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HomeMy WebLinkAboutMiscellaneous - 225 BRIDGES LANE 4/30/2018 J 225 BRIDGES LANE _f 210/104.D-0106-0000.0 i I i 7 +4 1 i NEW ENGLAND ENGINEERING SERVICES //Ia`' July 25, 2005 RECEIVED JUL 2 8 2005 North Andover Board of Health To6NORTH ANDOAIM 400 Osgood Street H0N,DEFRTMEI � North Andover, MA 01845 RE: TITLE V REPORT: RE: 225 Bridges Lane 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, Benjamin C. Os /od, Jr. J g Certified Title 5 Inspector 60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 ...................................... 1of11 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 225 Bridges Lane North Andover,MA Owner's Name: Lisa Morrill Owner's Address: 225 Bridges Lane North Andover,MA Date of Inspection: July 20,2005 Name of Inspector: (please print) Benjamin C.Osgood,Jr.Certified Title 5 Inspector Company Name: New England Engineering Services Inc. Mailing Address: 60 Beechwood Drive North Andover,MA 01845 Telephone Number: 978-686-1768 CERTNICATION 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 the on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15340 of Title 5(3 10 CMR 15.000).The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: C Date: The system inspection shall submit a copy of this' 'on 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. 2of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 225 Bridges Lane North Andover,MA Owner's Name: Lisa Morrill Date of Inspection: July 20,2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D {A. System Passes: J 65 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.,cS-,ystem Conditionally Passes: y� / 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 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: 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): $roken pipe(s)are replaced Obstruction is removed ND explain_ 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 225 Bridges Lane North Andover,MA Owner's Name: Lisa Morrill Date of Inspection: July 20,2005 C. Further Evaluation is Required by the Board of Health: N v 0 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 (SAS)Soil Absorption System and the(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 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 fat 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 organize 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 5ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 4of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 225 Bridges Lane North Andover,MA Owner's Name: Lisa Morrill Date of Inspection: July 20,2005 D. System 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 overload or clogged SAS or cesspool. % Static liquid level in the distribution box above outlet invert due to an overload or clogged SAS or cesspool -�4- Liquid depth in cesspool is less than 6"below invert or available volume is less than%2 day flow - Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped e Any Portion of the SAS,cesspool or privy is below high ground water elevation. X 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 fat 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 nitrogen is equal to or less than 5ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) N0 (YeslNo)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 coni d a large system the system must serve a facility with a design flow of ,000 gpd to 15,000 gpd. You must indicate "yes"or"no"to each of the following: (The following criteria app ge systems in addition to the criteria above) Yes No The system is within 400 fat of a s g water supply The system is within 200 fat tributary to a drinking water supply The system is located' a nitrogen sensitive area(Interim e Protection Area-IWPA)or a mapped Zone H of a public wat pply well If you answered"yes' to any question in Section E the system is considered a significant threat,or ered"yes"in Section D above the large system has failed The owner or operator of any large system considered a significant threat er 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. 5of11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 225 Bridges Lane North Andover,MA Owner's Name: Lisa Morrill Date of Inspection: July 20,2005 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 an 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 sign of break out? Were all system components,excluding the SAS,located on site? Were all 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 difference from owner)provided with information on the proper maintenance of the subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ / Existing information.For example,a plan at the Board of Health. V 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)] 7of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 225 Bridges Lane North Andover,MA Owner's Name: Lisa Morrill Date of Inspection: July 20,2005 BUILDING SEWER(locate on site plan) Depth below grader Materials of construction: cast iron ✓40 PVC other(explain Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): _ PIF LJaKS &(k� )�> tAJ $RSG1;4,iAIT- SEPTIC TANK: (locate on site plan) Depth below grade: l 2 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) Dimensions: h-6-0.0 CsA t-t�tirS . Sludge depth: -Z- Distance from top of sludge to bottom of outlet tee or baffle: z G Scum thickness: L a Distance from top of scum to top of outlet tee or baffle: 1 I Distance from bottom of scum to bottom of outlet tee or baffle 1 F" How were dimensions determined: .A► i_+5y z CC :5;Tv,y,I(- Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 44 k)I)- t ti rC)7 cc)AJ D k"Za N. r--1 c P E-PT -1-ZE i GREASE TRAP: locate on site plan) Depth below grade:[[ Materials 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 sludge 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. 8of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 225 Bridges Lane North Andover,MA Owner's Name: Lisa Morrill Date of Inspection: July 20,2005 TIGHT OR HOLDING TANK:_ (tank must be pumped at time of inspecrion)pocate on site plan) Depth below grade: Materials of construction: concrete metal fiberglass polyethylene other (expo) 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: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:r_ Comments(note if box is level and distribution to outlets equal,any evidnence of solids carryover,any evidence of leakage into or out of box,etc.): �G2S6 IN OK i-1 L6 TIQAL-, AJ10 EUILIGNCL D F L-EA- AG-& I ti n A. n L/'I . PUMP CHAMBER0 Ac _(locate on sire 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 appurtenances,etc.): 9of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 225 Bridges Lane North Andover,MA Owner's Name: Lisa Morrill Date of Inspection: July 20,2005 SOIL ABSORPTION SYSTEM(SAS): (locate on site Ulan,excavation not renuired If SAS not located explain why TYPE leaching pits number leaching chambers, number leaching galleries number leaching trenches,number in length _fir leaching fields,number,dimensions: A 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) A-(Zl;A OF r`(GLO b-po14.S AVO P-44 W'L. Nc7 E"��G►Jc JY �?0e� CESSPOOLS:N JA— (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) Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: u _(locate on site plan) Material of construction: Dimensions: Depth of solids Comments(note condition of soil signs of hydraulic failure,level of ponding,condition of vegetation,etc. 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 225 Bridges Lane North Andover,MA Owner's Name: Lisa Morrill Date of Inspection: July 20,2005 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. l� � z5 iv 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 225 Bridges Lane North Andover,MA Owner's Name: Lisa Morrill Date of Inspection: July 20,2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water fed Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record—If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health—explain: Checked with local excavator,installers—(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: US C's SDt�- N�A,�S tN 9tCfY� w�t7�/L �Peic�..i JI, Commonwealth of Massachusetts >la'5 �fifiicial Inspection 1='orm Nt �4Voluntary Assessments .19 , 11 Subsurface Sewage Qisposal System Form -Inspection results must be submitted on this form or on the official Title;5 lrispection Form dated 61151200_0 Inspection forms may not be altered in any way. A. tertification RECEIVED Important: When filling out 1. Property Information: JUN 0 3 2005 forms on the L Y 7 bt)d3 CrS IA.' computer, use only the tab key Prpperty Address .�/ TOWN OF NORTH ANDOVER to move your rtL4i �, 'M HEALT --- cursor-do not Over's Na e use the return 141e- key.4-- Owners Address Ah C0C City/Town State Zip Code Date of Inspection: bale 2. Inspector: LA arts N�apm�e of Inspector Company Name f- -7 chl'5AulPll 1� -- Company Address u City/Town State Zip Code VE-37y-M3 Telephone Number Certification Statement: 1 certlfy that l have 06itbnally inspected the sewage dispbsal '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 perfbinied based bn niy training and experience In the prbper functibn and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 1513'1-0 CMR 15.1000). The system•: sses {] conditionally Passes {] Pa4s [) N s Further Evaluatiog by the Local Approving Authority 5'r3J""s" Ins or's Signature Y Date The system irtspectbr shall subrftit a copy bfthis insPection:�epbi�tb the Approving Authority (Board of Health or DEP):within 30 days of completing this inspection; If the system is a shared system or iia§ a de§1gn fi1bVJ ort�n,0nn g•�d •r g•r8atef,tTii3 Tt1§'pebtbf slid tfie§ysteli't owner §hall submit the report to the appropriate regignafoffice of.the DEP. The original should be sent to the system owner Md i;UPM relit tb lht WYO?, Tf app olq alltliblity. "*"*This report only describes conditions atthe 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. t5trisp.,dac• 1112004 Title's Official tnspectton f>jTm.SUbsyrfaDe Sewage Otposal System Page 1 of 16 Commonwealth of Massachusetts Tile 5 Ofi icial Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification �-cont.) Z97 &r'J5u 4 Property Address A/^/1NA0v?1- City/Town State Zip Code XhAy &2('vft Owner's Nanfe 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 to 310 GMR 16.303 or in 310 GMR 16.304 exist. Any failure criteria not evaluated are indicated below. Comments: ��^^ __ I Se N, j s �v (S�(�D� �GKo1 1�l'vt g�1v�-�� j� pvv�y<.( y,ec�r Iy 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 exptain. ❑ 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: I t5insp.doc- i 1?26U Title 3 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts Title 5 Official inspection dorm Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 7-q7 &rd ei es t/ Property Address Clty(Town J State Zip Code Owners Name Date of Inspection B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ❑ distribution box is leveled or replaced ND 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): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: Cj 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 unloss Board of Health determines in a000rdanoo with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the lenvironmiant: ❑ Cesspool or privy is within 5D feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5insp.doc• 11/2004 Tttie 5 Official inspection f=orm: subsurface Sewage Oisposai System Page 3 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form i Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) Property Address City/Town State Zip Code Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (cont.): 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning In a manner that protects the public health, safety and environment: , ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water s-upply 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 weii**. Method used to determine distance: ** T-Ns 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 of less thtin 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attacheo to this form, 3. Other: t5insp.doc- 1112004 Title 5 Officiai inspection form: Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurfaw Sewage Disposal System Form A. Certification (cont.) 11-17 (3rr,4( ,es L- _. Property Address State ZipCode City/Town S-3/-c6- �� �� �;r� Owner's Name 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: e i Yes No Backup of sewage into facility or system component due to overloaded or 11 El clogged SAS or cesspool ❑ ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clo ped 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 j ❑ ❑ than Y2 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. El tributary portion of cesspool or privy is within 100 feet of a surface water supply or El tributary to a surface water surly. ❑ ❑ 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 conform 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 Cl El criteria system falls. 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. i t5insp.doc 1112004Titie 5 officiai inspection Form:subsurface Sewage Disposal System Page 5 of 16 , Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 2c/7 Grrdis 1.N --- - Property Address ys— Cityrown State AA Zip Code 4A4 619e,,ii-A. Owner's Name Date of Inspection E) Large Sy'stem's: To be c6nsid00 large 'system the 'system im'ust sante a Tatility 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 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 510 CMR 15.304. The system owner should contact the appropriate regional office of the Department, t5insp.doc l lM04 Title b 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 B. Checklist 2-'-/7 Property Address d/W�- Y*Day �ow� State Zip Code Ci� Owners ame Date of Inspection 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? obtained and examined? (If they were not El Were as built plans of the system 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? (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? ElWas the facility owner(and occupants if different from owner) provided with IZ inform>atlnn on the proper maintenance of subsurface sewage disposal'syste'ms? The size and location of the Soil Absorption System (SAS) on the site hasi 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)) t�insp.doc 111�ad4 Title 3 Official lnspecfion Form:Subsurface Sewage Disposal System Page 7 of )6 Commonwealth of Massachusetts Title 5 Official Inspection dorm Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information Property Address Ci /T n ''// State Zip Code e�. riT�1 Owner's Naryne Date of Inspection Residential Flow Conditions: y Number of bedrooms (actual): Number of bedrooms (design): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 640S Number of current residents: ❑ s `bio `'� 6� Does residence have a garbage grinder? 1Vo > Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes No i Laundry system inspected? es fes]' No Seasonal use? ❑ Yes,.O" No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ YesX/ No Last date of occupancy: Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sq-.ft.-, ete j: Grease trap present? ❑ Yes ❑ No industriai waste tlotding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Titte 5 system? ❑ Yes ❑ No Water muter M-adlqs, if avaliabW. Last date of occupancyluse: Date Other(describe): t5rnsp.doc 11/20( f Tine 5 officfai inspection Form:Subsurface Sewage Dispossi system, Page 8 of 16 I I Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) t4-7 &rA,, [a. Property Address o State Zip Code City/Town S_��, �� c Mit --- Owners NaFne Date of Inspection General Information Pumping Records: A10 Source of information: Was system pumped as part of the inspection? 1z Yes ❑ No If yes, volume pumped: gallons -- How was quantity pumped determined? fila l�Ati��• - Reason for pumping: 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 cb'ft�bl(b be bbtained Tom 'system 'ovine"r) ❑ Tight tank•Attach a copy of the DEP aWovai. Cl Other(describe): Approximate age of all'components, date installed (if known) and source of information: Were sewage odor's detected when al dving at the site? ❑ Yes ?� No t5insp.doc- 11/20N Title 3 O ictal Inspection Form:Subsurface Sewage Disposal System Page 9 of to Commonwealth of.Massachusetts Ti. le5 OW oial Inspection Form, , Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System information wont.) 27 Prop Address Ah City/Town State Zip Code Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron P�40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on conditionofjoints, venting, evidence of leakage, etc.): NO Sih OF /'C61A Of Septic Tank (locate on site plan): Z Depth below grade: feet Material of construction: concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other (explain) If tank Is metal, list age: year Is age confirmed by a Certificate of Compliance? (attach a copy of ❑ Yes ❑ No l7irnensions: Sludge depth: ,x y�y Distance from top of sludge to bottom of outlet tee or baffle Scum thtckness DlsCance from top of-scum to top of outlet We or VVT•a Distance from bottom of'scum to bottom bt butlet tee&bade �5 y How were dimensions determined' Cle4su,4, t5fnsp.doc•11/2004 iitte 5 Official tnspection form:Subsurface sewage Disposai 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.) 2-40l�1C� J Property Address State Zip Code City/Town j CIIA/ /41C Owner's Name Date of Inspection Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integnt; liquid levelsasrelated ttooutlet �inv/ert, evidence of leakage, 1 etc.): IK ''`i-p (i7VJ(C1/ �AWjej - ,�:-64 Irl &&4,41--of /�GIILI Grease Trap (locate on site plan): Depth below grade: feet 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: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integm liquid levels as gelated to outlet i'rive'rt, evidence bf leakage, etc.)` Tight or HoWing Tank(tank must be pumped at time of inspection) (focate on site pian): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain t5insp.doc 1112004 Titte 5 official inspection Form: Subsurface Sewage Disposal Sysre-,^ Page o; Commonwealth of.Massachusetts Ti:toWfiicial inspection �'orrni Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System information �-cont.) E/7 fir► �� �-�' Property Address City(Town State Zip Code C.,, S-31-oS Owner's Name Date of Inspection Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evid'e'nce bf 1' i3kege intbor but bi boz, etc.): U«Y �i e Cu"oyu^ 7, b'Pyio� K�c� �`t /c�l ►ti If1 0,//4 ��ec�i //,Vs DAe GAP 56oc Pump Chamber�tocate nn site pian): Pumps m w�rRlnp�rd�r: ❑ Yds ❑ No Alarm's in working order: ❑ Yes ❑ No 15insp.doc 1 V2004 Title 3 Wiicial lnspedtion 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.) 2(/7 13rd9ej 66,1 Property Address City/Tow // State Zip Code Cg,f�l — Owner's Name Date of Inspection Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why:. Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: --- - / r y� z leaching trenches number, length: /27 ❑ leaching fields number, dimensions: — — ❑ overflow cesspool number: —-- [] innovative/alternative system Type/name of teohnology: —" Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): tbinsp.doc- 1 iM64 T'ifle 9 Official Inspection Form:Subsurface Sewage bisposal System Page 13 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 2-v )�>r dy,s - Property Address City/Town State Zip Code Owners 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, Privy (locate on site plan.): Materials of construction: Dmensiens -- Depth of sofrds — - Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation etc.): ------------ t�insp.doc t i/��a4 Title b Official lnspec(ion Form:Subsurface Sewage bisposal System - Page i4 of is Commonwealth of Massachusetts Title 5 Official Inspection Form ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) Z y7 8r)cll G! Property Address 141 0/8 Its- Cityffowp State Zip Code &,/(,,/, ,M Owner's Name Date of Inspection Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system inciva nc to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet Locate where public water supply enters the building. Lj Lit-i1 ��v a�3W— ZS i5insp doc 1 VMN Title b Official Inspection Form: Subsurface Sewage D sposai Page i'- ;. Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments • Subsurface Sewage Disposal System Form C. System Information t,cont.) -2 Ll? igrrd Property Address 1t1,-*V0vc1' Jt/J O/8YS cityrrown State Zip Code c./-41 /�lGy�S s"3rd Owner's Name Date of Inspection Site (Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: 7 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: 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) ❑ Accq"qd USGS database - explain: You mast describe Clow you establlsbed the bi b ground water elevation: yo Sow, v�+ 151nsp.doc• 11/2004 Title 5 Official inspection Form:Subsurface Sewage Disposal System Page 16 of 16 NEW ENGLAND ENGINEERING SERVICES INC ' July 25, 2005 7RECE71VED North Andover Board of Health 400 Osgood Street TOZI°TM DEPAI E41 North Andover, MA 01845 RE: TITLE V REPORT: RE: 225 Bridges Lane 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, Benjamin C. Os /od, Jr. J g Certified Title 5 Inspector 60 BEECHWOOD DRIVE-NORTH ANDOVER, MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 1of11 ..' .` .. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 225 Bridges Lane North Andover,MA Owner's Name: Lisa Morrill Owner's Address: 225 Bridges Lane North Andover,MA Date of Inspection: July 20,2005 Name of Inspector: (please print) Benjamin C.Osgood,Jr.Certified Title 5 Inspector Company Name: New England Engineering Services Inc. Mailing Address: 60 Beechwood Drive North Andover,MA 01845 Telephone Number: 978-686-1768 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 the on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15340 of Title 5(3 10 CMR 15.000).The system: :2��Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: C 0 -i Date: The system inspection shall submit a copy of this' 'on 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. 2of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 225 Bridges Lane North Andover,MA Owner's Name: Lisa Morrill Date of Inspection: July 20,2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: 6-5 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: Alb,cb 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 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: 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: 3of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 225 Bridges Lane North Andover,MA Owner's Name: Lisa Morrill Date of Inspection: July 20,2005 C. Further Evaluation is Required by the Board of Health: N-0 0 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 I 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 (SAS)Soil Absorption System and the(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 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 organize 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 5ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 4of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 225 Bridges Lane North Andover,MA Owner's Name: Lisa Morrill Date of Inspection: July 20,2005 D. System 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 overload or clogged SAS or cesspool. ' Static liquid level in the distribution box above outlet invert due to an overload 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 -j� 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. -fi 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 nitrogen is equal to or less than 5ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) N0 (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 considerefa large system the system must serve a facility with a design flow of ,000 gpd to 15,000 gpd. You must indicate "yes"or"no"to each of the following: (The following criteria app arge systems in addition to the criteria above) Yes No The system is within 400 feet of a g water supply The system is within 200 feet o tributary to a drinking water supply The system is located' a nitrogen sensitive area(Interim We Protection Area—IWPA)or a mapped Zone 11 of a public wate pply well If you answered"yes' to any question in Section E the system is considered a significant threat,or ered"yes"in Section D above the large system has failed The owner or operator of any large system considered a significant threat er 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 5of11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 225 Bridges Lane North Andover,MA Owner's Name: Lisa Morrill Date of Inspection: July 20,2005 Check if the following have been done. You must indicate"yes"or"no as to each of the following.. i 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? V Have large volumes of water been introduced to the system recently or as part of an 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 sign of break out? Were all system components,excluding the SAS,located on site? ✓ Were all the septic tank manholes uncovered,opened,and the arterior of the tank inspected for the condition of the bales or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if difference from owner)provided with information on the proper maintenance of the subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ / Existing information.For example,a plan at the Board of Health. V 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)] 6of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 225 Bridges Lane North Andover,MA Owner's Name: Lisa Morrill Date of Inspection: July 20,2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design)_Number of bedrooms(actual): ! DESIGN flow based in 310 CMR 15.203(for example: 110 gpd x #of bedrooms): !�c"0 Number of current residents:_ Does residence have a garbage grinder(yes or no):y 5 Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required] Laundry system inspected(yes or no): -- Seasonal use:(yes or no): A/0 . Water meter readings,if available(last 2 years usage(gpd): Sump Pump (yes or no): Al O . Last date of occupancy C,P r,,"I COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats✓persons/sgk 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 �?ewa$- .96'(2- Was 9Ci2Was system pumped as part of the inspection(yes or no): AA 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 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 Attached 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 wen arriving at the site(yes or no): . 7of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 225 Bridges Lane North Andover,MA Owner's Name: Lisa Morrill Date of Inspection: July 20,2005 BUILDING SEWER(locate on site plan) Depth below grader Materials of construction: cast iron ✓40 PVC other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): 1°ipE �Jaas �s o��7 IAJ RsG19.5A.7 I SEPTIC TANK: (locate on site plan) Depth below grade: l 2 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) Dimensions: Sludge depth: z Distance from top of sludge to bottom of outlet tee or baffle: - 'z 6 Scum thickness: . L a Distance from top of scum to top of outlet tee or baffle: 1 i " Distance from bottom of scum to bottom of outlet tee or baffle i F3' How were dimensions determined: /v►E4+67U i c s-n-iC Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 114ti It, Iti rTt--07 cC> a AJ c RC je � t•�� Cs�vD GREASE TRAP: locate on site plan) Depth below grade: Materials 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 sludge 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. i I i i 8of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 225 Bridges Lane North Andover,MA Owner's Name: Lisa Morrill Date of Inspection: July 20,2005 TIGHT OR HOLDING TANK: �A _(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Materials 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: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:_ Comments(note if box is level and distribution to outlets equal,any evidnence of solids carryover,any evidence of leakage into or outofbox,etc.): 17,ys IN OX ca.J.S>Oi).3U 7tS�\-Zt6.illoA—, ��41— Al EUl11GntC� O F �E.k u��FFfi E i,v []>(2 nom. PUMP CHAMBER:— tj I AX _(locate on sire 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 appurtenances,etc.): 9of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 225 Bridges Lane North Andover,MA Owner's Name: Lisa Morrill Date of Inspection: July 20,2005 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not renuired If SAS not located explain why TYPE leaching pits number leaching chambers, number leaching galleries number leaching trenches,number in length _Zr leaching fields,number,dimensions: A 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) A-Ri oq- o F 14-S ^J C,4.," 0Z Na E- �j 0 r UN7tiCr SJA M� Soy 1.r vi2 vN�S.J,<}c. t'CG-t�ilg1JN. CESSPOOLS:N JA- (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) Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: locate on site plan) Material of construction: Dimensions: Depth of solids Comments(note condition of soil signs of hydraulic failure,level of ponding,condition of vegetation,etc. 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 225 Bridges Lane North Andover,MA Owner's Name: Lisa Morrill Date of Inspection: July 20,2005 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. l� i � 1 � ti� Zs 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 225 Bridges Lane North Andover,MA Owner's Name: Lisa Morrill Date of Inspection: July 20,2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record–If checked,date of design plan reviewed: ,—Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health–explain: Checked with local excavator,installers–(attach documentation) jt- Accessed USGS database-explain: You must describe how you established the high ground water elevation: l�e-cz) 4 i EP n. &ti K/f-S i3 e- (L.,hS6 Vii;.• ; , . , 4 Commonwealth of Massachusetts Oficial Inspection Form, Nt�f4oluntary Assessments SubsUi ace Sewage Qisposaf System Form inspeetien results trust be submitted on this form or on the offleial T41;J'0'5 inspection Form dated 611,512000. Inspection forms may not be altered in any wa I. k. CBrdification RECEIVE Important: When filling out 1. Property Information: JUN 0 3 2005 forms on the ?—'V7 &'d crs 4/ computer, use only the tab key Props Address TOWN OF NORTH ANDOVER to move your HEALT -- cursor-do not owa e ners N use the return Ole key. . OWner's Address /01/4 Clty/Town State — Zip Code Date of Inspection: oats 2. Inspector: 0;ptle4 &r Na a of Inspector Company Name -7 c4s'IAO/01 Company Address y� Clty/Town State Zip Code cm_371/-?IU3 Telephone N=ber Certification Statement: 1 certify that 1 have persbnally 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 perfibmied based ort my training and 'experience In the prbpet fuht tibn and maintenance of on site sewage disposal systems. I am a DEP approved system Inspector pursuant to Section 15.340 of Title 513'1D ICUIR 15.0D). The -syst'e'm`. sses {] Conditiorra#ly Passes [J Fails {] rther Evaiustio by the Local Approving �Authodty N s fu lloors Signature 61 Date The system inspectbr shall submit a copy of this inspection:Tepbi�16 the Appboving Authbity (Board of Health or DEP):within 30 days of completing this inspection. If the system is a shared system or hm t de§lp yitw of I-0,n'0'0 gpo' 'f g'fbbtbT,thb Trhbpbbtb'f bad IM §'y§tbl'n Whtit§hall submft the report to the appropriate regigna�office of.the DEP. The original should be sent to the system owner Md nplbt W116 the MYOT,Tf tppl1tADle,..8lid tete tippPOW10 wh6m. . ""This report only describes conditlons at;the time.of inspection and under the conditions of use at that time, This Inspection does not address how the system wiil.perform in the future under the same or different conditions of use,.: t5tnsp.�foc 11/20Q4 Tftle 3 official tnspectton FoTm:Sut7syrface Sewage Otsposa]System Page 1 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification iwnt.) Z y7 &rJg u 4A,, Property Address Cityfrown State Zip Code ,� 41 A.)(Y 5-3/-- 5- Owner's Nan1b 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 to 310 GMR 16.303 or in 310 GMR 16.304 exist. Any failure cfitefia not evaluated are indicated below. Comments: S from %s �v 6:�ood Cctd r f 'vt 5A&,L,1) kK y-ectr I.y _. 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,"ptease exptain. ❑ 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: t5insp.doc- 11%Z N Title i Ufflcial Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 7-q7 &dpes Property Address City/Town State Zip Code Owner's Name Date of Inspection B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The -system will pass inspeotion if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: Cj 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 isoard of Health determines in aeunrdanue with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environmtent: ❑ Oesspbbl or privy is within 50 feet bf a 'surface water i ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5insp.doc• 1112004 Titfe 5 Official Inspection Form: Subsurface Sewage Disposai System Page 3 of 16 Commonwealth of Massachusetts Op Title 5 Official inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) Property Address Cityfro� ��wnnState Zip Code Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (cont.): 2. System will fall unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manger 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 suppiy weii**. Method used to determine distance: ** T-Ns 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 attachee to this form, 3. Other: t5insp.doc• 1112004 Tine 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 (count.) 2,1 7 arr,49,es L.v - Property Address P-ANoo✓v State ZipCode C4[Town Owner's Na Date of Inspection r 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 ❑ ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ El due 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. El 11 tributary portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water suppiy. I ❑ ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. El El -well. portion of a cesspool or privy is within 50 feet of a private water supply well. El El from 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. t5insp.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of to Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) Property Address JV—/$V pDvC,/ -- Cityrrown State AA Zip Code C A1C 9 e-t-A Owner's Name Date of Inspection E) Large Sy'stem's: Tb be considered a l'a'rge system the systeim 'm'u'st serve a fiacilfty 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 DMR 15.304. The system owner should contact the appropriate regional office of the Department. t5lnsp.doc Title b 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 B. Checklist 2-E/7 Br-rd Property Address d/ Dovey Cityrrow State Zip Code Owners-ea-me Date of Inspection 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? El this 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? (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? ❑ n(' Was the facility owner(and occupants if different from owner) provided with JL' 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)) t�insp.doc t 10N Page 3 Official lnspecfion Form:Subsurface Sewage Disposal system Page 7 of 16 Commonwealth of Massachusetts J5111=11110 Title 5 Official Ins ection Form Inspection , Not for Voluntary Assessments Subsurface Sewage Disposal System Form i C. System Information _ 2,y 7 -- Property Address �JQ Ur/Sys Citylr n State Zip Code -3/-OS Owner's Na a Date of Inspection Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): 640 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): S Number of current residents: ❑ s '�10 t� 6C Does residence have a garbage grinder? AAD Is laundry on a separate sewage system? (if yes separate inspection required] ❑ Yes No I Laundry system inspected? /-/,?F es No Seasonal use? ❑ Yese' No /411 -- Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes.X No Last date of occupancy: fate Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): 'GMM R.asis of design flow(sea#s/persons/sq.ft., etOJ: Grease trap present? ❑ Yes ❑ No industriai waste hotdirtg tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Titte•5 system? ❑ Yes ❑ No Water mi$ter readings, if avaltabte:. Last date of bbc#tincyluse: Date Other(describe): t5insp.doc• 11/2004 Tate 5 OfficW fnspection Form:Subsurface Sewage Disposai 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.) ,44-7 �s w Property Address ,V.,4,v pawl✓ / � 0!Eels- City/Town YS — State City/Town �_,31-c Zip Code G,74y c 9(11A — Owner's NaFne — Date of Inspection General Information Pumping Records: A/© Source of information: Was system pumped as part of the inspection? Yes ❑ No If yes, volume pumped: gallons p/an cry -- How was quantity pumped determined? Reason for pumping: Type of System: XSeptic 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 cbfffbcl(tb be bbtaihed from system owner ❑ Tight tank..Attach a copy of the DEP apfxovaf. ' Cl Other(desoribe): Approximate age of ail components, date installed(if known) and source of information: mel — Were sewage odors detected when arrlving at the 'site? ❑ Yes ?� No t5insp.doc- 110N Title b Officlal lnspecilon Form:Subsurface Sewage Disposal System Page 9 of 16 Commonwealth of.Massachusetts Tele 5 Offclal inspection Fora Not for Voluntary.Assessments Subsurface Sewage Disposal System Form C. System information icont.) Z V 8r,z� rs Lti Prop Address P-4*PWC-r ddreC-r City/Town State Zip Code Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron P�40 PVC ❑ other(explain): Distance from private water supply well or suction line: teat Comments (on condition of joints, venting, evidence of leakage, etc.): ckA5 o F loak or . ry r- xs Septic Tank (locate on site plan): Z Depth below grade: feet Material of construction: concrete ❑ metal [],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 cer�1fiw8 ) ii QFnieRSiOnS: y.� Sludge depth: y�y Distance from top of sludge to bottom of outset tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffre Distance from bottom of scum to bottom of outlet tee o�baffle How were dimensions determined' t5lnsp.doc•11/2004 Title 5 officW tnspecthn 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.) 2-q'7 BnAQ 6v Property Address a�A,vna�c�' Zi --- State p Code City/Town 3f°b� Owner's Name Date of Inspection Comments (an pumping recommendations, inlet and outlet tee or baffle condition, structural integri(; liquid levels as related to outlet invert, evidence of leakage, etc.). 1d = iiy/ej Ar- � � cwt,�t,� ,,,k � /14L ±--- V< s o�ucf. wtf� v✓flCf T&1 x a ----- .. Grease Trap (locate on site plan): Depth below grade: feet 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: Date — Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integr ) liq-bid level's as (elated to outlet i'hVert, evidence bfi leakage, etc.)` Tight or Hotding Tank (tank must be pumped at time of inspection) (locate on site pian): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) t5msp.doc 1112004 Titie 5 Official inspection Form:Subsurface Sewage Disposal Syste;. Page 1 of - Commonwealth of.Massachusetts le .S- Official Inspection Form TMS.. . p Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information -cont.) Property Address OOV"/ State Zip Code City/Town0. Owner's Na�h/e'—! . Date of Inspection Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Distribution Box(if present must be opened) (locate on site plan): /ti Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any avid"encs ,f 1' akage intb '- out bf boX, Etc j:f U«Y r',/ e [?ucry o�u^ �i'Qyia� K`cfl /`� �c�� kelt/ o Pump Chamber�tocate on site pian): Pumps In working-0rder: ❑ Yes ❑ No Alarms in working bider: ❑ Yes ❑ No t�insp.doc 11PLab4 Title 3 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.) Property Address City/Towr� State Zip Code C01141 y — Owners Name —� Date of Inspection Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why:. Type: ❑ leaching pits number: — ❑ leaching chambers number: ...... leaching galleries number: —- - I i leaching trenches number, length: ❑ leaching fields number, dimensions: -- -- ❑ overflow cesspool number: ❑ innovative/alternative system ' Type/name of teohnology: --..._..._. Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): t5insp.doc- t i004 Title 5 Officlal Inspection Form: Subsurface Sewage Disposal system Page 13 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont,) 2,-n )3r»1 tj. 1-v - - Property Address City(rown State Zip Code Owners 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, Privy (locate on site plan): Materials of construction: Depth of-solids — - Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation etc.): t$insp.doc- i 10N Title 3 Official Inspection Form:Subsurface Sewage bisposal System Page 14 of tc Commonwealth of Massachusetts Title 5 Official Inspection Form ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 2,y7 8ri`c4q 1W. — - Property Address 41 City/Tow / State Zip Code Owner's Name Date of Inspection Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system incluoinc to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet Locate where public water supply enters the building. D-r3W- 29� ;;;�v CEN< 15insp.doc - t 1/2004 fiitle b Official Inspection Form: Subsurface Sewage Dsposai Page I Commonwealth of Massachusetts ID Tltl.e 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System information (cont.) _ ?1/7 13,,&ev Z Property Address B YS ss Q 1t ,1)kV0vcT City/Town State Zip Code C" Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: 7 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: 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) Cl Accq"Qd USGS database-explain: You must describe flow you established the bi h grotffjd water elevation; f a�1 y0 SUMP V . ti ccllar- t5lnsp.-foc 11/2004 Titte 5 Officiai tnspection form:Subsurface sewage Disposal System Page 16 of 16 !-address �2� 8A i tw-6� AN Title of File Page of Date File Open: Date file closed: Doc Document/Action Title Date of Refer to other Purpose of Document/Action and notes: action Document/ document/ Num• Action Department Board of Appeals — Board of Health Planning Board _ Conservation Commission — Building Departmer t NEW ENGLAND ENGINEERING SERVICES INC July 29, 1999 North Andover Board of Health Town Hall Annex 27 Charles Street North Andover, MA 01845 RE: TITLE V REPORT: 225 Bridges Lane,North Andover Enclosed is a copy of the Title V report for the above referenced property. The systemap sses our inspection. If there are any questions please call me at my office, 686-1768. Sincerely Ben�CC Os o27r. E.I.T. J g President TGiNN®F NO"R` N®OVERS �nE--vAR :11:ALTH - 99 ' 33 WALKER ROAD-SUITE 23-NORTH ANDOVER, MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 COMMONWtALTH O� MASSACHUSETTS t L� EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENMONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM a PART A CERTIFICATION Property Address:'qa j ljle,bgic L14.1 N'ANa1vW- Name of Owner S}r}� CT CrAddress of Owner: a-a 5 RtiXt C-S ( N.. N• �VEe� Date of Inspection: ` I a-S�9 Name of Impactor:(Please Print) Benjamin C. Osgood, Jr 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: New England Engineering_Services Inc. MaFTing Address: 33 Walker Rd , S »�1, Nnrt-h Andover, MA 01845 Telephone Number: 978-686-1768 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: "' Passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails p Inspector's Signature: C' Date: < ; X9,n The System Inspector shall submit a copy this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner -shall submit the report to the appropriate regional office of the Department of•Environmental Protection. The original should be sent to-I&M system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS ? TN1S 1S A (zIr01SED 71r[-E S gF0'27k__ rsluet> +e TC'`./VN OF k,0 Tjq A • rte-_ , . 2 1999 revised 9/2/98 Page I of 11 %J0 P—led on Rrcyclyd Paw, • I I r � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property.Address: a a J� 1 1�C S I"N' 1 )`I, k►ow EC(- Owner: >(}{y CT l SES Date of Inspection: s INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: ` V/ 1 have not found any information which indicates that any of the failure conditions described in 310 CMR,15.303 exist. Any failure . criteria not evaluated are indicated below. COMMENTS: B. 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. Indicate yes, no, or not determined(Y, N. or NO). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection-,or the septic tank, whether or not metal,is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping-tnore than four-times n yeardue to broken or obst, cted pipe(s). The system wilt Van inspection if(with approval of the Board of Health): - broken pipe(s)are replaced obstruction is removed ) ) ) revised 9/2/98 Pagc2ofII • i t i i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: a $fit Ci�.S t_N. 1 Owner: ':Y Aq%-L CT% Daae of Inspection: ! ! C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the envirogment. 11 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 WHICKYALL.PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIBONMEN-T: _ Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone 1 of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER 4 i revised 9/2/98 Page 3ofII I i I i I • 1 1 1 I SUBSURFACE SEWAGE DISPOSAL SYSTEM(INSPECTION FORM PART A CERTIFICATION (continued) Property Address: a aS Q IR V ZKWL N l N.kM D v✓E_P Owner: —_T/Fit"( Cr 1 L-E S ) r Date of Inspection: OT 1 a3194) D. SYSTEM FAILS: F You must indicate either "Yes" or "No" to each of the following: have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be`necessary to correct the failure. Yes No Backup of sewage irvto4ocih"r-e-"temcomponent-dueto en ovetloeded or-LbggedSASor•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 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is-within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for -coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: 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: The system serves a facility with a design flow of 10.000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system-iii-within 200 feet of-04f4KAary-4o a eurfaoa-ddr>kiwg-watersupply - --- - - - 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) ' The owner or operator of any such system shall upgrade the system inti accordance with 310 CMR 15.304(2). Please consult the local regionals office of the Department for further information. c I r revised 9/2/98 Page 4ofII I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: "lasCrf owner: Ar ry Ct,t-K S Date of Inspection: ! ! c1 r r Check if the following have been done: You must indicate either "Yes" or 'No" as to each of the following: Yes No _ Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system:composa n.U.haua.b n pumpo"or"atlsast two vvoaks an&the system has li"aaacraiuiag,wMUKal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ✓ As built plans have been obtained and examined. Note if they are not available with NIA. _✓ _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. ✓ The site was inspected for signs of breakout. ✓/ _ All system components, excluding the Soil Absorption System;have been located on the site. _✓ _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was,inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. / The size and location of the Soil Absorption System orr the site has been determined based on: Existing information. For example, Plan at B.O.H. Determined in the field (if any of the failure criteriarelatedto Part C is at issue, approximation of distance is unacceptable) . 115.302(3)(b)) _✓- _ The facility owner(and.occupaots.if different from.owner).wareprouided.with ? a pznpAr maintansocA.0f SubSurface Disposal Systems. 4 4 revised 9/2/98 page 5ortI SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: e).-I's 9.42\t C,W S L.N. � Owner: '5(}(4 ( -1 LSC�s 'Date of Inspection: ROW CONDmONS RESIDENTIAL: Design flow: g.p.d./bedrobm. t Number of bedrooms (design):= Number of bedrooms(actual): Total DESIGN flow Number of current residents:,�l Garbage grinder(yes or no):JS Laundry(separate system) (yes or no).''L; If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no):_U _ Water meter readings,if available(last two year's usage(gpd): 1 OWN Sump Pump(yes or no): rVo Last date of occupancy:PuKtZSNT- COMM ERCIAL/INDUSTRIAL: Type of establishment: Design flow: qpd (Based on 15.203) Basis of design flow 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: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: po W—(>V-o s J7rc -A 0 r-r't'iz- -f TGA'lz (2 owWAYc%-Z- System System pumped as part of inspection: (yes or no)_)[kS If yes, volume pumped: i 000 gallons Reason for pumping: TYPE OF SYSTEM V"* 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) 1/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed{if known)-end source of-Wormation: 1 9 5 Sewage odors detected when-arriving at the site: (yes or no) /V 0 ) f revised 9/2/98 P2gc6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: o s 6�t� S LN•f N• ARbOVEP- owner: -S Npk Q-(LAE S Date of Inspection: ")(b r BUILDING SEWER: (Locate on site plan) r Depth below grade: Material of construction: V cast iron i 40 PVC—other (explain) Distance from private water supply well or suction line N4 Diameter 4 I r Comments: (condition of joints, venting, evidence of leakage,-etc.) - (�l P LceK� CTcroD N 1'bt �C,vVt rc.N SEPTIC TANK:_ (locate on site plan) Depth below grader Material of construction:—Zconcrete_metal—Fiberglass _Polyethylene—other(explain) If tank is (petal,list age_ ls.age.confrmed by Certificate of Compliance_ (Yes/No) Dimensions: /5ey Cr&4-L vM 5 Sludge depth: Distance from top of sludge to bottom of outlet tee or traffle: - -' Scum thickness: /'U ��� '��� � E 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 dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or-baffles. depth of liquid level in relation to outlet invert, structurel4ntegrity, evidence of leakage, etc.) T9"t< m,44-;r--R LEs/EL k4l-"c A-v&t�, it, yyw I1VSPifCI'ieN why DO^IC rA-P41�—' CiOAIl- A-r 45E4-41 IZE P/N kCD gU Am Oye S eP Tl e- s T"A'N K //%t D 0D1y71T:'oy. GREASE TRAP: rV (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: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) f 'y revised 9/2/98 Page 7orrr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: N-AN 6o tJE�2 Owner: ;TPA '(T(L eS Date of kupection: 01 TIGHT OR HOLDING TANK:(Tank must be pumped prior to, or at time of, inspection) (locate on site plan) t Depth below grade:_ Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) ` Dimensions: V — Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order:Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX:_ (locate on site plan) O �( Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) — — (�ax t Ak Q:LgoD c omD1 77 ON. /VO rE✓r Oft!CE o'g GC.4K.Fci-"r AE- Cf+,Z,z.fOYcir- PUMP CHAMBER:_A (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 appurtenances,etc.) revised 9/2/98 p2ge8of11 I I f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ; SYSTEM INFORMATION (continued) Property Address: S 131 t S L�•j N• 40 2 Owner: -j 4-^k CC t_';;S Date of Inspection: el I a 3�o) SOIL ABSORPTION SYSTEM(SAS):— (locate SAS)_(locate on site plan,.if possible:excavation not required,location may be approximated by non-intrusive methods) If not located, explain: ' Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries,number:_ leaching trenches,number,length: leaching fields, number,dimensions: / i mOv F-r.. LZf'tc tf- )C--/E t'Is overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) A(?-k A o f F t& e t.-oo K S CESSPOOLS:tel/ (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) i Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of•vegetation, etc.) _ PRIVY:�- (locate on site plan) Materjals of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation;etc.) } R revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART G SYSTEM INFORMATION(continued) Property Address: 22.6- Owner: 2jowner: RN Date of kupection: 9/23/17,S SKETCH OF SEWAGE DISPOSAL SYSTEM: r include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) c < 1 I Ij V J` V� w 1.� revised 9/2/98 Page 10 of II I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEIJI INFORMATION(continued) Property Address: Z ZS ►i t2 t D�E7 l N. 44-)D O J cA_ Owner: Date ofrhspection: NRCS Report name `s Soil Type_ 641 Lr 2/ /t r r , Typical depth to groundwater 7 b•U USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater L Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed.Site(Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) i) , ► i S �� ��Ps FFw t�; OT �9_rc,I— 0 ?a t'L:�-rc;- w-71-t n® w c r t-v+N,a s y &K rr 0 . �"• U5 Sc 5 iAIR-t�3 Irt c� CQcQ1ti� t p revised 9/2/98 Page it or ii i i i F O lu1 U . ' TOWN OF NOR'111 AVDOVER LUT RELEASE FORT1 SUBDIVISION ASSESSORS MAP SUBDIVISION LOT(S) PERMANENTTADDRESS ASSIGNED BY U.P.W. i.STREET 1,3 e , �. APPLICANT 2 Y1 c� �� l e S Pima: &Y'T •- loY& - ?ATE OF APPLICATIONy� TOWN USE BELOW 'T11iS LINE ` ;PLANNING BOARD DATEAPPROVED TOWN PLANNER DANE REJECTED I GOi1SERVATzoN corMzsszoN DATE APPROVED CONSERVATION ADHIN. DA'T'E REJECTED B01LRD OF HEALTH DATE APPROVE-D 8 Zf3 0 HEALTH SANIT ZIA1i llA'TL' REJECTED ''DEPARTMENT OF PUBLIC WORKS DRIVEWAY PER1-iIT SEWER/WATER CONNECTIONS FIRE DEPT. N RECEIVED BY BUILDING INSPECTION DATE This form shall be signed by the agents of the Planning and llca.ltli Boards , the Conservation Coirunission prior to the issuance of any bulldlny; Per.mlts for the subject lot. This form shall not releive the applicant from Lite �, f� nnn1ir-nh1p Town reuuirement or bylaw. MORTGAGE INSPECTION PIAN 225 BRIDGES LANE No. ANDOVER MASS SCALE: 1"240' MARCH , 198T WILLIAM G. TROY REG/STEREO LAND SURVEYOR 12 EUCLID ROAD -TEWKSBURY, MASS. 28.26' 44, 5 S s.f. 'Poo L i o EXISTING - DWELLING 70'l 6 S'+ L=32.86' 205.10' BRIDGES !LANE ~� Y HEREBY CERTIFY TO THE TITLE INSUROR AND TO THE BANK THAT THE DWELLING IS LOCATED ON THE LOT AS SHOWN AND THAT IT DOES h:'4!T`, CONFORM WITH THE TOWN OF No. ANDOVER ZONING REGULATIONS REGARDING SETBACKS FROM STREETS AND LOT LINES. o E FURTHER CERTIFY THAT THIS DWELLING IS NAT LOCATED IN THE FEDERAL FLOOD HAZAR A A AS SH01MD0 ON MAP DATED IO MAY 77 lj� +� =� / . .. REGISTERED LAND URVEYOR z THIS PLAk FOR IMIORTGACE PURPOSES -NOT FOR BOUNDARY DETERMINATION. 7 BOUNDARIV 6NFORMATION TAKEN FROM.' N.E.R.D. PLAN 9060 a m kA OF JOSEPH yG 13ARBAGALLO NO. 464 O/S T SS�ONAL SP�\� • G �_ r d �J W q I � I of y o �,r ' •, Health .,. ..fudover9Masa f SUBSURFACE'DISPOSAL DESIGN CHECK Me LOT i �' LLYj APPRUM DATE 2-20�5 DISAPPROVED DATE__ .� Provided: -- Reasons: ritle v FAIL ac Reg 2.5 The submitted plan must show as a minimums a) the lot to be served-area dimensions lot ##abutters blocatfon and log deep observation hoiea-distance to ties location and results percolation testa-diatance to ties d design calculations do calculations showing required leaching area (e) location and dimensions of aystem-including eeserve area f) existing and proposed contours (g) location any wet areas within 3D0' of sewage disposal system or disclaimer-check Wetlands mapping (h) surface and subsurface drains within 100' of sewage disposal system or disclaimer (i) location any drainage easements within 1 !01 of sewage disposal system or disclaimer-Planning Board filet (J) known sources of water supply within 200 of sewage disposal system or disclaimer (k) location of any proposed well to serve 1. t-100I from leaching facility (1) location of Water lines on property-101 . Iron 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 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 sWimad ng pool (d) 251 from subsurface drains leg 10.2 Distribution Boxes (a) slope greater than 0.08 leg 10.4 b) sump SOIL PROFILE & PERCOLATION TEST DATA North Andover, Mass. Street No �2i Ct�,S Lot No 6~ X-oc/Subdiv. , Pland Owner 'V-Uj C.G Investigator S 41S06©d Observer ["t SOIL PROFILE DATES 1_x'l ev 2.Elev 3.Elev 4.Elev 0 0 0 0 1 1 1 1 Tiles Pits est 3 3 3 3 4 o f 4 4 4 S 5 --�� 5 5 5 6 6 6 6 7 7 7 7 8 too V-- A'O 8 8 8 9 9 9 9 10! 10 10 10 Benchmark Location Elevation Datum PERCO TION TESTS DATES b [� r o L� p) Pit Number �� i �Gj p- 2 �') 3 4 Start Saturation ['.�3 [' '3a Soak-Minutes •fig [ art -lest--TIMe-lest--TZo Drop of 3"-Time `L•• Drop of 6"-Time T%0 V 2: 315 M6ms-lst 3" drop _ Nins.2nd " Drop2 3 Percolation a� TO: NORTH ANDOVER, MASS f`57 I BOARD OF HEALTH FROM: DESIGN ENGINEER Re: Soil Absorption Sewage System Inspection This is to certify that I have inspected the construction of the said disposal system at S 7 /3R l �D(5:-L2 � 4/%E" North Andover, Mass. SITE LOCATION The grades and construction are as specified in my plans and specifications dated L 19 ZA COMMO,y`y eg. n er/ e ni ian �S113S�a 6v 1AA, Ala COM6-7 MONS ,S'.,4 w.e. zz f /k /3 OX t 9 4 4 1o �' S7 f P i l 1 1 i I � i �000 S-f E D i s o o t A/ S-4 i°ti c to iyk 31,�/z) �-E s �•9N,E Board of Health sEPTIC STSTEM North -AndaVerZHaaa. , INSTA?1.ATICK CMK LIS_ LOT'J ' b l ww OVED ' DATE DI SAPPRO ED AVATZ OK uu FAIL --- e�nst Dw& FM OK 1. Distance Tos a. Wetlands b. Drains c.. Well 2. Water Line Location 3• No PPC Pipe 4. Septic Tank a. Tees -_Length & To Clean Out Gu -er. b. Cement Pipe to Tank - On Both amide of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Lines FloAmg Equal Amounts. c. No Back Flow 6. Leach Field or Trench a. Dimensions b. Stone Depth c. Capped Ends d. Clean Double Washed Stone 7. Leach Fits a. Dimensions b. Stone Depth c. splash Pads d. Tees e. Cen,ent Pipe to Pit - Both Sides f. Clean Double Washed Stone 8. No Garbage Di.spo sal 9. Final Grading Inspection 10. Barricading Covered System u 11. As Built Submitted a. Lot Location b. Dimensions of System c. Location with Regard_to Pere Test d. Elevations e: Water Table r i +w..r+ ..A.w....sm.+rnaewww.w:enrwwwrxrwwnuyyww:ur+Mrr.rrrrvr:►vwarn+rwanwwawnmar• . MM1RWI/M1b/,MMAYIMMYXWNIMMyMRyggIWFl4M1VWb11HNIYMIi'MIJIM�NgwM[YpIyYIIMAMMNI/IbEMIW�VOANRiI11iVibwMM1MAMYHgW`1MU•RARNWYpIJM1lM V.A IV..CCS P SE S Sl/�FgGE SEWA46 A/SPL7►S4L. SYS726A1 FNG P.eo,oas�o Lor a eAd/,vr, € s LS"H/L/ s / DE Rc�ry• I tve, ALlo / ' • DIES/G E .i==�;r;; _Leaf ,'' _ ..�� ''j 4 / WESTWA,e1a MAS S. f c, tog ... f70 TYPE OF BU/LWiVc�. �r /� ti 1�1,vt OI,/VC. 04RAGE CE PL 6 LLA�f UMBJ�v FAQ! A,, s f SElU.4GE t<LDW 17 a SEPT/C TAMC /S G c Fi r-/O" ePEPGoLAT/opt/ X573404 TE J. a TLhz' EGEVATiGN 171, 4. / n /7 ` .BJTTv EC,EY � _ ..< .. ... `_ W...�._...__ . _ _. __ F __ f`,r � f I 1 M gTit�+V !(r 7• (.0 14 7. �. ! S.4rU.eA7'io�t/ J S Af1A.1. •S /K/N. / AfJAZ- M v. f tb G" *R.OP tisin� tcLc,P,-oG4 TioN RATE T PITS -me/c C/ VD _ r - DATE 1 0 . ._. __ _ _ __..._ _�,\._ .... _.`__.._ _ _..�. TDP E[E1�AT/dull �7/• - S 4 _,. t7o • o SO/L Tb�cic A ND 7151/ W � TL-R rABcE COCA Tio A/ A076Ir 113 ,0 c 9 •.2.5- I I TESTS COA/DaCTE0 BY SAIA !3a6 .4 CNk/•St/'.R NScN E-NGr- a P o s A D TESTS W17-A/ESSED BY /v1 I k N R o S 7'- /I am �LAA. TE"RI.4 C5'"EET I OF ,� y r »,eave•r - a ' - • - '. - - ,�••� �SE.�tED cT0/�tlT, cSO[./D P 1/.L'. P/PE • - &a2 E4 t//iiAGEN T') CS O • f1�E l�L._L C�tlDS 4"Wf'E,eFae.4r� woe EctuivAcENr) ALE E SEE SECT/DA.! 4T 40wE. ,e/GNT� 4,Q EA /C_%o n 57 00 4741. C4NG.QETE SEPT/G TANK 3 ¢ 9SScY/D P.k1 C.,.5EA4SD TO/A17'S s-.04, f-!Bso�PT/DN �Ep IDLAAJ - I • /UoT Tp CSC.4LE v 17 s t` 4"¢ - .SE'4G E� P. v G'Rel-Sf/L-41, -T 7-0 NE o Cif !k � � �• ' - rc9 � i -(4F EOlJ/✓.44EN7- Q I CD -� " � lL s � G�L/SNED STONE � Q � � • CaOUBLE H/ QS//E� :. 7-0 MEET A.4.-s- O. IN B11_�i.!kFC_ /61Y= // li✓�y! SiS/YD Gk�T VE`:. - _S • �/ �v /6 4 a 465ORPT/O&! &EO SEcT/D,t,/ i '•�� ,�1o.e l''=4�0' l/E,e�- /"3 �' P.P.DF/LE 'IND f�Bs�.�PT/0,,, aE� GAN f- "L) cSEGT/ONS HEE'�" �F