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Miscellaneous - 211 CANDLESTICK ROAD 4/30/2018 (2)
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. ISI Commonwealth of Massachusetts I RECEIVED Title 5 Official Inspection Form till;; 2 2 2014 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments TOWN OF NORTH ANDOVER 211 Candlestick Road I HEALTH DEPARTMENT Property Address Robert Donahoe Owner's Name North Andover City/Town MA 01845 State Zip Code 8/8/2014 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 1. Inspector: Neil J. Bateson Name of Inspector Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover City/Town 978-475-4786 Telephone Number B. Certification MA State S115 License Number 01810 Zip Code 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 ❑ Need urther aluati n by the Local Approving Authority 4 A 8/8/2014 Insfiect6rs tignature 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 • 3113 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 211 Candlestick Road Property Address Robert Donahoe Owners Name North Andover MA 01845 8/8/2014 Cityrrown 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 exist. Any failure criteria not evaluated are indicated below. Comments: After permit from B.O.H., install new d -box with riser, replace collapsed pipe & outlet tee in septic tank, septic system now passes Title % Inspection. 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 - 3113 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 2 of 17 PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of 8/8/14 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Repair of D -Box By: Todd Bateson At: 211 Candlestick Rd. Map 106A Lot 0205 North Andover, MA 01845 of this c ` id)ate shall not be construed as a guarantee that the system will function satisfactorily. Michele Grant 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 (ommunity Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 211 Candlestick Rd. MAP: 106A LOT: 0205 INSTALLER: Todd Bateson DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS D -Box INSPECTION: 8/8/14 DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS Comments: SEPTIC TANK ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered ❑ 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 ❑ 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 El cement around inlet & outlet Comments: CONTROL PANEL Comments: DISTRIBUTION -BOX Comments: ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Installed on stable stone base H-20 D -Box Inlet tee (if pumped or >0.08'/foot) Hydraulic cement around inlet & outlets Observed even distribution VSchedule Speed levelers provided (not required) 40 PVC Pipe U Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 211 Candlestick Road Property Address Robert Donahoe uwners Name North Andover MA 01845 7/2/2014 CitylTown 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 n 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. 4 3. Other: Riser on septic tank, outlet tee in septic tank, d -box , riser on d -box & collapsed pipe in leach line needs to be replaced. 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 % day flow t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts Map -Block -Lot 106.AO205 ----------- BOARD OF HEALTH Pennit No ------------ North Andover - BHP -2 - 014-07 - 15 ---- ------- ------- -- P.I. FEE F.I. $1 25 .00 DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd -Bale -son --------------------- ---------- ------ --------------------- to (Repair) an Individual Sewage Disposal System. atNo -2-1-1-CANDLE-S-TICK-ROAD ------ as shown on the application for Disposal Works Construction Permit No. -13HP-20147071. Dated --- July -29,29-1-4 -------------------------------------------------------- Issued On: Jul -29-2014 BOARD OF HEALTH ---------------------------------------------------------------------------------- I Town of North Andover HEALTH DEPARTMENT ss A CHECK#: LOCATION: H/O NAME CONTRACT 6962 Type of Permit or License: (Check box) 0 Animal $ 0 Body Art Establishment $ 0 Body Art Practitioner $ 0 Dumpster $ • Food Service - Type. $ • Funeral Directors $- 0 Massage Establishment $ 0 Massage Practice $ • Offal (Septic) Hauler $ • Recreational Camp $ 0 Sun tanning $ 0 Swimming Pool $ • Tobacco $ • TrashlSolid Waste Hauler $- • Well Construction $ SEPTIC Systems: • Septic - Soil Testing $ • Septic - Design Approval $ YSeptic Disposal Works Construction (DWQ ! W- O� Septic Disposal Works Installers (DWI) $ 0 Title 5 Inspector $ 1:1 Title 5 Report $ 0 Other (Indicate) $ P, Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer ri Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Q r� Application for Septic Disposal System Construction Permit - TOWN OF NORTH ANDOVER MA 01845 Construct a new onsite sewage disposal system* 7- Our - TODAY'S DATE - Full Repair !UL ?, 6 2014 ❑ Repair or replace an existing on-site sewage disposal system*L-26 N OF NORTH ANDOVER [9.1fepair or replace an existing system component– What?RTMENT A. Facility Information a 11 4f1'J&- �-Jc Address or Lot # City/Town70, ,, d Vx A- A . 2.- *TYPE OF SEPTIC SYSTEM*: ➢ ❑ Pump cavity (choose one) ***If pump system, attach copy of electrical permit to application*`* ➢ onventional 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) ➢ ❑ Pressure Dosed (D -Box Present) S.A.S. ➢ ❑ Does the system require an effluent filter? Yes No If yes, does plan specify make and model of filter? YES = (no further info. needed) NO = (installer must specify brand of filter before DWC issuance) What is the Make? What is the Model? 2. Owner Information Name Address (if different from above) .� City/Town State Zip Code Telephone Number 3. Installer Information Name Name of 131-q Address '1i A-jvi°-y2 City/Town 4. Desinr Name Address City/Town CON ENTERPRISES, INC. 111 ARGILLA ROAD State Zip Code Telephone Number (Cell Phone # if possible please) Name of Company State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit - Page 1 of 2 12 LIGATIONS An the-Ngnh Andovtsr.l€c=cd &ijjmg= fir t it td=tm - . for . t6leptic System,•forthe�propa ista (Ad 'Dnepr C sytt=) Forpim by f r Rchtme to t4t.I*Mdu c �-d Xna ce, sss m Aird elated i?�tec# i U=T a Go te` Wsta 1eddons dared (Lot reised dam) 1 sundetstod the following Obligations Ast mmmgmcAt ofvvs p.Miect: i. As the inatxd* I am .Obligated to abts & 02 P=its and Board QfHe21.th apl t ed pIsns Om to aoy.W 013 6 Mitre.• L= bm the i2k 'ow, t t�► "rt WD 2• As &ihmdIeA,j, iu earl for my and std adons. l£hom :con o ht:r mon trot as �oc#ed WIt .. eco, t�ctQ pz g , or any ? sr_ypq dulEi iason and the sustain is not ready, ti�efi item 6ree•ahiI1 upplkable. 3. As t f to. kage she - o�tid •pstof xo the-applkabk impact ogs a intt:d�t`to�a:• tta�ron_aslthhc�sstir��ne�#:tiA�.:,��k�.:�,._...e _---_�-�-_: is S ro sht •b 'P �' hich 'ODIIL' 'IGC �C iapCCtbat tioea•Dtat b$�C q bit ptt 8C11S.' t of�*t 3i� OK (or email to; from the etfgisza be: titaba�iittisd txt etc Bc d'tr£Ha� eft: :iiw&UP4, f� i ii �sge es asst cii�a titrse, Inst� sariu'st be ptastit fear t irispecd* Walt pii&p tom; C &c icsd avgtk;txyat tae re sdy gttd able to • cerise pump .#ni 3t#'t31k �d �1�Isum- to �s3.. • ' ! . - - .. . • - c. F t � t�ititer zisust s�equrt i�spectia arbep taigading• capltte; Inset does snot 4. A -a tkt: iastatteo umkftland that oitty IM pt do= the '(allttrtai W#A gMdan) 4nd I on ceS=ed aQr piece thg;tiam&ti to of lite q8jejj4jtjfiin 62 idstaktim: -T r, '5.. Ai theinsMe ,- uitdemzitd Mr, W-40. x i . , . a: 1?stern�itrtYo� �&a� ��pra�� efeit oitfre rx�vrttr'osr �9s•her� rscachea`� b, lmpc6rha Dile Asad Rand atme v he used C. Finsllaarpeett'orr�p�a�r�ti'af.eftttet�affore�ritt: d I A tlati,oftia�lr, l�.ge�x pYtp as mu4 vmt�pump duaftbaritftAft w lanGCoilier rl-`odav5s Bete). 4 TOWN. PAGE 2 OF 2 TODAY'S DATE $.250.00 - Full Repair $125.00 - Component A. Facility.Information continued.... 5. Type -of Buildincl:esidential Dwelling or []Commercial B. Agreement The underslgned agrees to ensure the construction and maintenance of the afore -described on-site sewage disposal system in accordance withthe 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 IS u by this Board of Health. Name Date Application Approv 13Oioard of Health.Representative) Name ' Date Application Disapproved. for the following reasons: For Office Use Only: 1 Fee Attached. Yes 2-'ProiectMariaget Obligation Form Attached. \Yes - 3.: Pum�S s�te_m? Ifso) Attach copy ofElectdcal Permit 4. Foundation As Built. (new construction -ronly),- Yes_ (Same scale as approved plan) 5. FloorPlans? (new construction only): Yes No No No No Application drog0tal System:Construction Permit Page 2 of 2 6953 .......... Town of North Andover HEALTH DEPARTMENT S CHU CHECK#: LOCATI No?] H/O NAME: CONTRACTOR NAME: Type of Permit or License: (Check box) 0 Animal $ • Body Art Establishment $ • 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 $ 0 Sun tanning $ • Swimming Pool $ • Tobacco $ • Trash/Solid Waste Hauler $- • Well Construction $ SEP77C Systems: • Septic - Soil Testing $ • Septic - Design Approval $ 0 Septic Disposal Works Construction (DWQ $- 0 Septic Disposal Works Installers (DW) $ 0 Title 5 Inspector $ Ytte 5 Report $10?4) Ti Y -V- 0 Other (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,. 211 Candlestick Road Property Address Robert Donahoe Owner Owner's Name information is required for North Andover MA 01845 7/2/2014 every page. City/Town State Zip Code Date of Inspection Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. t, /I Q4 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 1. Inspector: Neil J. Bateson Name of Inspector Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover City/Town 978-475-4786 Telephone Number B. Certification MA State S115 License Number 01810 Code TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 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 ❑ NeedXf urther Evaluation by the Local Approving Authority ) /7/2/2014 Ins ct s S nature 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 t i Owner information is required for every page. t5ins • 3113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 211 Candlestick Road Property Address Robert Donahoe Owner's Name North Andover Cityrrown B. Certification (cont.) MA 01845 7/2/2014 State Zip Code Date of Ins 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): Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 um 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 211 Candlestick Road Property Address Robert Donahoe Owner's Name North Andover Cityfrown B. Certification (cont.) MA 01845 State Zip Code 7/2/2014 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 ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): ❑ Y ® N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ® N ❑ ND (Explain below): ❑ 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 t5ins • 3/13 Title 5 Official 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 211 Candlestick Road Property Address Robert Donahoe Owner's Name North Andover MA 01845 7/2/2014 Cityrrown 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: Riser on septic tank, outlet tee in septic tank, d -box , riser on d -box & collapsed pipe in leach line needs to be replaced. 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 '/z day flow t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 211 Candlestick Road Property Address Robert Donahoe Owner Owner's Name information is required for North Andover MA 01845 7/2/2014 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® 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 Commonwealth of Massachusetts u°<Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 211 Candlestick Road Property Address Robert Donahoe Owner information is required for every page. Owner's Name North Andover MA 01845 7/2/2014 CityfTown 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 ® ❑ 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 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1-91 ti 211 Candlestick Road Owner information is required for every page. Property Address Robert Donahoe Owner's Name North Andover City/Town D. System Information Description: Number of current residents: MA 01845 State Zip Code 7/2/2014 Date of Inspection 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.) Yes ❑ No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Yes Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current 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 the Title 5 system? Water meter readings, if available: Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 211 Candlestick Road Property Address Robert Donahoe Owner Owner's Name information is required North Andover MA 01845 7/2/2014 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: Date pumped two years ago, owner 1500 gallons Measured tank. Inspect tank & tees. ® Yes ❑ No ® 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 forth: Subsurface Sewage Disposal System - Page 8 of 17 Commonwealth of Massachusetts 3 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 211 Candlestick Road Property Address Robert Donahoe Owner information is required for every page. Owner's Name North Andover MA 01845 7/2/2014 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 27 years old, 11/1/1987, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 2.8 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.): 4" PVC through wall, 3" PVc in house, no leaks visible. Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 1.8 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) Dimensions: 10'x5'x4' Sludge depth: 21 ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts sD Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 211 Candlestick Road Property Address Robert Donahoe Owner Owner's Name information is required for North Andover MA 01845 7/2/2014 every page. Cityrrown 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 30" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Septic tank 18" deep, needs riser. Outlet tee corroded, needs to be replaced. No evidence of leakage. t5ins • 3113 Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal feet ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 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 211 Candlestick Road Property Address Robert Donahoe Owner Owner's Name information is required for North Andover MA 01845 7/2/2014 every page. Cityrrown 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 ❑ fiberglass ❑ polyethylene ❑ 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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 11 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 211 Candlestick Road Property Address Robert Donahoe Owner's Name North Andover MA 01845 7/2/2014 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 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.): D -box cover broken, replaced. Evidence of carryover, pumped d -box to clean. D -box corroded needs to be replaced. Riser needs to be installed on top of d -box. 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.): " 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: t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17 Commonwealth of Massachusetts ID I Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .'" 211 Candlestick Road Property Address Robert Donahoe Owner Owner's Name information is required for North Andover MA 01845 7/2/2014 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 3 trenches 51' long ❑ 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.): Soil ok. Vegetation ok. No sign of ponding to surface. Leach trench # 3 has collapsed pipe, needs to be replaced. 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 • 3113 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 211 Candlestick Road Property Address Robert Donahoe Owner Owner's Name information is required for North Andover MA 01845 7/2/2014 every page. 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 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 or 17 Owner information is required for every page. t5ins • 3/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 211 Candlestick Road Property Address Robert Donahoe Owner's Name North Andover MA 01845 7/2/2014 Cityrrown 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 0 A 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 211 Candlestick Road Property Address Robert Donahoe Owner information is required for every page. Owner's Name North Andover Cityrrown D. System Information (cont.) State 01845 Zip Code 7/2/2014 Date of Inspection Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: '4 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 8/21/1986 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Design plan ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: test pit data on design plan 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 up Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 211 Candlestick Road Owner information is required for every page. Property Address Robert Donahoe Owner's Name North Andover MA 01845 7/2/2014 Citylrown 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 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 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. A. Facility. Information 1. System Location: Left / Right front of house, Left / i ht rear of hous Left/ right side of house, Left/ Right side of building, Left / Right front of building, Le lg rear of building, Under deck Address Cityrrown . State Zip Code 2. System Owner. Name r Address (if different from location) Citylrown ' Zi Code G6- Telephone Number r '. r B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Canons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Y" No . If yes, was it cleaned? ❑ Yes ❑ No '5. Condition rsteM AAt_ — � AMI -1.1 , 6. System Pumped By. Neil. Bateson Name Bateson Enterprises Inc Company 7. Locatiofi vel re contents were disposed: O- S. Lowell Waste Water —I _ F5821 Vehicle License Number 17'o._ 1 A-/ Date t5form4.doc- 06/03 System Pumping Record • Page 1 of 1 Summary Record Card generated on 6/25/2014 12:24:48 PM by Karen Hanlon Town of North Andover Tax Map # 210-106.A-0205-0000.0 Parcel Id 17349 211 CANDLESTICK ROAD DONAHUE ROBERT J 211 CANDLESTICK ROAD N. ANDOVER, MA 01845 Page 1 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1 Acres FY 2015 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until DONAHUE ROBERT J Payor 211 CANDLESTICK ROAD N. ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/inactive Bldg Id. 17633.0 - 211 CANDLESTICK ROAD Last Billing Date 4/2/2014 3170303 03 Cycle 03 Active UB Services Maint. UB Meter Maintenance Account No. 3170303 Serial No Status Location Brand Type Size YTD Cons 29519944 a Active ERT HH b Badger w Water 0.63 0.63 933 Date Reading Code Consumption Posted Date Variance 6/11/2014 1408 aActual 30 85% 3/11/2014 1378 aActual 16 4/11/2014 -45% 12/10/2013 1362 aActual 29 1/17/2014 -59% 9/11/2013 1333 aActual 72 10/15/2013 44% 6/12/2013 1261 a Actual 50 7/24/2013 153% 3/13/2013 1211 a Actual 20 4/22/2013 -26% 12/11/2012 1191 aActual 26 1/9/2013 -59% 9/13/2012 1165 a Actual 66 10/15/2012 88% 6/12/2012 1099 a Actual 34 7/16/2012 67% 3/14/2012 1065 a Actual 21 4/14/2012 -7% 12/12/2011 1044 aActual 22 1/17/2012 -55% 9/12/2011 1022 a Actual 52 10/13/2011 63% 6/7/2011 970 a Actual 30 7/20/2011 47% 3/8/2011 940 a Actual 20 4/13/2011 -37% 12/9/2010 920 a Actual 32 1/12/2011 -71% 9/10/2010 888 a Actual 118 10/15/2010 219% 6/7/2010 770 a Actual 35 7/15/2010 47% 3/9/2010 735 a Actual 24 4/14/2010 -5% 12/8/2009 711 aActual 25 1/12/2010 -38% 9/9/2009 686 a Actual 42 10/15/2009 -14% 6/8/2009 644 a Actual 44 7/20/2009 121% 3/16/2009 600 a Actual 23 4/29/2009 -30% 12/9/2008 577 a Actual 31 1/20/2009 -53% 9/8/2008 546 a Actual 68 10/10/2008 99% 6/6/2008 478 a Actual 33 7/16/2008 37% 3/7/2008 445 a Actual 23 4/11/2008 -51% 12/11/2007 422 aActual 52 1/22/2008 -50% 9/6/2007 370 a Actual 86 10/12/2007 88% 6/18/2007 284 a Actual 55 7/20/2007 129% 3/14/2007 229 a Actual 24 4/16/2007 -9% 12/8/2006 205 aActual 24 1/19/2007 -65% 9/12/2006 181 a Actual 70 10/20/2006 146% 6/14/2006 111 a Actual 31 7/10/2006 43% 3/8/2006 80 a Actual 17 4/17/2006 -53% V 4 `TITLE V INSPECTIONS Dean G. Luscomb II & Sons E-� P.O.B. 135 Middleton, MA 01949 R 1-508-774-4065 -;i a11 A LICENSED PLUMBER #20285 -� -V" FILE # NA y 500A St'2HEURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PROPERTY OWNERS NAME: P! o n e- t J e r ry Pe -+e rho r) PROPERTY ADDRESS: a I l Canclle4 k. Rd WAncbyp.r- MA ADDRESS OF OWNER S 0 IY?p- of different) DATE OF INSPECTION: ADrd Q NAME OF INSPECTOR : -I-) e: Q n (7pLs C D m 1 U A L I T Y I S N U M B E R O N E T 0 U S G Dean G. Luscomb 1I & Sons P.O. Box 135 Middleton, MA 01949 1-978-774-4065 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS A' DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE aINTER STREET, BOSTON NLA 02108 (617) 292.5500 TRliDY COXE Secretary DAVID B. STRUHS ARGEO PAUL CELLUCCI Commissioner Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION ,! Property Address: vA// �`nAd6U"�Neme of Owner _V,GtiC Address of Owner: ,Sarn.G Date of tnspecbon:/9/� /,/3 +� Name of Inspector: ('tease Print)t� %;. iLuSC13M51 1 am a DEP approved system inspector pursuant to Section 15.340 of Trtie 5 (310 CMR 15.0001 Company Name: Dean G L U S c O m h TT & S CI ng MaSingAddress: P.O. Box 135 Telephone Number: Middleton MA 01 949 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 performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Date: %I Inspector's Signature: �aQOD The System Inspector shell submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department ofEnvironmental Protection. The original should be sent to Rte system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS revised 9'2/98 Page 1 of 11 `= Pr—ed or+ Recycled Paper L. Dean G. Luscomb II & Sons Middleton, MA 01949 1-978-774-4065 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A n_ / 11� // n) CERTIFIC�A�ON (continued) Property Addr ss:�// C�a note 5 r G ��(. kl, owner: f7erson Date of Inspection:/jam/UU INSPECTION SUMMARY: Chadd .q•/ B, C, or D: A. SYSTEMA PASSES: I have not found any, information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEMA CONDMONALLY 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. Indicate yes, no, or not determined (Y, N. or ND). Describe basis of determination in all instances. If "not determined", explain why not. N The septic tank is metal, unless the owner• or operator hes provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. NSewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced N• The system required pumping -more than.fourifines a yeardue to broken or obstructed pipe(s). The system w44l�ess'� inspection if (with approval of the Board of Heaith): broken pipe(s) are replaced obstruction is removed revised 9/2/98 Page 2 or I I G - Dean G. Luscomb II & Sons Middleton, MA 01949 1-978-774-4065 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) rt Propey Address: a2 nn /f' Owner: 'Peb lsph Date of Inspecbon: /�K/ U C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and 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.INILL PRQTECT THE PUBUC HEALTH AND SAFETY AND THE ENVIRONMENT: Al Cesspool or privy is within 50 feet of surface water t%/ 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 IAND PUBLIC WATER SUPPLIER. IF ANY) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HFALT44 AND SAFETY AND THE ENVIRONMENT: LjThe system hes 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. A) The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. /U The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less then 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER N revised 9'2/98 Page 3 of 11 Dean G. Luscomb II & Sons Middleton, MA 01949 �. 1-978-774-4065 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A / CERTIFICATION (continued) Property Address:.2// &-,'l lPSt owner: Date oflnspection:�� o D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failu,e. Yes No N Backup of "wage irvto 4eci{i"r-s,rstem "mponentdoego en overloaded orc4vggad SAS or,cesspoo4. -- 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 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ _ C) Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. — � t Any portion of a cesspool or privy is -within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Yv Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for —coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. LARGE SYSTEM FAILS: Yau mus dicate either "Yes" or "No" to each of the following: The wing criteria apply to large systems in addition to the criteria above: The system serves a 'lity with a design flow of 10,000 gpd or greeter (Large System) and the system is a significant threat health and safety and the env ent because one or more of the following conditions exist: to public Yes No the system is within 400 feet of a surface drinking wt) )y the system is-wi*iA 200 feet of ' Wer"oa4urfao"F"w+g-water eu the system iso ed in a nitrogen sensitive area (Interim Wellhead Protection Area • IWPA) o apped Zone II of a pt.blic wa pply well) The ownef'or operator of any such system shell upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. re•-71sed 9/2/98 Page 4orII ' Dean G. Luscomb II & Sons Middleton, MA 01949 1-978-774-4065 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:OI/ 6111 a/e'5' "CI� " " lj fiver Owner: -pe terSah Date of Inspection: yIS-160 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yep No ✓ Pumping information was provided by the owner, occupant, or Board of Health. None of the system conWoa&nts k-s&..b"n puatpsd4or-atJeast -two weeka and -the vystem hasewsal fiow rates during that period. Large volumes of water have not been introduced into the system recently or as pert of this inspection. V _ As built plans have been obtained and examined. Note if they are not available with NIA. t/ The facility or dwelling was inspected for signs of sewage back-up. L The system does not receive non -sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. I/ _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffle! or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System orrthe site has been determined based on: Existing information. For example. Plan at B.O.H. _✓ _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) 11 5.302(3)(b)1 The facility owner (snd.occupanu, if differaw from.owoer).warapmvlded.with iafounation on .the-Arnpwxaain+an-na^f SubSurface Disposal Systems. revised 9;2/98 Page 5 or ii Dean G. Luscomb II & Sons Middleton, MA 01949 1-978-774-4065 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C _- SYSTEM INFORMATION ProprrrY Address: �l1 Ca•►��esck, �tl, �,a%vfer- Owne.:'Pe 1LCOS'on Date of Inspeetion:{Z5 FLOW CONDITIONS RESIDENTIAL: Design flow: J/0 g.p.d./bedro m. Number of bedrooms (des gn):Number of bedrooms (actual); Total DESIGN flow fyj Number of current residents:_i Garbage grinder (yes or no .Alo Laundry (separate system) (yes o no :VD; If yes, separateinspection. requilted Laundry system inspected (yes or no Seasonal use (yes 00:_ _ o Water meter readings, if available (last two year's usage (gpd): Town �t`er 0" �Reco��s aL i1o, �,m J4�t's Sump Pump (yes 01 0): NU b� 1nSreckv,0 Last date of occur) ancy:�rr-er Type oT2sta. lishment: Design flow: d (Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: lyes or no) Non -sanitary waste discharged to the system: (yes or no)_ Water meter readings, if ev i Last date of occupant : OTHER: (Describe) _ Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information, Z& sF aMaac1 <"r -A, /99 Q��or� System pumped as part of inspection: (yes oitliZ�LlJo If yes, volume pumped: S DOj�allons // // Reason for pumping: D /i��'LY Cc'� x4r. /,i Vd TYVF SYSTEM V Septic tank/distribution box/soil ebsorption'system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval a/ - Other / j� C APPROXIMATE AGE of all components, date i''�t 406PH known) -and source ef•iw(om►ation: A14" ��� 4� . ��wt 47 a �ZS tz fta!/Sc` Sewage odors detected when arriving at the site: (yesno) J� revised 9/2/98 Page 6of11 Dean G. Luscomb II & Sons Middleton, MA 01949 1-978-774-4065 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Add.es3:.2// ti. Avlover- Ownef: t�r�'prsG/I Date of Inspection: 5 1 O BUILDING SEWER: YQS (Locate on site plan) b ' Depth below grade:;/ Materiel of construction:cast iron V 40 PVC other (explain) _ UC dkce — Distance from piivate water supply well or suction line Diameter y �i Comments: (condition of jojnts, ventin evidence of f9aka9e,-etc4 n / -T 4t Soiv+�S 44-1 Urn. GOUT( �CA 12-,-`4�AlA h0 SiSh f OY' /ems' SEPTIC TANK:_fS (locate on site plan) Depth below grader Material of construction: —L/concrete —metal Fiberglass Polyethylene other(explein) 1— if tank is fnetal, list age X4 )s.age.con�f/irmed by Certificate of CompliaAce >x Dimensions:—,5-0 5 4j'eZc it'fQ rLOrrs �.SDUyQ� Sludge depth: ---' / Distance from top of sludge to bottom of outlet tee or baffle: rr Scum thickness: i /" / Distance from top of scum to top of outlet tee or baffle: C; Distance from bottom of scum to bottom ofoutlet tee or baffle: /4 How dimensions were determined: a .S G S a 7y— ,/0, 2 -"r -,G Comments: (recommendation for pumping, � -c�o-n_ evidence of leakage ,ptc.) / k x S GREASE TRAP: (locate on site plan) of inlet and outlet tee (Yes/No) baffles, depth of liquid levy in relation to outlet invert, t' awe %h 'qQo Deth below grade:_ Meteriel o ruction: _concrete —metal —Fiberglass —Polyethylene—other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: _ Comments: (recommendation for pumping, cond' ' inlet end outlet tees or baffles, depth of liquid level in relation to ou ' vert, structural integrity, evidence of leakage, etc. revised 9/2/98 P2ge7orn Dean G. Luscomb II & Sons Middleton, MA 01949 1-978-774-4065 SURSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / // D / SYSTEM INFORMATION (continued) P.op.Yty Ad1dress:s2.// �nQ'leSt'rCk AM• owner : fie' 7:er'S0n Date of Inspection TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) 00ta-t.aon site plan) Depth below grade Materiel o` construction _ trete _metal _Fiberglass _Polyethylene _other(explain) Dimensions' Capacity: gallons Design flow Alarm present gallons/day .� Alarm level: Alarm in workin ll r: Yes _ No_ Date of previous pumping:/ Comments ..,,.� (condition of inlet Tee. condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) it Depth of liquid level above outlet invert, ro Comments ✓ �,IOX 1< Wx16'f � Inote if level and distr button is equal, evidence of solids carryover, evidentq of leakage into or out of box, etc.) . —1&::qX c/ vel. S ;s Ch --1111 s ,s c, i- a� �s Glee ar.cl fru PUMP CHAMBER:P%O (locate -onsite plan) Pumps in working order: (Yes of -No) - Alarms in working order (Yes or No) Comments: (note condition of pump chamber. condition of pumps and appu s, et Page 8of11 It - Dean G. Luscomb II &. Sons Middleton, MA 01949 1-978-774-4065 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 02/,/�/C'SCK Nr/7�IQ0I2�i� Owner: 7-e' ers-o i. Date of Inspection:15-14 S /QD SOIL ABSORPTION SYSTEM (SASI:AeS (locate on site plan, if possible: excavation not required, location may be approximated by non -intrusive methods) If not located, explain: / I_ dt/ �'✓.f'ytTi�+/1,' /� Type: leaching pits, number:_ leaching chambers, number:_ / leeching galleries, number:_�CG`j —3—leaching trenches, number, length: I���K.�GS T �nC o leaching fields, number, dimensions: C/ overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, deq? soil, condition of vegetation, et ,S. is 1'7 o,r n r►l3fr G m ✓) f Oa !h i 1, +L i s e1 r c c'. :5. r I 'eo CESSPOOLS:. -a 0.-C."_cin site plan) Number and configu�r tiea. Depth -top of liquid to inlet Depth of solids layer:_ Depth of scum layer: Dimensions of cesspool:_ Materials of construction: Indication of groundwater: inflow (cesspool pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of pending, condition of -vegetation, etc.) PRIVY: L11 IloceZe.o sip,,,Fte plan) Materials of construction: Depth of solids: Comments: (note condition of soil, signs of revised 9/2/96 level of ponding, condition of Page 9 of 11 Dimensions' -""- 0 Dean G. Luscomb II & Son: Middleton, MA 01949 1-978-774-4065 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C lSYSTEM INFORMATION (continued) Property Ad1dress:�///1�/�SZ 1 C k'� Nr f�nq�dv�r 0wnew: P�c1-crSorn Date of Inspection://S-/Qd SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (l,ocate where public water supply comes into house) 7�ee-Trers 00 B> *D= 7Z"7" O -x CI�zf,ht-.,. C I;o D-- 90' /" XbT —'-- -Box X to D = 96"o 96"R to = X716 c� M 'G /U. Andovfr/ revised 9/2/98 ��c. �k ��, A), � aU Page 10 of 11 s Dean G. Luscomb II & Sons - Middleton, MA 01949 v„ 1-978-774-4065 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) P,operty Add.ess:,z C�c oWne.:7�.��.s©� Date of Inspection: S QQ +NRCS Report name Soi ( urVG C ES.se)e 65. ryas. L)ar4,c.1-jj Paj--�7 Soil Type CC _Ce-XVr!q.,4 Slonq Ent S—Aq 10cLeyy T+,, IS Vo .!NomA Typical depth to groundwater < Ila USGS Date website visited-40-/�0 Observation Wells checked _ ( I } O 5 3 Moderate d p Deep Groundwater depth: Shallow r 13 SITE EXAM Slope v- '%u 11 [G Surface water tJe^ �- Check Cellar L)N Nu Surv�n erv�p Shallow wells None 1 Estimated Depth to Groundwater 7.5 Feet+ Please indicate all the methods used to determine High Groundwater Elevation: / l.�s `��►e 3/�z%8G �n ,'rnae �' z/ �6 �o�,ws 1Ueve Ass«. LObtained from Design Plans on record �f t/Observed Site (Abutting property, observation hole, basement sump etc.) &Lwyf wl 4 Drtf (,d, /Up J�,rn/o naky Determined from local conditions "4"WOS�IG/c' jz- '51A�i��+ le 6w ¢4, a- w�,&y -Ais � m LIChecked with local Board of health _/Cchecked FEMA Maps VChecked pumping records 7,-- Lcnk �/- Checked local excavators. installers V Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) G - 4/ -197 7 = 77,E � was no rcifna/ wQr �170-444 w r elaora d � f � -0 '96" 14 b = 7Z, waS no 7T,,Se jzs fs w ke,� bon.e, 3 N.� e %TL.e., %3c, -or. a}- Y, 56,1,1 be 0 deeper, tkaw ' �� &low jr'ade, uS1n LltE� r '� Q r'e4r'e/1ic-es O —�bA 'A%-1'sed 9/2//98 PxReIll orlt o� Linin I.�YJ:7.a s /s," z #3 ISs'-3/ It �XisfiN� ••, �.wE!/ter SSG � r�L.J�P)c/ �• 'fi9 Nk ..-...�--,�.,.�..w.v�..;"�»i^.,T7�'N?.iRY`L�:.sr°ir^��.rM. ,m�e�.,�.t.r � T.r...-a.�.-...^�rr.o.—..*r.s+�rnz�•,*�s�c�.,.: elsR^s-+m�T Rr,� vp.�-*,am.�m+^:sr�rr�F Ri�F+�i�i':+�r7+x..3"""r�.P^."�'^S!•.t�i+M_�',�w..�e��!—�.r TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE; SYSTEM OWNER & ADDRESS JAN -62 A SYSTEM LOCATION (example: left front of house) DATE OF PUMPING: o Lt QUANTITY PUMPED �ALLONS CESSPOOL: NO YES , SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED _- OTHER (EXPLAIN) SYSTEM PUMPED BY: (2t,4-) COMMENTS: CONTENTS TRANSFERRED TO: lzl� t�ii fA0 C> C6 o d i57 Ell r I zo rt O N CA z to tri O 0 z x' CA d x �o a. ..' IWQ zz o a' OCH V E �- y 0 � � H lzl�