t _3 igna ure of H"r Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1