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Home My WebLink AboutMiscellaneous - 2177 SALEM STREET 4/30/2018 (2)41. North Andover Board of Assessors Public Access , Parcel ID: 210/090.13-0016-0000.0 Community: North Andover SKETCH Click on Sketch to Enlarge PHOTO N , ov, p CtS. L U r, 09', AvailableL Location: 2177 SALEM STREET Owner Name: HANJOO LEE & YOUNG KIM Owner Address: 2177 SALEM STREET City: NORTH ANDOVER State: MA ZIP: 01845 Neighborhood: 5 - 5 Land Area: 1.19 acres Use Code: 101- SNGL-FAM-RES Total Finished Area: 2576 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 528,700 494,300 Building Value: 345,700 324,800 Land Value: 183,000 169,500 Market Land Value: 183,000 Chapter Land Value: LATESTSALE Sale Price: 510,000 Sale Date: 01/27/2004 Arms Length Sale Code: Y -YES -VALID Grantor: ALAN POTTER Cert Doc: Book: 8533 Page: 308 Page 1 of 1 http://csc-ma.us/NandoverPubAcc/j sp/Home.j sp?Page=3&LinkId=806599 11/2/2006 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. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2177 Salem Street Property Address Richard & Colleen Graham Owner's Name North Andover MA 01845 City/Town State Zip Code 3/1/2016 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information Inspector: Anthony R Mottolo Name of Inspector RECEIVED MAR 2 4 201 E John Zanni Pumping Co. Company Name TOWN OF NORTH ER PO Box 407 HEALTH DEPARTMENT Company Address North Reading Cityrrown (781)944-0149 Telephone Number B. Certification MA State S15018 License Number 01864 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 ❑ Needs Further Evaluation by the Local Approving Authority Inspector's Si ure 3/13/2016 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 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2177 Salem Street Property Address Richard & Colleen Graham Owner's Name North Andover MA 01845 City/Town State Zip Code B. Certification (cont.) 3/1/2016 Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: , Z 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 A r determined," please explain. 'V The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 om z Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2177 Salem Street Property Address Richard & Colleen Graham Owner's Name North Andover MA 01845 3/1/2016 City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 2177 Salem Street Property Address Richard & Colleen Graham Owner's Name North Andover City/Town MA 01845 State Zip Code 3/1/2016 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, tv safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Z 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 '/2 day flow t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 ❑ ❑ 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. v y t't 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 2177 Salem Street Property Address Richard & Colleen Graham Owner Owner's Name information is required for every North Andover MA 01845 3/1/2016 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: ❑ Z Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Z 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. ❑ Z Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Z 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. v y t't 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 Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 2177 Salem Street Property Address Richard & Colleen Graham Owner Owner's Name information is required for every North Andover MA 01845 3/1/2016 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No M ❑ 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? N ❑ Were all system components, excluding the SAS, located on site? X ❑ 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 gpd 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 2177 Salem Street Property Address Richard & Colleen Graham Owner Owner's Name information is required for every North Andover page. City/Town D. System Information Description: Number of current residents: MA 01845 3/1/2016 State Zip Code Date of Inspection Does residence have a garbage grinder? Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) Laundry system inspected? Seasonaluse? Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: �C 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 ❑ Yes ® No N/A (private well) ❑ Yes ® No current Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2177 Salem Street Property Address Richard & Colleen Graham Owner Owner's Name information is required for every North Andover MA 01845 3/1/2016 page. City/Town 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 Board of Health 1500 gallons qauqe on truck requested by owner ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ® Yes ❑ No ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2177 Salem Street Property Address Richard & Colleen Graham Owner's Name North Andover MA 01845 3/1/2016 City/Town D. System Information (cont.) State Zip Code Date of Inspection Approximate age of all components, date installed (if known) and source of information: 1986, per system design plans at Board of Health Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: Material of construction: ® cast iron ® 40 PVC ❑ other (explain) ❑ Yes ® No 24" feet 4" Cl through wall, 3" PVC in house Distance from private water supply well or suction line: 130 feet Comments (on condition of joints, venting, evidence of leakage, etc.): All joints ok. No leakage. Venting is good. Septic Tank (locate on site plan): Depth below grade: 12 feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) 1500 gallon single compartment tank If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 101 x 5'W x 4'H Sludge depth: 14" t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Owner information is required for every page. VIA t5ins - 3/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2177 Salem Street Property Address Richard & Colleen Graham Owner's Name North Andover MA 01845 3/1/2016 City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? 18" 4" 5" 16" measuring tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank should be pumped every other year, depending on usage and waste content. Inlet baffle is intact and in good condition. Outlet tee is intact and in good condition. Liquid level is at outlet invert. No evidence of leakage into or out of tank. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2177 Salem Street Property Address Richard & Colleen Graham Owner Owner's Name information is required for every North Andover MA 01845 3/1/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): N)A 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: Design Flow: Alarm present: Alarm level: Date of last um in gallons gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No F p g a 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2177 Salem Street Property Address Richard & Colleen Graham Owner Owner's Name information is required for every North Andover page. City/Town State Zip Code Date of Inspection D. System Information (cont.) MA 01845 3/1/2016 Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert at outlet inverts Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box is level and distribution to the two outlets is equal. Flow equalizers are in place and are at correct settings. Pump Chamber (locate on site plan): Pumps in working order: NI Alarms in working order: ❑ Yes ❑ No* ❑ 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2177 Salem Street Property Address Richard & Colleen Graham Owner Owner's Name information is required for every North Andover MA 01845 3/1/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2, 60' L each ❑ 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 and vegetation are normal. No signs of hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration f v/A Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow t5ins • 3113 ❑ Yes ❑ No Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2177 Salem Street Property Address Richard & Colleen Graham Owner Owner's Name information is required for every North Andover MA 01845 3/1/2016 page. Cityrrown 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.): Ni� 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 2177 Salem Street Property Address Richard & Colleen Graham Owner Owner's Name information is required for every North Andover MA 01845 3/1/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand -sketch in the area below ® drawing attached separately See ne--x-F P4 -3E=_1 t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17 Driveway Pipe Atol=139 A to 2 = lX79 A to D-Boi, = 3911" B to 1= 2716" B to 2 = 348" B to D -Box = 51,12" Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2177 Salem Street Property Address Richard & Colleen Graham Owner Owner's Name information is required for every North Andover page. CitylTown D. System Information (cont.) Site Exam: ® Check Slope Z Surface water ❑ Check cellar Shallow wells Estimated de th to hi In round water MA 01845 3/1/2016 State Zip Code Date of Inspection 9 r� p g g 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: 4/1/1985 Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Perc test data shown on system design plans dated 4/1/1985. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2177 Salem Street Property Address Richard & Colleen Graham Owner Owner's Name information is required for every North Andover MA 01845 page. City/Town State Zip Code E. Report Completeness Checklist 3/1/2016 Date of Inspection ® Inspection Summary: A, B, C, D, or E checked Z 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 Q� 6lD ,64cNo\ 6 s LO1. y1 T ' 1 �t `� op_ cx.iic icwrcw - q. PUBLIC HEALTH DEPARTMENT [ommunity Development Division CE127I�FICATE OAF COMILIANff As of: November 7, 2006 This is to cert that the individual subsurface dzsposafsystem received a SATISEWTORYINSPECTIONof the: Outlet Tee replacement By. 0 Todd Bateson At: 2177,Salem Street .?VorthAndover, 911,4 01845 The Issuance of this certificate shall not 6e construed as a guarantee that the system will function satisfactorily. G 9wichefe E. Grant Public Ylealth Inspector 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 918.688.9540 Fax 918.688.8416 Web www.townofnorthandover.com V TOWN OF NORTH ANDOVER Of NORTH Office of COMMUNITY DEVELOPMENT AND SERVICES a `''��°� HEALTH DEPARTMENT A 1600 OSGOOD STREET; BUILDING 20; SUITE 2-36 NORTH ANDOVER, MASSACHUSETTS 01845IT .1.. �t�g �cHus Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION 1� ADDRESS: otd'77 WF-�99 ��' MAP: LOT: INSTALLER: 70--';q'd1 ��7°r✓ DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: � INSPECTIONS 11�,wl' TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑Existing septic tank properly abandoned ❑Internal plumbing all to one building sewer []Topography not appreciably altered Comments: SEPTIC TANK ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged - F -1 1500 gallon tank has been installed H-10 loading Monolithic construction ❑ Water tightness of tank has been achieved (Visual or Vacuum Test or Water held for 24hrs) ❑ Inlet tee installed, centered under access port ❑ Outlet tee (gas baffle or effluent filter) installed, centered under access port ❑ 24" inch cover to within 6" of final grade installed over one access port, must be over outlet of tank if effluent filter is present ❑ Hydraulic cement around inlet & outlet Wastewater System Documentation — Feb 2006 Page 1 of 6 w TOWN OF NORTH ANDOVER °a NORTH 1 Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT p 1600 OSGOOD STREET; BUILDING 20; SUITE 2-36 o.r, NORTH ANDOVER, MASSACHUSETTS 01845 �9SS�C U Susan Y. Sawyer, RENS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ Combo Tank installed. Size: ❑ 1000 gallon Pump Chamber installed H-10 loading Monolithic 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 ❑ 24" inch cover to within 6" of final grade installed over pump access port ❑ Water tightness of tank has been achieved Visual testing ❑ Hydraulic cement around inlet & outlet Comments: ADVANCED TREATMENT_ TECHNOLOGY_ ❑ Type of treatment device: Comments: ❑ Installed per manufacturers requirements ❑ All components working in accordance with manufacturer's requirements Wastewater System Documentation — Feb 2006 Page 2 of 6 TOWN OF NORTH ANDOVER t %►ORT" H Office of COMMUNITY DEVELOPMENT AND SERVICES - 6�,,`• °+ HEALTH DEPARTMENT ~ ° p 1600 OSGOOD STREET; BUILDING 20; SUITE 2-36 NORTH ANDOVER, MASSACHUSETTS 01845 93 SAC11US�t Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX D -BOX ❑ Installed on stable stone base �j Inlet tee (if pumped or >0.08'/foot) Hydraulic cement around inlet & outlets [� Observed even distribution Speed levelers provided (not required) Comments: SOIL ABSORPTION SYSTEM ❑ Bottom of SAS excavated down to soil layer, as Comments: provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 3/4-1 Y2" double washed stone installed ❑ 1/8-1/2" (peastone) double washed stone installed ❑ Laterals installed and ends connected to header ❑ Laterals vented if impervious material above ❑ Orifices @ 5 & 7 o'clock positions ❑ Gravel -less disposal systems: type, number and location as per plan ❑ Elevations of laterals installed as on approved plan ❑ 40 Mil HDPE barrier installed ❑ Retaining wall (boulder / concrete /timber/ block) ❑ Final cover as per plan Wastewater System Documentation — Feb 2006 Page 3 of 6 TOWN OF NORTH ANDOVER E NORTH q Office of COMMUNITY DEVELOPMENT AND SERVICES o� HEALTH DEPARTMENT p 1600 OSGOOD STREET; BUILDING 20; SUITE 2-36 NORTH ANDOVER, MASSACHUSETTS 01845"rSq�N„S i Susan Y. Sawyer, RENS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX PRESSURE DISTRIBUTION El Comments: -- inch manifold laterals installed with end sweeps size: material: Squirt test ft in height Equal distribution to all laterals orifice size inch as per plan CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: ❑ Rated for exterior if placed outside Comments: Wastewater System Documentation — Feb 2006 Page 4 of 6 7 TOWN OF NORTH ANDOVER HcnTH Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 1600 OSGOOD STREET; BUILDING 20; SUITE 2-36 NORTH ANDOVER, MASSACHUSETTS 01845 �'"ss' CN„Set`g Susan Y. Sawyer, REHSIRS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws Wastewater System Documentation — Feb 2006 Page 5 of 6 Tank SAS Sewer ❑ Property line 10 10 -- ❑ Cellar wall 10 20 -- ❑ Inground pool 10 20 -- ❑ Slab foundation 10 10 -- ❑ Deck, on footings, etc 5 10 -- ❑ Waterline 10 10 10' ❑ Private drinking well 75 1002 50 ❑ Irrigation well 75 100 ❑ Surface Water 25 50 ❑ Bordering Vegetated Wetland , Salt Marsh, Inland / Coastal Banka 75 100 ❑ Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ❑ Trib. to surface water supply 325 325 ❑ Public well 400 400 ❑ Interim Wellhead Prot. Area ❑ Reservoirs 400 400 ❑ Drains (wat. supply/trib.) 50 100 ❑ Drains (intercept g.w.) 25 50 ❑ Drains (Other) Foundation- 10 (5) 20 (10) ❑ Drywells 20 25 Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws Wastewater System Documentation — Feb 2006 Page 5 of 6 t TOWN OF NORTH ANDOVER aoRTN Office of COMMUNITY DEVELOPMENT AND SERVICES o°�°°� HEALTH DEPARTMENT '1600 OSGOOD STREET; BUILDING 20; SUITE 2-36 NORTH ANDOVER, MASSACHUSETTS 01845 �'"ss'„CN„5s� Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX SYSTEM ELEVATIONS Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 HIGH Lateral 1 LOW Lateral 2 HIGH Lateral 2 LOW Lateral 3 HIGH Lateral 3 LOW Lateral 4 HIGH Lateral 4 LOW Lateral 5 HIGH Lateral 5 LOW INVERT ON DESIGN PLAN FIELD INVERT ELEV. Wastewater System Documentation — Feb 2006 Page 6 of 6 f µORT Commonwealth of Massachusetts Map -Block -Lot 090. B- 0016 Board of Health p Permit No BHP -2006-0730 r North Andover----------------------- =: • `� ' P.I. FEE �Ss�cNusEc F.I. $125.00 ----------------------- Disposal Works Constr tion Permit Permission is herebyranted 8 - -y� --------------------------------------------------------------------------------- to (Repair -OUTLET TEE) an Individual Sewage Disposal System. at No 2-177 SALEM STREET ------------------------------------------------------------------------------------------------------------------------------------------------------ as shown on the application for Disposal Works Construction Permit No. BHP -2006-073 Dat o m __ 2, 2006 Issued On: Nov -02-2006 Board of Health 104 b, Map -Block -Lot o Commonwealth of Massachusetts o oso.B- ools - Board of Health ----------------------- A I -* North Andover rt �°•a a �cHu�tt 44o Certificate of Compliance �SS THIS IS TO CERTIFY, That the Individual Sewage Disposal System (Repair -OUTLET TEE) by Installer at No -2177---------------SALEM ---------STREET --------------------------------------------------------------------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. -BHP-2006--073 Dated ___November 02,-2006 --------------------- Printed On: Nov -02-2006 Board of Health ------------------------------------------- - ----- VtORToj A' 0 ik Town of North Andover HEALTH DEPARTMENT,&///4�� C U CHECK #: LOCATION: o2171 /3, 1-1/0 NAME: 1,4 9'0 CONTRACTOR NAME: "0 Type of Permit or License: (Check box) 0 Animal $ 0 Body Art Establishment $ 0 Body Art Practitioner $ 0 Dumpster $ 0 Food Service - Type. $ 0 Funeral Directors $ 0 Massage Establishment $ 0 Massage Practice $ 0 Offal (Septic) Hauler $ 0 Recreational Camp $ 0 Sun tanning $ 0 Swimming Pool $ 0. Tobacco $ • TrashlSolid Waste Hauler $- • Well Construction $ SEP77C Systems 0 Septic - Soil Testing $ 0 Septic - Design Approval �Septic Disposal Works Constru'D, n WC) (4 "ag! � e 0 Septic Disposal Works Installers (DWI) $ 0 Title 5 Inspector $ 0 Title 5 Report $ 0 Other (Indicate) $ '1901 Health Agent Initials Mite - Applicant Yellow - Health Pink - Treasurer oNTy Application for Septic Disposal Svstem . , pConstruction Permit — TOVN OF s^' ' NORTH ANDOVER, MA 01845 9 SSAC Nu5E1 Important: When filling out forms on the computer, use only the tab key to move your cursor- do not use the return key. TODAY'S DATE $ 250.00 - Full Repair $125.00 - Component Application is hereby made for a permit to: ❑ Construct a new on-site sewage disposal system* ❑ Repair or replace an existing on-site sewage disposal _system* ❑ C air or replace an existing system component � (QA - A. Facility Information Address or Lot # City/Town 2.- *TYPE OF SEPTIC SYSTEM*: ❑ Pump avity (choose one) ***If pump system, attach copy of electrical permit to application*** ❑ Conventional System (pipe and stone system) ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D -Box Present) S.A.S. P11 on Name Address (if different from above) City wn �i 3. Installer Information Name Telephone Number Name of Company Zip Code Address t ' n , J 14— City/Town State Zip Code Telephone Number (Cell Phone # if possible please) 4. Designer Information Name Name of Company Address City/Town 1 State' Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 Application for Septic Disposal System ° Construction Permit - TOVN OF ORTH ANDOVER, MA 01845 TODAY'S DATE $ 250.00 - Full Repair $125.00 - Component PAGE 2OF2 ! A. Facility Information continued.... 5. Type of Building: esidential Dwelling or ❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover and not to place the system in operation until a Certificate of Compliance has been issue this Board of Health. Name Date { Applica * n Approved By: Board of Health Representative) Naris Date Application Disapproved for the following reasons: { 1. Fee Attached? ! 2. Project Manager Obligation Form Attached? 1 3. Pump S sy tem? If so, Attach copy of Electrical Permit 4. Foundation As -Built? (new construction ronly): (Same scale as approved plan) 5. Floor Plans? (new construction only): Yes V No Yes V No Ye ( No Yes No 'es_ No SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS M As the North Andover licensed installer for the construction for the septic system for the property at: D 1 r7" SOJI-a,� SA----eeA. (Address of septic system) Relative to the application of t"'6 c ��•� (Installer's name) Dated df,. o ay s ate For plans by And dated With revisions dated I understand the following obligations for management of this project: (Engineer) ngina ate (Last revised date) 1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner, contractor, project manager, or any other person not associated with my company schedules an inspection and the system is not ready, then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against me and/or my company. a. Bottom of Bed - Generally, this is the first'(1') inspection unless there is a retaining wall, which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection - Engineer must first do their inspection for elevations, ties, etc. As -built of verbal OK (or e-mail to: healthdept@townofnorthandover.com) from the engineer must be submitted to the Board of Health, after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system, all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade - Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation) and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute _reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible 5. As the -installer, I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board of Healib staff or consultant. d. Installation of tank, D -Box, pipes, stone, vent, pump chamber, retaining wall and other components. 6. As the installer, I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: (Today's Date) �v p 5� /-eSdsi./ � (Name - Paint) Signed) li Z-4- 3.og J 0 �1 J �x� um �r I o ' �► sr, w 1seA csa� ,� I Sir ,c,-x,,4K. c Ld + 5 5, �� ti1ofL"C"11 %.ax7oufr�, l�j l S1,8SZ 5.F o `' �l A COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 2177 Salem Street _ North Andover_ Owner's Name: JIanjoo Lee Owner's Address: _2177 SalenvAreet _ North Andover, MA 01845_ Date of Inspection: 11/7/2006_ Name of Inspector: Neil J. Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address: _111 Argilla Road_ _Andover, MA 01810_ Telephone Number: _( 978 ) 475-4786_ RECE DEC 120,06 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 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 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: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: r ate: _11/7/2006_ 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. Notes and Comments: After permit from B.O.H., install new outlet tee with gas baffle, inspection from B.O.H., septic system now passes Title5 Inspection. ****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. 46 a` Y c c 1� w i a w h O y •a .c t ., :c Y c 1� w a w •c •c O I m c 0 y w LiO 1 O a w v v f•� +0. a Gy1 C d col- O 0 U cp 1� N le a w ac o 0 o i J Z Z Z O *� dCO G d Z �1 � y O OC)z z z w ch k J C) m W F- N o -- _ o o w m y d a o wQ o CO) a 0 0 �L LL O C L d 0 d d a1 a1 O a a ani h c c Zi I 0 N rn m a 0 Town of North Andover HEALTH DEPARTMENT "s CHU CHECK #: LOCATION: H/ONAME: CONTRACTOR NAME: z� TyRe of Permit or License: (Check box) 0 Animal $ 0 Body Art Establishment $ 0 Body Art Practitioner $ A� 0 Dumpster $ Food Service - Type. 0 Funeral Directors 0 Massage Establishment $ 0 Massage Practice $ 0 Offal (Septic) Hauler $ 0 Recreational Camp $ 0 Sun tanning $ 0 Swimming Pool 0 Tobacco $ 0 Trash/Solid Waste Hauler 0 Well Construction $ SEPTIC Systems: 0 Septic - Soil Testing 0 Septic - Design Approval $ El Septic Disposal Works Construction (DWQ $ 0 Septic Disposal Works Installers (DWI) $ 0 Title 5 Inspector $ $ 12� Title 5 Report 0 Other (Indicate) $ k� j .1944 j Health Agent Initials White - Applicant Yellow - Healtk Pink - Treasurer' COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION '1-4 TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTc SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 2177 Salem Street North Andover_ Owner's Name: Hanioo Lee Owner's Address: _2177 Salem Street _ North Andover, MA 01845_ Date of Inspection: _10/18/2006_ Name of Inspector: Neil J Bateson Company Name: Bateson Enterprises Inc._ Mailing Address: _111 Argilla Road_ _Andover, MA 01810 Telephone Number: _( 978 ) 475-4786_ RECEIVED NOV 0 12006 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 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 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 _X Conditionally Passes Needs Further Evaluation by the Local Approving Authority FA. Inspector's Signature: Date: _10/18/2006_ 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. Notes and Comments: ****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. Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _2177 Salem Street _ North Andover_ Owner:_ Lee Date of Inspection: _10/18/206 _ Inspection Summary: Check A,B,C,D or P / 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: X One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain . Outlet tee in septic tank needs replaced. N 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. ND explain: N 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 distribution box is leveled or replaced ND explain: N 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 obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _2177 Salem Street_ _ North Andover— Owner: _Lee Date of Inspection: _10/18/2006 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 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 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: Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _2177 Salem Street _ _ North Andover. Owner: _Lee Date of Inspection: _10/18/2006 _ D. System Failure Criteria applicable to all systems: You must indicate "yes" or `no" to each of the following for all inspections: _ _No Backup of sewage into facility or system component due to 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 —No Liquid depth in cesspool is less than 6" below invert or available volume is 1/2 day flow. _No_ Required pumping more than 4 tunes 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 high ground water elevation. _No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _No_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _ _No Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ _No 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 than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must 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: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either "yes" or "no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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. Page 5 of l l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: _2177 Salem Street _ _ North Andover _ Owner: _Lee Date of Inspection: _10/18/2006_ 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? 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: Yes No _Yes_ — Existing information. _Yes_ _ 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)] Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: _2177 Salem Street _ North Andover_ Owner: _Lee Date of Inspection: _10/18/2006_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): _4 Number of bedrooms (actual): _4_ DESIGN flow based on 310 CMR 15.203 _600 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 Laundry system inspected (yes or no): — Seasonal use: (yes or no): No_ Water meter reading: –No, on well water >I00' from system_ Sump pump (yes or no): _No_ Last date of occupancy: _Current COMMERCIALANDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): _gpd Basis of design flow (seats/persons/sgft,etc.): _ Grease trap present (yes or no): _ Industrial waste holding tank present (yes or no): Non -sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: — Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: _Pumped three years ago, owner _ Was system pumped as part of the inspection (yes or no): No_ If yes, volume pumped: gallons -- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X 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 ob_tained from system owner) _ Tight tank , Attach a copy of the DEP approval Other (describe): -,_-_ Approximate age of all components, date installed (if known) and source of information:_ 20years old, 6/16/1986, as built plan Were sewage odors detected when arriving at the site (yes or no): _No Page 7 of l l OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _2177 Salem Street _ North Andover _ Owner: _Lee Date of Inspection: _10/18/2006_ BUILDING SEWER _ X _ (locate on site plan) Depth below grade: _24" Materials of construction: X cast iron _X_40 PVC ,other supp Distance from private water ly well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.) _ 4" Cast iron thru wall, 3" PVC in house, no leaks. SEPTIC TANKS: X Depth below grade: _12" Material of construction: X concrete _ metal _fiberglass _polyethylene _other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): ` (attach a copy of certificate) Dimensions: _10' x 5' x 4' Sludge depth: — 5" — epth-5"_ Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: _4" Distance from top of scum to top of outlet tee or baffle:_N/A_ N/A= Outlet tee has corroded hole in it. Distance from bottom of scum to bottom of outlet tee or baffle: 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 _ Inlet tee ok. Outlet tee needs replaced, has corroded hole in it. Depth of liquid at outlet invert. No evidence of septic tank leaking. _ GREASE TRAP: _(locate on site plan) Depth below grade: _ Material of construction: _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 (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _2177 Salem Street _ North Andover— Owner: _Lee Date of Inspection: _10/18/2006_ 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/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: Depth below grade 36"_ 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 level & distribution equal. No evidence leakage. Evidence of carryover. Found liquid above inverts of ox, camera leach lines, found sludge in pipes giving a false higher level. Also found roots in pipes due to trees growing over the trenches. PUMP CHAMBER: _ (locate on site plan) Pump in working order (yes or no): Alarm in working order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): _ Page 9 of l l OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _2177 Salem Street _ _ North Andover Owner: _Lee_ Date of Inspection: _10/18/2006 SOIL ABSORPTION SYSTEM (SAS): _X (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: _ leaching chambers, number: leaching galleries, number: _X leaching trenches, number, length: 2 trenches 60' long_ leaching field, 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 oL Vegetation ok. No sign of ponding to surface. Camera leach lines found roots in pipes from trees growing over leach area. CESSPOOLS: Number and configuration: _ Depth — top of liquid to inlet invert: Depth of sludge layer: — Depth of scum layer: __.. Dimensions of cesspool: Materials of construction: Indication of groundwater inflow (yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Page 10 of l l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: _2177 Salem Street _ _ North Andover— Owner: _Lee Date of Inspection: _10/18/2006 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 Driveway House Well Pipe Septic Tank 2 1 D - Box Ato1=13' Ato2=13'7' A to D -Box = 3911" Bto1=27'6" Bto2=34'8" B to D -Box = 5112" Page l l of l l OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 2177 Salem Street _ _ North Andover — Owner: _Lee_ Date of Inspection: _10/18/1006 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water _ 6' _ Please indicate (check) all methods used to determine the high ground water elevation: X Obtained from system design plans on record - If checked, date of design plan reviewed: _4/1/1985_ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Checked with local excavators, installers- (attach documentation) Accessed USGS database -explain: _ You must describe how you established the high ground water elevation: _As per design plan_ Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 2177 Salem Street, North Andover Owner: Lee Date of Inspection: 10/18/2006 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. Qi N61J.Bateson Bateson Enterprises, Inc. t Y . ''COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION fl t TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESS S SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: .• ( -) 2, 5dlf -�w �! 1'I/ Owner's Name: Owner's Address: Date of Inspection: Q 3 r Name of Inspector: (please print) 3dw 5.4 ,� Company Name: AgnAu r jr -'5p"-ft Mailing Address:t f Telephone Number:2.2L -3 2 -)-�r 72-2 / Sip - 8 2003 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 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 Needs Further Evaluation by the Local Approving Authority F ils Inspector's Signature: &X41q Date: ,.-p 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. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page 1 Page�2 of I.1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: / � X% 4.- Owner: Date of Inspection: 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 15-393- or. in 310 CMR -15.304 exist. -Any failure criteria not evaluated -are indicated below. ' Comments: k B. System Conditionally Passes: J� , One or more system components as described in the "Conditional Pass" section need to be replaced or repaired: The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. The septic tank is metal and over 20 years old* or 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. ND explain: Observation of sewage backup or break out -or high static water- leW 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 distribution box is leveled or replaced IOND explain: 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): ND explain: broken pipe(s) are replaced obstruction is removed - 2 .— f Page 3 of 1'l. ` , t ♦Y OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ,)/ 27 Xv. 5j-- Owner: 'JA ff �° T- 4 Date of Inspection: !!2 --&V— cls 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 Ts failiing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(i)(b) that the systein ,. not functioning in a manner which will protect public health, safety and the environment: Cess' pool 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 I a9 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 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: 3 Fj .J. Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _ t _� 1 1f Owner: Date of lnspection: `` —0'%' D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: i Yes No acl ttp:.of sewage -into facility or system component due to overloaded..or clogged SAS or cesspool t%Discharge or ponding of effluent to the surface of the ground or surface waters_ due to an overloaded or _ dogged SAS or cesspool ' Staticaiquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or , c�esspool L-�- Liquid`depth in cesspool is less than 6" below invert or available volume is less than'/2 day flow ,v2'��Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number v of times. pumped ,.e 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. y portion of a cesspool or privy is within a Zone 1 of a public well. y portion of a cesspool or privy is within 50 feet of a private water supply well. t 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, s' 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 than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] (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. k. 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• You must indicate either "yes" or "no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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. 4 Page 5 of 11 A OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: �2 1 2;0 5ra+ Owner: % �%' ✓ Date of Inspection:. — 3 Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes o. Pumemg info ation'was provided bythe owner, occupant, or Board of Health r Wereany of the system components pumped out in the previous two weeks ? r . ✓^ = Has the system received normal flows in the previous two week period ? o• Havee large volumes of water been introduced to the system recently or as part of this inspection ? Y 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 ? `' cf Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of theeliaffles 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 Absof ption System (SAS) o�n. the site hays, been determined based on: Yes/no' es' no _ 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) [3 10 CMR 15.302(3)(b)] 5 .m, Page 6 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1 ! P� J Owner: 414 Date of In ection: d_:2-- G 3 FLOW CONDITIONS RESIDENTIAL ;. Number of bedrooms (design): 1A Number of bedrooms (actual) DESIGN. flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 0Q t'Number of current residents: Zk Does residence have a garbage grinder (yes pr no): a ,$ Is laundry on a s6`parate sewage system (yes . GQ or noA [if yes separate inspection required) Laundry.system inspected (yes or no): _ Seasonal°use. (yes or no VIbU ar Water meter, readings, if ale (last 2 years usage (gpd)): P Sump pump (yes o`r no): Last date of occupancy: COMMERCIALAN )USTRIAL Type of establishment:' Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sgft,etc.): Grease trap present (yes or no): _ Industrial waste holding tank present (yes or no): Non -sanitary waste discharged to the Title 5 system (yes or no): _ Water meter readings, if available: . Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information:% ' Was system pumped as part of the inspection (yes or no): ..5 If yes, volume pumped:/�allons -- How was quantity pumped determined? . Reason for pumping: 13, 'P 1 TYPE,OF SYSTEM �eptic tank, distribution box, soil absotQtion system _ Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) Tight tank _ Attach a. copy of the DEP approval Other. (describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site (yes or no): 6 Page 7 of I 1 f OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: %. f°1 Owner: z xl!; Date of Inspection: L/ 3 GREASE TRAP. _(locate on site plan) Depth below grade: _ Material of construction: _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 (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7 BUILDING SEWER (locate on site plan) Depth below grade:a.- Materials of construction: 'cast iron _40 PVC _other (explain): Distance.from private.waer supply.well.or. suction liner Comments (on condition 3of joints; venting, evidence of leakage, etc.): SEPTIC TANK: (locate on site plan) "" V*i, Depth'below grade Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of certificate) _/ /, /11 Dimensions: JO Sludge depth` Distance from top of sludge to bottom of outlet tee or baffle:. 4� Scum thickness: / ,r Distance from top of scum to top of outlet tee or bafile`7 " Distance from bottom of scum to bottom of outlet tee or baffle: / y '• How were dimensions determined: _1�7�- Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels ` as related to outlet invert, vidence of leakage, etc.): d la 1-0 P)1-1 f Vf'd7Y1 1 GREASE TRAP. _(locate on site plan) Depth below grade: _ Material of construction: _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 (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7 *-age 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: % % 5;ll . / M� t Owner: le *" ✓ Date of Inspection: 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 ;" polyethy,lene. other explain):, Dunensions:;,k . Capacity. d '¢ gallons Design Flow " gallons/day Alarm;resent.(yes or no): AlarmVlevel: ` " " Alarm in working order (yes or no): v...,. Date of last,pumpmg:' 4 Comments (condition of alarm and float switches, etc.): DISTRIBUTION B0 (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:Pti& �,? Comments (note if box is level and distrio outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): PUMP CHAMBER: _ (locate on site plan) Pumps in working order (yes or no): Alarms in. working. order,�(yes or iho):: Comments (note condition of pump chh ber, condition of pumps ad appurtenances, etc.): El 8 Page 9 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM,INFORMATION (continued) Property Address: Owner: A 19r Date of Inspection: 4 �Q T SOIL ABSORPTION SYSTEM (SAS): L4'suocate on site plan, excavation not required) If SAS not located+explain why: leaching'pit% number: 2 klekhing'chaiiibers, number: 3l�eaching galleries,, number: leaching trenches number, length: " le`aching,f lds; number, dimensions: overflow cesspool, number: innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): CESSPOOLS:" (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth — top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow (yes or no)4 Comments (note_pnditio&of sdi�), .signs of -hydraulic failure; leveltbf ponhing, condign of vegetation, etc.): �l t 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.): 9 a/ Page l0 of l l OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM q PART C SYSTEM'INFORMATION (continued) Property Address•/f tJ j • Owner: i!1tP t/ s Date of Inspe&ion: 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. 10 • _ .f � �, � 4 :r .jam r �,. ~ Ne y11 of 11 LL ,., OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM `t PART C " SYSTEM INFORMATION (continued) Property Address: ! Owner Date of Inspection:°- U,4 SITE EXAM Slope. r Surface water Check cellar Shallow wells Estimated de thgr to,ound 'water� feet Please locate (ch ck) all methods used to determine the high ground water elevation: Ali - system design plans on record - If checked, date of design plan reviewed: k,Observvd iite abutting property/observation hole within 150 feet of SAS) 1 Checked with local -Board of Health -explain: Checked.with local excavators, installers- (attach documentation) A'tcessed USGS database -explain: You must describe how you established the high ground water elevation: �*"S `� D•Rf ��/�' S h e mat. 10014)r11_0W 0 L/ T C k1 Y ); oKow1 7y F fzz Lp :.t M II WELL DATABASE ADDRESS: 1'7'7 AGE OF'WT-LL: WELL DRILLER: WELL PER.NgT'r: WELL LOCATION: ._w`ELL PERIWr DATE: DE= OF --TYPE OF WELL: b. DUG c. UNKNOWN N. 36) I /OF c_ �_�NOWN TYPE OF WATER BEARING RO"� DATE:. WATERANALYSIS 46 llrGH MANGANESE: MGHIRON: (1�0/NTTAMNANTS. y N L'� c,� ..-------� l nh.-, l �J f,r r !x C ,J1hlw !w:' i :%:�,..,: I • ,. -- �'• f•r n�U,J�, 1 y �'Y 'Y �`�i�� r� J r.1°;Vf ,'�� S I f � "'Ctll j`r�'' + � � r. i ' a, 'U �, , , �J:.j ^,, i 45 5j 11j ,J 1', t )� ✓r I �a l J �l , I /111'1 J' ` 1 rri r ! 3 c I i , , yJ r + ,. r ' , I r^ i,+,JS.', ,'�..c�•if/, q I �k:,��'"I I'"ti'�I�'�•I j•�,;. «�,I ;�y,t, l�.. ir. ••J,r'"7 �, a 0. "01 SYSTEM p {•-- �, �rrtpo NA 44 5 �>VY1'EM.OW h0DRC S :.SME 01 L01'AT10N -- `oe�C' (ez�mRIel_cfa�f�ronl of nog U i i GY9F Pu..MP':.I•N4 Q UA.NTITY f UM PGDNO ,, S. S f TIC' TANK SV '�•�TUh�E OFSEft;Y10E;`-'ROUTINE,.•' ��~• '•� EMERCEN,cy ��•.�3�Y;�iT oris;:\ ,j ':,t•- fl Rr`.Y:O:K.''`SC'':' L3AFFl,'L5' EA cH FI CL D I Z UN U S..,..Y..,,S:O�•�:.p'.:..•,�----- . w - S I • , ,S,C•l: u!.r. �.A,<R.L�.I.�:G�..�R.. ...' >i,tJ..�.tH�R• J✓'n(�L,A.INJ ... :.%:�flF '�/:`!,I''iyi'yyl;jl: iti'<',:'r1iti:. p :'�;i: iilFi}�,i7a'I,:i'.S�•:;:t..�..�•—..•"..r,� ��(; �:�u. Y!'' )I ,.S�S'nn ..L;enr '•; k�i ,, ;S 1•pl!{l!,!k!•k.,• .+'Hr%2>i»<;d: ".'G.. t+i•�',i;�i �i;f:: )J; ..__._._ . � t ,�'i �7+. ! i yyt'1�rlt (,i, (;� � I •fit y � A( •., ,r�,. '/ . ,ll �'I:IGM PUMf'c(j o /.'r.,•. cr': ':�,•I iwj: Is��':Y:..'ii�l(,r ,yi J::'i ir�;'d. Y� �'�' •'L: .. �l'•. is 1 `!. •, �. G. •1'l l,.:+'�, �'l.'J. �i l��t,l i:., .�,.i�'li�.,�s'. �'.!y��•�.I.%,. <iJ;.p>�.�'{:� f/t\ni;.i!i',�'•;;S•,�.�i��d��J77 Thr ' - ,. _ �' ... - !'��"i'%.r,p .j {'�!'r''I,IiC;I:'q �; �i '.Y„�s•r; :, r;•`''v'i �';i::, .. ::L .. .;�y..,)�:.J.J'::�')n:''��h''Y/•,': 1,•��1111,9 (.'. �'�)J' �.�)4.:i' fl:,.�.,�tt : '�,�.. ,A j7•.`, !'.1{'3.7::1 `.Y', r'.)':'.'ii. .:T' .ii'I':N)•yf :f;'.;1;'.i'1 i31, 'i' ',Sj:l �i it tli•:'.,;..i��;i,.;;::;.. 5 LABORATORY ANALYSIS G y Stevens Water Analysis 38 Montvale Avenue • Stoneham, MA 02180 • Mass. (617) 438-6114 • Salem, N.H.. (603) 893-3106 LABORATORY NUMBER: 2065 SAMPLE DATE: 11/5/85 SUBMITTED BY: WILMINGTON PUMP SUPPLY 639 Woburn Street Wilmington, MA 01887 SAMPLE SOURCE: New Artesian Well - George Kenney, No. Andover, MA ANALYSIS: According to Standard Methods of Water and Wastewater Analysis, 15th Ed. Total Coliform . . . . . . . . . 0 per 100- ml a, K' Chlorides . . . . . . . . . . . . 7 mg/L gay pH . . . . . . . . . . . . . . 8.4 n_ Hardness . . . . 58 mg/L Manganese . . . . . . . . . 0.06. mg/L Sodium .. . . . . . . . . 24 mg/L Iron . . . . . .. . . . . . . . .0. 95 mg/L Nitrate . . . . . . . . . . . . . less than 0.10 mg/L Nitrite . . . . . . . less than 0.10 mg/L COMMENT: The results of. these analyses meet the required federal and state standards for drinking water. However, the iron, manganese and sodium concentrations exceed the t�< recommended standards. Although iron and manganese are not harmful to your health, they can affect the taste, color and odor-of your water. Iron, manganese and sodium are frequently found at elevated. levels in new wells; however, it is likely that the con- centrations will decrease when the well is put into .regular use. In Massachusetts the recommended sodium standard is 20 mg/L. FIZ4.'vi Chemist Microbiologist — BOARD.OF HEALTH 1 o.Andovcor, Mass. y APPROVED DATE ProvidCds Title V I FAIL I OK Reg 2.5 Reg 6 Reg 10.2 Reg 10.1 s SUBSURFACE DISPOSAL DESICK CHECK : IST FA mz"' DISAPPROVED Reasons s LOT DATE The submitted plan must show as a adnimm,m= ;a) the lot to be served-area,dimensions lot #abutters lb location and log deep observation hoes -distance to ties �c location and results percolation tests -distance to ties ,d design calculations & calculations showing required leaching area ;e) location and dimensions of system-ine'Juding reserve area ;f) existing and proposed contours ;g) location any wet areas within 1001 of aewage disposal system or disclaimer -check wetlands mapping ;h) surface and subsurface drains within i )0 1 of sewage disposal system or disclaimer ;i) location any drainage easements wl.thlz 3.001 of sewage disposal system or disclaimer -Planning Hoard fl%es J) known sources of water supply' with' , 2'`0I of sewage disposal o system or disclaimer Q location of azW proposed well to serve lot -1001 from leaching facility 1) location of water lines on property -10c from leaching facility m) location of benchmark n) driveways o) garbage disposals p) 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 r) maximum ground water elevation in area sewage disposal system s) plan must be prepared by,a Professional Engineer or other professional authorized by law to prepare such plans Septic Tanks (a) capacities -150.% of flow, water table, ••ees, depth of tees, access, pumping (b) cleanout (c) 101 from cellar wall or inground swi= ng pool (d) 251 from subsurface drains Distribution Boxes a) s ope greater 0.08 b) of _H�1 N�:I�TN /JtiI��EI�, MA. SS �D�Vf�ITio�vs U� SAPPx� vE� R�45oNS Dwr6' 1ATE IPPR 00106 /urho►�)Ty f D� Sr�-(c SYsTEN1 t � 5TA L.Z,,QTEoIJ C--X4V4T(ol� VJSPt�-G►tOti U/JrC Q PAJSS F4(L FINAL iV5P6GTlonj Q PPRovED G)/JTC /JPr'(zi�U(NG ��r�t01�(Ty AWT(OMAL I,�j5trrc.j (oN5 (I -p koy) �S�PPRvv�1� ' RE/j50 NS " FwpL APPF�pvAL D,a►C 746 APP3wvj6 d17 Important: When filling out forms on the computer, use only the tab key ` to move your cursor - do not use thereturn key. Commonwealth. of Massachusetts City/Town of System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. The System Pumping Record must be submitted to the local Board of Health or other approving authority. . A. Facility Information 1. System Locatio Address 1 -7 t http://www.mass.go.v/dep/`water/apptovalt/t5forms.htn-*insoect t5form4.doc- 06103 Sy -stem : in ng:Reco(d • Page.1 of 1