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Miscellaneous - 20 WINTERGREEN DRIVE 4/30/2018 (2)
/NV P/PE OUT 01-1-1005E /36 6S /NV P/PE /HTO T4NK /36,3$ 136.2 /NV. P/PE 01-170F TANK 136,10 156,41 /NV P/PE /HTO 0,50,y 135,8G 136,10 INV. P/PE OUT Of D. BOX 135,79 13 -01 /NV ENO OF PIPE 2 13y,U �3s7a y l3S. S0 136,72 AWG Z'.e EL EMT/ON AVERAGE STONE DEPT,4( AT P,20BE SUB-SU�.�'E D/SPOSQL .: } V AIM NORTH AN A$S • ��T�r2, fi4G�'2r45 5C,4LE;40�Js Q.�ITE. •' TuG.Y 31;1957 C�,el,5;r 4,44 itIYVAMRcooelN!i, INC. //4 KENOZ.4 Z.A E1� VE,E',4/LG OW, NOTE: T/1/S PL4N /5 N07,4 W,4,ee,4NTY :. , s ! OF Tf/E 5Y57EM BL11' .4 MEW, /C4T/ON �? Of T11E LOC4T/0N OF 7Wr EX/ST/iVC'!;::: . ST,E'UCTURE$:'' t O'icejet Pro L7700 All -in -One series Fax Log for TOWN OF NORTH ANDOVER 9786888476 May 11 2009 9:OOAM Last Transaction Date Time Type Station ID Duration Pages Result May 11 8:59AM Fax Sent 89788580590 0:46 1 OK M's A S LO i ZS, 63 C\ Lo I iS oc. rANGC:�W aar� tAlue Z SLOPE' 2�QU/2�i1�1F/VT � of ����1� (/50) X = /50 — _ ........................... �o c DES/6N EL EI/.4T/ON 4T ......... (TOP OF 570NE) EX/5T/NCS ELEWT/ON AT ......... 2EQ01RE0 FILL If At ONi� / T DSS/�:N .4.5 30/C7 f1S 61//1 T, /Nv P/PE OUT OFyOUSE Z P/PE TgNK INV. INTO 136,35- / 3 6 P Z r �� ,pit '� � fir. '�` � .. , •� - ��"' - . 1361 10 /36 -. Size INV PIPE INTO D. BOX l � r 3`� 0." .YK /NV PIPE our OF D. Box J35,79 i c.z DT 3 0 /NV ENO OF P/PE . . /3S S� /3572 4 yam, S62' SF FD2 GV TE2 EL E"I/<t TION /3©STI) A?T� FiaFrQr4.S ,4VE2,46E STONE Lo I iS oc. rANGC:�W aar� tAlue SLOPE' 2�QU/2�i1�1F/VT � of ����1� (/50) X = /50 — _ ........................... �o c DES/6N EL EI/.4T/ON 4T ......... (TOP OF 570NE) EX/5T/NCS ELEWT/ON AT ......... 2EQ01RE0 FILL At ONi� / T DSS/�:N .4.5 30/C7 f1S 61//1 T, /Nv P/PE OUT OFyOUSE a / ,�+//�?FWz SAYD —%5&& P/PE TgNK INV. INTO 136,35- / 3 6 P Z r /NV. P/PE OUT OF T,4NK 1361 10 /36 -. Size INV PIPE INTO D. BOX l � r 3`� 0." .YK /NV PIPE our OF D. Box J35,79 i c.z NO /NV ENO OF P/PE L/ /3S S� /3572 FD2 GV TE2 EL E"I/<t TION /3©STI) A?T� FiaFrQr4.S ,4VE2,46E STONE SC.4�E`. /%� ria} F f' :0.4TE: �'Wwyl 31�, 11.5-7 .. ,, DEPT// ,47 P,e03E/NEE�L'/N,6, IMC, PLAIN /,S NOT ,4 l�t�,4�e�P.c1NT Y yy //¢EiVOZ.4 ¢�ll;�;QYE�',�,�/LL, M,4. OF TAT SYSTEIW BUT ,4 l/E2/F/C,4T/ON OF Tf/E. LO"T/ON OF 7WE Ea1/5T%l4* ST�UCTU2ES: RECEIVED _�LN Commonwealth of Massachusetts f f � W City/Town of North Andover 'j,,,' System Pumping Record `'��I�OvI. t+i'cALTH [)5pAtT T Form 4 M DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. 6. ckstern Pumped By: Oise Name Stewart's Septic Service Company 7. Location where contents were disposed: rSWwart's Pre-treatment Plant, 20 So. Mill Bradfot Hauler of Receiving Facility Vehicle License Number Ma 01835 Date Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 A. Facility Information Important: When filling out forms 1. System Location: on the computer, Win ruse only the tab t vL key to move your Address cursor - do not use the return North Andover Ma 01845 key. City/Town State Zip Code 2. System Owner: daGrdo 2nan Name Address (if different from location) City/Town State Zip Code Telephone Number B. Pumping Record l /y 1. Date of Pumping o / J p g Date 2. Quantity Pumped: /5W Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. ckstern Pumped By: Oise Name Stewart's Septic Service Company 7. Location where contents were disposed: rSWwart's Pre-treatment Plant, 20 So. Mill Bradfot Hauler of Receiving Facility Vehicle License Number Ma 01835 Date Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 Important When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. VQ 4 ream Commonwealth of Massachusetts C1tylTown of North Andover item Pumping Record a F- —EC EIVED� GOT 0 9 2014 Y TOVVN Ur NUK I h ANUOVER Form 4 1 HEALTH DEPARTMENT DEP has provided this form for use by local B that of Health. here. Before using this form, er forms may be used, b heck with your ut the Information must be substantially the same as provided local Board of Health to determine the form they use. The System Pumping Record must b.e Inubmitted to the local Board of Health or other approving authority within 14 days from the pumping accordance with 310 CMR 15.351. A. Facility Informati®n 1. System Location: -?h 6V i r North Andover CitylTown 2. System Owner: O�S1 Name Ma State Address ('rf different from location) State Cityrrown Telephone Number B. Pumping Reco rd 2. Quantity Pumped: 1. Date of Pumping Date 01886 Zip Code Zip Code 1ao Gallons 3. Type of system: ❑ Tight Tank E] Grease Trap Cesspool(s) Septic Tank ❑ 9 ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If. Yes, was it clearied? El Yes E] No 5. Condition of System: 6. System Pumped By: Vehicle License Number Name Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Hauler Date Signature of Receiving Facility Date System Pumping Record - Page t5form4.doc• 03/06 ✓ V/ 4- JUN 17 2009 TOWN OF NU H ANDOVER HEALTH C' VRTMENT Commonwealth of Massachusetts Title 5 Official Inspection Form IR Subsurface ewage Di os I System Form - Not for Voluntary Assessments Property Address Owner Information is required for /. every page. •V, Y Owner's Name City/Town D. System Information (cont.) State Zip Code 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 building. USA FIRST-CLASS FOREVER o W 00 < 0 1_ r 4190 ' h _ 9 Town of North Andover HEALTH DEPARTMENT ,SSACMUSt� CHECK #:D7 DATE: / LOCATION: H/O NAME: CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 I ector $ the 5 Report ❑ Other. (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer 4*190 hr .,A4D 0 Town of North Andover HEALTH TU "UP A 1DTU1F1%TT U CHECK #: DATE, ]W/, LOCATION: H/O NAME: CONTRACTOR NAME: Type of Permit or License: (Check box) 0 Animal 0 Body Art Establishment 0 Body Art Practitioner 0 Dumpster 0 Food Service - Type: 0 Funeral Directors 0 Massage Establishment 0 Massage Practice 0 Offal (Septic) Hauler 0 Recreational Camp • Sun tanning • Swimming Pool 0 Tobacco 0 Trash/Solid Waste Hauler 0 Well Construction SEPTIC Systems 0 Septic - Soil Testing * Septic -Design Approval * Septic Disposal Works Construction (DWC) * Septic Disposal Works Installers (DWI) * Title 5 Inspector M, Title 5 Report 0 Other. (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer i Commonwealth of M 'ssachusetts . RECEIVED F Title 5 Offic, al Inspection Form °I Subsurface Sewage Disposal System Form - Not for Voluntary Assess ents JUN 12 2009 le Y1-Vr TOW OF NORTH ANOOVE PrOpertv Address Owner LLLP Information is Owneramg required for Y101&'V'2 every page. ity/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. 1 IMPORTANT: When filling out A. General Information forms on the computer, use only the tab key 1. Inspector to move your cursor - do not use the return Name of Inspector key. Gj i! e S tJ ' ► y �_ Company Name �nJ � rac / 1 1 V �- W 'G (r SL � V 11. ` C. Ll.i � S 4/ � I �` � r l `► � — Company Address Brun City/Town State Zip Code ejLr-S Telephone Number License Numr e -r ( 79t• d q `f ?-L(. B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: 91 Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority nsp o s g t ' I Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. - ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. (5 insp doc • 08/06 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments IT - Property rProperty Address Owner Owner's Name Information is required for every page. Cityfrown 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: 1 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 excist. Any failure criteria not evaluated are indicated below. Comments: V r-ecov,Aynlvld� B) System Conditionally Passes: CJQ, ❑ 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,ND) in the ❑ for the following statements. If "not determined," please explain. ❑ The septic tank is metal and over 20 years old" or th septic tank (whether metal or not) is strictually unsound, exhibits substantial infiltration exfiltration or tank failure is imminent. System will pass inspection if the existing tank i replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspectio If it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tan s less than 20 years old is available. ND Explain: ❑ Observation o/ed ge backup or break out or high static water level in the distribution box due to broken or i pipe(s) or due to a broken, settled or uneven distribution box. System will passinspect ith approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed (5 Insp doc • 08106 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form i; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name Information is required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.); ❑ distribution box is leveled or replaced ND Explain: ❑ The System required pumping re than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if ith approval of the Board of Health): ❑ broken pipe(s) ar eplaced ❑ obstruction i emoved ND Explain; C) Further Evaluation is Required by the Board of Health; ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the env�nment. 1. System will pass unless Board of Health determiRsi in accordance with 310 CMR 15,203(1)(b) that the sy/nm functioning in anner which will protect public health, safety and the environ ❑ Cesspool or privfeet a surface water ❑ Cesspool or privet of a bordering vegetated wetland or a salt march 2. System will fail unlerd of Health (and Public Water Supplier, if any) deterines that the systeoning in a manner that protects the public health, safety and environmen ❑ /syvstem s a septic tank and soil absorption system (SAS) and the SAS is within 100 feetater supply or tributary to a surface water supply. ❑ s a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ s a septic tank and the SAS is within 50 feet of a private water supply well. (5 insp doc • 08/06 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 3 of 15 Owner Information is required for every page. .Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments O lJ tn+er- C-) r Property Address Owner's Name City/Town B. Certification (cont.) State Zip Code Date of Inspection C. Further Evaluation is Required by the Board of Health ont.): El The system has a septic tank and SAS and the S 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 wa analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the esence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes Ng ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ d Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ 5� Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ W'A ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than % day flow ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ 5� Any portion of the SAS, Cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. (5 Insp doc • 011106 Title 5 Official Inspection Forth Subsurface Sewage Disposal System • Page 4 of 15 =A & Owner Information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner's Name City/Town S. Certification (cont.) State Zip Code Date of Inspection D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ 16 Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Ef 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.] ❑ d This system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ [d The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the Questions in Section D. Yes No ❑ ❑ ❑ ❑ ❑ ❑ the system is within 400 feet of a s the system is within 200 feet drinkiing water supply to a surface drinking water supply the system is locatedin itrogen sensitive area (Interim Wellhead Protection Area - IWPA or a map d Zone II of a public water supply well If you have answered "yes" to any q tion in Section E the system is condidered a significant threat, or answered "yes" in Section D a e the large system has failed. The owner or operator of any large system considered a signific hreat under Section E or failed under Section D shall upgrade the system in accordance wit 10 CMR 15:304. The system owner should contact the appropriate regional office of the D artment. (5 insp doc - 08/06 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 5 of 15 Owner Information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner's Name City/Town C Checklist State Zip Code Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No E ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ E Were any of the system components pumped out in the previous two weeks? ❑ Has the system received normal flows i6 the previous two week period? ElR Have large volumes of water been introduced to the system recently or as part of this inspection? [1� ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ Was the facility or dwelling inspected for signs of sewage back up? [� ❑ Was the site inspected for signs of break out? []� ❑ Were all system components, excluding the SAS, located on site? [� ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? This size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ Existing information. For example, a plan at the Board of Health. (� ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 6 of 15 (5 Insp doc • 08106 Commonwealth of Massachusetts Title 5 Official Inspection Form i. Subsurface Sewage Disposal System Form Not for Voluntary Assessments ............ Property Address Owner s Name nformation is Owner' Information required for every page. Cityfrown State Zip Code Date of Inspection 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): Li qU oto Number of current residents:--��,-/-- Does residence have a garbage grinder? ❑ Yes ED No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes No Laundry system inspected? A)1 A ❑ Yes ❑ No Seasonal use? + El Yes �No Water meter readings, if available (last 2 years usage (gpd)): 5 q �ci a'ed —5 06,4,04— C ,—,/ // Yes ❑ No Sump pump? A -fyf Last date of occupancy: C— Date Commercial/Industrial Flow Conditions: . Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft.,etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to Water meter readings, if Last date of occupancy/use Other (describe): 5 system? Gallons per day (gpd) Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No (5 insp doc . 08/06 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 7 of 15 Owner Information is required for every page. (5 Insp doc - 08/06 Conimonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner's Name City/Town D. System Information (cont.) Pumping Records: State Zip Code Date of Inspection General Information Source of information: b w yj e—y Was system pumped as part of the inspection? El Yes E ' No If Yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping Type of System: W, 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: Were sewage ordors detected when arriving at the site? El Yes V(No Title 5 official Inspection Form Subsurface Sewage Disposal System • Page 8 of 15 Owner Information is required for every page. . CommmonWealth.of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not.for Voluntary Assessments OU WA-Kf-(E)tee.1�V1 ' Property Address Owner's Name Citylrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer (locate on site plan): Depth below grade: ° feet Material of construction: Q cast iron 0 40 PVC ❑ other (explain) Distance from private water supply well or suction line: /y feet Comments (on condition of joints, ve ting, evidence of leakage, etc.): a. o V f V�J Septic Tank (locate on site plan): Depth below grade: Material of construction: E concrete ❑ metal ❑ fiberglass feet ❑ polyethylene ❑ other (explain) If tank is metal, list age: �/ J14 years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No ------------------------------------------------------------------------------------------------------------------------------------ Dimensions: Sludge depth Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle v Distance from bottom of scum to bottom of outlet tee or baffle / ',)-- How were dimensions determined? 6d /� `' /1 1� (5 insp doc • 08106 Title 5 Official Inspection Forth Subsurface Sewage Disposal System • Page 9 of 15 4 a Distance from bottom of scum to bottom of outlet tee or baffle / ',)-- How were dimensions determined? 6d /� `' /1 1� (5 insp doc • 08106 Title 5 Official Inspection Forth Subsurface Sewage Disposal System • Page 9 of 15 Owner Information is required for every page. Commonwealth, of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner's Name Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or condition, structural integrity, liquid levels as related to out et invert, evidence of leakage, etc.): �rl/<!5 c(Av-"VA0 4Pprz�19"Pi op -e +)A4 1 -phi e 1—.tie2 15,1-6ytS u�c.k��tR=f ee5 ?A /Jlacp—'" Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal El Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle r?c,ovn r4ivl feet ❑ polyethylene ❑ other (explain) Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ polyethylene ❑ other (explain) (Slnsp doc • 08106 L/ Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 10 of 15 Commonwealth of Massachusetts I, Title 5 Official Inspection Form I; Subsu''rfa``ce, �Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Information is required for every page. Owner's Name City/Town D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: Design Flow: Alarm present: Alarm level: Date of last pumping: Comments (condition of alarm and fl State Zip Code Date of Inspection gallons is per aay Yes ❑ No Alarm in working order: ❑ Yes ❑ No Date etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert a Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): L iiYr1�Z 15 tie u -e °}--b rby A �PS -ey.Q vi �l n) au, �6 � o L�) e 1 /i n25 - M i m i n l vfC — Aid �) 6V15 Ot '5-Uf('K ft Pump Chamber (locate on site plan' Pumps in working order: Alarms in working order: ❑ Yes ❑ No ❑ Yes ❑ No (5 insp doc • 08106 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 11 of 15 CommonWealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name Information is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): 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: --j --e ❑ 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.): sv� , �; (4yS au 1� � wa(d� aSltin' (5 insp doc • 08/06 Title 5 Official Inspection Forth Subsurface Sewage Disposal System - Page 12 of 15 Owner Information is required for every page. Commonwealth Qf Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner's Name Cityrrown D. System Information (cont.) State Zip Code Date of Inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth - top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No 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.): (5 Insp doc • 08/06 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 13 of 15 Owner Information is required for every page. 50fo P Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments WIA+9.f' h"9,,�1�Y. Property Address Owner's Name City/Town D. System Information (cont. State Zip Code 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 building. 35 9/ 3317 �y-5 17-azF a (5 Insp doc • 08/06 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form I=, Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Property Address OwnerOwner'sis Owner's Name I required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth of ground water: feet Please indicate all methods used to determine the high ground water elevation: 761 FE] 01 Obtained from system design plans on record If checked, date of design plan reviewed: ate -2 --31-a-7 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: a (5 Insp doc - 08/06 Title 5 Official Inspection Form Subsurface Sewage Disposal System - Page 15 of 15 r•• s pox 4 Spry f... s,. - yam• 0i _ � .. �. Y• � ._ .__. ..: :fir • Ake Z.ti.��r 562 x'F "F 4�3t.�tL - • ' "�"ANGLEW�a4 Lrval�, , 3 //j+ �,y/�//�/� Jam► j(y}}^.'�/y�/{fir .egy OF ................... .., DESlcr+� EtEi.,dMN Ar...,.... 6X1577N%.'fLD'A776/1. f/f .r... �... �GfL C/N4%"!/ i1LL 6 ......r.i.r.. .. r. VENO 45 asWr EIV PF Gm'!T. Af f —d -d . !36.YF /N7'd TANK i36�S lab I /y PIPE 06Ji` OF MM fNd! P/i�f !N;rO li B011 135.8b !N/ PTFE%r OF l� BAX 13579 i36� 0 , •� . - fNk N6plw Ally ,riYO Of 1'jf�E t3S % u�erx ELEY.artJN .. �asziKu E: 7ur-r 3r; 11 L17 . ,av�,ea�E s72?�vt: INC. DE?Ti! 4T /ROSE. `z i l y 114 KEN42.�t: YF��EYI/GG; AM. h/OTE. T+V/S PLAfN • 15 N4T .4 >.> ofT,S+E sTYsr-cm $!! .,o Jun 0:5 0:I 09 01-- 82 1 APW 8786889573 P.1 4, 5mmmmy Rxmd Cwd rwAla8 oA 1i14fM 111-M Pm byKor-t Pap+1 Town of North. Andover Tax Map # 210^104."192-0000,0 Parcel Id 16616 20 WINTERGRI"EN ©RIVE FCifl ONG, CHIT 20 WINTERGREEN DRIVE N. ,ANDOVER, SAA 01845 Class .. T1D1 Sin�fe Family �- - Properb TY� Size Total 1 Acres F, 2009 ... UFS Mallinq Index NamelAddress KWONG, CHIT 20 WINTERGREEN DRIVE N. ANDOVER, MA 0'1843 Trim Loan NumCb& ActhWinaet. From Pays' Until UB Aqc_aunt Mahn. ACtiveltnarY►ue Account NO ' Cycle occupant Ndt e Last Billing Date 4/612009 BId91d. 18078.0 - 20 WINTERGREEN VRIW AcVnfe 31SDI 06 03 Cyde 03 UB SerVlseS W10t„ Account No, 3180106 Rai ChargeR1Wtip8ertUserr Service Code 9.18 it MISCFEE ADMIN FEE WTR WATER 11 01 ALL METER SIZE 47.46 11 UB Meted Maintenartoe Account No, 3160106 Brand Type sin Ym Cons Serial No 5ldtus I..owt161► til MET!: W water 1 115 13240202 a Active Data Reading Do Code Conanri►F>ti14 Posited DM Variance 37% 3/1712009 baa a Actual 14 10 412 2009 10MU209 -86% 121151200& 9/16/2008 590 580 a Actual a Actual 13 1011011009 439% -19% 6110/2008 502 a Actual 13 18 7/1612008 4!1112[108 •.4596 3114/2006 12/17/2007 499 473 a AM* a Actual 31 1022/200$ -70% 138% 9/1411007 442 a Actudi 94 45 10t121Za07 107 170% 6/21/2007 348 a Actual 12 4 411181206=07 0 3116/2007 303 aActual 12 1!1912207 -77% 12/131xD06 /200 91196 287 27'5 a Acbmi a Actual 56 1 415% -17uk 612012005 219 a Actual 11 11 066 7/ 000 )7008 4/17120 4M7 1496 3/20/2006M a Actual 1 a 10142006 1/312006 191 a Actual 71 1a11412D05 2640A 9/1512D05 183 a Actual 17 7/15!2005 41 6/14JZD05 11.2 a Acturyl 15 5 % 312512005 95 a Actual 12 1!141800.4 � 78% 12/1512004 60 a Actual 52 101812 �G 48 9/17/2004 89 a Actual 5 CK -87% 6/1512004 4/23/2004 16 11 s Actual c Correction 05 SM -112004 5417!2004 0% C10 54+ERT 11265 0 1zgV.003 yv 0% 1212312003 1730 n Now Meter V✓►,f/ / �p5 r Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Q . seem Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Asses: Address 70s NNme� r City/Town ,-!§ reQn r RECEIVED JUN 3 0 2009 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 6tg�f� 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. A. General Information Inspector: Name of Inspector A Company Name Com ny A dres City/Town Telephone Number f -'S�er V I C B. Certification 09`76 Mate Zip Code License Number I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience.in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: (d Passes I❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspe to ' Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments WiAtf r�- 'D re vi Proprty Address LXj 0Y\ � Ow is N e Clty/Town t3. certification (cont.) I at -05 �, — q --,o State Zip Code Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: 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: uwl��� � r� Lolmy►�l-� viol @� q' B) System Conditionally Passes: or -Q. ❑ 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. 7 Check the box for "yes", "no" or "not determined" (Y, N,N[ for the following statements. If "not determined," please explain. / The septic tank is metal and over 20 years old* or th septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration r exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replace ith a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if i s structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less an 20 years old is available. El Y ❑ N ❑ ND ( plain below): t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �y w l nib r C, (--f- P v1—])'r Proerty Address GG U..J (i � 1 Ow a 's Na e b �Ad vi Cltyfrown B. Certification (cont.) B) System Conditionally Passes (cont.): v)05 State Zip Code C9 Date of Inspection ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND 'Explain below): ❑ obstruction is removed ❑ Y ❑ N D (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ ❑ ND (Explain below): ❑ The system required pu/replad times a year due to broken or obstructed pipe(s). The system will pass inspecal of the Board of Health): ❑ broken pipe(s) ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is re❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Boar of Health in order to determine if the system is failing to protect public health, safety or th nvironment. 1. System will pass unless Board of Health gotdimines in accordance with 310 CMR 15.303(1)(b) that the system isZfunctig in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is withurface water ❑ Cesspool or privyi�`within 50 feet of a bordering vegetated wetland or a salt marsh t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. t5ins • 09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments f r (—,,e, 1v Address Ow is N e Ci y/Town B. Certification (cont.) 010 Stato Zip Code 4-1--o Date of Inspection 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 a public health, safety and environment: ❑ The system has a septic tank and soil absorption system AS) and the SAS is within 100 feet of a surface water supply or tributary to a surface wat supply. ❑ The system has a septic tank and SAS and the SA Is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and t SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the AS 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 wate analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the pr sence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that n attached to this form. o ther failure criteria are triggered. A copy of the analysis must be 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 ❑ Ly Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ U 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 ❑Nin ❑ l l� Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address K:w 0 y !q) Owner Own r Na e information is )) L�. /� required for ' ��d OSI _t f U l 3 15 C --q — o q every page. City own State Zip—Code Date of Inspection / B. Certification (cont.) Yes No ❑ 6� 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. ❑ GZ 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. 11 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 10 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.] ❑ E� The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ 21*' 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 f lowing, in addition to the questions in Section D. Yes No ❑ ❑ the system is withinZnitrogen ace drinking water supply ❑ ❑ the system is withinutary to a surface drinking water supply ❑ ❑ the system is locatnsitive area (Interim Wellhead Protection Area — IWPA) or af a public water supply well If you have answered "yes" to any qyegtion in Section E the system is considered a significant threat, or answered "yes" in Section D abvVe the large system has failed. The owner or operator of any large system considered a significan rest under Section E or failed under Section D shall upgrade the system in accordance with W CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a-0 (,) I>n ,e e &r jPrortyeAddress Lo-q1AC1 vvvnci a i�ai C n ovtr 01? Cit /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 No LJ ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ L14 Were any of the system components pumped out in the previous two weeks? 9 ❑ Has the system received normal flows in the previous two week period? ❑ Ga/ Have large volumes of water been introduced to the system recently or as part of this inspection? p/ ❑ 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? ,�,( LI ❑ Was the site inspected for signs of break out? ❑ Were all system components, excluding the SAS, located on site? d ❑ 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? d ❑ 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: d ❑ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design). Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments W) A - t fc1 r p -t ✓1) r Pro erty Address w 0A (71 Owner Owr}p ,s Name information is J\VI �`y'V� 0 V required for � every page. Cityfrown State Zip Code Date of Inspection D. System Information Description: /t/Al 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 [v� No Laundry system inspected? lU A ❑ Yes ❑ No Seasonal use? ❑ Yes d No Water meter readings, if available (last 2 years usage (gpd)): S 2P Q k"c �'ej-.54 >M t 4 Detail: % Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Gallons per day (gpd) Yes ❑ No c 1A Date ❑ Yes ❑ No ❑ Yes ❑ No Non -sanitary waste discharged t he Title 5 system? ❑ Yes ❑ No Water meter readings, if av ' able: t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments WInf Rr-�r4�y� Y- Trty Address Uj 0-V/1 G, Own r' Na In o V�'r Cit /Town D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: 610'5 State Zip Code General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: � 0(Jk) gallons A 114 Type of System: dSeptic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool of Inspection ❑ Yes (�( No ❑ 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 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 =;ply Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �JiY\tercq�-e n—TT- PropPIA) Address dV1 (;i vw er 5 N lR t b ve 4C:r own d � b1 � � 6 , q �- � q State Zip.Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: IRR�--Bo- Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: Material of construction: 0 cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: ❑ Yes d No feet �JI-A X feet 16 Comments (on condition of joints, venting, evidence of leakage, etc.): kA , Septic Tank (locate on site plan): Depth below grade: Material of construction: [concrete ❑ metal ❑ fiberglass If tank is metal, list age: feet ❑ polyethylene ❑ other (explain) AJ /A years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: I �" Sludge depth: t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Address Li 6)ij Fi vwne s nam V� A 6 V -C C 6 Cityrown 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 a- ,� Distance from top of scum to top of outlet tee or baffle / Distance from bottom of scum to bottom of outlet tee or baffle ll How were dimensions determined? � U d 04 I � b ►'� Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): N rc'h AY,(k =lg'es t Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal 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: Ct feet .-/VO 5 ❑ polyethylene ❑ other (explain): Date t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Proprty Address W vVj Owner Own is Narna information is We r' /�� required for ' n �t l� every page. Ci crown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Capacity: Design Flow: Alarm present: Alarm level: Date of last pumping: Comments (condition of alarm ❑ fiberglass ❑ polyethylene ❑ other (explain): gallons per day ❑ Yes ❑ No Alarm in working order: Date switches, etc.): * Attach copXof current pumping contract (required). Is copy attached? ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 11 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2--0 WI 'p -le � Prop rty Address ' Owners Narr CityrTownn D. System Information (cont.) 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 (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump /er,on of pumps and appurtenances, etc.): —Z Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins - 09= Title 5 Official Inspection Forth: Subsurface Sewage Disposal System - Page 12 of 17 State Zip Code Date of Inspection 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 (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump /er,on of pumps and appurtenances, etc.): —Z Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins - 09= Title 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 Pror y Address Owner O is N is e information J v „n J� b i `� required for ' I`� IN b O "J every page. C /Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: L� leaching trenches number, length: d ❑ 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.): Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 _A Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Address Owner's N7'nd -- o -I Q Ci !Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins - 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments _..k )'Rn oy>ef Citirrown D. System Information (cont.) (vl� 0-0'� - State Zip Code 4-9-0q Date of Inspection Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below [drawing attached separately t5ins - 09/08 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Na e information is required for ' � QT- b every page. Citylrown State Zip.Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water / ❑ Check cellar \/ ❑ Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: U Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 09/06 Title 5 Official Inspection Form; Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 120 f J 7 Vj L!Ur1e--1C,- to Property Address V Wo vi C�- Owner owner's Name information is required for }�l�i��j every page. City[Town State Zip Code Dateof I section E. Report Completeness Checklist inspection Summary: A, B, C, D, or E checked ['Inspection Summary D (System Failure Criteria Applicable to All Systems) completed D System Information — Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 09108 Tile 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 Y r•• Of ✓.►err 1��........r...�. (/SDS tSQ �ESIGM N 1.RFt1dON AT... . E,tt5!7N4 f7R ... ............................. IIVVNPF gwr OFfl"E . • /3665 ..► ' tAIV PYPF INTO r4'VR 136,35 136. tNV PIPE OUT OFMN X 13 6� 1p 13b, }rVd!PlPF INTO fJMY 1,V-66,t3�6�iD •..•; < '� mss -ac,` x •• �- tN'!. PIPE Our OF Q BO11' 19" Clf PIRA r ` �3S Z AMRT�f �1ttit y�i4 S 7-v,'NO z I F7Ft�R fi41x�2AS tOF,POrAl OC:: S7�iV1:'I"=_AdiE: Tu�-Y 31� 198y PreoBE NOTE: T+V1 p -AY • 15 Or Q Wele4NTY Of T{ E SYSTEM etl r of 1xIE 40"TION fes' 7W -c EX/S77N'!7.:.:.. Jun ma rag Q A ! 3zp DPW 9786889573 P.1 Sammy Roteid Cmd {nested 01Ii1 MW 111--2 a PM bYKOM Nwho P� 1 Town of North- Andover Tax Map # 210-104. 1 -Q0WO Parcel Id 16516 20 WINTERGREEN DRIVE K WONG, CHIT 20 WINTERGREEN DRIVE N. ANDOVER, MA 01845 i Resldei>tiai Class ... ... —�_lly -- - = PrWrtl► iY Slza Total 1 Acres FY 2009 , UB Mailing Index Name/Address 'type Yearn Number Actl WlnacL From Until KWONG, CHIT Payor 20 WINTERGREEN DRIVE N. ANDOVER, MA 0184'5 US Agcount Maint< cyCte accupantN Account No 8ni1± AGtivaJfrlact'we Bldg K 1 so78.o - 20 WINTERGREEN DRIVE Last Billing D06 402009 3160106 03 Cycie 03 UB Sellyices Maitrt Account No, 3188106 Service Cade Raga Charge Multiplier/tls� MISCFEE ADMIN FEE 11 9.18 it WTR WATER 01 ALL METER SIZE • 47.46 11 ue mct+eir Maintenance Amount Flo, 3180108 Brand Serial No mdus YTD Cons 13240202 a fictive METE METE pate Reading 3/17/2009 604 1211.512008 $90 9116/2008 580 6110/2008 502 3/14/2008 489 12/1712007 473 9/14/2007 442 8/21/2007 348 3/16/2007 303 12/1312006 287 9119/2046 275 6/20/2006 214 312012006 208 1/3/2006 101 9/15/2005 183 6114/2005 112 3!2512005 95 12115/2004 60 911712004 88 6/1512004 16 4/2312004 11 C/o 54+ERT 115 10/2012008 12/2312003 1730 I-ocatlan Brand Type Size YTD Cons 00 METE METE W Water 1 1 115 Code Conaurnption Posted Date Vallance a Actual 14 4/291200+9 37% a Actual 10 11=2009 -86% a Actual 78 101"102008 439% a Actual 13 7116/2008 -19% -45% a Actual 16 4/1112008 -7Q% a ACtual a Actual 31 94 1122!2008 1011212047 138% a Actual 45 7,012007 170% 8 Actual 16 411617007 22% a Actual 12 1/19/2007 -77% a Actual 56 10/2012008 415% -179 a Actual 11 7/10006 14% a Actual 11 4/17/2008 -m aActual SA 71 1117/2008 1011412005 264% a ACtUal a Aatual 17 7/15/2005 40% a Actual 15 4/5=5 11 ch a Actual 12 1/14/2005 -76% a Actual 02 10/BM04 486% a Actual 5 7/30004 •82% c Correction 65 511712004 va n Now Meter 0 12/2317.003 Wto of HSTF -j N�I�TH 4&)POULl-�, MA, +-O-r 30 �1PP�� CAS% wA G-i{-S�NE�7 - cc�nl D WEu_ ,�P ouCDD4(C 'S's 56PTrl G 'SYS TEM 1>��516.A 4 CO�J iT J5 �►S,eI'P>�.ovEp OgTE J R �ASoNS A API-1wiN6 /urhoi?►Ty r PLI)L 7 �(� StP��I c SYSTEivt L.v SiA 11.QT►��J Ex/, v4T(c►lj FINAL IV5PEc1-100 V4 rC �j �-O�SS [] F41t_ 4PPROOEP D/JTC.l���ia Apjj;� OOI� )G AUTHol?t-r/ G � DI.SA PP�UvEV DArC ) ECA'so NS FV AL APPI;�jVAL DAVF 314-1- APP►3wvJ6 /6uiNoRIr4