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Miscellaneous - 202 FOSTER STREET 4/30/2018 (2)
I I Ul ti E L -F- VA -r I a PI PE-VUT-OF-H 59-- V a -NO-C�F-Pj U: A 5 U I'LT CYST �M E -L-1 tj AS A 5 Sc r E 5 I it E L -F- VA -r I a PI PE-VUT-OF-H 59-- V a -NO-C�F-Pj U: A 5 U I'LT CYST �M E -L-1 tj AS A 5 Sc r E 5 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. remm Commonwealth of Massachusetts Title 5 Official Inspegtion Form Subsurface Sewage Disposal System Form - Not for Voluntary Asses: 202 Foster Street Property Address Katherine M. Cain Owner's Name No. Andover City/Town Ma. 01845 6-10-14 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: F. Paul Cardone Name of inspector Septic Compliance, Inc. Company Name 447 Boston Street Company Address Topsfield City/Town 978-8°15-3115 or 978-681-0726 Telephone Number B. Certification AUG 2b 2014 T1011% OF NORTH ANDOVER Ma. 01983 State Zip Code 3294 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: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further luation by the I Approving Authority Inspec is Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Eval by t cal Approving Authority stor's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 tH Commonwealth of Massachusetts 0 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 202 Foster Street Property Address Katherine M. Cain Owner Owner's Name information is required for every No. Andover Ma. 01845 6-10-14 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: When A. General Information filling out forms RECEIVEDon the computer, use only the tab 1. Inspector: key to move your cursor - do not F. Paul Cardone JUN 16 2014 use the return key. Name of Inspector TOWN OF NORTH ANDOVER Septic Compliance, Inc. I HEALTH DE ARTME Company Name Co 447 Boston Street Company Address erum ' Topsfield Ma. 01983 City/Town State Zip Code 978-815-3115 or 978-681-0726 3294 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Eval by t cal Approving Authority stor's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 tH Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 202 Foster Street Property Address Katherine M. Cain Owner's Name No. Andover Ma. 01845 6-10-14 City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins • 3/13 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 202 Foster Street Property Address Katherine M. Cain Owner Owner's Name information is required for every No. Andover page. City/Town B. Certification (cont.) Ma. 01845 6-10-14 State Zip Code Date of Inspection ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): D -Box is beginninq to deteriorate and is in need of replacement ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh !Sins • 3/13 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System • Page 3 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 202 Foster Street Property Address Katherine M. Cain Owner's Name No. Andover Ma. 01845 6-10-14 City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow t5ins • 3/13 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 202 Foster Street Property Address Katherine M. Cain Owner Owner's Name information is required for every No. Andover Ma. 01845 6-10-14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 M =`= Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 202 Foster Street Property Address Katherine M. Cain Owner Owner's Name information is required for every No. Andover Ma. 01845 page. City/Town State Zip Code C. Checklist 6-10-14 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 600 t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form z� 4i=! Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 202 Foster Street Property Address Yes ® No ❑ Katherine M. Cain ® No ❑ Yes Owner Owner's Name No information is required for every No. Andover Ma. 01845 6-10-14 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 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? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: N/A Gallons per day (gpd) ❑ Yes ® No Occupied Date ❑ Yes ® No ❑ Yes ® No ❑ Yes ® No t5ins • 3/13 - Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 202 Foster Street Property Address Katherine M. Cain Owner Owner's Name information is required for every No. Andover page. City/Town D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: Ma. 01845 State Zip Code Date General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: 6-10-14 Date of Inspection Owner and records on file ® Yes ❑ No 1000 gallons Pumq Truck aauae Routine and to properly check interior of the tank. ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 202 Foster Street Property Address Katherine M. Cain Owner Owner's Name information is required for every No. Andover Ma. 01845 6-10-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 20 vears of aae Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): ❑ Yes ® No Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): All appeared to be qood. Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal a feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 5'deep 6' wide 8' long Sludge depth: 3" t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form -'i�i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments _1 202 Foster Street Property Address Katherine M. Cain Owner Owner's Name information is required for every No. Andover page. City/Town D. System Information (cont.) Ma. 01845 6-10-14 State Zip Code Date of Inspection Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 2 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Tape and dip -stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): We recommend tank be pumped on a yearly basis,outlet baffle on.inlet pipe needs to be moved away from outlet baffle,liquid level was good,no evidence of leakage. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness N/A feet ❑ fiberglass ❑ polyethylene ❑ other (explain): 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: t5ins • 3/13 Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts " W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 202 Foster Street Property Address Katherine M. Cain Owner Owner's Name information is required for every No. Andover Ma. 01845 6-10-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El other (explain): Dimensions Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.) * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 202 Foster Street Property Address Katherine M. Cain Owner's Name No. Andover Ma. City/Town State D. System Information (cont.) 01845 6-10-14 Zip Code Date of Inspection Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Good level 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.): Box was level,ran some water through box distribution was equal,no carryover,box is in need of replacement due to deterioration and needs a series of risers to bring up to within 8" below grade. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.) N/A * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Gins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 202 Foster Street Property Address Katherine M. Cain Owner Owner's Name information is required for every No. Andover page. City/Town t5ins • 3113 State Zip Code 6-10-14 Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1 field 21'wide long ❑ 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.): good none none no grassy back vard area Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A 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 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 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 202 Foster Street Property Address Katherine M. Cain Owner's Name No. Andover Ma. 01845 6-10-14 City/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 N/A Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 . Commonwealth of Massachusetts _; Title 5 Official M fficial Inspection Form 11Ell Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Ma. 01845 6-10-14 rage. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand -sketch in the area below ❑ drawing attached separately t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 202 Foster Street Property Address Katherine M. Cain Owner Owner's Name information is required for every No. Andover Ma. 01845 6-10-14 rage. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand -sketch in the area below ❑ drawing attached separately t5ins • 3/13 Title 5 Official Inspection Form: 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 202 Foster Street Property Address Katherine M. Cain Owner Owner's Name information is required for every No. Andover page. City/Town D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Ma. 01845 6-10-14 State Zip Code Date of Inspection Estimated depth to high ground water: 84 Soil Logs- Perc Rate 4min/inch feet Please indicate all methods used to determine the high ground water elevation: 1/' 10 Obtained from system design plans on record If checked, date of design plan reviewed: 9-13-78 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 xplain: You must describe how you established the high ground water elevation: All liquid levels were qood No Sump Pump Basement was dry Soil Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 202 Foster Street Property Address Katherine M. Cain Owner Owner's Name information is required for every No. Andover page. City/Town Ma. 01845 6-10-14 State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins - 3/13 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 Of .l _ SNORiM F Town of North Andover ,SSACNUstt HEALTH DEPARTMENT CHECK #: $ n 1 f I lU _ DATE: l� 1 LOCATION: H/O NAME: CONTRACTOR N 6823 Lq, Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type. $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ TrashlSolid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ YTitle 5 Report $�x_ ❑ Other. (Indicate) $ rtn Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer O� N �rH qti O O �13 �`rSA C HUs�� PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF' COMPLIANCE As of: 6/30/2014 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Complete Repair of D -Box By: James Boraezek At: 202 Foster Street Map 104.D Lot 0066 N th Andover, MA 01845 this certlfiqakall not be construed as a guarantee that the system will function satisfactorily. Public Health Agent 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com North Andover Health Department Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 202 Foster St. MAP: 104.D LOT: 0066 INSTALLER: James Boraczek DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPIONS D-BoxET INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base Cleanouts per plan ❑ Bottom of tank hole has 6" stone_ base ❑ Weep hole plugged 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port 4 ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped: ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION -BOX X Installed on stable stone base NO ❑ H-20 D -Box ❑ Inlet tee (if pumped or >0.087foot) X Hydraulic cement around inlet & outlets X Observed even distribution X Speed levelers provided (not required) - X Schedule 40 PVC Pipe Comments: Much work has been done. 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"` 'si � ��` yr .r: � ',f..� ,L"l.�s...�..!'°a.b:1��.u.�'.�.,t�; �.�1 �' ����ita�:•�� '��` 1� ���q � 4 ate, le/ LI, i N � �r Blackburn, Lisa From: Isaac Rowe <irowe@millriverconsulting.com> Sent: Monday, June 30, 2014 1:41 PM To: Grant, Michele; Sawyer, Susan; Blackburn, Lisa Cc: 'Pam Lally'; 'Isaac Rowe' Subject: 202 Foster Street Attachments: 202 Foster Street - Inspection report 6-30-14.PDF Susan/Michele/Lisa, Attached is a copy of notes depicting the elevations and length of new piping. I will send photos along too. Everything looked good and there is plenty of drop from the inlet to the outlet of the existing tank with sufficient pitch to the new d -box. Please let me know if you have any questions. Thanks, Isaac M. Rowe, R.S. Project Manager Mill River Consulting 6 Sargent Street Gloucester, MA 01930-2719 Phone: 978-282-0014 ext.804 Fax: 978-282-1318 iroweCaD-millriverconsulting.com www.millriverconsultin-g.com Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records. For more information please refer to: http://www.see.state.ma.us/ore/preidx.htm. Please consider the environment before printing this email. i 1 IIt LIC L ( lit17 r x ° Ll t I r Ob 11 { i 114, , `Ll 4 # I I f o I F 1 I J 3 i f ,)1 i !I Hl HIM Ida _. �--�'-T SZ, ©-Z S _- kp I 7 - in I � Id X I S �I r LA 40 { e � E LE.NVA i' 14OP443. I NV PIPE OUT OF N5E I NI V PIPE I NTD ?A14V ( y PIPE OUTOE T -ANLL l Cz 1. 9 ct tw\,/ PAPE INTO D e5OX i S-t.o(n INV PI PEnuT DBnX ,5(0,0\ Z. O\W ENID op- PIPE 1ao 613 �42 � g ; fi &UIL-T IN Cl�t�1�a �0X # FraA,r.t� GGt=�a►�n,S AsSvGtA.-r-ES � N Cwt Ni✓E QS � Al2Li-i IT�G'T'� f� f 6844 Of NORT :1M . O • Town of North Andover HEALTH DEPARTMENT ,sSwCM�1`+t4 CHECK #: % ' 2-71 DATE: .4 <3 c0 1 y LOCATION: H/O NAME: CONTRACTOR NAME: 13v e Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste`Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ Other. (Indicate) $ %S�L t - Health agent Initials White - Applicant Yellow - Health Pink - Treasurer e a • .t''""%:. Commonwealth of Massachusetts Map -Block -Lot n�..� 104.D0066 BOARD OF HEALTH _________ Permit No North Andover BHP -2014-0675 'f ------------ ------- ..«. FEE $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted James -Boraczek ----------------------------------------------------------------------------------------------------- to (Construct) an Individual Sewage Disposal System. at No 2 EE ----20----------FOSTR-------------STRET ------------------------------------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. BHP -2014-067 Dated June 25, 2014 ----------------------- ----------------------------- F--------- -- --------------------------------- Issued On: Jun -25-2014 - -- ---------------------------------------- JB�OARDOF,HE LTkH ....................................................................................................................... ................................. 202 FOSTER STREET Reference No: BHJ-2014-000041 Permit No: BHP-2014-0675 Department: ................................... North Andover BOARD OF HEALTH ........................................•-------------...........------.................. FeeType: Account No: 1001001.1.5.0510.00 .................................... DWC-Component Repair PERMIT Receipt No: REC-2014-001693 ....................................; ........................................••---------......................---------------- Paid By: Paid in Full On: Wed Jun 25,2014 Robert K. Daigle, Jr. ................................... .---------------------------------•-•........----------..........-•--•------------------ Received By: Check No: 14267 ................................... Lisa Blackburn DEPARTMENT'S COPY Amount: $125.00 �.......... ---------------------------------------••-••---•-•-.....------------................------------------............ ............. .............--•--; . ......................... ....................--------------------.......... 202 FOSTER STREET ............................................................... Reference No: BHJ-2014-000041 Permit No: BHP-2014-0675 Department: ................................... North Andover BOARD OF HEALTH .•-•..................................••-•-•••.....------------------------............ Account No:. 1001001.1.5.0510.00 Fee Type: .................................. DWC-Component Repair PERMIT Receipt No: REC-2014-001693 •...............................................................................•-•-..-- Paid By: Paid in Full On: Wed Jun 25 2014 Robert K. Daigle, Jr. .........................................•----........---------------..................•. Check No: 14267 Received By: ................................... ; Lisa Blackburn .................................•--•------------------------...----................--- CUSTOMER'S COPY Amount: $125.00 t t,°RT#j Application for Septic Disposal System Z� 3; �`°�• - •' ' °� TODAY'S DATE -Construction Permit - TOWN OF , MA 01845 $ 250.00 —Full Repair ORTH ANDOVER $125.00 - Component SACHUSQ Important: Application is hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on the computer, use ❑ Repair or replace an existing on-site sewage disposal system* only the tab key to move your �epair or replace an existing system component — What?C1-X / D 44fif cursor - do not use the return key. A. Facility Information 202 �S�er Sf Address or Lot # ./i/°'4.v paver City/Town - 2.- *TYPE OF SEPTIC SYSTEM*: ❑ Pump ravity (choose one) ***If.pu p system, attach copy of electrical permit to application*** Conventional System (pipe and stone system) ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D -Box Present) S.A.S. 2. Address (if different from above) City/Town 3. Installer Information Name y %ire Lc ) lv- State Zip Code / - y�-,�- a��a Telephone Number fle Name of Company Address N City/Town State .. Zip Code Telephone Number (Cell Phone # if possible please) a. Designer Information Name Address City/Town Name of Company State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 V Application for Septic Disposal System Xonstruction Permit —TOWN OF TODAY'S DATE $ 250.00 - Full Repair $125.00 - Component PAGE 2 OF 2 A. Facility Information continued.... 5. Type ofBuilding:`Residential Dwelling or ❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. 6- Nan,e Date Applica ' n Approvedroard of Health Representative) me Date Ap lication Disapproved for the following reasons: For Office Use Only: L Fee Attached? Yes No 2. Project Manager Obligation Form Attached? Yes 3. Pump Svstem? If so, Attach copy ofElectrical Permit Yes 4. Foundation As -Built? (new construction ronly): Yes (Same scale as approved plan) 5. Floor Plans? (new construction only): Yes No No No No Application for Disposal System Construction Permit • Page 2 of 2 SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: 2-02 r -_O t 1 s (Address of septic system) Relative to the application of IlKn /✓0/l� C2C�� (Installer's name) Dated —Z5"/ - o ay s ate For plans by (Engineer) And dated rigina ate With revisions dated (Last revised date) I understand the following obligations for management of this project: 1. As the installer, I am obligated to obtain all permits and Board of Health approved plans p6or to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner, contractor, project manager, or any other person not associated with my company schedules an inspection and the system is not ready, then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against me and/or my company a. Bottom of Bed — Generally, this is the first (V5 inspection unless there is a retaining wall, which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection — Engineer must first do their inspection for elevations, ties, etc. As -built of verbal OK (or e-mail to: healthdel2t&townofnorthandover.com) from the engineer must be submitted to the Board of Health, after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system, all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade — Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation) and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible. 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board of Health staff or consultant. . d. Installation of tank, D -Box, pipes, stone, vent, pump chamber, retaining wall and other components. 6. As the installer: I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: CWT (Today's Date) e--1 � �,C1h1-fs /Sor c2C16 (Name —Print) me —Signed) Tp OF -- F p�IDOVER/ BOARD JpY 6 Town of North Andover, MA Wat:rshed Septic System servicing Report t --._ Date Homeowner: Pumper Street Address: Phone ��► PhoneON N46, r Nature of Service: Routine Emercency Observations: Good Condition Full to Cover 40— Baffles in Place Leachfield Runback Excessive Solids Heavv Grease_ Roots: Other (Explain) Description of Work: Vu _IA . —.----- Comments !_\ z� bo aoz��d , �\ +� x•61 �.,,,f,8 •2 `O Ci 0 \ ,a 0 bL' v Ago")\ 00 fq llo \ JS LSSA W r v i w N -I W I i 4 .'� ppb ,OpOs••i Z2, , 00 a. 6 G � i • I, -a - LoT 2 . I 10 i A= 4Co 318 D •N L OT >s` -Ica -1(o"E--� I I 73.95 `ccs 18.T9� I I \ A= SZ ,OZIS S.F. O N53°-40' 35"E N 4!o°- 0 Z'- 5 8'. 9.15 nI O.00r 3 j 7 .lq. 0. o 404 42" F_ oN - ®71.84 „ 38° I I. - 3Co E y,-77. �o a SOIL PROFILE & PERCOLATION TEST DATA Board of Health -North Andover, Mass. Street Lo=t No. 1 Subdivision' Owner Investigator Observer SOIL PROFILES 1. Date 2. Date 3. Date 4. Date Elev. Elev. Elev. Elev. Feet Inches O 0 Ties to Test Pits 1. 4. P,ov,�J. Note: Top & subsoil depth; depths of other soil types; 'depth of water table; depth of refusal. _ PERCOLATION TESTS Da:te'j-j[-7j Date Date Date Date Pit Number 1 2 3 4 5 Start Saturation b Soak=Mins. Start Test -Time IS Drop of 3" -Time •~ ;vc Drop of 6" -Time Mins. 1st 3" Drop Mins. 2nd 3" Drop Rate Min./In. a . OF"I \- C�T `Z. S� N 21 P 7 _D Ido' r i *Iv PIPE OUT OF NSE U 1 LOT 1 m\/ PIPE 1 NTo -rA-t4 - - t ►k,►\/ MPEOUTOFTrAKII< S r -r WV PIPE INTO 122,50)( ( S't ©L f CNV E -Mo OF PI PIs �J I t.l F 52A. t4 V- C,. A, r� AS 5e>- } UUY UU Z_UU11U ,U 117 <3UBSURFACE DISPOSAL SYSTEM CHECK LIST NORTH ANDOVER BOARD OF HEALTH APPROVED DATE PROVIDED QQ DISAPPROVVD DATE TIME REASON �,v.s,Q_,c� O,n A.� • Title 5 Reg. 2.5 Reg. 6 Fail 1OK1 The submitted plan must show as a minumum: �) the lot to be served (area,dimensions,l.ot #,abutters) (Planning Board files) location and log of deep observation holes -distance to ties _,(� location and results of percolation tests -distance to ties —( -d")"' design calculations & calculations showing required leaching area __(_�iocation and dimensions of system (including reserve area) _� existing and proposed contours 4g location of any wet areas within 1001.of the sewage disposal system ot--disclaimer (check wetlands mapping) ._{a-)- surface and subsurface drains within 100' of sewage disposal system or disclaimer j (i) -location of any drainage easements within 100' of 4 sewage disposal system or disclaimer (planning board. files) i sources of water supply within 200' of sewage disposal system or disclaimer __kk�- location of any proposed well to serve the lot (100' __1 from leaching facility) --(I-)—location of water lines on property (10' from leaching facilities) location of benchmark <— c Win) driveways garbage disposers no PVC is to be used in construction -;, a profile of the system (elevations of basement, plumbers l pipe septic tank, distribution box inlets and outless, distribution field piping and any other elevations) maximum ground water elevation in area of sewage disposal; system t _�_s)_._plan =must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Septic Tanks (a) C acities - 150% of flow, water table, tees, depth CK tees, access, pumping, ( Cleanout c) 10' from cellar wall or inground swimming pool (d) 25' from subsurface drains . ,,. "o loath of Health forth AnPvarXHaae. BEPTIC SYSTEM INSTALLATICK CHECK LIST LOT NFD DATE DI UPPtRO70 AVATI ON OA FAI easanst SAIL OK 1. Distance Tot f �� a. Wetlands -y r b. Drains c. Well 2. Water Line Location 3. No PPC Pipe Septic Tank a.. -Tees -_Length k To Clean Oat Covers. b. Cement Pipe to Tank On Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Lines Flowing Equal. Amounts c. No Back Flow 6. Leach Field or Trench v11a. Dimensions b. Stone Depth c. Capped Inds d. Clean Double Washed Stone' 7. Leach Pit# a. Dimandions b. Sto Depth c. Sp ash Pads d. T s Is: t Pipe to Pit - Both Sides. f. Clean Double Washed Stone 8. No Garbage Disposal 9. Final heading Inspection 10. Barricading Covered System 11. As Built Submitted. --- a. Lot Location . b. Dimensions of System c. Location with Regard -to Pere Test d. Elevations e. Water Table /W cn CL C L O N 4-J Q) L Q Q) 0 0 m r c a N E E O v c fu O L Q) En (z O v r E E O 00 C C Rl a i tp Q) L 8 0 a Iv w u 0 0 w 0 v H O C. L LL L v � o + � O A .a+ C v o E c m O GGQ i C � d C � c _O Q 4 � � L n C V O O C 0 Z Q) L Q Q) 0 0 m r c a N E E O v c fu O L Q) En (z O v r E E O 00 C C Rl a i tp Q) L La,!n of North Andt� -Mer. MA ,ter. shed Septic ; systeffi ..... Ssrvicincr Ren art Date: Homeowner : �f Pumper Street6 f Address Phone -" c, / �1 Natu:: e of Service: Routine K Emer 3ency Observations: Good Condition, i Full to Cover i Baff:'es in Place Leachfield Runback 1 Exce.-,sive Solids Heavj Grease Roots Other (Explain) Description of fork: i Comments: