HomeMy WebLinkAboutMiscellaneous - 2189 TURNPIKE STREET 4/30/2018 (2)r,
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Commonwealth of Massachusetts
Title 5 Official Inspection Form "polo,Va k-
Not for Voluntary Assessments �3
Subsurface Sewage Disposal System Form
Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated
6/15/2000. Inspection forms may not be altered in any way.
A. Certification RECEI EM
Important:
When filling out 1. Property Information: 0 C T 13 2006
forms on the
computer, use 2189 Turnpike Rd N Andover
only the tab key Property Address I I UVVN OF NOR;-H ANDOVER
to move your II Woong Koo HEALTH UEi'ART^,�L NT
cursor - do not Owner's Name
use the return
key. 2189 Turnpike Rd
Owner's Address
N. Andover MA. 01845
Citylrown State Zip Code
Date of Inspection: Date 6
Date
2. Inspector:
N . Timothy White
Name of Inspector
Homepro North shore
Company Name
PO BOX 101
Company Address
ROWLEY Ma. 01969
Citylrown Zip Code
1-978-948-8428
Telephone Number
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 ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
/11 , 1 '1.� $, 9-30-06
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
Shortcut to TITLE V.lnk.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 1 of 16
` Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
` Subsurface Sewage Disposal System Form
M
A. Certification (cont.)
2189 Turnpike Rd
Property Address
N. Andover Ma
City/Town
II Woong Koo
Owner's Name
State
9-30-06
Date of Inspection
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes:
01845
Zip Code
® 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.
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:
na
Shortcut to TITLE V.lnk.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 2 of 16
Commonwealth of Massachusetts
. Title 5 Official Inspection
Not for Voluntary Assessments
M yVOr
Subsurface Sewage Disposal System Form
A. Certification (cont.)
2189 Turnpike Rd
Property Address
N. Andover
Citylrown
II Woong Koo
Owner's Name
B) System Conditionally Passes (cont.):
Ma
State
9-30-06
Form
Date of Inspection
01845
Zip Code
❑ 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:
na
❑ 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:
n
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
Shortcut to TITLE V.Ink.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 3 of 16
` Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
2189 Turnpike Rd
Property Address
N. Andover
CityfTown
II Woong Koo
Owner's Name
Ma
State
9-30-06
Date of Inspection
C) Further Evaluation is Required by the Board of Health (cont.):
01845
Zip Code
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:
zj
** 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:
Shortcut to TITLE V.Ink.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 4 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
2189 Turnpike Rd
Property Address
N. Andover
Cityrrown
II Woong Koo
Owner's Name
Ma 01845
State ZipCode
9-30-06
Date of Inspection
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes No
❑ ®
Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ®
Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ®
Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ®
Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/z day flow
❑ ®
Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ®
Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ®
Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ®
Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ®
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ®
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for 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.
Shortcut to TITLE V.Ink.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 5 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
5.0r
` Subsurface Sewage Disposal System Form
A. Certification (cont.)
2189 Turnpike Rd
Property Address
N. Andover Ma.
City/Town State
II Woong Koo 9-30-06
Owner's Name Date of Inspection
01845
Zip Code
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the
questions in Section D.
YES
NO
❑
❑
the system is within 400 feet of a surface drinking water supply
❑
❑
the system is within 200 feet of a tributary to a surface drinking water supply
❑
❑
the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area — IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
Shortcut to TITLE V.Ink.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 6 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
B. Checklist
2189 Turnpike Rd
Property Address
N. Andover
City/Town
II Woong Koo
Owner's Name
Ma
State
9-30-06
Date of Inspection
01845
Zip Code
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
YES NO
®
❑
Pumping information was provided by the owner, occupant, or Board of Health
❑
®
Were any of the system components pumped out in the previous two weeks?
®
❑
Has the system received normal flows in the previous two week period?
❑
®
Have large volumes of water been introduced to the system recently or as part of
this inspection?
®
❑
Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
®
❑
Was the facility or dwelling inspected for signs of sewage back up?
®
❑
Was the site inspected for signs of break out?
®
❑
Were all system components, excluding the SAS, located on site?
®
❑
Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
®
❑
Was the facility owner (and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]
Shortcut to TITLE V.Ink.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 7 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
yySubsurface Sewage Disposal System Form
C. System Information
2189 Turnpike Rd
Property Address
N. Andover
Ma
01845
City/Town State Zip Code
II Woong Koo 9-30-06
Owner's Name Date of Inspection
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): 110 = 440
gpd
Number of current residents: 4
Does residence have a garbage grinder?
❑ Yes
®
No
Is laundry on a separate sewage system? [if yes separate inspection required]
❑ Yes
®
No
Laundry system inspected?
❑ Yes
®
No
Seasonal use?
❑ Yes
®
No
Water meter readings, if available last 2 ears usage
9 ( Y 9 (gpd)):
well
Sump pump? ❑ Yes ® No
Last date of occupancy: still occupied
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203): Gallons per day (gpd)
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:
Last date of occupancy/use:
Other (describe):
Shortcut to TITLE V.Ink.doc • 11/2004
❑
Yes
❑
No
❑
Yes
❑
No
❑
Yes
❑
No
Date
Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 8 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
2189 Turnpike Rd
Property Address
N. Andover Ma
City/Town State
II Woong Koo 9-30-06
Owner's Name Date of Inspection
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:
01845
Zip Code
last pumped 2 years Information from owner
gallons
❑ Yes ® No
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)
❑ 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:
13 years old information from owner
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Shortcut to TITLE V.Ink.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 9 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
C. System Information (cont.)
2189 Turnpike Rd
Property Address
N. Andover Ma.
01845
CitylTown State Zip Code
II Woong Koo 9-30-06
Owner's Name Date of Inspection
Building Sewer (locate on site plan):
Depth below grade: 7 in
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other (explain):
Distance from private water supply well or suction line: 27ft from incoming water line to
outgoing sewer line in basement
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints & venting good condition no evidence of leakage
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
® concrete ❑ metal
12 in
feet
❑ fiberglass ❑ polyethylene ❑ other (explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of ❑ Yes ❑ No
certificate)
Dimensions: 10 ft long - 5ft deep 5ft wide 1500
Sludge depth:
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?
2in
30 in
2in
6in
15in
rulers - measuring rod
Shortcut to TITLE V.Ink.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 10 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
2189 Turnpike Rd
Property Address
N. Andover Ma 01845
City/Town State Zip Code
II Woong Koo 9-30-06
Owner's Name Date of Inspection
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 was not pumped - inlet Baffle &- outlet tee in good condition - liquid at bottom of outlet invert -
tank appears to be in good condition no sign of leakage in or out of tank
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ® metal
rte. ��-L /C'C' CP
Dimensions:
Scum thickness
❑ fiberglass
61
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
feet
❑ polyethylene ❑ other (explain):
— _ � )c;d L', Lo
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
NA
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: NA
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain):
Shortcut to TITLE V.Ink.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 11 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
C. System Information (cont.)
2189 Turnpike Rd
Property Address
N, Andover
Cityrrown
II Woong Koo
Owner's Name
Tight or Holding Tank (cont.)
Dimensions:
Capacity:
Design Flow:
Alarm present:
Alarm level:
Date of last pumping:
Ma 01845
State Zip Code
9-30-06
Date of Inspection
gallons
gallons per day
❑ Yes ❑ No
Alarm in working order: ❑ Yes ❑ No
Date
Comments (condition of alarm and float switches, etc.):
NA
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
d -box was level - distribution was equal - no evidence of any solids carryover - no sign of leakage in
or out of d -box d- box was 28in below qrade - size was 17x17 in inside depth 13in
Pump Chamber (locate on site plan):
Pumps in working order:
Alarms in working order:
Shortcut to TITLE V.Ink.doc • 11/2004
❑ Yes ❑ No
❑ Yes ❑ No
Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 12 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
2189 Turnpike Rd
Property Address
N. Andover Ma
01845
City/Town State Zip Code
II Woong Koo 9-30-06
Owner's Name Date of Inspection
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
na
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits
❑ leaching chambers
❑ leaching galleries
® leaching trenches
number:
number:
number:
number, length: 4 Trenches - 55ft
long 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.):
dry gravel sand soil - no hydraulic failure - no ponding - system was in front lawn -
Shortcut to TITLE V.Ink.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 13 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
y` Subsurface Sewage Disposal System Form
M yver
C. System Information (cont.)
2189 Turnpike Rd
Property Address
N. Andover
City/Town
II Woong Koo
Ma
State
9-30-06
01845
Zip Code
Owner's Name Date of Inspection
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth — top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
na
Privy (locate on site plan):
Materials of construction:
Dimensions
NA
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Shortcut to TITLE V.Ink.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 14 of 16
Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
2189 Turnpike Rd
Property Address
N. Andover
Ma. 01845
Cityrrown
State Zip Code
11 Woong Koo
9-30-06
Owner's Name
Date of Inspection
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.
Shortcut to TITLE V.Ink.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 15 of 16
� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
,ySubsurface Sewage Disposal System Form
C. System Information (cont.)
2189 Turnpike Rd
Property Address
N. Andover
Citylrown
II Woong Koo
Owner's Name
Site Exam:
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water:
Ma.
State
9-30-06
Date of Inspection
Please indicate all methods used to determine the high ground water elevation:
111
Obtained from system design plans on record
If checked, date of design plan reviewed:
Date
01845
Zip Code
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:
from past title 5 inspection shows ground water at 4ft from orignal grade system is raised
Shortcut to TITLE V.Ink.doc ° 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System
Page 16 of 16
NEW ENGLAND ENGINEERING SERVICES
INC
E
D04l"?GIVERrE T
October 1, 2004
North Andover Board of Health
Town Hall Annex
27 Charles Street
North Andover, MA 01845
RE: TITLE V REPORT: RE: 2189 Turnpike Street, North Andover, MA
Dear Sir or Madam:
Enclosed is a copy of the Title V report for the above referenced property. The system PASSED
our inspection.
If there are any questions please call me at my office, 686-1768.
Sincerely
0 �/
Benj C O Jr.
J g
Certified Title 5 ' spector
60 BEECHWOOD DRIVE -.NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099
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: l 811
Owner's Name: g p-,4 p k," t
Owner's Address: -z sq - T1, ,Iv; pr ii, e
IV o MHN o aj e2 AA 4
Date of Inspection• _ } 10 y
Name of Inspector. (please print) Benjamin C. Osgood, Jr.
Company Name: New England Engineering Services Inc.
MaGing Address: 60 Beechwood Drive,
North Andover. MA 01845
Telephone Number. 978-686-1768
Receive
OCT 5 2004
"OWN
'A O N DEPTH ANDO,,,,
�`rn�E,vr
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 toSection15.340 of Title 5 (310 CMR 15.000). The system:
-:�.L res
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: v Date: O rV
The system inspector shall submit a copy of this inspect a 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 l l
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: A t c3 G TV `e P 14 e Sp
A- J i-) oy c <—
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
1 .303 a 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 descx''bed in the "Conditional Pass" section need to be replaced or
repai<ed. 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.
Theseptic 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 level in the distributionbox 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:
t
The system required pumping more than 4 times a year due to broken or obstructed pipc(s). The system will.
pass inspection if (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
ND explain:
Pagel .of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: v2 t P q
P C3 i it f fs-- Do, et -
Owner:
.Date of Inspection:
C. Further Evaluation is Required by the Board of Health:
,AL Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to prded public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b) that the
system is not functioning in a manner which will protea public health, safety and the environment:
_ Cesspool or privy is within 50 fed of a surface.water
_ Cesspool or privy is within 50 fed of a bordering vegetated wetland or a salt marsh
...:Z- 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 coliforpi
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: ;Z1 I a q 7'u (Z vA Pi
}� 10 A.,-� 7 o ue,-f- ,A -
Owner: 0 2A -It-;> V� , 4 A 2c0
Date of Inspection: --- 2
D. System Failure Criteria applicable to all systems:
You mast indicate "yes" or "no" to each of the following for all inspections:
Yes No
BadaiP of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
Liquid depth in cesspool is less than 6" below invert or available volume is less than Yz day flow
— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped
_ ✓ Any portion of the SAS, cesspool or privy is below high ground water elevation.
— ✓ Any portion of cesspool or privy is within 100 fed 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.
of a cesspool or privy is within 50 fed of a private. water supply well. .
�Anyportioa
Any portion of a cesspool or privy is less than 100 feet but greater than 50 fed 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.]
(YeslNo) Thesystem 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 in either `yes" or `5no" to each of the following:
(The following crit ply to large systems in addition to the criteria above)
yes no
— _the system is within 400 fed o a ce drinking water supply
_ the system is within 200 feet of a tributary to a ace dripldni'water supply
—
the system is located in a nitro e�,se�sitive`a (Interim i�ellhead Protection Area - IWPA) or a mapped
Zone II ofra pub}ic-wat�-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.
s
Page 5 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: _,�Z 18 q i u jL vi pj K F
NI -1R it F A4 �-! V
Owner: 1�,le- &0 #9-rz0
Date of Inspection: �o y
Check if the following have been done. You must indicate `des" or "no" as to each of the following:
Yes No
_ -Pumping information was provided by the owner, occupant, or Board of Health
Were any of the system components pumped out in the previous two weeks ?
Has the system received normal flows in the previous two week period ?
Have large volumes of water been introduced to the system recently or as part of this inspection ?
— Were as built plans of the system obtained and examined? (if they were not available note as N/A)
Was the facility or dwelling hVected for signs of sewage back up ?
Was the site inspected for signs of break out ?
— Were all system components, excluding the SAS, low on site ?
Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition
Of the baffies 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 Sail Absorption System (SA.S) on the site has been determined based ow.
Yes/no
EE' ung information. For example, a plan at the Board of Health.
Determined is
►/ � ed
the field ('if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) 13 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: t ger T`, R v, p i SL_(_ _—
)iZ �l i Ate? Al N -
Owner•
Date of Inspection: o r�
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15203 (for example: 110 gpd x # of bedrooms):
Number of current residents:^
Does residence have a garbage gander (yes or no): AID
Is laundry on a separate sewage system (yes or no): N [if yes separate inspection required]
Laundry system inspected (yes or no):
Seasonal use: (yes or no): ALD
Water meter readings, if available (last 2 years usage (gpd)): t)j a L_ L
Sump pump (j= or no): -ALO
Last date of occ fancy:--
COMMERCIAL/INDUSTRIAL
Type of establishment;
Design flow (based on 310 CMR 15.203) -
Basis of design flow (seats/persons/sq%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:
bTHER (describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection (yes or no): At
If yes, volume pumped: Gallons — How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank, distribution box, soil absorption system
_ Single cesspool
Overflow cesspool
— Privy
— Shared systm (yes or no) (if yes, attach previous inspection records, if any)
_ Innovative(Alte mative 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 -
0 -5--f rypre 0 `✓L,Q As 6u,—
Were sewage odors detected when arriving at the site (yes or no):
Page 7 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 2 t Pq -rL) p_vi j2, tLc 77
Owner; i2 9-A-9 w A L >
Date of Inspection: Z� o
BUILDING SEWER (locate on site plan)
Depth below grade:_
Materials of construction: cast iron IZ40 PVC other (explain):
Distance from private water supply well or suction line: IS
Comments (on condition of joints, venting, evidence of leakage, etc.):
f i P L L-c�o
j4_5 Y1 C vJ' t Ay 9 t1s tit eE A V
SEPTIC TANK: _ (locate on site plan)
Depth below grade:1 Z "
Material of construction: _concrete metal fiberglass _polyethylene
If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of
certificate)
Dimensions: (5cso(,-_,���� N
Sludge depth: 2
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness; 2 -
Distance
Distance from top of scum to top of outlet tee or baffle: 6 "
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined:-
Comments
etermined:Comments (on pumping recommendations, inlet and outlet tee or bade condition, structural integrity, liquid levels
as related.to outlet invert, evidence of leakage, etc.):
3�vt� K 1 iv K is 9cl-I dry l a r ce
GREASE TRAPAbIllocate 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: i u it o
Owner. - .� P -M-0 w y �"
Date of Inspection: 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- 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.):
MSTRMUTION BOX: Of present must be ope ned)(locate on site plan)
Depth of liquid level above outlet invert: C>
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.):
2s xsx �CiP(�r�ll��gp C o P� C fir i�Cp i�N)� N F( h» r�✓i ►lf
Ql�i1 Ca ff C7 C_I L S. et^� a �. r :'✓' .�
PUMP CHAMBER (locate on site plan) .
Pumps in working order (yes or no):
Alarms in working order (yes or no):
Comments (note condition of pump chamber, condition of pumps and appuct nm= etc.).
Page 9 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
. Property Address: ;g t a q
Owner:
Date of Inspection; q Dy
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required)
If SAS not located explain why:
Type
leaching pits, number. _
leaching chambers, number:
leading galleries, number:
✓reading trenches, number, length: /f �� fz�,cictCe�S
leading fields, number, dimensions:
overflow cesspool, number:
innovativetaltemative system Typetname of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
_EtK ff F=-1 &D i--csc11�S AA' � 4 .t/l� �c� t C'�i�GE c5 I—
�0NP(n�G—, OSA ��e t �{L i?nt.. 064 Ue%r-s T7%�. .
CESSPOOLS: (cesspool must be pumped as part of inspectionxlocate 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):
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRIVY: &d—(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 11
OFFICIAL INSPECTION FORM = NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: �;Z t P-) a pe cue
JJ Fn -f "4
Owner:__
Date of Inspection:
SIETt;M 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 fed. Locate where public water supply enters the building.
Uj
Page 11 of 11
OFFICIAL INSPECTION FORM _ NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: a I 9ci i u 2vi pt rte ,s j
Owner: b9►4 P wy�
Date of Inspection:
SM EXAM
Slope 2
Surface water
Check cellar Vi0
Shallow wells �c
Estimated depth to ground water 1-/ feet
Please indicate (check) all methods used to determine the high ground water elevation:
Obtained from system design plans on recd - If checked, date of design plan reviewed:
4_ 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 mast describe how you established the high ground water elevation:
Sys'. r .� 3 �.c I � � ✓l comet i ✓�eu eF ��y�
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Mot rr♦ 0.++ � d
BOARD OF HEALTH
120 MAIN STREET TEL. 682-6483
NORTH ANDOVER, MASS. 01845 Ext. 32
October 16, 1992
Mr. Scott Giles
50 Deer Meadow Road
North Andover, MA 01845
RE: 5 Turnpike Street
Dear Scott:
This is to notify you that your septic plans for Lot #4
Turnpike, North Andover have been rejected for the following
reasons:
1. No profile; also elevation of bottom of bed.
(N.A.6.02b2 and 6.02r)
2. No locus plan. (N.A. 6.02b5)
3. Elevations of soil and perc tests missing. (N.A.
6.02j)
4. No wetlands disclaimer. (N.A. 6.02o)
5. Elevation of driveway missing. (N.A. 6.02p)
6. Downhill slope, y/x, to be shown. (N.A. 6.02u)
7. Location and elevation of foundation drain required.
(N.A. 6.02v)
8. No seasonal highwater table elevation referenced to
benchmark. (N.A. 6.04b)
9. Distance from dwelling to leach area not stated.
(N.A.6.03b)
10. Need note stating that excavation of topsoil and
subsoil shall extend at least 6 inches into the natural
pervious material. (N.A. 2.18)
If you have any questions concerning this letter or the
North Andover regulations, please do not hesitate to call me at
the Board of Health Office on Monday, Wednesday, or Friday.
Sincerely,
fd- VL;
Sandra Starr
Health Agent
PLAN REVIEW CHECKLIST
ADDRESS /aA/yL,�.�� ENGINEERS
GENERAL
3 COPIES_ STAMP C� if LOCUS NORTH ARROW SCALE C—
c/
CONTOURS PROFILE/ SECTION "' BENCHMARK SOIL &
PERC INFO ELEVATIONS�',� WETS. DISCLAIMER �� WELLS &
WETLANDS WATERSHED? DRIVEWAY_,4,_(Elev WATER LINE
FDN DRAIN✓ SCH40 (/ TESTS CURRENT?
SEPTIC TANK
MIN 1500G. ✓ .17 INVERT DROP GARB. GRINDER 7(+200% EDF)
25' TO CELLAR MANHOLE TO GRADE ELEVJ;� GW
D -BOX ago
SIZE # LINES FIRST 2' LEVEL STATEMENT
INLET OUTLETL6 2 = - / Z (2 11 OR .17 FT) TEE REQ' D?
LEACHING
RESERVE AREA 4' FROM PRIMARY? (%J 100' TO WETLANDS L,,-"2% SLOPE
100' TO WELLS 35' TO FND & INTRCPTR DRAINS 4' TO S.H.GW'
325' TO SURFACE H2O SUPP c.l" 4' PERM. SOIL BELOW FACILITY �-
MIN 12" COVER FILL? �25' if above natural elev; 101if below)
BREAKOUT MET?
TRENCHES
MIN 660 gpd 6,,- SLOPE (min .005 or 6"/1001) >3' COVER? - VENT
SIDEWALL DIST. 2X EFF. W OR D (MIN 61) IS RESERVE BETWEEN
TRENCHES? t/ IN FILL?JL,,`_ MUST BE 10' MIN. L' 4" PEA STONE? DK
BOT VD X LDNG + SIDE ['160 X LDNG 104 = TOT
, (L x W x #) (G/ft2) (DxLx2x#)
Health'
;...indover,Mass
APPROVED DATE
Provided!
Title V
Reg 2.5
�Ej
•
SUBSURFACE DISPOSAL DESICK CHECK LIST
LOT%1 )
DISAPPROVED DATE -_,Z- 1- 5
Reasons:
1, 1',E�EI?�� �c�, i� tJ►1 ��'�i' cOclO AUT i -'ii(
ClASE Zp 4,-5 5 TW &• IUD') FROA 51 it i o tN
Loz 3 Is srD� ,tib
The submitted plan must show as a minimums
a) the lot to be served-area,dimensions lot C abutteve
b 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 -including veserve area
f) existing and proposed contours
;g). location any wet areas idthin 1001 of sewage disposal system or
disclaimer -check wetlands mapping
'h) surface and subsurface drains within 1001 of sewage disposal
system or disclaimer
i) location any drainage easements within 1001 of sewage disposal
system or disclaimer -Planning Board files
J) known sources of water supply within 2(iI of sewage disposal
system or disclaimer
k) location of any proposed well to serve )ot-100I from leaching facility
1) location of water lines on property -101 from leaching facility
m) location of benchmark
n) driveways 1 N T��S
o) garbage disposals
p no PVC to be used in construction
q) profile of system -elevations. of base an: plumb, pipe, septic tank,
distribution box inlets and outlets, die-.:•tbution field piping and
Other elevations
r) maximum ground water elevation in area sewage disposal system
s) plan mast be prepared by a Professional Engineer or other
professional authorized by law to prepare such plans
Reg 6 Septic Tanks
(a) capacities -150 of flow, water table, tees, depth of tees,
access, pumping.
(b) cleanout
(c) ;101 from cellar wall or inground swimadng pool
(d) 251 from subsurface drains
Reg 10.2 Distribution Boxes
(a) pe greater UM 0.08
Reg 10.E b} sump
9.6 b) stand-by power
b fj c6 Design
Check List a Page 2
FAIL
OK
x
LeachingPits
_
Leaching pits are preferred where the installation is possible
Reg 1.1.2
a)
calculations of leaching area-rd nimum 500 eq ft
11.4
b)
spacing
11:10
c)
le)
surface drainage 2%
?.1.11
d)
cover material
2I x2' x4" splash pad
f)
tee at elbow
g)
no bends in pipe from d-box to pipe
Leaching Fields
Reg 15.1
a
no greater t'=an 20 minutes/inch
barea-minimin
900 s4 ft
15.4
c
construction of field gW�)r `/A'I�1/yt,_�
15.8
d)
surface drainage 2 %
3.7
e)
201 from cellar wall or inground swiradnt , pool
Leaching Tcenches
Reg 14.1
a)
c onst%aching area-min 5W sq Pt
14.3
b)
spacing-4 ft min 6 ft with reserve between
14.4
c)
dimensions
14.6
d)
construction
1.4.7
e)
stone
14.10
f)
surface drainage 2%
Downhill 8122e
a)
slope y x = be shown)
b)
y/x X 150 - (to be shown)
EMS
Reg 9.1
a}
approval
9.6 b) stand-by power
- �URA/Pi KZ_
AS -BUILT CHECK LIST
and
FINAL INSPECTION
Proposed Elevations
House / 1-1 /,A 7
Tank IN J g D, 77
Tank OUT /a O, C_�-,;Z-
D-box IN
D -box OUT
Trench Inverts
Line 1
/oq o l b -
Line 2
11q, 6 -
Line 3
11P.0 -
Line 4
//7, d -
As -Built Elevation
i�L1•l,�
1,526), 7,9
S�1,
i o.37
--119,74-
118,96
-119,74-
Bottom of Exc.%
Stone OK? " XD -box checked? Pipes cemented?
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Town of North Andover, Massachusetts Form No. 1
NORTH d BOARD OF HEALTH
19
A
4 ° ° Ew°• APPLICATION FOR SITE TESTING/INSPECTION
A�R-Aq TED PP0.�GJ .
9SSACHUS��
.. !�
Applicant I V�.A '
NAME
Site Location_ T4
I -11P
Engineer c �
NAME
Test/Inspection Date and Time_
Fee
f 1 4;-� 3
CHAIRMAN, BOARD OF HEALTH y/
Test No. "DUS
S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No.
kq,
X�'1141
�zI� X,.`i:`5.
Ai
'80N" kV
-z .... . ... .
1 ��. iii'
I
Department of Environmental Management/Division of Water Resources
WELL COMPLETION REPORT
WELL LOCAT ON GEOGRAPHIC DESCRIPTION
Address���O N (9 E a of
(teed (circle)
City/Town''/CSl'' '+E�• �fl( Alx7i-MYJls� -
Well owner SMG 150441-1041V C 0 (road)
Address �/SU)A.5/ij/✓ /off/ UMN S E 0 of
^�y '�y,� j1 (mi, in tenths) -Q (circle) �,}
(! rY//' intersect. w,1_91W olez' s `6
Board of Health permit obtained: yes no ❑ (road)
WELL USE WELL DATA
Domestic I] Public [] Industrial ❑ Total well dept I ft.
Monitoring ❑ Other Depth to bedrock 4r S ft.
Water -bearing rock/unconsolidated material:
Method drilled Y
Description
Date drilled
r2^ ,
Water -bearing zon,,e��sa,:���',
CASING t) From To 32s'
TypeE� L
21 From To
Length F0 ft. Dia(.I.D.) in. 3) From To
Length into bedrock ft.
Gravel pack well: dia.
Protective well seal:
Screen: dia.
Grout.❑ Other106MOC- Slog length from_ to
STATIC WATER LEVEL (all wells)
Static water level below land surface J0 ft. Date
WELL TEST (production wells)
Drawdown Oft• after pumping hr. min. at gpm
How.measured k�C[ �' Recovery 'lip ft. after__'�!_hr. min.
LOG of FORMATIONS COMMENTS 8
Materials Feorn - To ,
Fi.CC o /6' rUrgcaJso�/ �;
Dnlle�3:.
M£ C{1/GLS, Firm r X/7 se CC. fry
Address`
City/TownC
Super sing Iler R g # n-----"
{"" i tvrewl'aupePvrrsshig'-registered well driller
Please Prim firmlY- BOJ RD' -O -F.` ;HEALTH' .COPY
NUMBER
FEE
3�o THE COMMONWEALTH OF MASSACHUSETTS
$25.00
TaWM....--- of.......... NCLRTx_•ANDauFR--------------- -------------
This is to Certify that .................Wilmington Pump .......................................................
NAME
639 Woburn Street, Wilmington,_ MA 01887 ........................
IS HEREBY GRANTED A LICENSE
For .......... 1,ot... #5..-T.UrIIP2i.-lie---Strgeat-------------------
•-----•---------------•-•-••------------•-----------•----•---•--•••-•-• ••----•-•••-••----•...--------•---------••--•-------••---•----•-----•-••-----••-•--••--••-------•---
----•-••----------------•--•-••••••••---•....------••-•-•••-•--•-••-••-••----•-••---•---.....--------------...-----•----•----••--••---•---....-•----•-•----•--•••----••----
---•----•--•---•-----••----•--•---••••--••-------••-•--•-•--•-------•••------••---•---...----••...-•-------•...--•---••...................................................
This license is granted in conformity with the Statutes and ordinances relating thereto, and
expires ------- December31, 1993 Unless sooner suspended.. _
evoked.
t.
December. 4' 19 -9..
•
--------- ------..............
FORM ass HOBBS & WARREN. INC.
P
BOARD OF HEALTH
Town of North Andover,Mass.
Permit # Date %.-> 19'
APPLICATION FOR WELL & PUMP PERMIT
Application is hereby made for permit to drill a well ). Application is
made to install ( ) a pump system'.
Location: Address SA uEm "7-ued ,rte ll�" V ����' 1 Lo t #f _
Owner A d d r e s s 4f,(,1 Ni>y/�/i�UE/��T el.
Well Contractor( Addresses Te1.,�SSh
Pump Contractor Address Tel..
WELL CONTRACTOR .(To be completed at time of purnp test)
Type of Well i>C� Well used for
-Diameter of Well �`� Size of. Casing"
Depth of Bed Rock wS Depth casing into Bed Rock 45-- o la'«IG
Was Seal Tested? Yes (19) No (—) Date. of Testing
Depth --o- Well --' Well Ended in W.ha.t. Material
Depth to Water_ 15,0 f Delivers S Gals.Per Min. for 4 hours
Drawdown feet after pumping—_hours-at ^_ CPM
Date of• Completion 1�:� %�,7w a-,,
r
Signature Well Contractor
:�:t:tiX�:t:;:;:'c::� •'•:::'::;:;. _..a........�,.:: .......,.::•�::••�•:::: •:•;.....,.. c .-:':�:;::;c::•�•�:::::::. :cam*
PUMP INSTALLER (To be'' filled in- before installation)
S•i ze & Name Pump _ _ _ _—� _ Pump Type Used
Water Pump Delivers GPM Size of Tank
Pipe Material Used in Well: Cast Iron (—) 0:11vani.zed (_) Plastic (_3
Well Pit (_) or Pitless Adaptdr (_)
Was sleeve used to protect pipe? Yes.(_) NO(_) Type or Name Well Seal
Date
�4�4i1r14��r�r�4i�rt4►'ri4��r�rC��r��r�M�a�C�r�'t�M�k�1ri't�4�Ytilr4e�4�'eti4�1r�4�Y:4�4�r:'t�r�rr�e:rtietit,:;::"::,:,r::ir,.;:ta,::::r:: �:::r, i , , ,
Date Water analysis rep6r--t 'submitted to Board of Hical,th
Date release given to owner of record & Bldg.. Insp
Health Inspector
62(/XCIZ�161Z &6 kww-
:kvrdteadeff Xaiforatatp, Atc.
66 LITTLETON ROAD WESTFORD, MA 01886
Report Numbers C-wpa-7528
Clients
Wilmington Pump Supply Inco
P.O. Box 517
Filmington, MA 01887
Sample Taken ay! WP8 Staff
(508) 692.8395 FAX (508) 6920023 1.800.649 -TEST
Report Dates Dec. 11, 1992
Sample Taken Ats
Chester sul.livan
Turnpike at.
N. Andover,Maes.
ons December 10, 1992
CHRTIFICATE OF ANALYsis
TEST PARAMETERS EPA Max RESULTS VNITO
Total coliform (P)
0
0 Per 100ml
calcium
No Limit
65.9
mg/L
Capper (s)
1.3
<0.01
mg/L
iron (s)
0.3
4=0-:_Q-8,
mg/L
Magnesium
No Limit
10.2
mg/L
Manganese (s)
0.05
<0.01
mg/L
sodium
20
18.8
mg/L
Potassium (S)
No Limit
7.5
mg/L
Alkalinity (s)
No Limit
162
mg/L
Ammonia
No Limit
<0.01
mg/L
Chloride (0)
250
26.7
Mg/L
chlorine (total)
0.7
X0.02
mg/L
Color (B)
15
10
CPU
Conductivity
No Limit
445
umhos/cm
Hardness
No Limit
207
mg/L
Nitratee(as N)(P)
10
0.09
mg/L
Nitrites(as N)
1
+40.01
mg/L
pH (0)
6.5-8.5
7.3
ou
Odor (8)
3
.60
,� TON
Gulphat®s (B)
250
15.6
mg/t,
Turbidity
5
3.3
NTU
Gediment
pod/nag
poo
NT -Not Tented, #-Value Exceeds EPA STD,
TNTC -Too Numerous
to count
*=Background Bacteria Noted,
"-EPA Advieory
Limit
FvExaeede EPA Advisory Limit
(P) -Primary EPA standard, (S)
-secondary
EPA standard (may
affect
aesthetics of drinking water
i.e. taste,
color, etc.)
Thie water sample, as teited, is considered SAFE to drink according
to EPA guidelines. However, one or more of the parameters exceeds
EPA secondary standards as indicated by the (f) sign.
Massachusetts state Certified Michael P. Carlson, for..
Testing Laboratory I#MA048 Thorsteneen Laboratory Inc.
WELL DATABASE
ADDRESS:
AGE OF�'N =�� ilii 7 T t 2i,� LL D R-1L1.�....
y -y"- r Yz 4ti i 'WELL LOCAT 0of:
--Vf'LLL.PL� b T-73,' jE: l'�2 (� �j�. DEF7HGF WHT
-=E:OF WELL: DRILLED' b. DUC L -OW -
--
_ �A��v�s�sDA - �LGgtir�c�ALti� a
ELC�LE�ON _N O "T CQN"L`�A-N-L"S: .Y
r�i —ti -L DATAB?_SE
ADDRESS: l c- %` �tiv ✓�� S
AGE OF W=r. 'v E L.L. DRD:I.
WEL L PERM T- WE.L.L L OCA70
WELL PFR2�fl i -DATE:'`:
DEPTH OF WEL1:k
TYPE OF WElL: a . D=LFD b. DUCT c. LFK:, 07wN
TYPE OF WATE R.3EAR DNG ROCK:
WATER ANA YS?S DATE: HIGH _NLA NGAv-ESE: Y N
=- -- i"RON: Y N OTN�=R CONTAIN A -NTS: Y N
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FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
,5-06
APPLICANT: �. S �r f I�i UG h _,L /��' Phone C T
LOCATION: Assessor's Map Number Parcel 2 e l0 C O/,p`
�
Subdivision 140 Lots) W'
Street+ /G(x,,-y St. Number :21e
************************Of:Eicial Use Only************************
cR�ECCOM EENDAATIIOON�S OF TOWN AGENTS:
Date Approved
Conservation Administrator Date Rejected
Comments r�'�' -K5GhJ-
Town Planner
Comments
Health Agent
Comments
Public Works - sewer/water connections
Date Approved If
Date Rejected _.
Date Approved
Date Rejected
- driveway]permit � A / -/f,
LAWI_Iory (moi rs'/CC
Fire Department
Received by Building Inspector Date
I
CERT/F/ED FOUNDATION PLAN
S LOCATED /N Na:`,PwoR Ma,.
SCALE / �' DATE tR q3
Scott L. Gi/es RL.5
V) 50 Deer Meadow Rood
North Andover, Moss.
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/ CERT/FY THAT OFFSETS SHOWN ARE FOR THE USE
THE OFFSETS OF THE BU/L DING /NSPEC TOR ONLY ��E' f
SHOWN COMPLY AND SUCH USE /S FOR THE
WITH THE ZONING DETERM/NATION OF ZONING
BY LAWS OF CONFORMITY OR NON-CONFORMITY
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CERT/F/ED FOUNDA TION PLAIV
LOCATED /N Na •oR MA -
SCALE /= DATE-
Scott L. Gi/es R.L.S.
50 Doer Meadow Rood
North Andover, Moss.
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" Fµt7 MPE t= 113.74
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4 g7.25
Mn
/ CERT/FY THAT OFFSETS SHOWN ARE FOR THE USE
THE OFFSETS OF THE SU/L DING /NSPEC TOR ONLY
SHOWN COMPLY AND SUCH USE IS FOR THE goy
WITH THE ZONING DETERMINATION OFZONING Q1
BYLAWS OF CONFORMITY OR NON—CONFORMITY
►alp, %NU�/EtZ,MA,. WHEN CONSTRUCTED. 'sy'-'S'ERE,
WHEN BUIL T.
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