HomeMy WebLinkAboutMiscellaneous - 235 CANDLESTICK ROAD 4/30/2018 (2) 235 CANUU-b I ILA rcvr+u as L,�• 1
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Commonwealth of Massachusetts GV��
Title 5 Official Inspection For 1ti�11 `
p
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Q•
235 Candlestick Road ,spy
Property Address —r`
Doris Barrett
Owner Owner's Name
information is
required for every North Andover MA 01845 8-11-2017
page. Cityfrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered i a y
way. Please see completeness checklist at the end of the form.
Important:When A. General Information (�
filling out forms
on the computer, .
use only the tab 1. Inspector:
key to move your
cursor-:do not Neil J. Bateson
use the return Name of Inspector
key.
Bateson Enterprises Inc.
Company Name
111 Argilla Road ^0 v
Company Address ,s' DSa,C
Andover MA 01810
City/Town State Zip Code
978-475-4786 SI-15
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection.The inspection
was performed based on my training and experience in the proper function and maintenance of on site j
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑
NeecL& Further Evaluation by the Local Approving Authority
8-11-2017
Inspe6torls Signatury Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original should be sent to the system owner and copies sent to the
buyer, if applicable, and the approving authority.
****This'report only describes cotiditions 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 j
the same or different conditions of use.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
235 Candlestick Road
Property Address
Doris Barrett
Owner Owner's Name
information is
required for every North Andover MA 01845 8-11-2017
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
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 j
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
235 Candlestick Road
Property Address
Doris Barrett
Owner Owner's Name
information is North Andover MA 01845 8-11-2017 I
required for every
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
I
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
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C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
•''� 235 Candlestick Road
Property Address
Doris Barrett
Owner Owner's Name
information is
required for every North Andover MA 01845 8-11-2017
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
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D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
El ® 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 Y2 day flow
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
235 Candlestick Road
,p
Property Address
r
Doris Barrett
Owner Owner's Name
information is
required for every North Andover MA 01845 8-11-2017
page. Cityffown State Zip Code Date of Inspection I
B. Certification (cont.)
'I
Yes No
❑ ® 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.
I
❑ ® 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. i
i
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet j
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, E
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- j
10,000gpd. j
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
e
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
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i
` Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
235 Candlestick Road
Property Address
Doris Barrett
Owner Owners Name
information is
required for every North Andover MA 01845 8-11-2017
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ Z Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of !
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner) provided with
® ❑ information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
Determined in the field (if any of the failure criteria related to Part C is at issue
® ❑ approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information !
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 600
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
235 Candlestick Road
Property Address
Doris Barrett
Owner Owner's Name
information is
required for every North Andover MA 01845 8-11-2017
page. Cityfrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
PDoes residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d Yes
9 ( Y 9 (gP ))� I
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
t
235 Candlestick Road
Property Address
Dons Barrett
Owner Owner's Name
information is
required for every North Andover MA 01845 8-11-2017
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
I
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Pumped 2016, owner
Was system pumped as part of the inspection? ® Yes ❑ No
1500
If yes, volume pumped: gallons
How was quantity pumped determined? Measured tank
Reason for pumping:
Inspect tank&tees
I
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
I
❑ 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) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins.dop•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
235 Candlestick Road
Property Address
Doris Barrett
Owner Owner's Name
information is North Andover MA 01845 8-11-2017
required for every
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
i
Approximate age of all components, date installed (if known)and source of information:
Tank& leach trenches 29 years old, 7-26-1988, as built plan. Outlet tee in septic tank&d-box was
replaced 9-3-2014. Info @ B.O.H.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.8
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
4" PVC through wall, 3" PVC in house. No leaks visible.
Septic Tank(locate on site plan):
Depth below grade: 0.8
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 certificate) ❑ Yes ❑ No
Dimensions:
10'x 5'x 4'
Tf
Sludge depth:
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'r 235 Candlestick Road
Property Address
Doris Barrett 1
Owner Owner's Name
information is
required for every North Andover MA 01845 8-11-2017
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
30"
Scum thickness
3"
Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom of outlet tee or baffle
12"
How were dimensions determined?
Tape measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Inlet tee partially clogged , clean same. Outlet tee ok. Depth of liquid at outlet invert. No evidence
of leakage. Pumped septic tank.
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:
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
235 Candlestick Road
Property Address
Doris Barrett
Owner Owner's Name
information is
required for every North Andover MA 01845 8-11-2017
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
I
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Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
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Date of last pumping: Date
I
Comments (condition of alarm and float switches, etc.):
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*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
15ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 3235 Candlestick Road
Property Address
Doris Barrett
Owner Owner's Name
information is
required for every North Andover MA 01845 8-11-2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box level &distribution equal. Evidence of light solid carryover, pumped d-box to clean.
No evidence of leakage
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Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No* `
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): j
If pumps or alarms are not in working order, system is a conditional pass.
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Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
" 235 Candlestick Road
Property Address
Doris Barrett
Owner owner's Name
information is
required for every North Andover MA 01845 8-11-2017
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 2 trenches 50'
long
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soil q,k. Vegetation ok. No sign of ponding to surface.
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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
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
235 Candlestick Road
Property Address
Doris Barrett
Owner Owner's Name
information is North Andover MA 01845 8-11-2017
required for every
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
I
t5ins.doe-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
kviTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
235 Candlestick Road
Property Address
Doris Barrett
Owner Owner's Name
information is
required for every North Andover MA 01845 8-11-2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
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a = 3r7+11 " X23`y u
t5ins.doc-rev.6/16 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
235 Candlestick Road
Property Address
Doris Barrett
Owner Owner's Name
information is
required for every North Andover MA 01845 8-11-2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
I
® Surface water
® Check cellar
I
® Shallow wells
Estimated depth to high ground water: 4
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 3-12-1986
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
Design plan
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
As per test pit data on design plan.
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Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
235 Candlestick Road
Property Address
Doris Barrett
Owner Owner's Name
information is North Andover MA 01845 8-11-2017
required for every
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
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t5ins.doc,•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
�. Commonwealth of Massachusetts
.CIWTown of .
System Pumping.Record
Form 4
DEf'has.provided this forni for use-by local Boards of Health. Other forms may•be used,but the
information,must be substantially the same as that provided here. Before using.this form,check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted.to
the local Board of Health or other approving authority.
A. Facility. Informs a#ion
1. System Location: Left/t cont of nous Left/Right rear of house, Left./right side of house, Left I
Right side of building, Left/Right front of buldirig, Left/Right rear of building, Under deck
Address
��c-�P4
City/rown State - Zip Code
2. System Owner.
_ ._ ----
Name'
Address(if different from location)
Cityrrown • StateC�
A
J 1 C4•�(q �� Zip Code
Telephone Number ,
.B. Pumping Record �
#7 1 -z
1. Date of Pumping 2.. Quantity Pumped: Gallons
.3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
9
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Ld'No If yes,was it cleaned? ❑ Yes ❑ No
' 5. Condition o stem:
14&A �_z_
6. System Pumped By:
Neil.Bateson.' F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
ncCompany
7. Locatio where contenta•were disposed:
G S Lowell Waste Water
Signitu a Haul Date `
form4.doo-06/03 System Pumping Record•Page 7 of 1
V
Town of North Andover I
Tax Map # 210-106.A-0204-0000.0
Parcel Id 17348 r
235 CANDLESTICK ROAD
BARRETT, WILLIAM
235 CANDLESTICK ROAD
N. ANDOVER, MA
01845
Class 101 Single Family Property Type 1 Residential
Zoning2 1 Residential Zoning3 1 Residential
Size Total 1 Acres
FY 2018
UB.Mailing Index
Name/Address Type Loan Number Active/Inact. From Until
BARRETT,WILLIAM Payor
235 CANDLESTICK ROAD
N.ANDOVER,MA
01845
UB Account Maint.
Account No Cycle Occupant Name Active/Inactive
Bldg Id. 17637.0-235 CANDLESTICK ROAD Last Billing Date 7/18/2017
3170307 03 Cycle 03 Active
UB Services Maint.
Account No.3170307
Service Code Rate Charge Multiplier/Users
MISCFEE ADMIN FEE 0.635/8 7.82 1/
WTR WATER 01 ALL METER SIZE 57.00 /1
UB Meter.Maintenance
Account No.3170307
Serial No Status Location Brand Type Size YTD Cons
36433623 a Active ERT HH b Badger w Water 0.63 0.63 1498
Date Reading Code Consumption Posted Date Variance
6/8/2017 1496 a Actual 15 7/25/2017 21%
3/8/2017 1481 a Actual 12 4/12/2017 -71%
12/9/2016 1469 aActual 42 1/23/2017 -76%
9/9/2016 1427 a Actual 171 10/24/2016 306%
6/13/2016 1256 a Actual 46 8/2/2016 232%
3/9/2016 1210 a Actual 13 4/22/2016 -69%
12/1,0/2015 1197 aActual 43 1/20/2016 -56%
9/9/2015 1154 a Actual 98 10/16/2015 96%
6/9/2015 1056 a Actual 49 7/24/2015 277%
3/11/2015 1007 aActual 13 4/28/2015 -45%
12/11/2014 994 aActual 24 1/15/2015 -81%
9/11/2014 970 aActual 127 10/15/2014 747%
6/11/2014 843 aActual 15 7/16/2014 24%
3/11/2014 828 aActual 12 4/11/2014 -70%
12/10/2013 816 a Actual 39 1/17/2014 -58%
9/11/2013 777 aActual 93 10/15/2013 166%
6/12/2013 684 a Actual 35 7/24/2013 153%
3/13/2013 649 a Actual 14 4/22/2013 -25%
12/11/2012 635 aActual 18 1/9/2013 -88%
9/13/2012 617 a Actual 154 10/15/2012 777%
6/12/2012 463 a Actual 17 7/16/2012 25%
3/14/2012 446 a Actual 14 4/14/2012 -24%
12/12/2011 432 aActual 18 1/17/2012 -87%
9/12/2011 414 a Actual 145 10/13/2011 167%
6/7/2011 269 a Actual 51 7/20/2011 256%
3/8/2011 218 a Actual 14 4/13/2011 -70%
12/9/2010 204 aActual 47 1/12/2011 -63%
9/10/2010 157 a Actual 134 10/15/2010 605%
6/7/2010 23 a Actual 18 7/15/2010 56%
7990_ gORTq
Town of North Andover
HEALTH DEPARTMENT
,SSACNUSt1
CHECK#: /5-13 DATE: 8 -d A-40/7
LOCATION: 3 5 S i
r
H/O NAME:
CONTRACTOR NAME: 13a,t- 501
Type of Permit or License: (Check box)
❑ Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service-Type: $
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
` ❑ Offal(Septic)Hauler $
F
G ❑ Recreational Camp $
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ Trash/Solid Waste Hauler $
t
❑ Well Construction $
SEPTIC Systems:
I
❑ Septic-Soil Testing $
I
❑ Septic-Design Approval $
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
Title 5 Report a 55 $ 50
r\ P
4
! ❑ Other:(Indicate) $
H/4)
He gent Initials
White-Applicant Yellow-Health . Pink-Treasurer
� l
I
Y
Commonwealth of Massachusetts Map-Block-Lot
` 106.A0204
----------------------
BOARD OF HEALTH
Permit No
North Andover BHP-2014-0763
P.I. FEE
F.I. $125.00
-----------------------
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted -Todd-Bate-son
----- ------------------------------------- ------------------------ -
to(Repair)an Individual Sewage Disposal System. -D b0K 4- aV i-PL i
at No 235 CANDLESTICK ROAD
as shown on the application for Disposal Works Construction Permit No. BHP-2014-076 ep er 03,2014
�
Issued On: Sep-03-2014 BOARD OF HEALTH
Commonwealth of Massachusetts Map-Block-Lot
106.A0204
BOARD OF HEALTH -----------------------
Permit No
North Andover BHP-2014-0763
-----------------------
FEE
$125.00
-----------------------
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Todd Bateson
to(Repair)an Individual Sewage Disposal System.
at No 235 CANDLESTICK ROAD [.FI L COPY
as shown on the application for Disposal Works Construction Permit No. BHP-2014-076 Dated September 03,2014
Issued On: Sep-03-2014 � ^� _
BOARD OF HEALTH
A 699
0:♦``r • L
t Town of North Andover
HEALTH DEPARTMENT
CHECK#:
LOCATI0
H/O NA
CONTRACTOR NAME:
Type of Permit or License:(Check box)
❑ Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service-Type: $
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal(Septic)Hauler $
❑ Recreational Camp $
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ Trash/Solid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
Septic Disposal Works Construction(DWC)
Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
❑ Title 5 Report $
❑ Other:(Indicate) $
Health Agent Initials
White-Applicant Yellow-Health Pink-Treasurer
`1 Application for Septic Disposal System
TODAY'S DATE
Construction Permit — TOWN OF
NORTH ANDOVER, MA 01845 $25.0000-comRepair
Important: Application is hereby made for a permit to:
When filling out ❑Construct a new on-site sewage disposal system'
forms on the
computer,use ❑Repair or replace an existing on-site sewage disposal system= _
only the tab key ®pair or replace an existing system component—What? t>—�� � —
to move your
cursor-do not
use the return A. Facility Information
key.
Address or Lot#
Cityfrown
2:*TYPE OF SEPTI YSTEM*: L'nta
2 2014
➢ ❑Pump ravity(choose one)
"`tf pump sys ,attach copy of electrical permit to application*' Ti-!ANDOVER
➢ onventional System (pipe and stone system) PARTMENT
➢ ❑ Infiltrator or Biodiffuser(Gravel-Less)(Attach a copy of your certificafiotyofsysterrl.)
➢ ❑Pressure Distribution S.A.S.(No D-Box)
➢ ❑ Pressure Dosed(D-Box Present)S.A.S.
➢ ❑ Does the system require an effluent filter? Yes No
If yes, does plan specify make and model of filter? YES=(no further info. needed)
NO=(installer must specify brand of filter before DWC issuance)
What is the Make? What is the Mode.
2. Owner Information
�a �r5 �►-r��
Name /
Address(if different from above)
/lilt
CityfTown State Zip Code
12 r -3 9714_
Telephone Number
3. Installer Information
.).:A-JQ f�54 A—.) IBATMON ENTERPRISES,INC.
Name Name ofCpmpanMDOVER,
, MA 01810
Address /'tom
A
City/Tom State Zip Code
Telephone Number(Coil Phone#if possible please)
4. Designer Information
Name Name of Company
Address
Cityrrown State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit♦Page 1 of 2
(Wit Application..for Septic Disposal :System -/
TODAY'S DATE
p
Construction Permit - TOWN OF
! MA 01.845 $.250.00-Full Repair
ORTH ANDOVER,
•••
5 $725.00,-Component
PAGE 2 OF 2
A. Facility.Information continued....
5. Type,of Building: esidential Dwelling or[]Commercial
B. Agreement
The undersigned agrees to
g g ensure the construct/on and maintenance of the afore-described
on-site sewage disposal system In accordance with the provisions of Title 5 of the
Environmental Code,as well as the Local Subsurface Disposal Regulations for the Town of
' North Andover, and not to place the system in operation until a Certificate of Compliance has
been Issuedby this Board of Health.
Name Date
Application Approved By: (Board of Health Representative)
Name Date
Application Disapproved.for the following reasons:
For Office Use Only:
1 Fee Attached. Yes No
2." PtojectMariaget Obligation Form Attached? Yes No -
3.: Purn,�S,vstem? Ifsoj Attach co,nv ofElectrical Permit Yes No
4. FOundadda As Built.?(new construction-ronly); Yes_ No
(Same scale as approved plan)
y "
A Floor Plans?(he.w construction only); Yes_ _
No
ApplCctlon forpjsposal Systerii: onstrncfloo Permit Rage 2 of 2
SEM, G'SI'ST : ►R1?jBCT MA
-NT�DBT.�,i�Y'I8M
As f is NQxth Audover•lic=cd&ijftjjgr kr fft.�a tic
(Ad4ow ofseptic Ipt=) Bos Pho by
R02tin0 to tke.appumtba of a �►�Qso v {Bngiue
(minces pante AM dated
Dated ��--`
® s a Jid�dared
(Last mvised dete)
I uadMtod the following obligations fat numg=cut of Iismjcct~
1. As the iastalle 4 I Os.oblsgaW to obt aim all pe=ns and;Board of fIeaiffi
qTWVC4 l to
p otmlag any:wo*tin a aite: LM=havr ktttti rovedatfalls an
As
2. a t i�z{ot Mutton and'AI=pt tdcWL L hOMeoa�utt.,cont meto;,ptoj gee or any
item th pliaeble. y compky tditca ase iaspaoa and the apstctii no re9dy�t
�, .+egg to.hsg+e tlYe w��
� tedam t d prfa ID the applkabk k*ctipo as
ap
shtt>Yct bei �� � � k�A' uipeetaas; s the is e'rctaitiiag ,Mich
6. 1a�=C61 bot dgea•uvt have to be,present•,
el s- 11 M I of s t &t iiep for cimtsom t ea,etc,
. 'vabi�I OK-(os a maii•ta:
-be tiibWt6cd.•to*hc.Board•ofHcA - $asst flee teen mt?st
' •-
hept far this• �doa, Vat P ?W �. �-��'�`�titae. .1lin�tatici iriiist
• P A. be ready 4n,&able to
pump.to�or3c
' ,•
C. •L#���,–�tte�ttzllet:meeat t+altiettt'ittsspe ���l.�tdbtg-3��plete: Irtstaljec docs$ot
have to be vt ffate.-
4. 14s the mstalia'I undiftUnd that city=4Wdficdip0ij.-
Ot the; c&(t�Jwdw
aasuplete dietial�nIlatitta of the syatstttl �°�� t teni teggit ed
} app 'foe iastttltatian:j
4
uw
sous for 'e—r Rfy
1 orth Attdt>Qer.sit cifi ..+ '
5.. Aa the.Yaat3 •I code tzu thatI tuuat ie o mag h;~p ca-af thi fen
owittg coast ciitxe.
�: 1)eterm�aaetYo�r t!theWOF"clee+nt�aa erltle c»�emr hAs'hcop machedt
A ht,'tea oftba nand send tie�v be sited :
C* FiruJ.f�rtpeosr hpBvt�lfelth `'orconfulst>rt
d L�deUat�att<tift �J�-.�e�pY�t4s,use,�at�l�aia� b�,�`tsel r�sa�l mer '
4'OtIIipaacno.
6- As WasOcUmW Lim s*kr 1 9i,file -lWnn-0f Ift astrm
_ ��+ ��� t� � � �FjAf��7�iannt t►eMu 1.�..1s�..
1ie4 G�8„�'t�i1s O�f tb.Mn» +
Uaders3onddcaEd Settt�tc,fnatz �:Fs=/`�
Plo
d Ox Datil
y
` Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessm s
!c7EC4E I V
CD
235 Candlestick Road
Property Address c1. Q��
Doris Barrett �
Owner Owner's Name TOWN Uh NUK I H ANDOVER
information is TH DEPARTMENT
required for North Andover MA 01845
every page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:
When filling out A. General Information
forms on the
computer,use 1. Inspector:
only the tab key
to move your Neil J. Bateson
cursor-do not Name of Inspector
use the return
key. Bateson Enterprises Inc.
Company Name
111 Argilla Road
Company Address
Andover MA 01810
Citylrown State Zip Code
978-475-4786 S115
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ N e I Further Evaluation by the Local Approving Authority
9/3/2014
In e o Signatu Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 17
i
t Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
235 Candlestick Road
Property Address
Doris Barrett
Owner Owners Name
information is
required for North Andover MA 01845 9/3/2014
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
f
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are I
indicated below.
Comments:
after permit from B.O.H., install new outlet tee with gas baffle in septic tank& new d-box, septic
system now passes Title 5 Inspection
i
I
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 I
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined"(Y, N, ND)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.
❑ Y ❑ N ❑ ND (Explain below):
I
i
I
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
i
i
i
i
Ot NOR7/j 6987
3j°`_ _�•OOL
F , 9
Town of North Andover
`,�'•�.;„o:: ,' HEALTH DEPARTME T
�sS"cNus°t
CHECK#: DATE:
LOCATION:a7l� ( AIN t I c/41*( i
H/O NAME:
CONTRACTOR NAME:
Type of Permit or License: (Check box)
❑ Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service-Type: $
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal(Septic)Hauler $
❑ Recreational Camp $
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ Trash/Solid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
Title 5 Report $
❑ Other:(Indicate) $
Health Agent Initials
White-Applicant Yellow-Health Pink-Treasurer
r t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
p ,
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
235 Candlestick Road
Property Address J
Doris Barrett
Owner Owner's Name
information is
required for North Andover MA 01845 8/21/2014
�
every page. City/Town State Zip Code Date of Inspection L �`
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:
lip A. General Information
When filout
g
forms on the
computer,use 1. Inspector:
only the tab keyAUG 2 2 2014
to move your Neil J. Bateson t
cursor-do not Name of Inspector I TOWN OF NORTH ANDOVER
use the return �_ HrALTH DEPARTty',ENT
key. Bateson Enterprises Inc.
Company Name ---.-
111 Argilla Road
Company Address
((� Andover MA 01810
0 Citylrown State Zip Code
978-475-4786 S115
Telephone Number License Number
I
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
❑ Passes ® Conditionally Passes ❑ Fails
❑ N ds ,urther valuation by the Local Approving Authority
8/21/2014
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
""This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
1!
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
235 Candlestick Road
Property Address
Doris Barrett
Owner Owner's Name
information is
required for North Andover MA 01845 8/21/2014
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
I
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
® One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
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.
❑ Y ❑ N ® ND (Explain below):
t5ins-W3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
235 Candlestick Road
Property Address
Dons Barrett
Owner Owner's Name i
information is
required for North Andover MA 01845 8/21/2014
every page.a e. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
i
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ® N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ® N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ® N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below):
e
I
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
235 Candlestick Road
Property Address
Doris Barrett
Owner Owner's Name
information is
required for North Andover MA 01845 8/21/2014
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
I
Outlet tee in septic tank&d-box needs to be replaced.
I
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
11 ® 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 %day flow
t5ins-3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
I
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r 235 Candlestick Road
Property Address
Doris Barrett
Owner Owner's Name
information is
required for North Andover MA 01845 8/21/2014
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
El ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
I
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
11 Elthe 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 u h
upgrade the
system in accordance with 310 CMR 15.304.The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
235 Candlestick Road
Property Address
Doris Barrett
Owner Owner's Name
information is
required for North Andover MA 01845 8/21/2014
every page. CitylTown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
i
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
'® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
®
Were the septic tank manholes uncover❑ p ed, 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
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 600
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
I
235 Candlestick Road
Property Address
Dons Barrett
Owner Owner's Name
information is
required for North Andover MA 01845 8/21/2014
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
i
i
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use?
❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)): Yes
Detail:
i
Sump pump? ❑ Yes ® No
Last date of occupancy: Current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present?
El Yes ❑ No
Industrial waste holding tank present? El Yes No
Non-sanitary san tary waste discharged to the Title 5 system? El Yes ❑ No
Water meter readings, if available:
t5ins'3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
235 Candlestick Road
Property Address
Doris Barrett
Owner Owner's Name
information is
required for North Andover MA 01845 8/21/2014
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Pumped 2014, owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
®
Septic tank, distribution box soil absorption sstem
❑ 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)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
235 Candlestick Road
Property Address
Doris Barrett
Owner Owner's Name
information is
required for North Andover MA 01845 8/21/2014
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
26 years old, 7/26/1988, as built plan
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.8
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
4" PVC through wall, 3" PVC in house, no leaks visible.
Septic Tank(locate on site plan):
Depth below grade: 8
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
i
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
10'x5'x4'
Dimensions:
0"
Sludge depth:
t5ins•3/13 Title 5 Official fnspection Forth:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
235 Candlestick Road
Property Address
Doris Barrett
Owner Owner's Name
information is
required for North Andover MA 01845 8/21/2014
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
33" i
Scum thickness
0"
li
Distance from top of scum to top of outlet tee or baffle8
Distance from bottom of scum to bottom of outlet tee or baffle 15"
How were dimensions determined? Tape Measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Inlet tee ok. Outlet tee needs to be replaced, has corrosion holes. Depth of liquid at outlet invert.
No evidence of leakage. Center cover has riser 2"deep.
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
t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
I
235 Candlestick Road
Property Address
Doris Barrett
Owner Owners Name
information is
required for North Andover MA 01845 8/21/2014
every page. Cityf town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons 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.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
•''r 235 Candlestick Road
Property Address
Doris Barrett
Owner Owners Name
information is
required for North Andover MA 01845 8/21/2014
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
i
D-box level &distribution equal. Evidence of leakage, has corrosion holes. Evidence of light
carryover.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc. : i
*If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
i
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
235 Candlestick Road
Property Address
P
Doris Barrett
Owner Owner's Name
information is
required for North Andover MA 01845 8/21/2014
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 2 trenches 50'
long
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soil ok.Vegetation ok. No sign of ponding to surface.
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
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
235 Candlestick Road
Property Address
Doris Barrett
Owner Owner's Name
information is
required for North Andover MA 01845 8/21/2014
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
I
i
i
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
4
Commonwealth of Massachusetts
ID Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
F
.�' 235 Candlestick Road
Property Address
Doris Barrett
Owner Owner's Name
information is
required for North Andover MA 01845 8/21/2014
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
wa'1r-ec'
&
Coe s
U-) 1
a
i
i
t5ins-3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
235 Candlestick Road
Property Address
Doris Barrett
Owner Owner's Name
information is
required for North Andover MA 01845 8/21/2014
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
®
h
P
Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water:
4
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 3/12/1986
Date
❑ Observed siteabuttinproperty/observation hole within 150 feet of SAS
site(abutting ) i
Iain:®
Checked with local Board of Health-explain:
Design plan
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
I
�h
You must describe how you established the high ground water elevation:
As per design plan test pit data
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5lhs•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
235 Candlestick Road
Property Address
Doris Barrett
Owner Owner's Name
information is
required for North Andover MA 01845 8/21/2014
every page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
I
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
I
t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17
• Summary Record Card generated on 8/19/2014 11:27:57 AM by Karen Hanlon Page 1
Town of North Andover
Tax Map # 210-106.A-0204-0000.0
Parcel Id 17348
235 CANDLESTICK ROAD
BARRETT, WILLIAM
235 CANDLESTICK ROAD
N. ANDOVER, MA
01845
Class 101 Single Family Property Type 1 Residential
Zoning2 1 Residential Zoning3 1 Residential
Size Total 1 Acres
FY 2015
UB Mailina Index
Name/Address Type Loan Number Active/Inact. From Until
BARRETT,WILLIAM Payor
235 CANDLESTICK ROAD
N.ANDOVER, MA
01845
UB Account Maint.
Account No Cycle Occupant Name Active/Inactive
Bldg Id. 17637.0-235 CANDLESTICK ROAD Last Billing Date 7/8/2014
3170307 03 Cycle 03 Active
UB Services Maint.
Account No. 3170307
Service Code Rate Charge Multiplier/Users
MISCFEE ADMIN FEE 0.635/8 7.82 1/
WTR WATER 01 ALL METER SIZE 57.00 /1
UB Meter Maintenance
Account No. 3170307
Serial No Status Location Brand Type Size YTD Cons
36433623 a Active ERT HH b Badger w Water 0.63 0.63 845
Date Reading Code Consumption Posted Date Variance
6/11/2014 843 aActual 15 7/16/2014 24%
3/11/2014 828 aActual 12 4/11/2014 -70%
12/10/2013 816 aActual 39 1/17/2014 -58%
9/11/2013 777 aActual 93 10/15/2013 166%
6/12/2013 684 a Actual 35 7/24/2013 153%
3/13/2013 649 a Actual 14 4/22/2013 -25%
12/11/2012 635 aActual 18 1/9/2013 -88%
9/13/2012 617. a Actual 154 10/15/2012 777%
6/12/2012 463 a Actual 17 7/16/2012 25%
3/14/2012 446 a Actual 14 4/14/2012 -24%
12/12/2011 432 aActual 18 1/17/2012 -87%
9/12/2011 414 a Actual 145 10/13/2011 167%
6/7/2011 269 a Actual 51 7/20/2011 256%
3/8/2011 218 a Actual 14 4/13/2011 -70%
12/9/2010 204 aActual 47 1/12/2011 -63%
9/10/2010 157 a Actual 134 10/15/2010 605%
6/7/2010 23 a Actual 18 7/15/2010 56%
3/9/2010 5 a Actual 5 4/14/2010 -100%
1/29/2010 0 n New Meter 0 4/14/2010 -100%
1/29/2010 4450 r Replacement 7 4/14/2010 39%
12/8/2009 4443 aActual 20 1/12/2010 -70%
9/9/2009 4423 a Actual 70 10/15/2009 233%
6/8/2009 4353 a Actual 19 7/20/2009 46%
3/16/2009 4334 a Actual 15 4/29/2009 9%
12/9/2008 4319 aActual 13 1/20/2009 -84%
9/8/2008 4306 a Actual 81 10/10/2008 292%
6/6/2008 4225 m Manual estimate 20 7/16/2008 37%
MSG
3/7/2008 4205 a Actual 14 4/11/2008 -81%
Commonwealth of Massachusetts RECEIVED
City/Town of .
S stem Pumping Record Sri' 1 2014
Y ■- �+ TOWN ur NUR i h ANDOVER
Form 4 HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using-this form, check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Le Ri ht front of house eft/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address �;L 2c�>
Cityrrown State Tip Code
2. System Owner.
Name
Address(d different from location)
Citylrown ' State
Zi Code
Telephone Number
r
B. Pumping Record
1. Date of Pumping pate 2. Quantity Pumped: Gallons —�
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yeasto If yes, was it cleaned? ❑ Yes ❑ No.
" 5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location ere contents were disposed:
[-S Lowell Waste Water
Siq4WfHaule Date
t5fomt4.doc-06/03 System Pumping Record•Page 1 of 7
I
Commonwealth of Massachusetts
City/Town of North Andover � t-
RECEiVa
System Pumping Record
Y P 9
Form 4
j�JL 07 2014
DEP has provided this form for use by local Boards of Health. Other forMsfmay,be.;uspd,ILbut the
information must be substantially the same as that provided here. Beord_u�ih�-�this-formteheck ith your
local Board of Health to determine the form they use. The System Pumping Record must be su mitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:When
filling out forms 1. System Location:
on the computer,
use only the tab �!)5
key to move your Address
cursor-do not North Andover Ma 01886
use the return
key. City/Town State Zip Code
2. Syste ner:
Name
rdum
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
�v
1. Date of Pumping Date /q 2. Quantity Pumped: Gallons /
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No lf.yes, was it clearied? ❑ Yes ❑ No
I
5. Condition of System:
6. System Pumped By:
Name Vehicle License Number
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
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
i
I
Commonwealth of Massachusetts
RECEIVED
d City/Town of No Andover
System Pumping Record JUN 102013
Form 4
TOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. H T T ut the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility information
Important:When
filling out forms 1. System Location: �-, aCLon the computer, I �use only the tab
key to move your Address
cursor-do not No andover Ma
use the return
key. City/Town State Zip Code
rab 2. System Owner: i
V-C��e�f
Name
I
rerun
Address(if different from location)
City/Town State Zip Code
i
I,
Telephone Number
B. Pumping Record
(�W
1. Date of Pumping Date r 2• Quantity Pumped:
Gallons i
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name Vehicle Licensd Number
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
t5form4.doc•03106 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts �r
'
City/Town of No.Andover I
Y SAY . � 2ut2
System Pumping Record
TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important: {
When filling out 1. System Location,
forms on the i
computer,use C&
only the tab kev Address
to move your U No Andover Ma
cursor-do not City/Town State Zip Code
use the return _
key. 2. System Owner:
4•
rre -�---
Name
Address(if different from location)
City/Town State Zip Code
• i
Telephone Number
B. Pumping Record
q /17 /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 �o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
C P a
6. System Pumped By:
'1 �`M
e Vehicle License Number
Stewart's Septic Service
Company
•S
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Si ature of Haul r Date
Signature of Recei in aci ty Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of North Andover
a System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
rngzE
. -9- 90771
A. Facility Information
Important: JUN —7 'Loll
When filling out 1. System Location:
forms on the
computer,use 235 Candlestick Rd TOWN OF NORTH ANDENT R
only the tab key Address T`
to move your North Andover Ma 01845
cursor-do not
use the return City/Town State Zip Code
key. 2 System Owner:
k?k] Barrett
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Da9e11 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
Good Condition
6. System Pumped By:
Frank Eldridge
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Ha I Date — q - 1
Signature of Rec iv' g Fjcility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
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t5f=4.doc''ot1103
System Pumping Record•Page 1 or i
a
� 4
v 51
k' Commonwealth of Massachusetts
City%Town of NORTH ANDOVER MASSACHUSETTS
S .y-stem Pumping Record OCT 1 2 2006
Form 4
TC; HAT DOVER
DEP has provided this form for use by local Boards of Health. The System PTmpIng Record mu:
be submitted to the local Board of Health or other approving authority,
A. Facility Information -
Important:
When filling out 1• System Location:
forms on the
computer, use
only the tab key Address
to move your
cursor•do not /Town �-"--
use the return Clt y tate_. —. _ --- ---
Zip Code
key.
2. System Owner:
m
Name --
—ern e —
Address(If different from location)
cityrrown _.- --------- __ ____----- — -
-sate-9��—��`9—
Telephone Num----ber ..-----_ -------------
T ,
B. Pumping Record
1• Date of Pumping Date U -- 2• Quantity Pumped: �--•----
Gallons
Type of system: ❑ Cesspool(s�Septic Tank ❑ Tight Tank
❑ Other(describe): - M_—_ ------ -_---.__ —.... ------ -----._.......
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
f
5. Condition of System:
Sy em Pumped By:
Al I
ALL _ _— ---- -- -- --
ame --__................
Vehicle License Number
Company
Lod
7. Location where contents were disposed:
01110
V//")
Si ature of Hau Date ---
http://www,mask.govi/dep/water/ provals/t5forms.htm#inspect
t5form4.doc-06/03 System Pumping Record- Page ; of
rOwNN SEP — 7 2005
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TOWN OF NORTH ANDOVER
Y YS ___., _ HEALTH DC-PARTr,,E!NT Etii L7�Y1`lQl3 � ADDRESS - .._----
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TOWN OF NORTH ANDOVEE OCT 0 5 2004
SYSTEM PUM�PTNQ RECOR.I.)
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HEALTH DEPARTMENT -
SYSTEM OWNER.& ADDRESSI SYSTEM LOCATION
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DATE OF PUMPING:
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TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
S1 S'T'EM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
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U:\"I'E OF PUMPING: �`��d'� QUANTITY PUMPED C'ALLO'US
CI-_» UUL. NO YES SEPTIC TANK: NO YES "
NATURE OF SERVICE: ROUTINE EMERGENCY
Oli.SFRVATIONS:
COOD CONDITION FULL TO COVER
HEAVY CREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER Oj�HER (EXPLAIN)
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,s � L^1 PUMPED BY
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No Andover J&S Development dba
1600 Osgood St Stewart's Septic
Building 20 Suite 2-36 Andover Septic
No. Andover, Ma 01845 58 South Kimball Street
Bradford, MA 01835 RECEIVED
MAY 18 2012
TOWN OF NORTH ANDOVER
Date Name & Address Gallons Comments I HEALTH DEPARTMENT
5-Apr Andriolo 37 Birch Lane 1500 Good
Sullivan 47 Boxford St 750 Good
6-Apr Saplenza 40 Sterling Ave 1500 Heavy bottom
9-Apr Disalvo 400 Winter St 1500 Good
10-Apr Sarano 265 Hay meadow Rd 1500 Xxxsolids
12-Apr Lind 575 Wintery Ste-. 1500 Good
16-Apr Distefano zv&Raleigh Tavern Lane 1000 HG
Walsh 58 Paddock Lane 1500 Good
18-Apr Schrader 35 Woodberry Lane 1000 Good
Ahlhdm 48 Hawkins Lane / 1000 Good
19-Apr Barrett 235 Candel Stick Rd 1500 Good
20-Apr Harold 453 Forest St 1500 Good
Duffy 67 Shirwood Dr 1500 Good
Zoll 333 raeligh Tavern Lane 1500 Good
23-Apr Haffeners Car wash 564 Chickering Rd 2000 red tank
25-Apr Valle 58 Evergreen Dr 1000 Good
27-Apr Lucas 39 deer meadow Rd 1500 Good
30-Apr Meaney 745 Foster St 1000 Good
04/06/1997 15:02 5083736611 STEWART/ANDOVER - PAGE el
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MA 02835
L� # 4�-O 976-372-7472
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Addresso?:�.��.���� t,�.sT��rl 46 Title of File
Page of
Date File Open: Gate fie closed: .
Doc Docurnent/Action Title Date of 6tefer to other Purpose of Qocume�nt/Action and nates
action Document/ document/
Num. Action Department
-------------
Board of Appeals — Board of Health PlannM--.Board _ Conservafion Commission — Buildin Department
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vnsrxs.:aarxs:^.r��Gart3�aw•-ira.�.u.<MnrA�.r�+„rt,-wmw..�,�c_:� ,�..pa,"',:�:f_y.R`+W.tWYfM.Q�'fls!PNg. AV "s�Rs'd„�,+!,ntaynl
NEW ENGLAND ENGINEERING SERVICES
lk INC
May 5, 1999
North Andover Board of Health
Town Hall Annex
27 Charles Street
North Andover, MA 01845
RE: TITLE V REPORT: 235 Candlestick Road,North Andover
Enclosed is a copy of a revised Title V report for the above referenced property. The previously
submitted report contained the wrong address. The report was submitted as 325 Candlestick Rd. in
lieu of 235 Candlestick Rd. Please replace the previously submitted copy with this copy. Also, the
systemap sses our inspection.
If there are any questions please call me at my office, 686-1768.
Yours truly,
1�7 (?
Benjamin C. Osgood Jr., E.I.T.
President
TOWN OF NORTH ANDOVER/
BOARD OF HEALTH
(MAY
i
33 WALKER ROAD-SUITE 23-NORTH ANDOVER, MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099
t
3
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
kip ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 I
4
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
�� / n cn CERTIFICATION
Property Address: � � nq .P1 c_:;, i*Ct Q Name of Owner =rL"
Address of Owner:
t l4'`�'h"C Q A , cel"ItileS�1�C
Date of Inspection: y�Z)l q y i(/•
Name of Inspector:(Pt a Print) Benjamin C. Osgood, Jr
I 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.
MaillingAddress: 33 Walker Rd., Shite 23, 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 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
Inspector's Signature: - CVhe
Date: Z� o
The System Inspector shall submit a copy this inspection repopproving 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*Environmentat Protection. The original should be sent to-Itm
system owner and copies sent to the buyer,if applicable, and the approving authority.
NOTES AND COMMENTS
revised 9/2/98 Page l of it
`� Printed on Recycled Pip,,
f
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART A
CERTIFICATION (continued)
Property Address: z 3,',— �u.�c tF 't:(
Owner: f."�� r, i3 �e-14
Date of Ifupection: '41
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
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:
i
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 ND). 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 of 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
i
I
The system required pumpirtg-mom than four-times a yeardue to broken or obst, cted pipe(s). The system willpesS
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
I
revised 9/2/98 Page 2ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued) =
Property Address: 2 3 s �tr-CO I,-.s1/� � ►Zc� /U. 19 �c)� 2
e
0 wner:
Dake of Inspection: D 6 CIS. t�x, -r e J
�{L
r (1
`)Iztl2q
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 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-MLLJPRQTECT THE PUBLIC HEALTH AND SAFETY AND THE EN lBONMENL-
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.
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 HEALT41 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 I 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
revised 9/2/98 Page 3of11
i
E
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Pr Address:
Owner: nn �.
Date of Inspection: `' j Y' cl r• c
D. SYSTEM FAILS: Z, I j
You must indicate either "Yes" or "No" to each of the following:
I 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 into lecili"r-s"tem component-due tto en overloaded orciogged SASor•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 112 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-is--within 200 feet of-*4Aiutery-4ea-"rteoadrinkw►9•awter•supply -- -- -—
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further inforciation.
revised 9/2/98 Page 4ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: z3 cc .- ���;h t �<<. A- . ; , CLQ,. c
owner:♦, I I
Date of Inspection:
t-i 12-1
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, br Board of Health.
None of the system�compoaanu.lwwl»on pomped�for-atloa:i two Lvaakc arsd the ryctam has6wewcr itaog wwisl tfow
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 on-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 criteria related to Part C is at issue, approximation of distance is unacceptable)
115.302(3)(b)1
I
The facility owner (and.occupants.if different from-owner).were,prnuidad.with infnrmatipppn
SubSurface Disposal Systems.
i
revised 9/2/98 Page 5ofII
• � Ii
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
f
Property Address: �C�rnC3'11c' : t ��c`1 ! �T \ p
Owner:
,Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL: /SG'
Design flow:i0_g.p.d./bedroom.
Number of bedrooms (design): Number of bedrooms (actual):
Total DESIGN flow S OC,
Number of current residents:
.2
Garbage grinder(yes or no): NO
Laundry(separate system) (yes or no):4(); If yes, separate inspection_required
Laundry system inspected (yes or no)
Seasonal use (yes or no)-.Ail
Water meter readings,if available(last two year's usage(gpd):
Sump Pump(yes or no):-,,� �
Lest date of occupancy: -,,-,-nervi
i
i
i
I
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property address: �G..C- �s
Owner: y�
Date of Inspection: L ` y C9�
BUILDING SEWER: l
(Locate on site plan)
Depth below grade:
Material of construction:JzIcast iron_40 PVC_other(explain)
Distance from private water supply well or suction line N' 0
Diameter—!r—
Comments:
'' `—
Comments: (condition of joints,venting,evidence�of faa(�Cage,-etc.) `-- —-
isc
SEPTIC TANK:—
(locate on site plan)
•• I
Depth below grade:L_
Material of construction:-VIconcrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is (netal,list age_ Is.age.confwmed by Certificate of Compliance_(Yes/No)
Dimensions: 1,5-e,6 &r, '1 S
Sludge depth: Z„ ,
Distance from top of sludge to bottom of outlet tee or(raffle:Z 8
Scum thickness: 0 i
Distance from top of scum to top of outlet tee or baffle: .15�
Distance from bottom of scum to bottom of outlet tee or baffle:Z Z
How dimensions were determined: Ai,45Vo%; -`c- S i l c(<
Comments:
(recommendation for pumping, condition of inlet and outlet tees or-baffles, depth of liquid level in relation to outlet invert, structures-integrity,
evidence of leakage,etc.) �/��/ NC / �� G r� D (,p k D' .n C
GREASE TRAP:
(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid levet in relation to outlet invert, structural integrity,
evidence of leakage,etc.)
revised 9/2/98 Pagc7of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
/ /1
Property Address: Z13S CG�nntS ie4 t Cc IC(Xn ill (rv�c�o. LiL
Date of kis
pection: I I I
TIGHT OR HOLDING TANK:&I'L) (Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order:Yes_ No_
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches,etc.)
I
DISTRIBUTION BOX:_
(locate on site plan)
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.) —
R:. r h �4 t c c o -cf!.�l t) �ti eL� C %r n c c' c A �r� �:�;y�� C�✓y�i c�err c. . e ,
PUMP CHAMBER:N�
(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.)
I
I
revised 9/2/98 Page 8ofII
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: Z r c,, ,C 1, . ,(� R SA AJ . A„S bk'r L
Owner:
Date of Inspection:
i
SOIL ABSORPTION SYSTEM(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.
overflow cesspool, number:_
Alternative system:
Name of Technology: .
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding, da p soil, condition of vegeta ion, etc.)
7s
i
CESSPOOLS:
(locate on site plan)
Number and configuration:
Depth top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow(cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure,level of pending,condition of-vegetation. etc.) =
PRIVYs'vZ
(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.)
revised 9/2/98 Page 9ofII
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM
PART C
j 11 SYSTEM INFORMATION(continued)
Property Address: G �S �a..S l S Q� c k. R lYn. +,G, C/—
owner:
Date of Inspection: I� '
�I z,( ��'
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
I
I
r
I
--J
revised 9/2/98 Page 10 of II
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
• t
PART C `
SYSTEM INFORMATION(continued) {
Property Address: :=7 fc . �� �t fi c(C 1 AJ (4,k v„`ee
owner: nn
Pate of Irtspection:
Lill
NRCS Report name
Soil Type_ -
Typical depth to groundwater ) to 10
USGS Date website visited
Observation Wellvchecked {�{
Groundwater depth: Shallow Moderate Deep I
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation: `
_G 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
I
Checked pumping records
Checked local excavators, installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
J /
C.
revised 9/2/98 Page 11 of 11
NEW ENGLAND ENGINEERING SERVICES
INC
April 29, 1999
North Andover Board of Health
Town Hall Annex
27 Charles Street
North Andover,MA 01845
RE: TITLE V REPORT: 325 Candlestick Rd.,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.
Yours truly,
4� � ��/
Benjamin C. Osgood Jr., E.I.T.
President
TOWN OF NORTH ANDOVERI-1
BOARD OF HEALTH
ti-�il q 1
t ;
33 WALKER ROAD-SUITE 23-NORTH ANDOVER, MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099
r
-23
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
i
DEPARTMENT OF ENmoNMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500
h b :
TRUDY CORE
Secretary
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEMA INSPECTION FORM
PART A
l / n CERTIFICATION
Property Address: _325 �'C2.�Lc� `lCts Qb�. Name of Owner a,;15 i-rct n
,U- 0,10. 0-t 2 Address of Owner: ,3c4 S
Date of Inspection: �/�21/q.7 AJ- �ND�)�'Cr'� i&4,4
Name of Inspector:(Pl a Print) Benjamin C. Osgood, Jr
I 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.
Mang Address: 33 Walker Rd. , Suite 21, 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 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:
t/ Passes
Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspectors Signature: - c Date: ZI a
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-"
system owner and copies sent to the buyer, if applicable, and the approving authority.
I
NOTES AND COMMENTS
I
revised 9/2/98 Page Iof11
%. Primed on Recycled Paw,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 3<� C��.,�� �e, c �c R rV. ti A,1,
Owner:
Date of Inspection: !-� Z`( �' ►
INSPECTION SUMMARY: Check A, B, C, of A
A. SYSTEM PASSES:
I 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 ND). 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 pumpirtg-Tnore than four-times n yeardue to broken or obstructed pipe(s). The system willVass--
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
I
revised 9/2/98 Page 2of11
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
owner:
Date 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 environment.
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 WHICH-WILLPRO-TECT THE PUBLIC HEALTILAND SAFETY AND THE BIMIRONMENJ
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 I 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
revised 9/2/98 Page 3ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: C, s c c 0
Owner:
Date of Inspection:
D. SYSTEM FAILS: SII 2 I
You must indicate either "Yes" or "No" to each of the following:
I 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 eewage irrtoiecility-or-"stem component-due tto an overloaded orcbggedSASSor•cesspool. �--1-
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.
4
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-is-within 200 feet o�tery-toe-our feos4;l4nkiwg•awter•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)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further inforgiation.
revised 9/2/98 Page 4ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner:
Date of Inspection:
11 2.11
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 compoaants.kawbaan pumped4oratlsast lwo we ks an&1he'system hasbaw=cei =650W.}low
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.
i
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 orrthe site has been determined based on:
_ Existing information. For example, Plan at B.O.H.
Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
115.302(3)(b))
_ The facility owner(and.ocrupants.if differaw from-ocaner).wem—prauWad,withinformatiom,onJhA prLnpp■rnaffint.n.QQ ^f
SubSurface Disposal Systems.
revised 9/2/98 Page 5of11
�I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
/�
SYSTEM INFORMATION
Property Address: ?j 2 j e e,( }.,le /2S' /(��• �,�'C�
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL: 15`O
Design flow:4g.p.d./bedroom.
Number of bedrooms(design): Number of bedrooms(actual):
Total DESIGN flow &c&
Number of current residents:Z
Garbage grinder(yes or no):
Laundry(separate system) (yes or no):AV; If yes,separsteinspection required
Laundry system inspected (yes or no)
Seasonal use(yes or no)."
Water meter readings,if available(last two year's usage(gpd):
Sump Pump(yes or no):• t1 �
Last date of occupancy: ,),-/er�'t
C O M M ER C IA L/IN D U S TR IA L:
Type of establishment:
Design flow: gpd ( Based on 15.203)
Basis of design flow
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_ j
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 REC,?RDS and source 9f infoJmation:
System pumped as part of inspection: (yes or no)6Z,
If yes, volume pumped: gallons
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)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
n � /
APPROXIMATE AGE of all components, date installed{if known)-and source of•information:• ��;,/� `T y �� / ✓�
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Sewage odors detected when-arriving at the site: lyes or no)�i%
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revised 9/2/98 Page 6ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Prop"Address: 3 2�- cU..�C des (,. yQ
owner:
Date of Inspection: I>1'�'> rff
BUILDING SEWER:
(Locate on site plan)
Depth below grade:z`�
Material of construction: cast iron_40 PVC_other(explain)
Distance from private water supply well or suction line All �
Diameter—!r—
Comments:
' `—
Comments:(condition of joints,venting,evidence often e,-etc.) —-
SEPTIC TANK:_
(locate on site plan)
r.
Depth below grade:
Material of construction: ✓concrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is fnetal,list age_ Js.age.confirmed by Certificate of Compliance_(Yes/No)
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Dimensions: 1"5-e,C
Sludge depth: Z„ ,r
Distance from top of sludge to bottom of outlet tee orbaff1e:28
Scum thickness:—O +
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:Z Z
How dimensions were determined: Me-As., ,c- S VCk
Comments:
(recommendation for pumping, condition of inlet and outlet tees or-baffles, depth of liquid level in relation to outlet invert,structuret4ntegrity,
evidence of leakage,etc.) ! 41 6-0,0 K 4, '17 0,4-1-
61%
•v 61% i r.1ch L)/t-
GREASE TRAP:
(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(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.)
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revised 9/2/98 Page 7ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM !,
PART C
SYSTEM INFORMATION(contirwed)
Property Address:
L ,
Owner: r��
Dote of kupection: �✓f 4+
i
z i) lh
TIGHT OR HOLDING TANK-/t/r) (Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain)
Dimensions: ~
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order:Yes_ No_
Date of previous pumping:
Comments:
i
(condition of inlet tee, condition of alarm and float switches,etc.)
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DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert: �7
Comments:
(note if level and distribution is a ual, evidence of solids carryover, evidence of leakage into or out of box, etc.) —
R ec<< [�r'l I c /rte
PUMP CHAMBER:A/e
(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.)
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revised 9/2/98 P2ge8ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 3 2 J fc �.cC s�.L a-c, A.) . r4 nc�7�fL
Owner:
Date of Inspection: i
SOIL ABSORPTION SYSTEM(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: c c �n ,,�c `�
leaching fields, number,dimensions: ✓
overflow cesspool, number:_
Alternative system:
Name of Technology: .
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding, daR/1psoil, condition of vegeta on, etc.)
�'YYLt eT �'.'1P+YkCS �ccLlS �� /L /YtG//
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CESSPOOLS:Z—
(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)
o �
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.)
revised 9/2/98 Page 9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
I
Property Address: 3ei-
Owner: �� s
Date of Inspection: i;.
z`(
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
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revised 9/2/98 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
I
n 1 / SYSTEM INFORMATION(continued)
Property Address: 3
Owner: n
Date of kupecn: {'f
tio
L
NRCS Report name 15;1111 -;' Ca Tb
Soil Type_ '-1 L.
Typical depth to groundwater >(P-D
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 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� 0cs�v
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revised 9/2/98 Page II of II