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Home My WebLink AboutMiscellaneous - 24 CARLTON LANE 4/30/2018 (2)0 7009 o � ire. `.•.pc �21 s Town of North Andover ;'•:`'s HEALTH DEPARTMENT ,SSACNpst4 CHECK #: 1DATE: LOCATION: CA .f 1h 1m I A A 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 S � w 9r LJAJ Ir ` Commonwealth of Massachusetts rSEP CEIVED . Title 5 Official Inspection Form 8204 Subsurface Sewage Disposal System Form - Not for Voluntary Assessment1 (a.rty vP �v�.rt rJ`vE 4�M °r 24 Carlton Lane He1> LTH DEP R_ >vi�NT Property Address Donald Mendenhall Owner Owner's Name information is IV required for North Andover Ma 01845 9/8/14 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered i any way. Please see completeness checklist at the end of the form. -.M� Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. rab rensn A. General Information 1. Inspector: Dean Dynan Name of Inspector Company Name 2 Suntaug Street Company Address Lynnfield City/Town 508-726-9935 Telephone Number B. Certification Ma State S112837 License Number 01940 Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority a6, "0 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Iij� Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Carlton Lane Property Address Donald Mendenhall Owner's Name North Andover City/Town B. Certification (cont.) Ma 01845 9/8/14 State Zip Code Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 4 bedroom single family dwelling with pipe in stone drainfield in working order 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 • 3/13 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 GSM 24 Carlton Lane Property Address Donald Mendenhall Owner Owner's Name information is required for North Andover Ma 01845 9/8/14 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): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 i Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Carlton Lane Property Address Donald Mendenhall Owner's Name North Andover Ma 01845 9/8/14 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: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins - 3/13 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 24 Carlton Lane Property Address Donald Mendenhall Owner Owner's Name information is required for North Andover Ma 01845 9/8/14 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® 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 the system is within 200 feet of a tributary to a surface drinking water supply 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. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Carlton Lane Property Address Donald Mendenhall Owner Owner's Name information is required for North Andover every page. City/Town C. Checklist Ma 01845 9/8/14 State Zip Code Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ 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): 440 t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 t Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Carlton Lane Property Address Donald Mendenhall Owner information is required for every page. Owner's Name North Andover Cityrrown D. System Information Description: 1500 gallon tank with 1140 SF Ma 01845 State ZiD Cod in stone drainfield 9/8/14 Date of Inspection Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) ❑ Yes ® No occupied Date ❑ Yes ❑ No ❑ Number of current residents: ❑ 2 ❑ Yes Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 9 ( Y 9 (gpd)): 90 gpd ave Detail: see attached for water usage Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) ❑ Yes ® No occupied Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 24 Carlton Lane Property Address Donald Mendenhall Owner information is required for every page. Owner's Name North Andover Ma 01845 9/8/14 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: Date Homeowner / Board of Health gallons ❑ Yes ® No ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 24 Carlton Lane Property Address Donald Mendenhall Owner Owner's Name information is required for North Andover Ma 01845 every page. Citylrown State Zip Code D. System Information (cont.) 9/8/14 Date of Inspection Approximate age of all components, date installed (if known) and source of information: system installed 1982 Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: 18"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.): building sewer in good condition no evidence of leakage Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 1500 concrete tank within 10" of grade 10" feet ❑ 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: 11' X 5'10" X 5'10" Sludge depth: 0-511 t5ins - 3/13 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 M 24 Carlton Lane Property Address Donald Mendenhall Owner Owner's Name information is required for North Andover Ma 01845 9/8/14 every page. City/Town State Zip Code Date of Inspection t5ins • 3/13 D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 351- Scum 5"Scum thickness 0-3" 6" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? infield with measure stick and tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1500 gallon concrete septic tank with concrete baffle inlet and PVC T outlet / Tank in working order with separation from inlet to outlet / no evidence of leakeage Liquid at bottom of outlet invert recommend pumping every three to five years depending on usage and number of occupants Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal feet ❑ 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 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 24 Carlton Lane Property Address Donald Mendenhall Owner information is required for every page. Owner's Name North Andover Ma 01845 9/8/14 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.): 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 Desi n Flow g gallons per day Alarm present: El Yes El No Alarm level: Alarm in working order: El Yes El 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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 24 Carlton Lane Property Address Donald Mendenhall Owner Owner's Name information is required for North Andover Ma 01845 every page. Cityfrown State Zip Code D. System Information (cont.) 9/8/14 Date of Inspection Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" above invert 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.): 16" x16" Concrete box level with four outlet pipes / some evidence of solids carryover / no evidence of leakage into or out of box Leach field pipes are orangeburg Pipe locator was inserted into leach field pipe with no obstruction D Box is 24" below arade 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.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 24 Carlton Lane Owner information is required for every page. t5ins - 3/13 Property Address Donald Mendenhall Owner's Name North Andover City/Town D. System Information (cont.) Type: ❑ leaching pits ❑ leaching chambers ❑ leaching galleries ❑ leaching trenches ® leaching fields ❑ overflow cesspool ❑ innovative/alternative system Type/name of technology: Ma 01845 State Zip Code 9/8/14 Date of Inspection number: number: number: number, length: number, dimensions: number: 1 @ 20'X 55' +/- Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach field found in green lawn area with slight slope so not to hold rain water / soils in good condition / no signs of hydraulic failure / no ponding/ no damp soild/ grass is uniform in good condition Leach field is a pipe in stone conventional system in working order Leach field is a gravity mound 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 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Owner information is required for every page. Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 24 Carlton Lane rroperry /.kaaress Donald Mendenhall owners Name North Andover Ma 01845 9/8/14 City/Town 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.): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts R Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 24 Carlton Lane Property Address Donald Mendenhall Owner information is required for every page. Owner's Name North Andover City/Town State 01845 Zip Code 9/8/14 Date of Inspection 0 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 lair La„ S P 6' i3 -C)3 a t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 ►/ . Commonwealth of Massachusetts vw W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 24 Carlton Lane Owner information is required for every page. rroperry Haaress Donald Mendenhall uwners Name North Andover Ma 01845 9/8/14 City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 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: 1982 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: plans on file dated 1982 for 24 Carlton Lane Checked abutter 44 Carlton Lane ESHGW more than 4' as per info on title V siting Soil Maps dated 2011 no sump pump in basement Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 24 Carlton Lane Property Address Donald Mendenhall Owner Owner's Name required for is North Andover required for Ma 01845 9/8/14 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 t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 Summary Record Card generated on 8/29/2014 9:17:46 AM by Karen Hanlon Page 1 Town of North Andover - ' Tax Map # 210-107.A-0010-0000.0 Parcel Id 17836 24 CARLTON LANE MENDENHALL, DONALD 24 CARLTON LANE N. ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.01 Acres FY 2015 UB Mailina Index Name/Address MENDENHALL, DONALD 24 CARLTON LANE N. ANDOVER, MA 01845 UB Account Maint. Account No Cycle Bldg Id. 14203.0 - 24 CARLTON LANE 2100197 02 Cycle 02 UB Services Maint. Account No. 2100197 Service Code MISCFEE ADMIN FEE WTR WATER UB Meter Maintenance Type Loan Number Active/Inact. From Payor Occupant Name Active/Inactive Last Billing Date 6/3/2014 Active Rate Charge Multiplier/Users 0.635/8 7.82 1/ 01 ALL METER SIZE 38.00 /1 Until Account No. 2100197 Serial No Status Location Brand Type Size YTD Cons 13242550 a Active ERT HH METE METE w Water 0.63 0.63 362 Date Reading Code Consumption Posted Date Variance 8/1/2014 610 aActual 11 12% 5/5/2014 599 a Actual 10 6/12/2014 19% 2/4/2014 589 a Actual 9 3/17/2014 7% 10/31/2013 580 aActual 8 12/20/2013 -26% 8/1/2013 572 aActual 11 9/18/2013 -10% 5/1/2013 561 aActual 11 6/18/2013 -12% 2/7/2013 550 a Actual 15 3/13/2013 47% 10/30/2012 535 a Actual 9 12/13/2012 -21% 8/3/2012 526 a Actual 12 9/26/2012 -35% 5/2/2012 514 a Actual 18 6/20/2012 16% 2/2/2012 496 a Actual 16 3/14/2012 -25% 11/1/2011 480 aActual 21 12/15/2011 25% 8/2/2011 459 a Actual 17 9/14/2011 34% 5/2/2011 442 a Actual 12 6/13/2011 -34% 2/4/2011 430 a Actual 20 3/15/2011 -61% 11/1/2010 410 aActual 48 12/13/2010 250% 8/3/2010 362 a Actual 14 9/13/2010 7% 5/3/2010 348 a Actual 13 6/9/2010 0% 2/1/2010 335 aActual 13 3/11/2010 8% 11/2/2009 322 a Actual 12 12/11/2009 -17% 8/3/2009 310 aActual 14 9/11/2009 35% 5/7/2009 296 a Actual 11 6/16/2009 -27% 2/3/2009 285 a Actual 15 3/16/2009 18% 11/3/2008 270 aActual 13 12/10/2008 -36% 8/1/2008 257 aActual 20 9/12/2008 23% 5/1/2008 237 aActual 15 6/18/2008 22% 2/6/2008 222 a Actual 14 3/14/2008 -28% 11/1/2007 208 aActual 18 1/15/2008 30% 8/3/2007 190 aActual 14 9/14/2007 11% I a� o E c CL) 3 O f+'C OJ � � Q GJ O � 14 Q � i D 0 0 V C O U7 0 m Z I MERRIMACK ENGINEERING SERVICES INC. Engineers • Surveyors a Planners 66 Park Street ANDOVER, MASSACHUSETTS 01810 (508) 475-3555 Fax (508) 475.1448 TO &)w OF 2-if5- AC N T,Qww OF- NOM -h Akzovar. WE ARE SENDING YOU ❑ Shop drawings ❑ Copy of letter LETTER OF TRANSMITTAL DATE �_z�_^ JOB NO. ATTENTION _5 RE: rTOWN fl' ;VQPTi Ai' i( lii, $04RD OF'rL k, i F 11 1 111 Ir• r El Attached ❑ Under separate cover via the foll j ing items: ❑ Prints ❑ Plans ❑ Samples ❑ Specifications ❑ Change order COPIES DATE NO. DESCRIPTION THESE ARE TRANSMITTED as checked below: ❑ For approval ❑ Approved as submitted ❑ Resubmit copies for approval ❑ For your use ❑ Approved as noted ❑ Submit copies for distribution ❑ As requested ❑ Returned for corrections ❑ Return corrected prints ❑ For review and comment !� A S WOO ❑ FORBIDS DUE REMARKS COPY TO 19 ❑ PRINTS RETURNED AFTER LOAN TO US SIGNED: If enclosures are not as noted, kindly notify us at once. a Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection William F. weld GOWM r Trudy Cox* Argeo Paul Caluccl LL Gowrnor David B. Struhs Cartrnsrorwr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: Zy L'Ae& IDAt LI.1♦ )JO. A►.1] v5Z Address of Owner. Date of Inspection: 0_(0_q(0 (If different) AMF_ AD olz a -cs 5 Name of Inspector. LES �,70Di Jy Company Name, Addressand Telephone Number. M6ePaMAcr_ MJ6iA.1eE2Wd SVCS, 6,4v PAQC Si: A�4wvmj MA - CERTIFICATION STATEMS6(3"4175 355 7 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: Date: 'Ya . The System Inspector shall submit a copy of this inspection report to the Approving Authority 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. I The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A], SYSTEM PASSES: V I have not found any information which indicates that the system violates any of the failure criteria as defined is 31.0 CMR. 15.303. Any failure criteria not evaluated are indicated below. . Bl SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. 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, 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 conforming by the Board of Health. septic tank as approved (revised 11/03/95) One Winter Street • Boston, Massachusetts 02108 • FAX (617) 556-1049 a Telephone (617) 292.551)0 A it Pnnted on Recycled Paper 0 1V SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Addr m • 41 C:AUT67 Li L.1j. Owner. Moss Date of Inspection: BJ SYSTEM CONDITIONALLY PASSES (continued) _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(,) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced. The system required pumping more than four times a year due to broken or obstructed pipe(s). , The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed CJ FURTHER EVALUATION IS REQUIRED BY THE BOARD OF fuHEALTH: _ Conditions exist which require further evaluation by the Board of Heath 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 THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DEPMMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNFR THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: ' The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well - The system has a septic tank and soil absorption system and is within 50 feet of a private water supply, well. The system has a septic tank and soil absorption system and 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. S) OTHER (revised 11/03/95) 2 0 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (oontinued) Property Address: 'Zi j CARL iO�j I f , Owner. MOSS Date of Inspection: 8„6 _% D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined 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. Backup of sewage into facility or system component due to an overloaded or clog&_.: SAS or cesspool. Discharge or ponding of eMuent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution bo: 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 pi 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 afalysis. If the well has been analyzed to be acceptable, attach copy of wfll water analysis for ooliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: 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 east: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surfacedrsnhdrinking suPP1Y the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone 11 of a public water•suppiy well) The owner or operator of any such system shall bring the system and facility into full compliance with the requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the De groundwater treatment Program Department for further information. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST . Property Address: ZLi &Aa4lb)-J Owner. Date of Inspection: Check if thefollowinghave been done: /Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. W[A As built plans have been obtained and examined. Note if they are not available with N/A. V/711 facility or dwelling was inspected for signs of sewage back-up. 1/ The system does not receive non -sanitary or industrial waste flow . ZTh. 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 or a raumated by non -intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub - Surface Disposal System. (revised 11/03/95) E d SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Z14 CAR.CTb l.( L,U , Owner. F'IC SS Date of Inspection: FLOW CONDITIONS RESIDENTIAL - Design gow 40 nsAssumso) Number of bedrooms: 14 6 Number of current residents: Z Garbage grinder (yes or no): kjQ Laundry connected to system (yes or no):_�V_5 Seasonal use (yes or no):WD ry Water meter readings, if available:"260-- G. Q.D. AUG . l I '�3 1—e Last date of omrpancy: LU-92A.r ( COMMERCIALANDUSTRIAU Type of establishment: ..� Design flow-. p1lons/day Grease trap present: (yes or no)_ Industrial 3Vaste Holding Tank present: (yes or no)_ Non -sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION i PUMPING RECORDS and source of information: ur3i ruutwo ov#rc /,Niasgg As fw-or��f✓2 (JlIr31 a e B a H System pumped as part of inspection: (yes or no)5 If yes, volume.pumped: 15,00 gallons Reason for pumping- 1 -IGLU DCD k.4 (,t LM -r v►.1 TYPl�0'P' SYSTEM Septic tank/distribution bex/soil absorption system Single cesspool Overflow. cesspool Privy Shared system (yea or no) (if yea, attach previous inspection records, if any) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information 23 "'YRS A3 P952 oi,;l g Sewage odors detected when arriving at the site-, (yea or'no) N� (revised 11/03/95) 5 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (oontinued) Property Addresc Z4J GA rU,-r6I..i Owner. MOSS Date of Inspection: $761q !0 SEPTIC TANK V (locate on site plan) Depth below grade: -L' Material of construction: ✓concrete _metal FRP othPriez�lain) 100 GAL 4CD6l✓ TA uQG SA FR E3 3 Ct/IICF &FP -e_ Tb Bo' 0 rz TA A44 Dim ensions�3' X L—' 1' Z Shudge depth Distance from top of sludge to bottom of outlet tee or baffle: ' scum thic]mese: S n Distance from top of scum to top of outlet tee or baffle:_ Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, oond}tion of cinlet and outlet tees or baffles, depth of liquid level in jelation to outlets invert, structural _ --- ty, evidence of leakage, etc.) , LI (Qv l f� CX rL & wyiU;( D i✓T , _STP.,v, ruPA L 11)-1i' Zi T`i 19 A nn8 . GREASE TRAP - (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP _other(ezplain) Dimensions: Scum thickness: Distance from top of scuua to top of outlet tee or baffle: Distance from bottom of scum to bottom of ou-at tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in rely on to ou_' - evert, structural integrity, evidence of leakage, etc.) (revised 11/03/95) g d SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Ad&wc 'Zy CAfuiou Uj, owner. e r MOSS Inspection: g-�-q(O TIGHT OR HOLDING TANK (locata onsite place) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Capacity. gallons Design flour ¢allona/day Alarm level• Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX i/ Z3 (locate on site plan) Depth of liquid level above outlet invert:14_ 4mments: I (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, a Sol.+o5 �4RlzY0v,�2 D&SE2uED [.i ouio LeNaL o— o(.T n. rf/sr r P. 7 � �, PUMP. CHAMBER (locate on site plan) Primps in working order -(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Prop"Add:esr. Zy CeA2L7a(.( LA�.cE °wne" Neo ss Date of Inspection: / SOIL ABSORPTION SYSTEM (SAS): L" - (locate an ske plan, if possible; excavation not required, but may be a roximated PP b7 non -intrusive methods) If not determined to be present, explain: Type: leaching pits, number._ leaching chambers, number._ laachmg galleries, number._ : leaching trenches, number,length: \ leeching fields, number, dimensions:� d; ZO X Lj S CA�PP.o><.l overflow cesspool, number._ Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) Wo SiGAjS OF 14NDRAV0 G FAI O$�FQ,Vlv() 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 grrnmdwater- inflow (" F C r1l must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: — (locate on site plan) Materials of construction: Depth of solids: Comments: (nota condition of soil, sig:os of hydraulic failure, level of Ponding: condition of vegetation, etc.) (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propwty Address: 2N eA Q4:7bQ Owner. SKETCH OF SEWAGE DISPOSAL SYSTEM. incinds ties to at load two permanent reference. la.dmar3n or benchmarks locate an -ang within 100. TA) b -20X 44 tl 14 lot DEPTH To GROUNDWATER Depth to givuadwater feet(4 PPPZK) method of dste:'miaation or approximatim. 116, l"Ka4T— (revised 11/03/95) 8 TOWN OFNORTH ANCKOVEk UA i.k SYSTEM PUMPJNp RECO}ZU SYS 1 cm OWNER & ADDRESS DATE OF PVMMNQ; SYSTB L ATInN �. ._ QUA NTiTY PUMPED; �'t�sPOOL; NO_.. YBg N^ rUltb ON SERVICE: RD' U'rtN�� RECEIVED VbSBAVA'CIUNJ: 0001) CONDITION " ��,� ,M COVER0 3 2005 QTSO�sB __.. BAM133 IN PLACE, JUN 6xCl3.98YVB SoLJLJ3ACKP UD RUNBACK TOWN ur NORTH ANDOVER 10LtD CARRYOYD$ FLOODED HEALTH DEPARTMENT pS OTHER EXPLAIN sylLvm pump4d br i l'UMMk'NTS. I t.uN rem's rw�N�r'BRRBu rc� m AUG 9 4 TOWN HEAL , . Building Commissioner/Inspector of Buildings NORTH ANDOVER, MA 01645 Board of Health/Board of Selectmen NORTH ANDOVER, MA 01645 NOTICE OF CASUALTY LOSS TO BUILDING LaMarche Associates 33 West Central Street Natick, MA 01760 508-650-9777 Fax: 508-650-9870 August 21, 2006 UNDER MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B Claim has been made involving loss, damage or destruction of the property captioned below, which may either exceed $1,000.00 or cause Massachusetts General Laws, Chapter 143, Section 6 t be applicable. If any notice underMassachusetts General Laws, Chapter 139, Section 313 is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss, cause of loss and LA file number. Insured: DONALD MENDENHALL Loss Location: 24 CARLTON LN NORTH ANDOVER, MA 01645 Policy Number: HMA2030739 Date of Loss: 8/15/2006 Cause of Loss: Wind LA File Number: MA -2-12011 On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by first class mail. A±*G:Ir�eg LaMarche Adjuster LaMarche Associates, Inc. - 800-349-1525 Page 1 of 1 �fl O m °W p, �A9 0 30�g.- o0 N h ti; z B � y- X35 W fA•/ p oti' � �. o -ter a as Z F� ti ry 0.'i m t y �•yNp F �[ I CLV'1 v (V, 4 . C 1,Q h NWH9 ^ - e 5y' � Fq'�o ° ' 9 tiB c•..;��n v ^nH o0 h N� NNS 0 y• p 9 9sz<Z �-� BF'EBE i 0 � 0 �2� .. E9 FB Do.... sb[�.:.. ... � 9e_'-- �•_�On' ti \' tl' O_% d'3.,to ,O --.L y o. ��— e 9' 8 0� o 0 0o ate_ ^ mz 1 N3W-�r >0 7.9iv� .ri9N h � - .9N c. N IIO pb .. 30o yy �,dN �.... '�� '� .. 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