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HomeMy WebLinkAboutMiscellaneous - 216 FOREST STREET 4/30/20181 N O N rn T O m m cn N � b cni Om o m 0 m Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Commonwealth of Massachusetts City/Town of _ 1Q©_„4,p6ver System Pumping Record Form 4 RECEIVED wky 4 2013 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information 1. System Location: 2/4 �U►�e5f" ��- Address City/Town 2. System Owner: L Name Ma State Zip Code Address (if different from location) Newbury City/Town State Zip Code Telephone Number B. Pumping Record /13 16 0 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System:�y A_� 6. System Pumped By: Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: St rt's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 1/1 ('�: g ature ,Hauler Date Signature of Receiving Facility Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 Insurance Adjustment Service, Inc. 936 Roosevelt Trail Unit 5 Windham, Maine 04062 207-892-0522 Fax 207-892-0526 UNDER MASSACHUSETTS GENERAL LAWS CHAPTER 139 SECTION 3B Date: March 11, 2011 TO: Board of Health/Building Inspector RE: Insured: Diane Bauer Property Address: 216 Foster St N Andover MA 01845 MAR 17 1011 Date of Loss: 2/5/2011 TOWN OF NORTHAr-k ff R Policy Number: 1062065 Type of Loss: File or Claim Number: 69083 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6, to be applicable. If any notice under Mass. Gen. Laws, Ch. 139, Sec. 38 is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, locations, policy number, date of loss and claim or file number. Thank you for your cooperation. Very Truly yours, Matt Martin Adjuster Ext. 109 Aoard of M alth 121orth A-ndcvor,Yass APPROVED DATE Provideds Title V Reg 2.5 SUBSURFACE MPOSAL' DMON CHECK LIST LOT DISAPPROVED DATE Reasons s Phe submitted plan must show as a mininums a) the lot to be served -area., dimensions lot #,abutters b location and log deep observation holes -distance to ties C location and results percolation tests -distance to ties ,d design calculations & calculations snowing required leaching area e) location and dimensions of system -including reserve area £) existing and proposed contours g) location any wet areas Athin 1001 of sewage disposal system or disclaimer -check wetlands mapping h) surface and subsurface drains within 1001 of sewage disposal system or disclaimer location any drainage easements Within 1001 of sesage disposal systta or disclaimer -Playing Board files J) knom sources of vAter supply within 2001 of sewage disposal system or disclaimer k) location of any proposed rel.l to serve lot -1001 from leaching facility 1) location of water lines on propsrt7-101 from leaching facility 0 location of benchmark irY driveways garbage disposals no PVC to be used in construction q) profile of system -elevations of basement, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and Other elevations rl maximum ground water elevation in area selvage disposal system s) plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans . Reg 6 Septic Tanks ( cTapacit ems -i-50% access, pumping cleanout of flow, water table, tees, depth of tees, 101 from cellar wall or inground sig pool 251 From subsurface drains Reg 10.2 Distribution Boxes a slope greater than 0.08 Reg 10.41 b) sump �0 ' )surface I Reg 121.1 14.3 14.4 14.6 U& 1.10 Reg 9.1 9.6 ILI ;1 N Leaching Pits Leaching pits are Dz'gferred where the installation is possible a) calculations o leaching area-� 540 sq ft b) spacing C) surface a 2% d) corer erial e) 2ex2l R splash pad f) tee t elbox g) no ends in pipe from d -box to pipe Leaching F_ee_l_d-H a) no greater than 20 minutes/inch % area -mini=m 900 sq. ft construction of field d) surface drainage 2 % e) 201 from cellar va11 or inground s -win ng pool L eachin SWqdches a) tculati o eaching area-mi.n 500 eq ft b) cing- ft min 6 ft with reserve between c) dimensi s d) cons ction e) stone f) surface drainage 2% a) sop y x = to be short) b) y/x 7 150 = (to be shown) EMS a) i4b4y b) power Board ocnHealth North A,t�T�189. ky Ti�CC MTS LIST T �STp IN tTI ALLArl d C C L K I ;moi LOT ------.A�ATIaN -- ON .- O - --K r -- . X �:►_LL 1. Distance Tos a. Wetlands b. Drains e. Well 2. Water Line Location 3• No PVC Pipe 40- Septic Tank—=- a... -Tees --Length & To Clean Out Covers - b. Cement Pipe to Tank - On Both Sides of Tank -- 5. Distribution Box a. Covers k Box - No CrFagks b. All Lines Flowing Equal Amounts c. No Back Flow b. beach Field or Trench a. Dimensions b. Stone Depth e. Capped 'Ends d. Clean Double Washed Stone 7. LeaVh a. s b. th c. ds d. e.pe to Pit - Both Sides f. Clean Double Washed Stone 8. No Garbage Disposal 9. Final Grading 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 a I 1 �4 0 ro rc: -P �4 0 z rc (V 44 .H u Q) ro 04 r4 U) (a Q �4 0" (a r -i U) �4 a) 4-) r� 2 0.0 .ri t7 -P �4 4-) rO 4-) 0 m u ro ra U) z r. (a 0 .H LO 4-J Q) fa ro u (a rq �4 44 U) Q) ,C� 04 E -i U) I �4 (a -P U) r. .ri 0) 0 �4 04 0 (a -rl ul LP 4-) 0 0 04 04 �4 U) 0 —1 ra �4 0) Q) (1) r -I fa -P 4-) .r -I :r. (n m 0 Q) >1 Q 0 .ri 4-) Cf) C14 u Z 14 0 .11 -P 4-) (a (a Z U z 0 0 > u 0 z rX4 W 4-) 0 4-3 .11 z ra HU) Q) < 4J 00 W u z m .H Q) kA H '72 4J 4J -P >1 44 M -P In �4 in 0 0 P4 4J LL < En -H .ri ro 0 0 0� p P4 E -i CO I 1 �4 0 ro rc: -P �4 0 z rc (V 44 .H u Q) ro 04 r4 U) (a Q �4 0" (a r -i U) �4 a) 4-) r� 2 0.0 .ri t7 -P �4 4-) rO 4-) 0 m u ro ra U) z r. (a 0 .H LO 4-J Q) fa ro u (a rq �4 44 U) Q) ,C� 04 E -i U) I �4 (a -P U) r. .ri 0) 0 �4 04 FORM 4 • SYSTEM PL11PL\G RECORD Commonwealth of Massachusetts , Massachusetts ,System Pumping Record N'stem Ukvner Date of Pumping: Cesspool: No Yes ❑ d 16 r-c:c' 5- P, Ljal-r Quantity Pumped: gallons Septic Tank: No ❑ Yes R System Pumped by: � ��� License #: Contents transferred to: Date _ Inspector 206 ANDOVER ST., SUITE 11 ANDOVER, MA 01810 (508) 475-1237 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property Owner's name Date of Inspection PART A CHECKLIST Check if the following have been done: _Aef:f Pumping information was requested of the owner, occupant, and Board of Health. _Z -None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ZAs built plans have been obtained and.examined. Note if they are not available with N/A. The.facility or dwelling was inspected for signs of sewage back-up. _,ZThe site was inspecteddOfor signs of breakout. All system components, excluding the SAS, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, 'material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the SAS on the site has been determined based on existing information or approximated by non -intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. — SERVING ANDOVER & VICINITY FOR OVER 40 YEARS — a SUBSURFACE BE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential number of bedrooms _ number of current residents _1 garbage grinder, yes or no laundry connected to system, yes or no seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: CSij list,\\ - %-A Last date of occupancy GENERAL INFORMATION Pumping records and source of information: EnQ e- Sen1 CA cin System pumped as part of inspection, yes or no if yes, - volume pumped —,5c�6 SkQ\kc--j Reason for pumping: i, ' Type of system Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) Approximate age of all components. Date installed, if known. Source of information: G !1 G Q 'i CSI _ n VJO_ Sewage odors detected when arriving at the site, yes or no 8 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: (locate on site plan) depth below grade•I_ material of construction: concrete metal FRP other(explain) dimensions:_(�u- sludge depth " distance from top of sludge to bottom of outlet tee or baffle !.�* scum thickness -SLL- distance from top of scum to top of outlet tee or baffle " distance from bottom of scum to bottom of outlet tee or baffle Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc.) �c�. ckc �lfV1Gr\\'T-•�r•_�f�Z L'". c::F_��c i �::1c1. �Ci n �[3 �Tc_t-�\t. �Y�3 �� DISTRIBUTION BOX: (locate on site plan) �Jrl� depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc.) PUMP CHAMBER: (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc.) 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods) If not determined to be present, explain: Type leaching pits and number leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil, signs of hydraulic condition of vegetation, recommendations for failure, level of ponding, maintenance or repairs,etc.) CESSPOOLS (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 (cesspool must bt pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic condition of vegetation, recommendations for failure, level of ponding, maintenance or repairs,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, recommendations for maintenance or repairs,etc.) 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks. locate all wells within 100' A DEPTH TO GROUNDWATER Q) 4 k depth to groundwater -e... ..-9 %eA method of determination or approximation: rA 4-c to Ct?•ti�2� Cfi uta � �' 3:, •;G GL �1it G4:tr 3b 4; `e ve 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not) UO Backup of sewage into facility? U Discharge or ponding of effluent to the surface of the ground or surface waters? VJO'Static liquid level in the distribution.box above outlet invert? Liquid depth in cesspool <6" below invert or available volume< 1/2 day flow? Required pumping 4 times or more in the last year? number of times pumped Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: %30 below the high groundwater elevation? UC,L within 50 feet of a surface water? within.100 feet of a surface water supply or tributary to a surface water supply? within a Zone I of a public well? within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS)? 00- within 50 feet of a private water supply well? ia0 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 analys" for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. 13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector Company Name 1P.ID- Q1QA\V +Is01_'s Z1�1�_ Company Address.A-,dc.���' Certification Statement I certify that I have personally inspected the sewage disposal system at this -address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and manitenance of on-site sewage disposal systems. Check one: have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15.303. Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15.303. The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector's Signature f�4� Date 4•aG Original to system owner Copies to: Buyer (if applicable) Approving authority Q) cn A U- « -- O O I� 1c C 'S C 10 C _Q Q i.� Q O O m H O L L O � sw+`C O C O 41 � O � C o E c O 3 •O R O �GQ U F- O Q 4 41 E 3 U O O C U •— C 1c 43,132 SF � � j• �STiNC 1 STR E L ----VAT IhlV- FILE. OUT DF HSE- 102 . / V 11r... 1 1 bay, MEuT.1 E L9, Id Lc 6 t �' V � �- � V �2 �1�,�. � i �► PG�'.�A1.-- F--tlo rp1Pe 10-0162- A O062 A&/Dovr::.R - t j' ! �•' . �� s t F 4 ! xs-r&,L)7- ! u I L L) e -l? Yin. 1; 1 5 CA. L -p- 1 11 4 0 9/zs/ 0 y' r �` ~.. ��.• F C2A P! iC. G. l� 1=c..frs AS � A.S'gvGi d.T'ES MI q WAPIF FM V C 14 ES7-A/U-I- U I LL) 9 9 j WELL DATABASE ADDRESS: AGE OF WELL: WELL DRILLER: ? WELL PERMIT #: WELL LOCATION: WELL PERMIT DATE: DEPTH OF WELL: TYPE OF WELL: a.. DRILLED b. DUG c. UNKNO TYPE OF WATER BEARING ROCK:. WATER ANALYSIS DATE: GH ANESE: Y N HIGH IRON: Y N OTHER CONT TS: Y N G' WELL DATABASE ADDRESS: AGE OF WELL: WELL PERMIT #: WELL PERMIT DATE: TYPE OF WELL: a.. DRILLED TYPE OF WATER BEARING ROCK: WELL DRILLER: f 0 WELL LO ATIO L DEP 0 WELL: b. DUG C. UNKNOWN WATER ANALYSIS DATE: HIGH MANGANESE: Y N HIGH IRON: Y N OTHER CONTAMINANTS: Y N