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_ Commonwealth of Massachusetts
City/Town of North Andover
Gystern Pumping Record
Form .4
wy DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be e lsubmitted to
the local Board of Health or other approving authority within 14 days from the pumping dat
accordance with 310 CMR 15.351.
A. Facility Information
important- When
filling out forms 1
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
2
a
ream
System Location:
Address
North Andover
City/Town
System Owner:
GCS n ►'fid
Name
TOWN til-tj6RTH AfvuGVER
HI=ALT�i p[' -i rZT� E�kT�
Ma 01886
State Zip Code
Address (if different from location)
State Zip Code
City/Town
Telephone Number
B. Pumping Record
/0� ���
1. Date of Pumping Date 2. Quantity Pumped: Gallons
❑
3. Type of system: ❑ Cesspool(s) (Septic Tank ❑ Tight Tank Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑Yes 10
No
-if yes, was it cleaned? ❑ Yes ❑ No
5. Condition oj:System:
6. System Pum d By:r7 �����
Vehicle License Number
Name
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler Date
Signature of Receiving Facility Date
System Pumping Record - Page
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computer, use
only the tab key
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use the return
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c6m, M ait
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... nw Massachusetts
I
City/Town'of NORTH ANDOVER, MASSACHUSETTS
'System Pumpn -4 g Record.
Form 4
DEP has provided this form for use by local Boards of Health. The System Pump�ng Record must
be submitted to the local Board of Health or other approving authority.
X Facility Information
1. System Location: "
2. System Owner.
Name
Address (it different from location)
�roc�
M9
state
Zip Code
SVne" of Hauler Data
http:/Awww.mass.gov/deptwater/approvalsh5forms.htm#inspect
t5form4.doco 0=3
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System Pumping Record - Page 1 of 1
Clty/Town
state
Zip Code
Telephone Number
B. Pumping Record
/000
1
Date of Pumping Date
2. Quantity Pumped:
Gallons
3.
Type of system: C3 Cesspool(s)
Septic Tank ❑ Tight Tank
Other (describe):
4.
Effluent Tee Filter present? ❑ Yes [I No
If yes, was it cleaned?
❑Yes ❑ No
5.
Condition of System:
e.
System Pumped By:
une
S7M
Vehicle License Number
mp y
7.
Location where contents were disposed:
� I
SVne" of Hauler Data
http:/Awww.mass.gov/deptwater/approvalsh5forms.htm#inspect
t5form4.doco 0=3
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System Pumping Record - Page 1 of 1
Date,g (3[701.?. ....
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies thatF:��qk .. 0.t ..... 15.t !�� r t ..... F--
. . ..
has permission to perform .... wlien .....0 4At 0 ...........
ding of.. rA .. ............. .... V4 �N
wiring in the buil k ! .. —44--71F
...... North Andover, Mass.
Feed. --t.!..... ..... Lic. No.
A
ELECT L INSPECTOR
Check 'q
67 6
Commonwealth of Massachusetts
Official Use Only
Department of Fire Services Permit No. 47195
BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked
[Rev. 11/99) leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
Al l work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL &FORMATION) Date: 5-31-0(o
City or Town of -To the Inspector of Wires:By this application the undersigned gives notice of his or her i, itention to erform the electrical work described below.
Location (Street &Number) �, 3 W ��'�
Owner or Tenant
Owner's Address ,.J 1,l : o n . _
Telephone No, 3 9
Is this permit in conjunction with a building permit? Yes 97 No
11(Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Ioo Amps 12-0/ *LYoVol s Overhead 2"Und d
❑ No. of Meters
New Service Amps / Volts Overhead ❑ Und rd
g ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: %1
a
Com letion n the ollowi Bl
No. of Recessed Fixtures f O
n to emu be waived b the Ins ector n Wires.
No. of Ceil.-Susp. (Paddle) Fans o otal
No, of Lighting Outlets
No. of Hot Tubs
r'
Transformers KVA
Swimming Poo! ve ❑ -
Generators KVA
❑ o, o melt Y rg g
No. of Lighting Fixtures
rnd. rnd.
Batte Units
No. of Receptacle Outlets
No. of Oil Burners
No, of Gas Burners
FIRE ALARMS No. of Zones
No. of etection and
No. of Switches
No, of Ranges
No. of Air Cond. Total
Initiating Devices
op Number ons W
Totals: '
No. of Alerting Devices
No. of Self -Con ed
No, of Waste Disposerseat
No. of Dishwashers
Space/Area Heating KW
Detection/Alerting Devices
Local ❑ Municipal ElOther
Connection
No, of Dryers
Heating Appliances KW
Security ystems:
No. o atero.o
No. of Devices or E uivalent
Heaters KW
o.o
Signs Ballasts
Data Wiringevices
or Euivalent:
al
No. of Dcommunications
No. Hydromassage Bathtubs
No. of Motors Total HP
TeleW
No. of Devices or E uivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
C17LECK ONE: INSURANCE Ltd BOND ❑ OTHER ❑ (Specify:)
Estimated Value of Electrical Work: Z o0 0 —
(When required by municipal policy.) (Expiration Date)
Work to Start: 5 - 3 1 —oto inspections to be requested in accordance with MEC Rule 10, and upon completion.
1 certify, under thepains and penaldes ofperjut , that the information on this application is true and complete.
FIRM NAME: LIC, NO.:
Licensee: &—t-&tn
(If applicable, enter "exempt" in
Address.j / �
OWNER'S IM
required by law
Owner/Agent
Signature _
Signature f 1C. NO.:
number line.) of Bus. Tel. No.:,Q% A ,Sro YO 5/P3
�' �' A /`t Alt. TeL No.-? 7
URANCE WAfVER: 1 am aware that the Licensee does not have the liability insurance coverage normallye
By my signature below, 1 hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent.
�� , Telephone No.PERMIT FEE S
PETER F. REILLY
136 ANDOVER STREET
ANDOVER, MA 01810
(978) 375-3750
. ,-; � ► 2003
TITLE V
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION
Property Address:
23 Willow Ridge Road, North Andover, MA 01810
Name of Owner:
John Curley
Address of Owner:
same
Name of Inspector:
Peter F. Reilly
Company Name:
same
Mailing Address:
136 Andover Street, Andover, MA 01810
Telephone Number:
(978) 375-3750
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. I am a DEP approved system inspector pursuant to Section 15.340 of Title
5 (310 CMR 15.000) The system:
✓ Passes
N/A Conditionally Passes
N/A Needs Further Evaluation By the Local Approving Authority
N/A Fails
Inspector's Signature: Date: October 18, 2003
Pet F. Fleilly
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within thirty (30) days of completing this inspection. If the system is a shared system
or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the 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 a the time of inspection and under 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 (See attached Disclaimer).
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION (continued)
Property Address: 23 Willow Ridge Road, North Andover
Owner's Name: Curley
Date of Inspection: 10/18/03
INSPECTION SUMMARY:
A. SYSTEM PASSES: Check A, B, C, D, or E / ALWAYS complete all of Section D
✓ I have not found any information which indicates that the system violates any of the failure criteria as
defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
The system met the Pass Criteria of Title V.
B. SYSTEM CONDITIONALLY PASSES:
N/A 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). Describe basis of determination in all instances. If "not
determined", explain why not)
N The septic tank is metal, and over 20 years old* or the septic tank (whether metal or not) is 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. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a
Certificate of Compliance indicating that the tank is less than 20 years old is available.
ND explain:
N Observation of a sewage backup or breakout or high static water level 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):
N/A broken pipe(s) are replaced
N/A obstruction is removed
N/A 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):
N/A broken pipe(s) are replaced
N/A obstruction is removed
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION (continued)
Property Address: 23 Willow Ridge Road, North Andover
Owner's Name: Curley
Date of Inspection: 10/18/03
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 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:
N/A Cesspool of privy is within 50 feet of a surface water
N/A Cesspool or privy is within 50 feet of a bordering vegetated wetland or 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:
N/A The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet
to a surface water supply or tributary to a surface water supply.
N/A The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply
well.
N/A The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply
well.
N/A The system has a septic tank and SAS the SAS is less than 100 feet but 50 feet or more from
a private water supply well.''*Method used to determine distance N/A
This system passes if the water well water analysis, performed at a certified DEP 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. A copy of the analysis must be attached to this form.
3. Other
N/A
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION (continued)
Property Address: 23 Willow Ridge Road, North Andover
Owner's Name: Curley
Date of Inspection: 10/18/03
D. System Failure Criteria applicable to all systems:
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes N o
No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
No Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool.
No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool.
N/A Liquid depth in cesspool less than 6" below invert or available volume <'/z day flow.
No required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped: once
No Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
N/A Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water
supply.
N/A Any portion of a cesspool or privy is within a Zone I of a private water supply well.
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well.
N/A 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 laboratory, for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate
nitrogen is less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis
must be attached to this form).
N/A The system fails. I have determined that one or more of the above failure criteria exist as defined in 310
CMR 15.303, therefore the system fails. The property owner should contact the Board of Health should be
contacted to determine what will be necessary to correct the failure.
E. Large Systems:
Tobe considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You Must indicate either "Yes" or "No" to each of the following:
(The following criteria apply to a large system in addition to the criteria above)
N/A The design flow of system is 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
N/A The system is within 400 feet of a surface drinking water supply
N/A The system is within 200 feet of a tributary to a surface drinking water supply
N/A The system is located in a nitrogen sensitive area (Interim Wellhead 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 such system considered a significant threat under
Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should
contact the appropriate regional office of the Department.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART B - CHECKLIST
Property Address: 23 Willow Ridge Road, North Andover
Owner's Name: Curley
Date of Inspection: 10/18/03
Check if the following have been done. You must indicate either "Yes" or "No" as to each of the
following:
Yes No
Yes Pumping information was provided by the owner, occupant, or Board of Health.
No Were any of the system components pumped out in the previous two weeks ?
Yes Has the system received normal flow in the previous two week period ?
No Have large volumes of water been introduced to the system recently or as part of this
inspection?
N/A Were as built plans of the system obtained and examined ? (If they were available note as N/A)
Yes Was the facility or dwelling was inspected for signs of sewage backup ?
Yes Was the site 4ms. inspected for signs of breakout ?
Yes Were all system components, excluding the SAS, have been located on the site ?
Yes Were the septic tank manholes uncovered, opened and the interior of the septic tank inspected
for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of
sludge, depth of scum ?
Yes Was the facility owner (and occupants of if different from the owner) provided information on
the proper maintenance of subsurface sewerage disposal systems ?
The size and location of the Soil Absorption System (SAS) on the site has been determined based on:
Yes No
Yes Existing information. For example, a plan at the Board of Health.
N/A Determined in the field if any of the failure criteria related to Part C is at issue (approximation
of distance is unacceptable) [15.302(3)(b)].
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION
Property Address: 23 Willow Ridge Road, North Andover
Owner's Name: Curley
Date of Inspection: 10/18/03
FLOW CONDITIONS
RESIDENTIAL:
Number of bedrooms (design):
Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203
(for example: 110 gpd x # of bedrooms:
Number of Current residents:
Does the residence have a garbage grinder (yes or no):
Is the laundry on a separate sewerage system (yes or no):
Laundry system inspected (yes or no):
Seasonal use (yes or no):
Water meter readings, if available (last 2 years usage [gpd]):
Sump Pump (yes or no):
Last date of occupancy:
COMMERCIAL/INDUSTRIAL:
Type of Establishment:
Design Flow gpd (based on 15.203):
Basis of Design Flow (seats/persons/sq.ft., 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)
PUMPING RECORDS
unknown
4
unknown
2
yes
no (if yes, separate inspection required)
N/A
no
unknown - private well
no
current
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
GENERAL INFORMATION
Source of Information: owner
Was system pumped as part of inspection (yes or no): no
if yes, volume pumped (gallons): N/A
How was quantity pumped determined ? N/A
Reason for pumping: N/A
TYPE OF SYSTEM
✓ Septic tank/distribution box, soil absorption system
Single cesspool
Overflow cesspool
Privy
NO Shared system (yes or no) (if yes, attach previous inspection records, if any)
Innovative / Alternative technology. Attach a copy of the current operation and maintenance contract
(to be obtained from the system owner)
Tight Tank Attach a copy of the DEP Approval
Other (describe):
Approximate age of all components, date installed (if known) and source of information: original tank and SAS
about 30 years old.
Were sewerage odors detected when arriving at the site (yes of no): no
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 23 Willow Ridge Road, North Andover
Owner's Name: Curley
Date of Inspection: 10/18/03
BUILDING SEWER: (locate on site plan)
Depth below grade: about 8" - 12"
Materials of construction: ✓ cast iron 40 PVC other (explain)
Distance from private water supply well or suction line N/A
Diameter: 4"
Comments: Condition of joints, venting, evidence of leakage, etc.)
Building sewer was watertight and appeared sound at foundation.
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: about 6" - 8"
Material of construction: ✓ concrete metal Fiberglass Polyethylene other (explain)
If tank is metal, list age N/A Is age confirmed by Certificate of Compliance N/A (Yes/No)
Dimensions: Rectangular - 1,500 gallons
Sludge depth: 0"-1"
Distance from top of sludge to bottom of outlet tee or baffle: 25"
Scum thickness: 0"-1"
Distance from top of scum to top of outlet tee or baffle: 7"
Distance from bottom of scum to bottom of outlet tee or baffle: 15"
How dimensions were determined: observation
Comments: (on pumping recommendations, of inlet and outlet tees or baffle condition, structural integrity, liquid
level as related to outlet invert, evidence of leakage, etc.)
Tank was watertight and functioning properly.
GREASE TRAP: N/A (locate on site plan)
Depth below grade:
material of construction: concrete metal FRP other (explain)
Dimensions: N/A
Scum thickness: N/A
Distance from top of scum to top of outlet tee or baffle: N/A
Distance from bottom of scum to bottom of outlet tee or baffle: N/A
Date of Last Pumping: N/A
Comments: (on pumping recommendations, of inlet and outlet tees or baffle condition, structural integrity, liquid
level as related to outlet invert, evidence of leakage, etc.)
N/A
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 23 Willow Ridge Road, North Andover
Owner's Name: Curley
Date of Inspection: 10/18/03
TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection) (locate on site plan)
Depth below grade:
N/A
material of construction: concrete metal
Dimensions:
Capacity:
Design Flow:
Alarm Present (yes or no):
Alarm level:
Alarm in working order (yes or no)
Date of last pumping:
Fiberglass Polyethylene other (explain)
N/A
N/A gallons
N/A gallons per day
N/A
N/A
N/A
N/A
Comments: (condition of alarm and float switches, etc.)
N/A
DISTRIBUTION BOX: ✓ (locate on site plan)
0" depth of liquid above outlet invert
Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage
into or out of box, recommendation for repairs, etc.)
D -box was level. Four lines leading to SAS were appear to be accepting effluent evenly. D -box was
about 6" - 8" below surface.
PUMP CHAMBER: N/A (locate on site plan)
Pumps in working order (yes or no) N/A
Alarms in working order (yes or no) N/A
Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.)
not applicable
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 23 Willow Ridge Road, North Andover
Owner's Name: Curley
Date of Inspection: 10/18/03
SOIL ABSORPTION SYSTEM (SAS): ✓ (locate on site plan, if possible; excavation not required)
If SAS not located, explain why:
Type
leaching pits, number
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
✓ leaching fields, number, dimensions
overflow cesspool, number
alternative system (name of technology)
N/A
N/A
N/A
N/A
1 field, 4 lines, est. size 20'x 40'
N/A
N/A
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.)
Soils in area of SAS looked good, no evidence of ponding, damp soil, or breakout.
CESSPOOLS: N/A (locate on site plan)
Number and configuration
N/A
Depth -top of liquid to inlet invert
N/A
Depth of solids layer
N/A
Depth of scum layer
N/A
Dimensions of cesspool
N/A
Materials of construction
N/A
Indication of groundwater inflow (cesspool
must be pumped as part of inspection)
N/A
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
recommendations for maintenance or repairs, etc.)
not applicable
PRIVY: N/A (locate on site plan)
Materials of construction
Dimensions
Depth of solids
N/A
N/A
N/A
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
recommendations for maintenance or repairs, etc.)
not applicable
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 23 Willow Ridge Road, North Andover
Owner's Name: Curley
Date of Inspection: 10/18/03
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Provide a sketch of the sewerage disposal system including ties to at least two permanent reference landmarks
or benchmarks. Locate all wells within 100'. Locate where public water supply enters the building.
SEPTIC TANK TIES
D -BOX TIES:
NOTE:
A0vc
vI1 .G
U
A to Center (C)
A to Box
Sepf,C-
+aI
D-b9x
18'0"
39'0"
2
Fl?c�v r
1�
B to Center 39'8"
B to Box 560"
The system is in the front yard. Domestic well is in the rear yard, at least 100
feet from the SAS.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 23 Willow Ridge Road, North Andover
Owner's Name: Curley
Date of Inspection: 10/18/03
SITE EXAM
Slope flat to gently sloping in area of system
Surface water none observed
Check cellar dry
Shallow wells none observed
Estimated Depth to Groundwater >1" (below bottom of SAS)
Please indicate (check) all methods used to determine the high ground water elevation:
Y Obtained from Design Plans on record - if checked, date of design plan reviewed: 11-5-76
Y Observed site (abutting property, observation hole within 150 feet of SAS)
Y Check with Local Board of Health - explain: information on file
Y Check local excavators, installers - (attach documentation)
N Accessed USGS Database - explain: website too complicated
You must describe how you established the high ground water elevation.*
The soils and grade changes in the area indicate no groundwater in the SAS. However, the precise
groundwater elevation cannot be determined for certain without a soil evaluation test.
*Inspector's Note: Soil Evaluation is the currently recognized method for determining
or establishing the high groundwater elevation. Since I am not a licensed or certified
soil evaluator, I am not qualified to determine or establish the high groundwater
elevation beyond the public information available, such as recent design plans of the
site or the nearby area. My estimation of the high groundwater elevation is based on
a due diligence effort to obtain all available information both on and off the site and
my experience as a certified subsurface disposal system inspector. (see attached
Disclaimer)
DISCLAIMER
This passing septic inspection under Massachusetts Title V is in no way a guaranty
or warranty of the inspected septic system. The inspection is a "snapshot in time" and
does not constitute a complete assessment of the quality or potential longevity of the
septic system. The pass/fail criteria are specific and outlined in detail in this report.
Under the limited criteria of a Title V inspection, it is impossible to determine how long
any septic system will last. The inspector made a diligent effort to certify the septic
system based on the criteria required under Title V.
Under Massachusetts Title V, soil evaluation is the accepted method of determining
the high groundwater elevation. This inspector is not a certified soil evaluator and is
therefore not qualified under Title V to determine or establish the high groundwater
elevation. The method used to estimate the high groundwater for this inspection was
based on the public records and methods of observation described on the previous
page. Groundwater levels can vary greatly from season to season, year to year and
soil evaluation is considered the most reliable method of groundwater determination
under Title V.
-A
Peter F. Reilly
Inspector
October 18, 2003
TOWN OF NORTH-AN'DOVER
SYSTEM PUMPING RECORD
�1 STEM OWNER & ADDRESS.. SYSTEM LOCATION _
• (example; Icf( from of house)
o? -3 GtJi // %�a°�e, ; � /'
lv, /14
I'C OF PUMPING: 7 if QUANTITY PUMPCD 0,�LLc»,
;.1:�.�I'UUL: NO YES SEPTICTANK: Q' YES
4.VL
MATURE OF SERVICE: ROUTINE EMERGENCY
ffl1.>FRYATIONS:
GOOD CONDITION. FULL TU CUVCIZ
HPAVY CREASC BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK..
CXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER p Hu (EXPLA.IN)
PUMPCD BY:
U� I I:"�"1' ' ti ANSFCIZIiED TO:
NDr
Y fejt 6vcr
jab
NA --46
Orn
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MORTIS Sjgvj= TANK BOIL
47 RAIIRuO gZnm
BPAOFMr Mh 01835
978-372.7471
W", ADQ ES
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5�
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156d
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WELL DATABASE
ADDRESS: 7
AGE CF 'N'? r v L 1 w` T �P . l
`� r Pt y f i : ,T: '7VLI_t, LOC. 71ON:
---'W..._LL.P—P7Z2YD:i' DATE: DEET OF �v
TSE OF V,T a_ DRTT r b. Lid L i0�vN __
'WAAYALvDA=-- - EICrnlfA��tCAZ1�5�: Y
ELG�IKaN: Y N O' =cGNtkHNA=L . yN ----_--==
fF
ADDRESS: 3 C� ✓J �� ,
r✓c�Z L�� j (-iG/ -
AGE OF W��.:..L Fir`I L DRILL��:
tiVELLPER. 'T WEALLOCA `-ICN.
WELL PER�ti i DAT.: DEP "� 0 WrLL:
TYPE OF WELL: DRILILED b. Dlic c. liNKIi0'riN"
TYPE OF WATERBEARLNG ROCK:
MATER
ANALYSIS YSIS DATE: HIGH tiL���iGANcSE:
=H LRON: Y N OTIE. CONTA�ICNAtiTS: Y
a
{� --J." 4,
TO: NORTH ANDOVER, MASS';"V 19 77
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
L e,'ir /3 W1 //o w /�/ cl (f,, North Andover, Mass.
SITE LOCATION
The grades and construction are as specified in my plans and specifications dated
19-r
%%
'�Skvcvoo
arian
i
SOIL PROFILE & PERCOLATION TEST DATA
Wave', /� /� /
Town/City No.&Street O/F /�o✓tall Lot No.+�
Loc./Subdiv. � �'��OW �Cl ____, Plan Owner Re)Zti�0_
Investigator Qally Observer
7` SOIL PROFILES -DATE '11,917e
3✓.Elev. 3° 4'El#.�
Elev. 3' Elev.
0 0 0
1 1 1
2 2 2 ... _
3 3 3
Benchmark
Elevation
4
5
6
8
9
10
4
5
6
8
9
10
Location
Datum
Percolation Tests -Date
4
5
6
8
9
10
Pit Number 1 2 3 4 5
Start Saturation
Soak -Mins.
Start Test -Time
Dro of 3" -Time
Drop of 6" -Time
Mins.lst 3"Dro
Mins.2nd 3"Drop
Notes & Sketches on Back Frank C. Gelinas & Associates, North And.
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P. 0 for use by local Boards of H
hai Ordild d this form st6m Pump g Re ord must
be submitted to the.local'Board of Health or other appro n
Ttva
V�t8o
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�A• FicllftJnfoMH DEP:
link'orta'n't::
1. System [.6c-atlon.-
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014 the tab key Address
to move Your
do not
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Address If different froM IoC&Uon
CRyrrown
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Telephone Number
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Date Of PumpU ng--'4.Date 2, Qua'ntlty Pumped:
IMP
Gallons
Cesspools)
M --Septic Tank
Tight Tank
.[]'.Other (descdbii;:-`-*-`
F t?.. 'yes -go"
4 EM.Woh�.Tee Filter resent? If yes, was it
[I Yes E] No
cleaned?
. . . . . . . . . . .
m:
q
Omped
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P 10PO
Qntbdts: �yir sed:
afar/approval S/t5f0rm3,htm#lnspect
'
t6f mAdw.06/03
lVehIcie'tJ e Number
Date
System Pumping Record - Page 1 of 1