HomeMy WebLinkAboutMiscellaneous - 254 BARKER STREET 4/30/2018i
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TOWN OF NORTH ANDOVER
SYSTEM PUMPING R-ECORD
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I LM OW ER & ADDRESS SYSTEM LOCATION-------'---
(example:: left front of house) -
D 0 r OF PUMPINC: QUANTITY PUMPID
%(7
)POOL NO �S SEf TIC TANK NO v `j
'I URE OF SERVICE: ROUTINE EMERCENCY
I>FRV.;\T10NS:
GOOD CONDITION
HFAVY CREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
>� > I LM PUMPED BY
U � I m F.NTS:
FULL TO COVER
BAFFLES IN PLACb'
LEACHFIELD IZi !��ACK
FLOODED
O�HFFR (EXPLAIN.)
U; l TRANSFEIMLD TO:
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:l,-q5q� cJ__
n Al / )(Y n/.,CU
Owner's Name: rLLCt E .,,
Owner's Address: `„ 1
Date of Inspection:
Name of Inspector: please print)
Company
Mailing Address: , --20 ) /
r �r • l��
Telephone Number: C17S-3 7�t
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 Section 15.340 of Title 5 (310 CMR 15.000). The system:
N Passes
Conditionally Passes
by the Local Approving Authority
Inspector's Signature: 4. , Mate: �� L� Z.-
The system inspector shall bmit a copy of this inspection report to the Approving Authority (Board of Health or
DEP) within 30 days of co pleting this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
�.a Page 2 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property ress:COI y- &(�
NO. U
Owner:
Date of Ins ion:
Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D
A. System Passes:
have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the "Conditional Pass" section need to be replaced or
repaired: The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass.
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/structurally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with .
approval of Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed -
ND explain:
A }!
Page 3 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address•� 6/-
_ ,
Owner: alo. 0,
". I
Date of Ins tion:
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(l)(b),that the
system is not functioninglh a manner which will protect public health,fsafety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the
system is functioning in a manner that protects the public health, safety and environment:
_ The system has a septic tank and 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 Jvolatile organic compounds indicates that the well is free from pollution from that.facility and
the presence of ammonia nitrogen and nitrate niAgeii is equal to oi• 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:
0 4- Page 4 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:0?5-
Owner:A122-,
Date of Ins tion:
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or "no" to each of the following for all inspections:
Yes N�o/�
_ V 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 r
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
ZRequired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped
_ s"Any portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
— _Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ 'Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory, for 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 sv_ stem 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.
4
« Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Propertyddressi-, j Q
UJ VOLly-_.�i__)
Owner•
Date of Insp tion:
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Ye�+ No
Pumping information was provided by tbe-owner,roccupant, or Board of Health ti
V Were any of the system,components pumped out in the previous two weeks?
Has the system received normal flows in the previous two week period ?
V Have large volumes of water been introduced to the system recently or as part of 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:
i' t r �'
Yes no
AeL _ 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 CMR 15.302(3)(b)]
5
I
Page 6 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address al-)
Owner•
Date of Inspe ion:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): Number of bedrooms (actual):
DESIGN flow based on 310 CMt 15.203 (for example: 110 gpd x # of bedrooms):
ents: /
Number of current resid
Does residence have a garbage grinder (yes or no):/VO
Is laundry on a separate sewage system (yes or no); [if yes separate inspectioyequired] �.
Laundry system inspected (yes orNo):{-
Seasonal use: (yes or no)IVO "
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump (yes or no):"
Last date of occupancy: Qe- G U { e
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow (based on 310 CMR 15.203): gpd
Basis of design flow (seats/persons/sgft,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 S
Source of information:vo�o_ F
Was system pumped as part of inspection (yes or no):
If yes, volume pumped: gallons -- How was ouantity pumped determined?
Reason for pumping;_ 7" /�1--
TYPgAF SYSTEM
JZSeptic tank, distribution box, soil absorptiam 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 q11 c2g oRp n s, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site (yes or no) &Q
6
` Page 7 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
M� A10. a I Y/
Owner:
Date of Insp ion:
BUILDING SEWER (locate on site plan)
Depth below grade: 6
Materials of construction: cast iron _40 PVC _other (explain):
Distance from private water supply well or suction line:
Comments (on condition of join venting,, evidence of leakage, etc.): i, 1
i
t
SEPTIC TANK: _ (locate on site plan)
Depth below grade: G
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: /< ye
depth:
Distance from top of sludge to bottom of outlet tee or baffle: 3 /
Scum thickness: e�
Distance from top of scum to top of outlet tee or baffle: „
Distance from bottom of scum to bottomutlet tee or baffle: / `f
How were dimensions determined: G v— q 3, U
Comments (on pumping recommendation , inlet and outlet tee or baffle condition, structural integrity, liquid levels
a�.rzled-to o tlet inve✓ �_ , evide a of le a e, tc.):
GREASE TRAP: (locate on site plan)
J T t . I • u L
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 11
k,
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address'
A NOJ
Owner:
Date of Inspe on•
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present (yes or no):
Alarm level: Alarm in working order (yes or no):
Date of last pumping:
Comments (condition of alarm and float switches, etc.):
DISTRIBUTION BOX:(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Q
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
le*aa e into or pput of boetc.): /
E
PUMP CHAMBER:
(1oc eon site plan)
Pumps in working order (yes or no):
Alarms in working order (yes or no):
jComments (note condition of pump-chl§mbe?, condition J"pu ps and 2ppurtenances, etc.):
1
8
• ' * Page 9 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:f
7
Owner:
Date of Ins a ion:
10jtCF2-
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: /'1/N C Ze S 3 U
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.): -/
D ! 1 v fC r -7S O /-V U ON
� d"
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:
Depthof scum layer:
Dimensions of cesspool:
Materials of construction: r
Indication of groundwater inflow (yes or no): _
Comments (note condition of soil, sign of hydraulic failure, level of pending, condition} of vegetation, etc.?: P
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.):
9
Page 10 of 1 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM`INFORMATION (continued)
Property Address: -j
U
Owner:
Date of nsp tion:
1
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.
'i i
v.
� QA,(
10
do Page 11 of 11
OFFICIAL, INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
A
,..Property Address:
Owner.•
At,
Date of Insp4on:
f
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
"I J,
'7
ed depth to ground w 1 11
% , ' I I
Estimated water , �ieet
Please indicate (check) all methods used to determine the high ground water elevation:
ZObtained from system design plans on record - If checked, date of design plan reviewed:
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health -explain:
Checked.with local excavators, installers- (attach documentation)
Accessed USGS database -explain:
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1
FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
*****************************APPLICANT FILLS OUT THIS SECTION***********************
APPLICANT ac *4
LLQ,
LOCATION: Assessor's Map Number f (�
SUBDIVISION
STREETZ5 � Rcil nor st
PHONE 0179_60_ Zd
PARCEL UOZ 6
LOT (S)
ST. NUMBER �S
****W*************.�******OFFICIAL USE ONLY***********************************
RECO M15NDATIONIS OF/TOWN AGENTS:
CONS
/"ATION A INISTRATOR DATE APPROVED
DATE REJECTED %T
COMMENTS
COMMENTS
FOOD INSPECTOR -HEALTH
SEPTIC INSPECTOR -HEALTH
UAI t HtJtC: I tU
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
COMMENTS Z_ 22
PUBLIC WORKS - SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT DV
FIRE DEPARTMENT ' -)Lzv t%
AQII�,I�Iqzaitf� ea_
RECEIVED BY BUILDING INSPECTOR
Revised 9\97 im
psi •�>jlL"
TE
THOMAS D. ZAHORUIKO
185 Hickory Hill Road, North Andover, MA 01845
Tel: 978-687-2635 Fax: 978-689-2310 E-mail: tomz@attbi.com
Sandra Starr, Health Director
North Andover Board of Health
27 Charles Street
North Andover, MA 01845
RE: 254 Barker Street
North Andover, MA 01845
Dear Sandy,
November 14, 2002
This is to inform you that I have purchased "254 Barker Street" with the intent of
rehabbing and reselling the property in the next few months. My plans call for
improvements within the existing structure; adding two bedrooms, one bathroom, and
updating the interior walls and flooring. The attached Title 5 Certification report certifies
that it "passes" inspection.
Acknowledging the concerns of the Health Department regarding these home
improvements, our proposal is as follows:
• Tara Leigh Development, LLC intends to install a gravity sewer line in Barker Street
in the Summer of 2003, pursuant to the Carter Farm residential development plans
which are currently being finalized with the Planning Board.
• A sewer service stub will be provided to this address as part of this sewer extension
project.
• Subsequent to that installation, Tara Leigh Development, LLC commits to complete
the sewer connection to this residence at no cost or obligation to this or any future
owner, within twelve months of issuance of occupancy permit.
• The sewer connection fee has been prepaid to the Department of Public Works for this
address, confirmation of which is provided by the attached Public Works receipt.
• Until such time as the sewer connection is completed, the septic system will be
inspected monthly by New England Engineering Services, and any deficiencies or
issues in the operation of the system will be reported to the Health Director.
I hope this proposal is satisfactory. Should you have any questions, please do not
hesitate to call me. Thank you for your consideration.
Sincerely,
D. Zahoruiko
Leigh Development, LLC
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:C96q &�r4
luo I 2�i
Owner's Name: lam
Owner's Address: J
Date of Inspection: ) i
Name of Inspector:
Company Name: L
Mailing Address:(Z
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 Section 15.340 of Title 5 (310 CMR 15.000). The system:
V Passes
Conditionally Passes
by the Local Approving Authority
F
Inspector's Signature:�� (� ate: l��eZ
—�
The system inspector shall#bmit a copy of this inspection report to the Approving Authority (Board of Health or
DEP) within 30 days of co pleting this. inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the sysem owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
f
Page 2 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property A,dilress:cq 4
Owner
Date of Ins tion:
Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D
A. System Passes:
have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the "Conditional Pass" section need to be replaced or
repaired: The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass.
Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please
explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed -
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
I
Q. OLWUDD�7-
Owner: AOP,
94 F-- �
Date of Inspe ion:
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
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:
Page 4 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 0ML
Owner- A/-V�
Date of Inspe tion:
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or "no" to each of the following for all inspections:
Yes No�1
_ V ackup 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
leStatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
�squid depth in cesspool is less than 6" below invert or available volume is less than day flow
'/2 equired 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.
:j
/Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
Any portion of a cesspool or privy is within a Zone l 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 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.]
tVO (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 ofa 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.
4
Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
' `iL 0A
1 1 o
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 weak period ?
/Have large volumes of water been introduced to the system recently or as part of this inspection ?
VWere 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:
Yes no
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 CMR 15.302(3)(b)]
5
Page 6 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner:
Date of Insp' c ion:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): Number of bedrooms (actual):
DESIGN flow based on 310 CMI 15.203 (for example: 110 gpd x # of bedrooms):
Number of current residents: /
Does residence have a garbage grinder (yes or no): 0
Is laundry on a separate sewage system (yes or no): O[if yes separate inspection 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): t�}! - %
Last date of occupancy: CCGy j0 t e_�ii�
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow (based on 310 CMR 15.203): gnd
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 S
Source of information: r
Was system pumped as part o th inspection (yes or no):
If yes, volume pumped: gallons -- How wntity pumped determined?
Reason for pumping: ij IF I ]' Z&V a
TYPEJOF SYSTEM
_L, -Septic tank, distribution box, soil absorption system
_ Single cesspool
Overflow cesspool
Privy
_ Shared system (yes or no) (if yes, attach previous inspection records, if any)
_ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be
obtained from system owner)
Tight tank _ Attach a copy of the DEP approval
_ Other (describe):
of N1 coo �nep�s, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site (yes or no) -A9
6
Page 7 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Date of Inspkcjion: ll�t; 1J
BUILDING SEWER (locate on site plan)
Depth below grade: L - —
Materials of construction: cast iron _40 PVC other (explain):
Distance from private water supply well or suction line:
Comments (on condition of joints, venting, evidence of leakage, etc.):
SEPTIC TANK: _ (locate on site plan) i
et
Depth below grade: 05
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) y
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: 3 /
Scum thickness: d
Distance from top of scum to top of outlet tee or baffle: �_ ¢
Distance from bottom of scum to bottom utlet tee or baffle: -�
How were dimensions determined: U
Comments (on pumping recommendation , inlet and outlet tee or baffle condition, structural integrity, liquid levels
GREASE TRAP: _(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass __polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments (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 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Insp n:
TIGHT or HOLDING TANK:
Depth below grade:
Material of construction: concrete
(tank must be pumped at time of inspection)(locate on site plan)
metal fiberglass _polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present (yes or no):
Alarm level: Alarm in working order (yes or no):
Date of last pumping:
Comments (condition of alarm and float switches, etc.):
DISTRIBUTION BOX:(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: C)
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
lee into or ut of boat-5F
etc.
U Ci. t S
Is
0 PoWal
Veon
PUMP CHAMBER: (loc 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 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspe ion:
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required)
If SAS not located explain why:
Type
leaching pits, number: _
leaching chambers, number:
IeWhing galleries, number: /
eaching trenches, number, length: 3 Z IYN C- S 3 o
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.): / r,N 4l -��c / &UfAc /yo V4
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 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.):
0
Page 10 of 1 l
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
ro
DaWit;
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.
Al,
q
�vCwV'er Sir
10
Page 11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Pleaseindicate(check) all methods used to determine the high ground water elevation:
1/ Obtained from system design plans on record - If checked, date of design plan reviewed:
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health -explain:
Checked.with local excavators, installers- (attach documentation)
Accessed USGS database -explain:
You rAust descri howyou established the high ground w r elev tion:
O
7 Ar O w et +-C r -AJ ,s
/1J O S � / /
14Lwa�5 0
j-
DATE OF.PUMPING.
—6 -
QUANTITY PUMPED GALLONS
;;CESSPOOL: NO
S
SEPTIC TANK: No YES C"
4S
NATURE OF SERVICE: ROUTINE
EMERGENCY.
PSgRVATIONS:
GOOD CONDITION'
FULL TO COVER
HEAVY GREASE
BAFFLES IN PLACE
ROOTS
LEACHFIELD RUNBACK
'TOWN OF NORTH AND
EXCESSIVE SOLIDS
FLOODED
SYSTEM PUMPING RECORD
DATE OF.PUMPING.
—6 -
QUANTITY PUMPED GALLONS
;;CESSPOOL: NO
S
SEPTIC TANK: No YES C"
4S
NATURE OF SERVICE: ROUTINE
EMERGENCY.
PSgRVATIONS:
GOOD CONDITION'
FULL TO COVER
HEAVY GREASE
BAFFLES IN PLACE
ROOTS
LEACHFIELD RUNBACK
EXCESSIVE SOLIDS
FLOODED
SOLIDS CARRYOVER
OTHER (EXPLAIN)
SYSTEM
PEDdBY:
r
pi
1
1
Kenneth TerrMig
ulBarker Street
APPLICATION FOR SEMIGE DISPOSAL INSTALLATION
HEALTH DEPARMENT--NORTH AIMOVER, MASS.
I hereby make application for a permit for a sewage disposal installation at
Barker Street _ . I will install this system in
accordance with all the lays of the Commonwealth of Massachusetts and regulations
of the Board of Health of the Town of North Andover.
Furthers I will construct the house sewer of bell and spigot pipe, the minimum
diameter being 4 inches, and will, maintain a minimum grade of 1% until 10 feet
preceding the septic tank where the grade shall not exceed 2%. I will install a
concrete septic tank of 1-2 gal, in size. A manhole (s) permitting easy
cleaning will be provided with removable cover (s) of iron or concrete within 12
inches of the ground surface. I will provide subsurface disposal field with open
jointed bell and spigot Ackron pipe at least 4 inches in diameter and laid in a
series of trenches, the bottom of which will provide a minimum of 120 lineal
(QX434 feet of effective absorption area. The pipes will be laid on a 6 inch
layer of washed gravel or crushed stone ranging in size from 3A to 1-1/2 inches
(dia.) and the pipes will be surrounded by similar material to a height of 2 inches
above the crown of the pipe. The joints of these pipes will be protected from
clogging and before filling the trench, 2 inches of gravel or stone 1/8tt to IAII
(dia.) will be placed over the course gravel or stone. The disposal field will be
installed at a grade of 4 to 6 inches/100 feet. No single tile line will exceed
100 feet in length and in any case, two lines of the will be installed. A minimum
of 6 feet will be maintained between the center lines of the disposal field trenches
and the average depth of trench shall not exceed 36 inches. No part of the in—
stallation will be less than 100 feet from any private water supply., 25 feet from
any stream, 20 feet from any dwelling or 10 feet from any property line. I further
officer, as provided belowp and to incorporate any additional requirements that
may be attached to the hermit. Plot Plans must be submitted with application.
DATE 2 S
Signature of Applicant
I hereby issue the above permit for the Board of Health of the Town of North
Andover, Massachusetts.
RATE �S 7
Signature of Health Agent
I have inspected the uncovered system indicated above and find everything done
as described,
NATE Idr
Signature o nsp ting Officer
Psroolation Test
Garbage Grinder —)td
July 8, 1957
Miss Mary Sheridan R. N.
Health Agent
Board of Health
North Andover, Mass.
Dear Miss Sheridan:
An examination was made as requested in order to
determine the suitability of the soil for the subsurface
disposal of sewage on the proposed Barker St. building
site of Kenneth A. Terroux.
The subsoil in the area was of a sandy clay content
and a 1 -minute percolation test was conducted.
The land in general is high, but on a water shed.
It is recommended that a 750 gallon concrete septic
tank be installed together with 120 lineal feet of drain
pipe in order to take care of an automatic washer.
Very truly yours,
0.
t C64-� C. -o -
William riscoll
t
43 -
BOARD OF HEALTH
TOWN OF' NORTH ANDOVERV MS.
Soca C.. '�o�M��►
I)ArGQ MA o.)
1. NAT JE .) � M O E ?" hi A • . A. ) E R �0 U K . .DATE
2. ADDRESS .I �s m �:'.� .Lar N0. . .!. TELC'iv��04�.SF�
9. N0, OF BEDROOM . . Z;"' . . DEN YES . � . . . NO.. . .
4. GARBAGE GRINDER YES . NO.. . 0
5. SHOW DIII ENSIOiS OF HOUSE
6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES
7 SHOW DD ENSIOIS OF LOT W111
8, SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL
9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM —
10. SHOW LOCATION CF BROOKSV STREAP.S# DITCHES, LEDGE OUTCROP, ETC.
11, SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE
NOTE: LOCAL REGULATIONS SHOULD HE READ CAREFULLY.
SEPTIC SYSTEM INSPECTION FORM
ADDRESS f �-
DATE INSPECTED �1 ,
PROPERLY FUNCTIONING? O N
WEATHER CONDITIONS
COMMENTS:
DYE TEST PERFORMED? Y N
DATE?
SKETCH: