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HomeMy WebLinkAboutMiscellaneous - 25 WINDSOR LANE 4/30/2018 (2)IC Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. DEP has provided this form for use by local Boards of Health. Other information must be substantially the same as that provided here. BE local Board of Health to determine the form they use. The System P the local Board of Health or other approving authority. A. Facility Information RECEIVED JUN - S 2009 your :d to 1. System Location: Left front, left rear, left side of house. Right front, right re,,af 'right of house. Address a � t/JI Cityfrown 2. System Owner: Name Address (if different from location) Cityfrown . B. Pumping Record 1. Date of Pumping 3. Type of system: 0 State Zip Code Sta Zip e !�V 7' �-S 3 Telephone Number Date 2. Quantity Pumped: Gallons Cesspool(s) eptic Tank Tight Tank Other (describe): 4. Effluent Tee Filter present? 0 Yeso 5. Condition lof�System: 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: O.L. Lowell Waste Water of If yes, was it cleaned? 0 Yes 0 No ) lv\'' 4e-w� F 5821 Vehicle License Number t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of System Pumping Record MAy 2 2 20 Form 4 LHEALTh WN OF NORTf I AVL'OVER L'c_:'Arh •,'FNT DEP has provided this form for use by local Boards of Health.. The eM-Pumping-Recor- ust be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Loca 'on: CI forms the C� computer. use only the tab key Address to move your cursor -A- use douse the°return key. http://www t5fonn4.doc• 06/03 City/Town 2, System Owner: h t t /fj Zip Code Address (if different from location) Cityfrown Stat �s Zip Cod ti 7 Telephone Namber .B. Pumping Record 1. Date. of Pumping2. Quantity Pumped: Date Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes U'No If yes, was it cleaned? ElYes ❑ No 5. Condition of System: 6. Syste P meed By Name Company - 7. Locatio here contents were "posed: /9, f�:s .htm#inspect Vehicle License. Number Town of North Andover of aoR*N, Office of the Health Department Community Development and Services Division i 400 OSGOOD STREET • ._: s—• r '` North Andover, Massachusetts 01845 s�cHugtt Susan Y. Sawyer, REHS/ RS Public Health Director 978.688.9540 - Phone 978.688.8476 - Fax C��i'�rCA2� o� Coa�t�LrANCE As of: September 10, -7-a- k - el__1� This is to cert Z-. -5 ",o . the individual subsurface dist Repaired— TankRep -c-KegI% Comp to r< C C. r ,john Soi At: 25 Windsor .Gane North Andover, mA 01845 alas been installed in accordance with the provisions of Titfe V of the State Sanitary Code and with the North Andover Board of Ifealth regulations. Iff- e Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. ecuov�i- 7 enc e� Susan T Sawyer, RESTS/ Public Yfeafth Director BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 ➢ OTHER: (Indicate) 2 C Q Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Town of North Andover q ' Health Department Date:V,z G�//�11,D dw Location: /1.4 (Indicate Address, if Residential, or Name of Business) Check #: IIP17&���% — C Type of Permit or License: (Circle) ➢ Animal $ ➢ Dumpster $ ➢ Food Service - Type. $ ➢ Funeral Directors $ ➢ Massage Establishment $ ➢ Massage Practice $ ➢ Offal (Septic) Hauler $ ➢ Recreational Camp $ ➢ SEPTIC PERMITS: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ eptic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ➢ Sun tanning $ ➢ Swimming Pool $ ➢ Tobacco $ ➢ TrasWSolid Waste Hauler $ ➢ Well Construction $ ➢ OTHER: (Indicate) 2 C Q Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer TOWN OF NORTH ANDOVER O� NORTM q Office of COMMUNITY DEVELOPMENT AND SERVICES 1,4.0 " HEALTH DEPARTMENT A 27 CHARLES STREET NORTH ANDOVER, MASSACHUSETTS 01845 AC NUS Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public .Health Director 978.688.9542 — FAX healthdeptEatownofnorthandov_er. com www.towaoffiorthandover.com APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: 4;) LOCATION: W-' r2 ode LICENSED INSTALLER NAME: d c PLEASE PRINT SIGNATURE: 4 CHECK ONE: FULL SYSTEM REPAIR: TELEPHONE# � COMPONENT REPAIR (indicate what parts): Ale,,.,— * /�r * NEW CONSTRUCTION: * If NEW CONSTRUCTION, please attach the Foundation As -Built Plan. $250.00 or $125 Fee Attached? Yes No Project Manager Obligation From Attached? Yes No Foundation As -Built? Yes No Floor Plans? Yes No Approval of Health Agent Date: ($250) ($125) I COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTALlPROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Owner's Name:'., %ry U �.�21 D Owner's Address: Date of Inspection: Name of Inspector:_Jplease print) �J O Y1 /J ��i jt) C e Company Name: G` ri C Mailing Address: ' f r m Gt . ST Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Sectio 15.340 of Title 5 (310 CMR 15.000). The system: asses Conditionally Passes Needs Further 8val ation by the Local Approving Authority Fail Inspector's Signature:14 Date: The system inspector shall s' bmit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of co � pletin& this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspec or and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments Irl ****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. Title 5 Inspection Form 6/15/2000 page 1 „_--�” gage 2 of 11 i OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: /� N (�S i� Al - -✓: 4 ter" Owner: Date of Inspection: Inspection Summary: Check A,B,C,D or E /ALWAYS complete all of Section D A.System P s: 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: J B. System Conditionally Passes: i One or more system components as described in the "Conditional Pass" section need to be replaced or repaired: The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. `— The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. O.Jf ND explain: Observation of sewage backup or break out -or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will ppass inspection if (with approval of Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): , broken pipe(s) are replaced `-� obstruction is removed , ND explain: " Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CE/RTIFICATION (continued) Property Address: Owner: .e'9•! D Date of Inspection: -eo 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 Healthdetermines in accordance witlit 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 J _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: _ The system has a septic tank and 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 coliform; bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: or 3 Page 4 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: COO&K/%�%Qf /— ,j a /r7-NA1Gc- C r Owner: 0-&L 2-1 O Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: Yes No,�r �ckup of sewage into .facility or system com4nent�due tol'ovefloaded or clogged SAS' or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or .*logged SAS or cesspool _V'' Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or A� cesspool _ lYfl squid depth in cesspool is less than 6" below invert or available volume is less than ''/z day flow K 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. y portion of a cesspool or privy is within a Zone I of a public well. y portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compomds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303. therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either "yes" or "no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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. 9 f 4* * Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Addressc;AO 41AV-6or,.. Owner: 6-vc 16 Date of Inspection: ^6 O Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes �o ,. Pumping dnformation wa4r6ideAy khe owr# T, oc�upah�' or Poard of Health t / .i Zwere 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 ? t� _ 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 s1ze and location of `the Soil Absorption Systeme(SAS) on the site has been determined based on:_ VYesnc 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) [3 10 CNM I5.302(3)(b)] .'' -t .� Page 6 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address; 7 l % NA0r /-'lj /V10 OTS---..' ,Hu Owner: to oCZ Date of Inspection: -- ^00 FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of edrooms): Number of current residents: Does residence have a garbage grind5r,(ytes of no): Is laundry on a separate sewage sys&rn (yes 6r no) S' f yev..sepafate ihspecti&'required] Laundry system inspected (yes or no): Seasonal use: (yes or no):" Water meter readings, if available (last 2 years usage (gpd)): Sump pump (yes or no): mo Last date of occupancy: p 1 Lo cA COMMERCIALANDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sqft,etc.): Grease trap present (yes or no): _ Industrial waste holding tank present (yes or no): Non -sanitary waste discharged to the Title 5 system (yes or no): _ Water meter readings, if available: Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection (yes or no): C If yes, vglume pumped:ga ]ons -- Fow,was uant' pumped determined? Reason forpufiping: //V t '7` '0W t4✓ TYP SYSTEM eptic tank, distribution box, soil absorption system _ Single cesspool _ Overflow cesspool _ Privy _ Shared system (yes or no) (if yes, attach previous inspection records, if any) _ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) _ Tight tank _ Attach a copy of the DEP approval _ Other (describe): of all componentsdate installed (if known) and source of information: Were sewage odors detected when arriving at the site (yes or no): 6 A , ' $ • P4 Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C /- , SYSTEM INFORMATION (continued) W Property Address: VIIJ <X,SQ/• GAJ Owner: 6-0 LC >-4 Q Date of Inspection: BUILDING SEWER (locate on site plan) Depth below grade: '36 Materials of construction: uerst iron _40 PVC _other (explain): Distance frorp private water Supply *II ot`-suctiort line: A A . AF, a � Comments (on condition of joints, venting, evidence of Akage,�etc.)" I ' SEPTIC TANK: zoocate on site plan) Depth below grade: Material of construction: concrete _metal _fiberglass _polyethylene —other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of certificate) Dimensions: S`S X.- /0� Sludge depth: , /' Distance from top of slydge to bottom of outlet tee or bathe: �J �' Scum thickness: Z_ G4 Distance from top of scum to top of outlet tee or baffle: p �� Distance from bottom of scum to botto outlet tee or baffle: How were dimensions determined: o Ce -Q - Comments (on pumping recommends ions, ' let and outlet tee or baffle condition, structural integrity, liquid levels as related to outiTt invert, ev evidence of 1 akage, etc,;): J a x GREASE TRAP: 1 n site plan) fT Depth below gr e: Material of construction: _concrete _metal _fiberglass polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): v Page 8 of l l OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: C;60r Owner'` -'t! !/' �!/� Date of Inspection: —G TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material oaf construction: , concre ,: metal y_fit glass _ oly�ethylene F o er(exp'lain): I Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: ,b/ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:v 4- (. � 1 S h T - Comments (note if box is level and distribut n to outlets equal, any evidence of solids carryover, any evidence of PUMP CHAMBER: (locate on site plan) Pumps in working order (yes or no): Alarms in working order' (yes or�ho)-V-- Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): '* •°'APage 9of11 w OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C , SYSTEM INFORMATION (continued) Property Address• 41,/i/ .so r �. r✓ Owner: e O L e?w D f-/ ('"r Date of Inspection: t✓✓ SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: _ leaching chambers, number: leaching galleries, number: J ��aching trenches, number, length: 11 6S' 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.): CESSPOOLesspool must be pumped as part of inspection)(locate on site plan) Number andtonfigguration: Depth — top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of gro ndwattr inflow (y or nod' ' yF Comments (note condition of soil, signs of hydraulic failure, level o ponding condition of vegetation, etc.): PRIVofconstcnuction: ate on site plan) Materi Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): a. s • Page 10 of 1 l OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM'INFORMATION (continued) Property Address: �,q Owner: ., l! Date of Inspection: ''fid SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 1010 feet( LgcatT where,fubli�wat%supply enters, the buitding.,� t i GYI 10 r F y �L Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C !! .. SYSTEM INFORMATION (continued) Property Address: W is dr 0� Owner: Date of Inspection: - --© 4 SITE EXAM Slope Surface water Check cellar Shallow wells r Estimated depth to ground water - Z'V feet Please indicate (check) all methods used to determine the high ground water elevation: 6/0 _ fined from system design plans on record - If checked, date of design plan reviewed: bserved site (abutting property/observation hole within 150 feet of SAS) 1 CChhyeked with local Board of Health -explain: ecked.with local excavators, installers -(attach documentation) Accessed USGS database -explain: You must describe how you established the high ground water elevation: 12 �� y i r '�R � f �' • r w 9 1 12 �� y i r '�R � f �' • r w 9 HP Fax KI'22Oxi Last Transaction Date Time T)W Aug 30 10:14am Fax Sent Identification 819783722450 Log for NORTH ANDOVER 9786889542 Aug 30 2004 10:26am Duration ' Pages Result 4:02 11 OK North Andover Board of Health 120 Main St. North Andover Ma.01845 Haul Lic. #151 -OOH Install Llc. # 128-0 Date Address 11/1/2000 303 Chester St 11/1/2000 50 Willow Rd 11/1/2000 160 Carelton Ln 11/1/2000 165 Bridal Path 11/4/2000 174 Ingals St 11/4/2000 1062 Salem St 11/6/2000 373 Raligh Tavern Ln 11/6/2000 252 Boxford St 11/6/2000 150 Liberty St 11/6/2000 149 Osgood St 11/7/2000 255 Haymeadow 11/7/2000 850 Winter St 11/8/2000 25 Windsor Ln 11/9/2000 249 Carlton Ln 11/9/2000 767 Johnson St 11/10/2000 56 Academy Rd 11/14/2000 Sugar Cane Ln 11/14/2000 250 Abbott St 11/15/2000 195 Winter St 11/15/2000 187 Winter St 11/16/2000 85 Laconia Cir 11/16/2000 86 Willow Ridge 11/17/2000 2135 Turnpike St 11/20/2000 203 Grandville Ln . 11/20/2000 391 Pleasant St 11/20/2000 124 Tucker Farm Rd 11122/2000 394 Boston Rd 11/22/2000 728 Forest St 11/22/2000 18 Johnney Cake St 11/24/2000 106 Rockey Brook Rd 11/24/2000 258 Rea St 11/28/2000 1815 Great Pond Rd 11/28/2000 1420 Great Pond Rd 11/29/2000 266 Lacy St 11/29/2000 155 Laconia Cir Andover Septic 47 Railroad St. Bradford Ma. 01835 Gallons Comments 1000 1000 1500 1500 1000 1250 1000 1000 Leachfield Run Back/ Ex. Solids 1500 1000 1500 1250 1500 1500 1500 1500 1500 1000 Extra Solids 1500 1500 1500 1000 1500 1000 Flooded 1500 1500 1500 1500 1500 1500 1000 1000 1500 1000 1500 gc a -1_ 3 o 0 c=/v 42 7 C 13d•�0 43-13/,3© A 111.45 � r r -1_ 3 o 0 c=/v 42 7 C 13d•�0 43-13/,3© A 111.45 F-IuRD or= Mei pj Noj�TH A&)pnk)e �, MA, � PPi�ov l; D C0AJPiTl0/,)5 : D I 5A FPP4 v5p RQsoms nor (I JCA) r7> FlltiRc� l -1�- - (A)A-rr- "'N Sjp►t'' -� �bWnl Q WELL 4PPROUeDIYITC 5EPT"1C Gy!S iEM UESt(-,'J pwr6' 1� -ZC/-& 1416 i YX4V4T(0lJ )��C�1�G►i0ti1 U/JrG FINAL. /PR�oviN6 /surhoj;�)Ty a 1,6s Q F4 ,6PPI3vVEP t -r& AP12M001 6 AUTHOJ� >�-ry ,4D1PITID,QAL INSr"-c j I(jtis X11=,a►�y� D15l�PP�vvE� D,aTC i��� tis •� FV AL APPROVAL 3-2(-F& AP��ovrn�G �� i Holl �j . COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPAITMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 25 Windsor Lane North Andover, MA Owners Name: Michael Chan Owners Address: 25 Windsor Lane North Andover, MA Date of Inspection: 09/24/04 Name of Inspector: Richard A. Briscoe Company Name: R. A. Briscoe, Inc. Mailing Address: 61 Garrison St. Groveland, MA 01834 Telephone Number: [9781372-2200 RECEIVED OCT 0 5 2004 TOWN Or NORTH ANDOVER HEALTH DEPARTMENT CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. I am a DEP approved systems inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: Passes Conditionally Passes Ne Further Evaluation By the Local Approving Authority 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 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 the system owner and copies sent to the buyer, if applicable and, the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and 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. Title 5 Inspection Form 6/15/2000 Page 1 Page 2 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 25 Windsor Lane North Andover, MA Owner: Michael Chan Date of Inspection: 09/24/04 INSPECTION SUMMARY: Check A, B, C, D, or E / ALWAYS complete all of section D: A. System Passes: XI 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: 121,9 One or more system components as described in the "Conditional Pass" section needs to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no, or not determined (Y, N, or ND) in the for the following statements. If "not determined", please explain The septic tank is metal and over 20 years old` or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not leaking and is a Certificate of Compliance indicating that the tank is less than 20 years old is avaliable. ND Explain: _Observation of sewage backup or breakout 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 the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ND Explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed ND Explain: Page 3 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 25 Windsor Lane North Andover, MA Owner: Michael Chan Date of Inspection: 09/24/04 C. Further Evaluation is Required by the Board of Health: X1.4 _ 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 the Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protect 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 to 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 I 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 coloform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria was triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: 25 Windsor Lane North Andover, MA Michael Chan 09/24/04 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 an 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. X 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. __)C Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped j Any portion of the SAS, cesspool or privy is below the high groundwater elevation. _�C Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. K Any portion of a cesspool or privy is within a Zone I of a public well. _c Any portion of a cesspool or privy is within 50 feet of a private water supply well. JG 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 coloform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] NO (Yes/No) The system fails. I have determined that one or more of the above failure criteria exists as described in 310 CMR 15.303, there fore 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: AA To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate "yes" or "no" as to each of the following: (The following criteria apply to large systems in addition to the criteria above) The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: yes no 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. Page 5 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Date of Inspection: 25 Windsor Lane North Andover, MA Michael Chan 09/24/04 Check if the following have been done: You must indicate either "yes" or "no" as to each of the following: Yes No Ye — Pumping information was requested of the owner, occupant, and Board of Health. Were any of the system components pumped out in the previous two weeks ? — Has the system received normal flow in the previous two week period ? Have large volumes of water been introduced to the system recently or as part of this inspection ? X 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 SAS, located on site ? X _ Were the septic tank manholes were uncovered, opened, and the interior of the inspected for condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum ? _ Was the facility owner (and occupants if different from the 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: Yes no Yes— 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) [15.302(3)(b)] 5 Page 6 of 12 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 25 Windsor Lane North Andover, MA Owner: Michael Chan Date of Inspection: 09/24/04 FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): AIA Number of bedrooms (actual) --!CZ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): �lis�R Number of current residents: H Does residence have a garbage grinder (yes or no):�5 Is laundry on a separate sewage system) (yes or no):. 4!!V, (If yes, separate inspection required] Laundry system inspected (yes or no): R� Seasonal use (yes or no): N0 Water meter readings, if available (last 2 year's usage (gpd)): Sump pump (yes or no): /Vv Last date of occupancy: —U� �� (;-0 COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow based on 15.203): and Basis of design flow (seats/persons/sqft, etc.): Grease trap present: (yes or no) Industrial Waste Holding Tank present: (yes or no) Non -sanitary waste discharged to the Title 5 system: (yes or no) Water meter readings, if available: Last date of occupancy/use: OTHER: (Describe) GENERAL INFORMATION Pumping Records Source of information: N&A,) T—a yk Was system pumped as part of inspection: (yes or no):_i0 If yes, volume pumped gallons - How was the quantity pump determined? Reason for pumping: TYPE OF SYSTEM X 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 copy of the current operation and maintenance contract (to be obtained from the system owner) Tight Tank Attach a copy of DEP Approval Other (describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site: (yes or no) 4-,oO Page 7 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: 25 Windsor Lane North Andover, MA Michael Chan 09/24/04 BUILDING SEWER: (Locate on site plan) Depth below grade: 3 Material of construction: �Ccast iron_ 40 PVC _ other (explain): Distance from private water supply well or suction line Comments (on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: M (locate on site plan) Depth below grade:. Material of construction: r -concrete _ metal _Fiberglass _ polyethylene _ other (explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance (yes/no): _ certificate) Dimensions: /500 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: Comments:(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, evidence of leakage, etc.): _ , GREASE TRAP: &D(locate on site plan) Depth below grade: (attach a copy of" Material of construction: _concrete _metal _Fiberglass _ Polyethylene _other (explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments:(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page 8 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 25 Windsor Lane North Andover, MA Owner: Michael Chan Date of Inspection: 09/24/04 TIGHT OR HOLDING TANK: A10 (Tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _ Polyethylene _other (explain): Dimensions: Capacity: gallons Design flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: Y6(if present, must be opened)(locate on site plan) Depth of liquid level above outlet invert: D Comments: (note if box is level and distribution to outlets is equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): PUMP CHAMBER: A (locate on site plan) Pumps in working order: (yes or no) _ Alarms in working order: (yes or no) _ Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Page 9 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 25 Windsor Lane North Andover, MA Owner: Michael Chan Date of Inspection: 09/24/04 SOIL ABSORPTION SYSTEM (SAS): QS (locate on site plan, excavation not required) If SAS not located, explain why: Type leaching pits, number: leaching chambers, number: leaching galleries, number: leaching trenches, number, length: _,/ — S� 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.) 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 (yes or no): 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.): Page 10 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: 25 Windsor Lane North Andover, MA Michael Chan 09/24/04 SKETCH OF SEWAGE DISPOSAL SYSTEM: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. llc Page 11 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 25 Windsor Lane North Andover, MA Owner: Michael Chan Date of Inspection: 09/24/04 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 system design plans on record - If checked, date of design plan reviewed: Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Checked local excavators, installers- (attach documentation) Accessed USGS database -explain: You must describe how you established the high ground water elevation: . /�_ Page 12 of 12 R. A. BRIS'COE, INC. 61 GARRISON ST. GROVELAND, MA 01834 TEL. (978) 372-2200 FAX (978) 372-2450 SEPTIC SYSTEMS: DESIGNED, BUILT, REPAIRED AND PUMPED Title V Inspections Title V Inspection Report Property Address: 25 Windsor Lane North Andover, MA Owner: Michael Chan Date of Inspection: 09/24/04 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby. disclaim any further operation of your current septic system. i R. A. Briscoe 12 r f / r'age 10 of 12 / OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: 25 Windsor Lane North Andover, MA Michael Chan 08/28/04 SKETCH OF SEWAGE DISPOSAL SYSTEM: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. C n ,-------------- 1 W(AA/i- Z-- GC A t, 10 COMM WEALTH OF MASSACHUSETTS E EC IVE OFFICE OF ENVIRONMENTAL AFFAIRS D P TMENT OF ENVIRONMENTAL PROTECTION 7CEI ED OCT 0 5 2004 TOWN ur- NuR1 ri ANDOVER HEALTH DEPARTMENT TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 25 Windsor Lane North Andover, MA Owners Name: Michael Chan Owners Address: 25 Windsor Lane North Andover, MA Date of Inspection: 08/28/04 Name of Inspector: Richard A. Briscoe Company Name: R. A. Briscoe, Inc. Mailing Address: 61 Garrison St. Groveland, MA 01834 Telephone Number: [9781372-2200 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. I am a DEP approved systems inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Is Inspector's Signature: C& Date: T-30 - C) Lf The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and, the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and 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. Title 5 Inspection Form 6/15/2000 Page 1 Page 2 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 25 Windsor Lane North Andover, MA Owner: Michael Chan Date of Inspection: 08/28/04 INSPECTION SUMMARY: Check A, B, C, D, or E / ALWAYS complete all of section D: A. System Passes: AIA 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 needs to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no, or not determined (Y, N, or ND) in the for the following statements. If "not determined", please explain _The septic tank is metal and over 20 years old` or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and is a Certificate of Compliance indicating that the tank is less than 20 years old is avaliable. ND Explain: _Observation of sewage backup or breakout 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 the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ND Explain: _The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed ND Explain: Page 3 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 25 Windsor Lane North Andover, MA Owner: Michael Chan Date of Inspection: 08/28/04 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 the Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protect 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 to 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 I 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 coloform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria was triggered. A copy of the analysis must be attached to this form. 3. Other: _ Sh o (A 01I L- t: v �I c� 0/L� S'f TO- G' fl��eP Gr l , r0J N D Lc i J'e'- /��e V i o JS r" rpiooT%_ t,c.a 3 �e Te,- m's jvtA �o .57 s?eM- A" Aro (( 6.-04 too M A► `� I o cN . 3 a + a -T D'GpT f, o S- (mss w eT 3 Page 4 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: 25 Windsor Lane North Andover, MA Michael Chan 08/28/04 D. System failure criteria applicable to all systems: OUP 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 an 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 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 SAS, 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. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coloform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] (Yes/No) The system fails. I have determined that one or more of the above failure criteria exists as described in 310 CMR 15.303, there fore 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: AA To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate "yes" or "no" as to each of the following: (The following criteria apply to large systems in addition to the criteria above) The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: yes no 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. Page 5 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 25 Windsor Lane North Andover, MA Owner: Michael Chan Date of Inspection: 08/28/04 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 requested of the owner, occupant, and Board of Health. Were any of the system components pumped out in the previous two weeks ? Has the system received normal flow in devious two week period ? 6-epTIa A44` et..JCf{ ►Y�cti�e5 �'1�r�e i�ci�tr/�toQ ND �� Have large volumes of water been inloduced 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 SAS, located on site ? _ Were the septic tank manholes were uncovered, opened, and the interior of the inspected for condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum ? A _ Was the facility owner (and occupants if different from the 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: Yes no -$ _ Existing Information. For example, a plan at the Board of Health. 1�/• �1'Le _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of ts-tance is unacceptable) (15.302(3)(b)) 5 . Page 6 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: Date of Inspection: 25 Windsor Lane North Andover, MA Michael Chan 08/28/04 RESIDENTIAL FLOW CONDITIONS Number of bedrooms (design):i/ANumber of bedrooms (actual) 'Y DESIGN flow based 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): AA1- Number of current residents: '0(Does residence have a garbage grinder (yes or no):_)�4--S Is laundry on a separate sewage system) (yes or no): ilei; [If yes, separate inspection required] Laundry system inspected (yes or no): do Seasonal use (yes or no): Water meter readings, if available (last 2 year's usage (gpd)): Sump pump (yes or no): Last date of occupancy: 4GGU��Lc� COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow based on 15.203): gpd Basis of design flow (seats/persons/sqft, etc.): Grease trap present: (yes or no) Industrial Waste Holding Tank present: (yes or no) Non -sanitary waste discharged to the Title 5 system: (yes or no) Water meter readings, if available: Last date of occupancy/use: OTHER: (Describe) GENERAL INFORMATION Pumping Records Source of information:re I" , Ooc T10 / Was system pumped as part of inspect�(es no): If yes, volume pumped gallons - How was the quantity pump determined? Reason for pumping: TYPE OF SYSTEM Septic tank, distribution box, soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative Alternative technology. Attach copy of the current operation and maintenance contract (to be obtained from the system owner) Tight Tank Attach a copy of DEP Approval Other (describe): Approximate age of all components, date installed (if known) and source of information: r Were sewage odors detected when arriving at the site: (yes or no) _Ab Page 7 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: 25 Windsor Lane North Andover, MA Michael Chan 08/28/04 BUILDING SEWER: (Locate on site plan) Depth below grade: .3 Material of constructioncas : t iron_ 40 PVC _ other (explain): Distance from private water supply well or suction line Comments (on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: (locate on site plan) Depth below grade:_ Material of construction: concrete _ metal _Fiberglass _ polyethylene _ other (explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance (yes/no): _ certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: Comments:(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, evidence o leakage, etc.): GREASE TRAP: � (locate on site plan) (attach a copy of Depth below grade: Material of construction: _concrete _metal _Fiberglass _ Polyethylene _other (explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last.pumping: Comments:(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page 8 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address Owner: Date of Inspection: 25 Windsor Lane North Andover, MA Michael Chan 08/28/04 TIGHT OR HOLDING TANK:/L-0 (Tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _ Polyethylene _other (explain): Dimensions: Capacity: gallons Design flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): i DISTRIBUTION BOX: IES(if present, must be opened)(locate on site plan) Depth of liquid level above outlet invert: a Comments: (note if box is level and distribution to outlets is equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): PUMP CHAMBER: A _(locate on site plan) Pumps in working order: (yes or no) Alarms in working order: (yes or no) _ Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): 8 Page 9 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: 25 Windsor Lane North Andover MA Micha-- el Chan 08/28/04 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located, explain why: Type leaching pits, number: leaching chambers, number: leaching galleries, number: - leaching trenches, number, length:_ 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.) CESSPOOLS: /t<) (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 (yes or no): Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: �O (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Page 10 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 25 Windsor Lane North Andover, MA Owner: Michael Chan Date of Inspection: 08/28/04 SKETCH OF SEWAGE DISPOSAL SYSTEM: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. /l .3.0t" L, Gt W 4— w, 10 Page 11 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells 25 Windsor Lane North Andover, MA Michael Chan 08/28/04 Estimated depth to groundwater *41 Feet Please indicate all the methods used to determine high groundwater elevation: Obtained from system design plans on record - If checked, date of design plan reviewed: Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Checked local excavators, installers- (attach documentation) Accessed USGS database -explain: You must describe how you established the high ground water elevation: I Page 12 of 12 R. A. BRISCOE, INC. 61 GARRISON ST. GROVELAND, MA 01834 TEL. (978) 372-2200 FAX (978) 372-2450 SEPTIC SYSTEMS: DESIGNED, BUILT, REPAIRED AND PUMPED Title V Inspections Title V Inspection Report Property Address: 25 Windsor Lane North Andover, MA Owner: Michael Chan Date of Inspection: 08/28/04 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. 12 RE CEIVED Commonwealth of Massachusetts CityCi /Town of g 2008\ /Town Pumping Record RTH ANDOVER p` Form 4 EPARTMENT 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 A C Important: A Ci 1� 1J When filling out 1. System Location: � �( _ r� forms on the computer, use only the tab key Address V a �-' � A to move yourcursor - do not use the return State Zip Code key. 2. System Owner: VQ Name law Address (if different from location) Citylfown StallB—yq Z`-, / Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ©'1qo-- If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: VN 6. System, Pure: l Name Company 7. Location where contents re dip sed: Signature H t5form4.doc• 06/03 FS -Fs -a -r Vehicle License Number Date System Pumping Record • Page 1 of 1 "Commonwealth of Massachusetts --- City%Town of I` System Pumping Record MAY 2 2 2007 Form 4 TOWN OF NORTH AND'O'VER DEP has provided this form for use by local Boards of Health.. Th -SYS�teM+um ri -Reco be submitted to the local Board of Health or other approving authority. - P g A. Facility Information Important: When filling out 1. Syst m Location: forms on the computer, use r only the tab key Address to move your cursor - do not use the return Cityrrown State Zip Code key. 2. System Owner: Name Address (if different from location ------------------------ Cityfrown State Zip Cade Telephone Number .B. Pumpil ' Record �--- ��� is 1. .Date. of Pumping pate 2. Quantity`Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank- ❑Tight Tank ❑ Other(d'escribe).` 4: Effluent Tee Filter present? ❑ Yes 2No . If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: vl-t l-� 6. System Pum d B Name Vehicle License Number `•�; Company -- . 7. Locathere contents We sposed:. ioI -A hftp://www.mass. t5form4.doc- 06103 must als/t