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HomeMy WebLinkAboutMiscellaneous - 2053 SALEM STREET 4/30/2018 (2)New England Claims Services, Ince 131 Dodge Street, Suite 6 Beverly, MA 01915 Phone #(978) 927-3000 Fax # (978) 927-3002 Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec 3B To: Building Commissioner or Inspector of Buildings City Hall North Andover, MAO 1845 To: Board of Health or Board of Selectman City Hall North Andover,MA 01845 RE: Insured: Cleon & Jane Richards Property Address: 2053 Salem'Street, North Andover, MA 01845 Cause of Loss/Date: Lightning/ 9/6/201.4 File or Claim No: BOS 052756 2014 TC ;vnr nc NORTH �nIM -R HEALTH i REpARTMENT Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER 143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Robert L. Smith, Jr. Adjuster On this date, I caused copies of this Notice to be sent to the persons named above at the addresses indicated above by First Class Mail. Signature NOTE TO FILE OF 2053 SALEM STREET: On July 12, 2001 the Conservation Administrator and the Health Director met on site with the owner of the property, Mrs. Jane Richards, to discuss intention to drill new well approximately 5 feet from an intermittent stream. The Conservation process to file a variance was discussed with the result that the homeowner decided to add a water - softening filter to the house's water supply instead of drilling a new well. The Health Director strongly recommended that a water analysis of the existing well be done on an annual basis. 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Wet Pipe m Sheet 3 14 3; ff f I 1 I I i i t ems'; THINGS TWD®. 1 ❑ �Sy�l, sfPKc"nt^TNr / .1'�Y rt El on Post -its 7675M 1993 - 107 FOREST STREET MIDDLETON, MA 01949 (978)774-7122 1 rc; a ECS, o 'Or; A Ju 2 5 FILE # 53101B ' ENVIRONMENTAL i SOLUTIONS, CORP. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PROPERTY OWNER'S NAME: RICHARDS PROPERTY ADDRESS: 2053 SALEM STREET, NORTH ANDOVER, MA ADDRESS OF OWNER: SAME (IF DIFFERENT) DATE OF INSPECTION: MAY 31, 2001 NAME OF INSPECTOR: THOMAS J. CHIGAS THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY 107 FOREST STREET MIDDLETON, MA 01949 (978)774-7122 FILE #.53101B _: •"we r. • ' ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION PROPERTY ADDRESS:2053 SALEM STREET NAME OF OWNER: RICHARDS NORTH ANDOVER, MA ADDRESS OF OWNER: SAME DATE OF INSPECTION: MAY 31, 2001 NAME OF INSPECTOR: (PLEASE PRINT) THOMAS CHIGAS COMPANY NAME: CURRIER ENVIRONMENTAL SOLUTIONS. CORP. MAILING ADDRESS: 107 FOREST STREET, MIDDLETON, MA 01949 TELEPHONE NUMBER: (978) 774-7122 CERTIFICATION STATEMENT I CERTIFY THAT I HAVE PERSONALLY INSPECTED THE SEWAGE DISPOSAL SYSTEM AT THIS ADDRESS AND THAT THE INFORMATION REPORTED BELOW IS TRUE, ACCURATE, AND COMPLETE AS OF THE TIME OF INSPECTION. THE INSPECTION WAS PREFORMED BASED ON MY TRAINING AND EXPERIENCE IN THE PROPER FUNCTION AND MAINTENANCE OF ON-SITE SEWAGE DISPOSAL SYSTEM. I AM A DEP SYSTEM APPROVED INSPECTOR PURSUANT TO SECTION 15.340 OF TITLE 5 (310 CMR 15.000). THE SYSTEM: YES PASSES CONDITIONALLY PASSES NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY FAILS INSPECTOR'S SIGNATURE: ��� , DATE: MAY 31. 2001 THE SYSTEM INSPECTOR SHALL SUBMIT A COPY OF THIS I/NgPECTION 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. NOTES AND COMMENTS: N/A **** 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. REVISED 6/15/2000 PAGE 1 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (CONTINUED) PROPERTY ADDRESS: 2053 SALEM STREET OWNER: FLORES DATE OF INSPECTION: JUNE 6, 2001 INSPECTION SUMMARY: CHECKO B, C, D OR E / ALWAYS COMPLETE ALL OF SECTION D A. SYSTEM PASSES: YES I HAVE NOT FOUND ANY INFORMATION, WHICH INDICATES THAT ANY OF THE FAILURE CRITERIA DESCRIBED IN 310 CMR 15.303 OR 310 CMR 15.304 EXIST. ANY FAILURE CRITERIA NOT EVALUATED ARE INDICATED BELOW. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: NO 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, OR ND) IN THE FOR THE FOLLOWING STATEMENTS. IF "NOT DETERMINED," PLEASE EXPLAIN. N THE SEPTIC TANK IS METAL AND OVER 20 YEARS OLD OR THE SEPTIC TANK (WEATHER 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 PAS INSPECTION IF IT IS STRUCTURALLY SOUND, NOT LEAKING AND IF A CERTIFICATE OF COMPLIANCE INDICATING THAT THE TANK IS LESS THAN 20 YEARS OLD IS AVAILABLE. ND EXPLAIN: N OBSERVATION SEWAGE BACKUP OR BREAKOUT OR HIGH STATIC WATER LEVEL IN THE DISTRIBUTION BOX IS 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 THE BOARD OF HEALTH). N BROKEN PIPE (S) ARE REPLACED N OBSTRUCTION IS REMOVED N DISTRIBUTION BOX IS LEVELED OR REPLACED ND EXPLAIN: N THE SYSTEM REQUIRED PUMPING MORE THAN FOUR TIMES A YEAR DUE TO BROKEN OR OBSTRUCTED PIPE (S). THE SYSTEM WILL PASS INSPECTION IF (WITH APPROVAL OF THE BOARD OF HEALTH): N BROKEN PIPE (S) ARE REPLACED N OBSTRUCTION IS REMOVED REVISED 6/15/2000 PAGE 2 OF I 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (CONTINUED) PROPERTY ADDRESS: 2053 SALEM STREET OWNER: FLORES DATE OF INSPECTION: JUNE 6 2001 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: NO CONDITIONS EXIST WHICH REQUIRE FURTHER EVALUATION BY THE BOARD OF HEALTH IN ORDER TO DETERMINE IF THE SYSTEM IS FAILING TO PROTECT THE PUBLIC HEALTH, SAFETY, AND 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: N/A CESSPOOL OR PRIVY IS WITHIN 50 FEET OF SURFACE WATER N/A CESSPOOL OR PRIVY IS WITHIN 50 FEET OF A BORDERING VEGETATED WETLAND OR A SALT MARSH. 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: N 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. N THE SYSTEM HAS A SEPTIC TANK AND SAS AND THE SAS IS WITHIN A ZONE I OF PUBLIC WATER SUPPLY. N THE SYSTEM HAS A SEPTIC TANK AND SAS AND THE SAS IS WITHIN 50 FEET OF A PRIVATE WATER SUPPLY WELL. N THE SYSTEM HAS A SEPTIC TANK AND SAS AND THE SAS IS LESS THAN 100 FEET BUT 50 FEET MORE FROM A PRIVATE WATER SUPPLY WELL. METHOD USED TO DETERMINED DISTANCE THIS SYSTEM PASSES IF THE WELL WATER ANALYSIS, PERFORMED AT THE DEP CERTIFIED LABORATORY, FOR COLIFORM BACTERIA AND VOLATILE ORGANIC COMPOUNDS INDICATES THAT THE WELL IS FREE FROM POLLUTION FROM THAT FACILITY AND THE PRESENCE OF AMMONIA NITROGEN AND NITRATE NITROGEN IS EQUAL TO OR LESS THAN 5 PPM, PROVIDED THAT NO OTHER FAILURE CRITERIA ARE TRIGGERED. A COPY OF THE ANALYSIS MUST BE ATTACHED TO THIS FORM. 3) OTHER: N/A REVISED 6/15/2000 PAGE 3 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (CONTINUED) PROPERTY ADDRESS: 2053 SALEM STREET OWNER: FLORES DATE OF INSPECTION: JUNE 6 2001 D. SYSTEM FAILURE CRITERIA APPLICABLE TO ALL SYSTEMS: YOU MUST INDICATE "YES" OR "NO" TO EACH OF THE FOLLOWING FOR ALL INSPECTIONS: YES NO NO BACKUP OF SEWAGE INTO FACILITY OR SYSTEM COMPONENT DUE TO AN OVERLOADED OR CLOGGED SAS OR CESSPOOL. NO DISCHARGE OR PONDING OF EFFLUENT TO THE SURFACE OF THE GROUND OR SURFACE WATERS DUE TO AN OVERLOADED OR CLOGGED SAS OR CESSPOOL. NO STATIC LIQUID LEVEL IN THE DISTRIBUTION BOX ABOVE OUTLET INVERT DUE TO AN OVERLOADED OR CLOGGED SAS OR CESSPOOL. N/A LIQUID DEPTH IN CESSPOOL IS LESS THAN 6' BELOW INVERT OR AVAILABLE VOLUME IS LESS THAN''/,. DAY FLOW. NO REQUIRED PUMPING MORE THAN 4 TIMES IN THE LAST YEAR NOT DUE TO CLOGGED OR OBSTRUCTED PIPE (S). NUMBER OF TIMES PUMPED NO ANY PORTION OF THE SAS, CESSPOOL OR PRIVY IS BELOW THE HIGH GROUND WATER ELEVATION. N/A ANY PORTION OF A CESSPOOL OR PRIVY IS WITHIN 100 FEET OF A SURFACE WATER SUPPLY OR TRIBUTARY TO A SURFACE WATER SUPPLY. N/A ANY PORTION OF A CESSPOOL OR PRIVY IS WITHIN A ZONE I OF A PUBLIC WELL. N/A ANY PORTION OF A CESSPOOL OR PRIVY IS WITHIN 50 FEET OF A PRIVATE WATER SUPPLY WELL. NA 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 COLIFORM BACTERIA AND VOLATILE ORGANIC COMPOUNDS INDICATES THAT THE WELL IS FREE FROM POLLUTION FROM THAT FACILITY AND THE PRESENCE OF AMMONIA NITROGEN AND NITRATE NITROGEN IS EQUAL TO OR LESS THAT 5 PPM, PROVIDED THAT NO OTHER FAILURE CRITERIA ARE TRIGGERED. A COPY OF THE ANALYSIS MIST BE ATTACHED TO THIS FORM.] NO (YES/NO) THE SYSTEM FAILS. I HAVE DETERMINED THAT ONE OR MORE OF THE ABOVE FAILURE CRITERIA EXIST AS DESCRIBED IN 310 CMR 15.303, THEREFORE THE SYSTEM FAILS. THE SYSTEM OWNER SHOULD CONTACT THE BOARD OF HEALTH TO DETERMINE WHAT WILL BE NECESSARY TO CORRECT THE FAILURE. E. LARGE SYSTEMS: T -QBE CONSIDERED A LARGE SYSTEM THE SYSTEM MUST SERVE A FACILITY WITH A DESIGN FLOW OF 10,000 GPD TO 15,00 D. YOU MUS DICATES EITHER "YES" OR "NO" TO EACH OF THE FOLLOWING: (THE FOLLOWI CRITERIA APPLY TO LARGE SYSTEMS IN ADDITION TO THE CRITERIA �VEJ NO THE SYSTEM SE A FACILITY WITH A DESIGN FLOW OF 10,000 qplClk GREATER (LARGE SYSTEM) AND THE SYSTEM IS A SIGNIFICANT THk5kT TO PUBLIC HEALTH AND SAFETY A HE ENVIRONMENT BECAUSE ONE OR MORE OF THE FOLLOWING CONDITIONS EXIST -,,- YES NO THE SYSTEM IS WITHIN 400 FEE SURFACE DRINKING WATER SUPPLY THE SYSTEM IS �ITHIN EET OF A T TARY TO A SURFACE DRINKING WATER SUPPLY THE SYSTEM IS ED IN A NITROGEN SE IVE AREA (INTERIM WELLHEAD PROTECTION AREA-IWPA) OR A MAPPED ZONE I PUBLIC WATER SUPPLY WELL IF YOU HAVE ANS D "YES" TO ANY QUESTION IN SECTION E THE SYSTEMS CONSIDERED A SIGNIFICANT THREAT, OR ANSWERED " " IN SECTION D ABOVE THE LARGE SYSTEM HAS FAILED.T WNER OR OPERATOR OF ANY LARGE SYSTE NSIDERED A SIGNIFICANT THREAT UNDER SECTION E OR FAILED I D ECTION D SHALL UPGRADE THE S M IN ACCORDANCE WITH 310 CMR 15.304. THE SYSTEM OWNER SHOULD CONTACT THE APPROPRIATE REGIONAL OFFICE OF THE DEPARTMENT. REVISED 6/15/00 PAGE 4 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PROPERTY ADDRESS: 2053 SALEM STREET OWNER: FLORES DATE OF INSPECTION: JUNE 6 2001 CHECK IF THE FOLLOWING HAVE BEEN DONE. YOU MUST INDICATE "YES" OR "NO" AS TO EACH OF THE FOLLOWING: YES NO YES PUMPING INFORMATION WAS PROVIDED BY THE OWNER, OCCUPANT, OR BOARD OF HEALTH. NO WERE ANY OF THE SYSTEM COMPONENTS PUMPED OUT IN THE PREVIOUS TWO WEEKS? YES HAS THE SYSTEM RECEIVED NORMAL FLOWS IN THE PREVIOUS TWO-WEEK PERIOD? NO HAVE LARGE VOLUMES OF WATER BEEN INTRODUCED TO THE SYSTEM RECENTLY OR AS PART OF THIS INSPECTION? YES WERE AS BUILT PLANS OF THE SYSTEM OBTAINED AND EXAMINED? (IF THEY WERE NOT AVAILABLE NOTE AS N/A) YES WAS THE FACILITY OR DWELLING INSPECTED FOR SIGNS OF SEWAGE BACK UP? YES WAS THE SITE INSPECTED FOR SIGNS OF BREAK OUT? YES WERE ALL SYSTEM COMPONENTS, EXCLUDING THE SAS, LOCATED ON SITE? YES 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? YES 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: EXPOSED TANK YES NO YES EXISTING INFORMATION. FOR EXAMPLE, A PLAN AT THE BOARD OF HEALTH. NO DETERMINED IN THE FIELD (IF ANY OF THE FAILURE CRITERIA RELATED TO PART C IS AT ISSUE, APPROXIMATION OF DISTANCE IS UNACCEPTABLE) [3 10 CMR 15.302(3)(b)] REVISED 6/15/2000 PAGE 5 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C PROPERTY ADDRESS: 2053 SALEM STREET OWNER: FLORES DATE OF INSPECTION: JUNE 6 2001 SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL: NUMBER OF BEDROOMS (DESIGN): 3 NUMBER OF BEDROOMS (ACTUAL): 3 DESIGN FLOW BASED ON 310 CMR 15.203 (FOR EXAMPLE: 110 GPD X # OF BEDROOMS): 330 NUMBER OF CURRENT RESIDENTS: 3 DOES RESIDENCE HAVE A GARBAGE GRINDER (YES OR NO): NO IS LAUNDRY ON A SEPARATE SEWAGE SYSTEM (YES OR NO): NO [IF YES SEPARATE INSPECTION REQUIRED] LAUNDRY SYSTEM INSPECTED (YES OR NO): N/A SEASONAL USE (YES OR NO): NO WATER METER READINGS, IF AVAILABLE (LAST 2 YEARS USAGE (GPD)): WELL ON SITE SUMP PUMP (YES OR NO): YES LAST DATE OF OCCUPANCY: CURRENT COMMERCIAL/INDUSTRIAL: E OF ESTABLISHMENT: DE FLOW (BASED ON 310 CMR 15.20 GPD BASIS O SIGN FLOW (SEATS/PE S/SQ. FT, ETC.): GREASE TRA SENT (YES O O): INDUSTRIAL WA OL G TANK PRESENT (YES OR NO): NON -SANITARY WAS SCHARGED TO THE TITLE 5 SYSTEM (YES OR NO): WATER METER DINGS, VAILABLE: LAST DATE OCCUPANCY/US (DESCRIBE): GENERAL INFORMATION PUMPING RECORDS SOURCE OF INFORMATION: OWNER WAS SYSTEM PUMPED AS PART OF INSPECTION (YES OR NO): YES IF YES, VOLUME PUMPED: 1000 GALLONS - HOW WAS QUANTITY PUMPED DETERMINED? SIZE OF TANK. REASON FOR PUMPING: INSPECTION TYPE OF SYSTEM YES SEPTIC TANK, DISTRIBUTION BOX, SOIL ABSORPTION SYSTEM N SINGLE CESSPOOL N OVERFLOW CESSPOOL N PRIVY N SHARED SYSTEM (YES OR NO) (IF YES, ATTACH PREVIOUS INSPECTION RECORDS, IF ANY) N INNOVATIVE/ ALTERNATIVE TECHNOLOGY. ATTACH A COPY OF THE CURRENT OPERATION AND MAINTENANCE CONTRACT (TO BE OBTAINED FROM SYSTEM OWNER) N TIGHT TANK ATTACH A COPY OF THE DEP APPROVAL N/A OTHER (DESCRIBE): APPROXIMATE AGE OF ALL COMPONENTS, DATE INSTALLED (IF KNOWN) AND SOURCE OF INFORMATION: 26 YEARS OLD: OWNER WERE SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE (YES OR NO): NO REVISED 6/15/2000 PAGE 6 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (CONTINUED) PROPERTY ADDRESS: 2053 SALEM STREET OWNER: FLORES DATE OF INSPECTION: JUNE 6.2001 BUILDING SEWER (LOCATE ON THE SITE PLAN) DEPTH BELOW GRADE: 25" MATERIAL OF CONSTRUCTION: YES CAST IRON 40 PVC OTHER (EXPLAIN) DISTANCE FROM PRIVATE WATER SUPPLY WELL OR SUCTION LINE: N/A COMMENTS: (CONDITION OF JOINTS, VENTING, EVIDENCE OF LEAKAGE, ETC.) THERE WERE NO SIGNS OF LEAKAGE IN OR AROUND PIPE. SOILS WERE CLEAN AND DRY SEPTIC TANK: YES (LOCATE ON SITE PLAN) DEPTH BELOW GRADE: 7" MATERIAL OF CONSTRUCTION:YESCONCRETE METAL FIBERGLASS POLYETHYLENE OTHER (EXPLAIN): IF TANK IS METAL, LIST AGE N/A IS AGE CONFIRMED BY A CERTIFICATE OF COMPLIANCE (YES OR NO) (ATTACH A COPY OF CERTIFICATE) DIMENSIONS: 81 X 5'W X 5'H OUTLET INVERT @ 4'= 1000 GALS SLUDGE DEPTH: 10" DISTANCE FROM TOP OF SLUDGE TO BOTTOM OF OUTLET TEE OR BAFFLE: 24" SCUM THICKNESS: <2" DISTANCE FROM TOP OF SCUM TO TOP OF OUTLET TEE OR BAFFLE: 5" DISTANCE FROM BOTTOM OF SCUM TO BOTTOM OF OUTLET TEE OR BAFFLE: 14" HOW WERE DIMENSIONS DETERMINED: SLUDGE JUDGE, ROD, AND RULER COMMENTS (ON PUMPING RECOMMENDATION, INLET AND OUTLET TEES OR BAFFLES CONDITION, STRUCTURAL INTEGRITY, LIQUID LEVEL AS RELATED TO OUTLET INVERT, EVIDENCE OF LEAKAGE, ETC.): THE TANK WAS PUMPED, LIQUID LEVEL WAS @ NORMAL HEIGHT. THERE WAS NO SIGNS OF LEAKAGE IN OR OUT SOILS WERE CLEAN AND DRY. THE INLET IS CEMENT CONSTRUCTION AND OUTLET BAFFLE IS SCH40 PVC INTACT. THE INTEGRITY OF TANK IS GOOD. NO SIGNS OF DECAY OR WEAR GREASE TRAP: NO (LOCATE ON SITE PLAN) DEPTH -BELOW GRADE: MATERIAL OF TRUCTION: CONCRETE METAL FIB SS POLYETHYLENE OTHER (EXPLAIN) DIMENSIONS: SCUM THICKNESS: DISTANCE FROM TOP OF SCUM TO TOP T E OR BAFFLE: DISTANCE FROM BOTTOM OF S O BOTTOM OF O TEE OR BAFFLE: DATE OF LAST PUMPIN COMMENTS (ON ING RECOMMENDATION, INLET AND OUTLET TE BAFFLES CONDITION, STRUCTURAL INTEG ) QUID LEVEL AS RELATED TO OUTLET INVERT, EVIDENCE OF LEA ETC.): REVISED 6/15/200 PAGE 7 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (CONTINUED) PROPERTY ADDRESS: 7 ATKINSON STREET OWNER: FLORES DATE OF INSPECTION: JUNE 6.2001 TIGHT OR HOLDING TANK: NO (TANK MUST BE PUMPED AT DEPTH BELO E: MATERIAL OF CONST TION: CONC MI (EXPLAIN) DIMENSIONS: CAPACITY: GALLONS DESIGN FLOW: G ONS/DAY ALARM PRESENT OR NO): ALARM LEVE ALARM IN WORKING ORDER DATE OF T PUMPING: NO): (CONDITION OF ALARM AND FLOAT SWITCHES, INSPECTION) (LOCATE ON SITE S POLYETHYLENE OTHER DISTRIBUTION BOX: YES (IF PRESENT MUST BE OPENED) (LOCATE ON SITE PLAN) DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT: 0" DEPTH BELOW GRADE: 30" COMMENTS (NOTE IF BOX IS LEVEL AND DISTRIBUTION TO OUTLET EQUAL, ANY EVIDENCE OF SOLIDS CARRYOVER, ANY EVIDENCE OF LEAKAGE INTO OR OUT OF BOX, ETC.): THERE ARE NO SIGNS OF LEAKAGE, HYDRAULIC FAILURE OR SOLID CARRYOVER IN OR AROUND AREA, ALL SOILS AROUND AREA WERE CLEAN AND DRY THERE WAS ONE INLET AND THREE OUTLETS ORENGBERG. PUMP CHAMBER: NO (LOCATE ON SITE PLAN) PUMPS IN WORKTNa ALARMS IN WORKING COMMENTS (NOTE ETC.): OF PUMP Com, CONDITION OF PUMPS AND APPURTENANCES, REVISED 6/15/2000 PAGE 8 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (CONTINUED) PROPERTY ADDRESS: 7 ATKINSON STREET OWNER: FLORES DATE OF INSPECTION: JUNE 6.2001 SOIL ABSORPTION SYSTEM (SAS): YES (LOCATE ON SITE PLAN, EXCAVATION NOT REQUIRED) IF SAS NOT LOCATED EXPLAIN WHY: TYPE: YES LEACHING PITS, NUMBER: TWO LEACHPITS 5'W X 8'L X 30" INVERTS nae, 24" LEACHING CHAMBERS, NUMBER: LEACHING GALLERIES, NUMBER: LEACHING TRENCHES, NUMBER, LENGTH: LEACHING FIELDS, NUMBER, DIMENSIONS: OVERFLOW CESSPOOL, NUMBER: INNOVATIVE/ ALTERNATIVE SYSTEM TYPE OF TECHNOLOGY: COMMENTS (NOTE CONDITION OF SOIL, SIGNS OF HYDRAULIC FAILURE, LEVEL OF PONDING, DAMP SOIL, CONDITION OF VEGETATION, ETC.) AT THE TIME OF THE INSPECTION THERE WAS NO LIQUID IN THE PIT.THERE WAS NO SIGNS OF HYDRAULIC FAILURE OR BRAKEOUTS IN OR AROUND AREA. THERE WERE NO SIGNS OF WETLAND VEGETATION OR MARSHES WITHIN 100' FROM SYSTEM. ALL SOILS AROUND SYSTEM ARE CLEAN AND DRY. CESSPOOLS: NO (CESSPOOL MUST BE PUMPED AS P NUM ND CONFIGURATION: DEPTH -TOP QUID TO INLET INVERT: DEPTH OF SOLID L DEPTH OF SCUM LAYER: DIMENSIONS OF CESSPOOL: MATERIALS OF CONST TION: INDICATION OF G WATER INFLOW (YE COMMENTS TE CONDITION OF SOIL, SIGNS OF VEGET ON, ETC.): NO (LOCATE ON SITE PLAN) MATERIAL CON DIMENSIONS: DEPTH SOLIDS: COMMENTS (NO VEGETATI , ETC.): INSPECTION) (LOCATE ON SITE PLAN) FAILURE, LEVEL OF PONDING, CONDITION OF SIGNS OF HYDRAULIC FAILURE, LEVEL OF PONDING, CONDITION OF REVISED 6/15/00 PAGE 9 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (CONTINUED) PROPERTY ADDRESS: 7 ATKINSON STREET OWNER: FLORES DATE OF INSPECTION: JUNE 6, 200] 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. jp 6 N or MSS: V Liu .H'a +++TTi 4 \I & .r_ -i. X Y � ' I Ts .� �' t � •. d �� y �f t ✓ O a3h iW41n �.," o n jo .. UJ o �• a dei-; `'`57�:r., ' 'I .� � !.0 ro 4A,;yam b +a"+r,:. W c rs -1Z 1� op N N REVISED 6/15/2000 PAGE 10 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (CONTINUED) PROPERTY ADDRESS: 7 ATKINSON STREET OWNER: FLORES DATE OF INSPECTION: JUNE 6.2001 SITE EXAM SLOPE YES SURFACE WATER NONE CHECK CELLAR YES SHALLOW WELLS NONE ESTIMATED DEPTH TO GROUNDWATER FEET PLEASE INDICATE (CHECK) ALL THE METHODS USED TO DETERMINE HIGH GROUNDWATER ELEVATION: YES OBTAINED FROM SYSTEM DESIGN PLANS ON RECORD - IF CHECKED, DATE OF DESIGN PLAN REVIEWED: YES OBSERVED SITE (ABUTTING PROPERTY/OBSERVATION HOLE WITHIN 150 FEET OF SAS) NO CHECKED WITH LOCAL BOARD OF HEALTH - EXPLAIN: NO CHECKED LOCAL EXCAVATORS, INSTALLERS - (ATTACH DOCUMENTATION) YES ACCESSED USGS DATABASE - EXPLAIN: MAPS YOU MUST DESCRIBE HOW YOU ESTABLISHED THE HIGH GROUND WATER ELEVATION: THE HOUSE HAS A SUMP PUMP AND THE BASEMENT IS DRY. THERE WASN'T ANY SIGNS OF WATER TABLE.THERE'S WETLAND VEGETATION @ 100' FROM SYSTEM. THERE'S NO ABBUTTING PROPERTY'S WELLS OR WETLANDS WITHIN 100' FROM SYSTEM. REVISED 6/15/2000 PAGE 11 OF 11 Form 4 -- System Pumping Record Commonwealth of Massachusetss Massachusetts System Pumping Record •y System Owner System Location Curs for Env,irenriontal Angola 07 F -rest St !! 4053 Salem St ATTiI • DAVID Maddlutncn. NA 41944-2013 r 14 Andovoc, H!A 01845 (97A) 774-1122 rzrr�� Type: Emergency Routine Cesspool: No Yes Septic tank: W =Yes Date of Pumping: Quantity Pumped; Gallons System Pumped By: Wind NOW Enviromnental, LLC Permit #: Contents transferred to: Contents Disposed at: Date: Pumper Signature: Condition of System/Other Comments Dep Approved from - 12/07/95 e lz / io4 tKR AP -E-A I 3D©r� � 8?0,10 � AzeA.r 1.o k2E * n too Al. t rp0 At 47` NST.30k.. r. P. ` E PLor P(AXI 6Y STILES SopVC-y CO: IDArt-'p MAY., I474, V. 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