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Home My WebLink AboutMiscellaneous - 254 LACY STREET 4/30/2018a y Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. VQ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 254 LACY STREET Property Address SARA TOMASELLI ( TRUSTEE Owner's Name N.ANDOVER City/Town MA 01845 State Zip Code 05/18/2017 Date of Inspection 6 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information Inspector: JOHN SOUCY Name of Inspector SOUCY SEWER SERVICE INC Company Name 78 N BROADWAY Company Address SALEM NH 03079 City/Town 603-898-9339 Telephone Number B. Certification State Zip Code 13397 License Number I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes n ❑ Conditionally Passes ❑ Fails ❑ Neeefs Further Evaluation by the Local Approving Authority a 05/18/17 Date The system inspector shall submit 19 copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc • rev. 6/16 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 254 LACY STREET Property Address SARA TOMASELLI (TRUSTEE) Owner's Name N. ANDOVER MA 01845 05/18/2017 CityTrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc • rev. 6/16 Title 5 Offidal Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17 M Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 254 LACY STREET Property Address SARA TOMASELLI (TRUSTEE) Owner's Name N. ANDOVER MA 01845 05/18/2017 City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc - rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 254 LACY STREET Property Address SARA TOMASELLI ( TRUSTEE Owner's Name N. ANDOVER City/Town B. Certification (cont.) MA 01845 State Zip Code 05/18/2017 Date of Inspection 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/ day flow t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Insp Subsurface Sewage Disposal System Fo 254 LACY STREET Property Address SARA TOMASELLI (TRUSTEE) Owner Owner's Name nformation is N. ANDOVER required for every page. Cityrrown B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or ection Form ❑ ® rm - Not for Voluntary Assessments ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, MA 01845 05/18/2017 and chain of custody must be attached to this form.] State Zip Code Date of Inspection ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17 ,N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 05/18/2017 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ M ED ® ❑ ® ❑ ® ❑ ® ❑ ® ❑ Pumping information was provided by the owner, occupant, or Board of Health Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 254 LACY STREET Property Address SARA TOMASELLI (TRUSTEE) Owner Owners Name information is required for every N. ANDOVER MA 01845 page. City/Town State Zip Code C. Checklist 05/18/2017 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ M ED ® ❑ ® ❑ ® ❑ ® ❑ ® ❑ Pumping information was provided by the owner, occupant, or Board of Health Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �^M 254 LACY STREET Property Address SARA TOMASELLI (TRUSTEE) Owner Owner's Name information is required for every N. ANDOVER MA 01845 05/18/2017 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Well, recommend removal of garbage grinder. Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) ❑ Yes ® No Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M y 254 LACY STREET Property Address SARA TOMASELLI (TRUSTEE) Owner Owner's Name information is required for every N. ANDOVER MA 01845 05/18/2017 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other (describe below): General Information Pumping Records: Source of information: SOUCY SEWER SERVICE INC Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? GAUGE ON TRUCK & MEASUREMENTS Reason for pumping: MAINTENANCE & INSPECTION 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 a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 254 LACY STREET Property Address SARA TOMASELLI ( TRUSTEE Owner Owners Name information is N. ANDOVER required for every page. City/Town MA 01845 05/18/2017 State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 20 feet Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): — Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): No aooarent leaks. Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal M1 feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'x 5'4" Sludge depth: 3" t5ins.doc • rev. 6/16 Title 5 Offidal Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 254 LACY STREET Property Address SARA TOMASELLI (TRUSTEE) Owner Owner's Name information is required for every N. ANDOVER MA 01845 05/18/2017 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 32" Scum thickness 2 Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? TAPE & SLUDGE TOOL Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Static level in tank good, no apparent leaks, baffel and outlet tee good, pump tank annually. Remove garbage disposal. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: t5ins.doc - rev. 6/16 feet ❑ polyethylene ❑ other (explain): Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 254 LACY STREET Property Address SARA TOMASELLI (TRUSTEE) Owner Owners Name information is required for every N. ANDOVER MA 01845 05/18/2017 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 254 LACY STREET Property Address SARA TOMASELLI (TRUSTEE) Owner Owner's Name information is required for every N. ANDOVER MA 01845 05/18/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): FLOWED CHECKED GOOD. "D" BOX REPLACED PRIOR TO INSPECTION, SEE PERMIT. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 254 LACY STREET Property Address SARA TOMASELLI (TRUSTEE) Owner Owner's Name information is required for every N. ANDOVER MA 01845 05/18/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields 20'x45'=900 SQ' 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.): NO SIGNS OF HYDRAULIC FAILURE Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y 254 LACY STREET Property Address SARA TOMASELLI (TRUSTEE) Owner Owner's Name information is required for every N. ANDOVER MA 01845 05/18/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc • rev. 6/16 Tide 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 254 LACY STREET Property Address SARA TOMASELLI (TRUSTEE) Owner's Name N. ANDOVER MA 01845 05/18/2017 City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand -sketch in the area below ❑ drawing attached separately /oNS do t' f F �A_�.- 0 .. 1N /y a •S 2 .2t:5%�K RdY /N /oo,p 7 F.�� o� !iNF 59 •� 9 b o k 4 r T.► o N Suis'« . ExrJ7/NG- jkut///NG W R PPRo k. � _4' r — fAM/! t t ? %%%ZS 137-17 L,ic y .sTREE r t5ins.doc • rev. 6116 Title 5 Offical Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 254 LACY STREET Property Address SARA TOMASELLI ( TRUSTEE Owner Owner's Name information is N. ANDOVER required for every page. City/Town D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells MA 01845 State Zip Code 05/18/2017 Date of Inspection Estimated depth to high ground water: 61+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: /1 ■ ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Dug hole with auger when "D" box hole was exposed no water at 3', "D" box B.B. 48" below grade. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 254 LACY STREET Property Address SARA TOMASELLI (TRUSTEE) Owner Owner's Name information is required for every N. ANDOVER MA 01845 05/18/2017 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information — Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 Commonwealth of Massachusetts Map -Block -Lot 105.00038 BOARD OF HEALTH ._................ Permit No North Andover BHP -2017-0412 P.I. ...... ___.._......._._.__.. :PEE / -- -6— F.I. __.._....._..___ ....:� --..- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted .._..- to (Repair) an Individual Sewage Disposal System. f at No 254 LACY STREET _.. -- - - ---------- _------- ----------_........_...--------------- ..... .................... as shown on the application for Disposal Works Construction Permit No. BHP -2017-041I7 ......... . ............ __rte Issued On: May -10-2017 BOARD OF HEALTH of No R rH qti 3� o0 k W-aaal 5 !! ISS/4CHUS�� PUBLIC HEALTH DEPARTMENT Town of North Andover Community and Economic Development Division CERTIFICATE OF COMPLIANCE As of: May 26, 2017 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: D -Box Repair By: John Soucy, Soucy Sewer Service Inc At: 254 Lacy Street Map lOS.0 Lot 38 North Andover, MA 01845 The Is:7 u of thi cate shall not be construed as a guarantee that the system will function satisfactorily. Bria J. VGrasse, CEHT Director of Public Health 120 Main St., North Andover, Massachusetts 01845 Phone 918.688.9540 Fax 918.688.9542 Web www.northandoverma.gov 0 7894 Town of North Andover HEALTH DEPARTMENT �,SSACNUStt CHECK #: yYS DATE: (p a aoi7 LOCATION: H/O NAME: So0rTCONTRACTOR NAME: -5-00r- ype of Permit or License: (Check box) Type ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service- Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $x Title 5 Report 5 5 PO - 50— $50- ❑ Other: (Indicate) $ He gent Initials White - Applicant Yellow - Health Pink - Treasurer 6y C;2 North Andover Health Department Community and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 254 Lacy Street INSTALLER: John J. Soucy DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: MAP: 105.0 LOT: 38 DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS Comments: SEPTIC TANK ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION -BOX ® Installed on stable stone base ❑ H-20 D -Box ❑ Inlet tee (if pumped or >0.08'/foot) ® Hydraulic cement around inlet & outlets ® Observed even distribution ® Speed levelers provided (not required) ® Schedule 40 PVC Pipe Comments: 5/18/2017 Did flow test. Installed flow levelers and repeated tests. OK. Need to install risers to grade and re -inspect. 5/24/2017 — re -inspected and graded SOIL ABSORPTION SYSTEM (General) ❑ Bottom of SAS excavated down to C soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 40 Mil HDPE barrier installed ❑ Laterals installed and ends connected to header (and vented if impervious material above) ❑ Elevations of laterals and chambers installed as on approved plan ❑ Retaining wall (boulder / concrete / timber/ block) ❑ Final cover as per plan Comments: SOIL ABSORPTION SYSTEM (Gravel -less Chambers) ❑ Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ❑ Number of chambers per row: ❑ Number of rows (trenches): Comments: Total Chambers = FINAL GRADE ❑ Loamed ❑ Seeded ❑ Cover per plan Comments: DOCUMENTS NEEDED ❑ Certification of Installation Form submitted By engineer and signed and dated by Engineer and installer ❑ As -Built Plan BM = HR= HI = SYSTEM ELEVATIONS ROD AS -BLT INVERT DESIGN INVERT ELEVATION ELEV ELEV Benchmark Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 TOP Lateral 1 INVERT Lateral 2 TOP Lateral 2 INVERT Lateral 3 TOP Lateral 3 INVERT Lateral 4 TOP Lateral 4 INVERT Lateral 5 TOP Lateral 5 INVERT Lateral 6 TOP Lateral 6 INVERT Top of Chamber Bottom of Bed/Chamber SKETCH PLAN CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback ' Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). s As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws Tank SAS Sewer ® Property line 10 10 -- ® Cellar wall 10 20 -- ® Inground pool 10 20 -- ® Slab foundation 10 10 -- ® Deck, on footings, etc 5 10 -- Waterline 10 10 101 ® Private drinking well 75 1002 50 ® Irrigation well 75 100 ® Surface Water 25 50 ® Bordering Vegetated Wetland , Salt Marsh, Inland / Coastal Banka 75 100 ® Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ® Trib. to surface water supply 325 325 ® Public well 400 400 ® Interim Wellhead Prot. Area ® Reservoirs 400 400 ® Drains (wat. supply/trib.) 50 100 ® Drains (intercept g.w.) 25 50 ® Drains (Other) Foundation 10 (5) 20 (10) ® Drywells 20 25 ' Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). s As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws ,--Z V'A z a,,, / n North Andover Health Department Community and Economic Development Division � oL-bow r�Po.;r ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 254 Lacy Street INSTALLER: John J. Soucy DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: MAP: 105.0 LOT: 38 INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned' ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Watertightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port Comments: PUMP CHAMBER Comments: CONTROLPANEL Comments: DISTRIBUTION -BOX Comments' (I ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Installed on stable stone base -� H-20 D -Box �-8—' Inlet tee (if pumped or >0.08'/foot) [� Hydraulic cement around inlet & outlets [^�/ Observed even distribution L� peed levelers provided (not required) EY Schedule 40 PVC Pipe D-) 10 F -) ( /' oy �� `f ei f s' D (_- (V 2 'J �S SOIL ABSORPTION SYSTEM (General) ❑ Bottom of SAS excavated down to C soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 40 Mil HDPE barrier installed ❑ Laterals installed and ends connected to header (and vented if impervious material above) ❑ Elevations of laterals and chambers installed as on approved plan ❑ Retaining wall (boulder / concrete / timber/ block) ❑ Final cover as per plan Comments: SOIL ABSORPTION SYSTEM (Gravel -less Chambers) ❑ Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ❑ Number of chambers per row: ❑ Number of rows (trenches): Comments: Total Chambers = FINAL GRADE ❑ Loamed ❑ Seeded ❑ Cover per plan Comments: DOCUMENTS NEEDED ❑ Certification of Installation Form submitted By engineer and signed and dated by Engineer and installer ❑ As -Built Plan BM = HR = HI = SYSTEM ELEVATIONS ROD AS -BLT INVERT DESIGN INVERT ELEVATION ELEV ELEV Benchmark Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 TOP Lateral 1 INVERT Lateral 2 TOP Lateral 2 INVERT Lateral 3 TOP Lateral 3 INVERT Lateral 4 TOP Lateral 4 INVERT Lateral 5 TOP Lateral 5 INVERT Lateral 6 TOP Lateral 6 INVERT Top of Chamber Bottom of Bed/Chamber SKETCH PLAN w CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback ' Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws 01 Tank SAS Sewer ® Property line 10 10 -- ® Cellar wall 10 20 -- ® Inground pool 10 20 -- ® Slab foundation 10 10 -- ® Deck, on footings, etc 5 10 -- ® Waterline 10 10 10' ® Private drinking well 75 1002 50 ® Irrigation well 75 100 ® Surface Water 25 50 ® Bordering Vegetated Wetland , Salt Marsh, Inland / Coastal Banka 75 100 ® Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ® Trib. to surface water supply 325 325 ® Public well 400 400 ® Interim Wellhead Prot. Area ® Reservoirs 400 400 ® Drains (wat. supply/trib.) 50 100 ® Drains (intercept g.w.) 25 50 ® Drains (Other) Foundation 10 (5) 20 (10) ® Drywells 20 25 ' Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws 01 04 tdORrH 4y d ACfJU Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Q joiny 5e " C7 co/nco'5�1 /,P/ Application for Septic Disposal System Construction Permit -TOWN OF NORTH ANDOVER, MA 01845 Application is hereby made for a permit to: ❑ Construct a new on-site sewage disposal system* 5/9/17 TODAY'S DATE 350.00 - Full Re air $175.00 - Component ❑ Repair or replace an existing on-site sewage disposal system* ® Repair or replace an existing system component —What? H20"D" BOX A. Facility Information 254 LACY STREET Address or Lot # N. ANDOVER City/Town 2.- *TYPE OF SEPTIC SYSTEM*: ►°,y= �,P�� ➢ ❑ Pump 1� Gravity (choose one)QPQ`�� ***If pump system, attach copy of electrical permit to application*** OF �,pP1 ➢ El Conventional System (pipe and stone system) _110' �Q�� ➢ ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type�2Tf system.) ➢ ❑ Pressure Distribution S.A.S. (No D -Box) ➢ ❑ Pressure Dosed (D -Box Present) S.A.S. ➢ ❑ Does the system require an effluent filter? Yes No if yes, does plan specify make and model of filter? YES = (no further info. needed) NO = (installer must specify brand of filter before DWC issuance) What is the Make? 2. Owner Information PAUL BENINATO Name 254 LACY STREET What is the Model? Address (if different from above) N.ANDOVER Cityrrown ANTHONY.THOMASELLI@GMAIL.COM Email address 3. Installer Information JOHN SOUCY Name 78 N. BROADWAY Address SALEM City/Town 4. Desianer Information Name Address City/Town MA 01845 State Zip Code 978-771-5049 Telephone Number SOUCY SEPTIC SERVICE INC Name of Company NH 03079 State Zip Code Telephone Number (Cell Phone # if possible please) Name of Company State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 Application for Septic Disposal System Construction Permit —TOWN OF NORTH ANDOVER. MA 01845 PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: ®Residential Dwelling or ❑Commercial B. Agreement 5/9/17 TODAY'S DATE $350.00 - Full Repair $175.00 - Component The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North An e . I understand that until a final Certificate of Co fiance has been issued by this B rd of e4ift the installed system is not approved. 7 J, fi�me / ///� // Date ` -/ A n ved By: (Board of Health Representative) jd Na Date Application Disapproved for the following reasons: For Office Use Only: 1. Fee Attached? Yes No 2. Project Manager Obligation Form Attached? Yes No 3. Pump System? If so, Attach co4!v ofElecttical Permit Yes No Applicant received copy of "Electrical Inspection Notes for Septic Systems" Yes No Handout? 4. Reviewed approval letter, all paperwork received. Yes No M1SSing: S. Foundation As -Built? (new construction only). (Same scale as approved plan) Yes No 6. Floor Plans? (new construction only): Yes No Application for Disposal System Construction Permit • Page 2 of 2 SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: (Address of septic system) Relative to the application of (Installer's name) Dated 7/ ` / o a s ate Wz For plans by /t// v r' (Engineer) And dated With revisions dated I understand the following obligations for management of this project: (Original ate (Last revised date) 1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner, contractor, project manager, or any other person not associated with my company schedules an inspection and the system is not ready, then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against me and/or my company. a. Bottom of Bed — Generally, this is the first (1`� inspection unless there is a retaining wall, which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection — Engineer must first do their inspection for elevations, ties, etc. As -built of verbal OK (or e-mail to: healthdept@townofnorthandover.com) from the engineer must be submitted to the Board of Health, after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system, all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade — Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation) and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible. 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board of Health staff or consultant. d. Installation of tank, D -Box, pipes, stone, vent, pump chamber, retaining wall and other components. 6. As the installer, I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: ( oda y's Date (Name —Print) ame — ed) n Commonwealth of Massachusetts Map -Block -Lot 105.00038 BOARD OF HEALTH North Andover CERTIFICATE OF COMPLIANICE THIS IS TO CERTIFY, That the Individual Sewage Disposal System (Repair) by I ---------------------------------------------------------------------------------------------------------------------- - - - ------------ Installer at No 254 LACY STREET 9 ------------------------------------------------------------------------ -------�- has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. BHP -2017-041 Dated -_ May 10,_ 2017 ----------------------------------------------------------------- Printed On: May -10-2017 BOARD OF HEALTH k Commonwealth of Massachusetts Map -Block -Lot 105.00038 BOARD OF HEALTH Permit No North Andover BHP -2017-0412 ----------------------- FEE ------------------ DISPOSAL WORKS CONISTRUCTIONI PERMIT Permission is hereby granted ----------------------------------------------- ------------------------------------------------------ to (Repair) an Individual Sewage Disposal System. _�.. at No 254 LACY STREET ��- ---------------------------------------- --� ----------------------- as shown on the application for Disposal Works Construction Permit No. BHP -201 T-041 i`Dated May 10, 2017 - - - &j'------------------------ ----------------------------------------------------------------- Issued On: May -10-2017 BOARD OF HEALTH 7b59 .o Town of North Andover ,,, .: HEALTH DEPARTMENT ,SS,q U`''El u CHECK #: DATE: LOCATION:oZ S//��,,y S H/O NAME: 15eA/nod CONTRACTOR NAME: 0 -0/I f) Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector 44$� ❑ Title 5 Report / $ ❑ Other. (Indicate) $ Heaft Agent Initials White - Applicant Yellow - Health Pink - Treasurer Cf NORT :,y 6598 it � ... o ; .� hoc • Town of North Andover :. ��'•�,', HEALTH DEPARTME ,��st� T ss CHECK #: DATE: LOCATION: 95 M ( H/O NAME: of n CONTRACTOR NAME:_ I �f' A ,�! ,r Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ 'T Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector Title 5 Report $ $—T ❑ Other. (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer 3 i FILE #N A a, d q ay 13 TITLE V INSPECTION Dean G. Luscomb II & Sons P.O. Box 135 Middleton, MA 01949 S �,' Z 113 978-774-4065 Licensed Plumber # 20285 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PROPERTY OWNERS NAME 2 n i h Gz`%a PROPERTY ADDRESS oR 5 4 L QC e y 34 N.Aodoyer MA DATE OF INSPECTION S e p f e t, j k e r a y a Q 3 II NAME OF INSPECTOR Dia h G . L us C O rv) Y� � QUALITY IS NUMBER ONE TO US l . ar fa'. , i FILE #N A a, d q ay 13 TITLE V INSPECTION Dean G. Luscomb II & Sons P.O. Box 135 Middleton, MA 01949 S �,' Z 113 978-774-4065 Licensed Plumber # 20285 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PROPERTY OWNERS NAME 2 n i h Gz`%a PROPERTY ADDRESS oR 5 4 L QC e y 34 N.Aodoyer MA DATE OF INSPECTION S e p f e t, j k e r a y a Q 3 II NAME OF INSPECTOR Dia h G . L us C O rv) Y� � QUALITY IS NUMBER ONE TO US l . ar fa'. , Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. v �I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , 254 Lacey Street Property Address Beninato Owner's Name North Andover City/Town MA 01845 September 24, 2013 State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Dean G. Luscomb II SEP 3 U 2013 Name of Inspector " TOWN 01= NORTH ANDOVER Dean G. Luscomb II & Sons HEALTH_ DE_PARTN'ENT r` Company Name P.O. Box 135 Company Address Middleton City/Town 978-774-4065 Telephone Number B. Certification MA State S1848 License Number 01949 Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspe is Signature September 24, 2013 Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 254 Lacey Street Property Address Beninato Owner Owner's Name information is required for North Andover MA 01845 September 24, 2013 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Chec coA ,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described S in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are / indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 254 Lacey Street Property Address Beninato Owner Owner's Name information is required for Northp Andover MA 01845 September 24, 2013 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): O ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): U ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR tl 15.303(1)(b) that the system is not functioning in a manner which will protect public health, V safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 254 Lacey Street Property Address Beninato Owner's Name North Andover Cityrrown B. Certification (cont.) MA 01845 September 24, 2013 State Zip Code Date of Inspection 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well*". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 254 Lacey Street Property Address Beninato Owner Owner's Name information is required for NorthP Andover MA 01845 September 24 2013 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: F_1 ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 1 0,000g pd. ❑ ® 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) L e Systems: To be considered a large system the system must serve a facility with a desig ow of 10,000 gpd to 15,000 gpd. For large syste you must indicate either "yes" or "no" to each of the foll ' g, in addition to the questions in Section Yes No ❑ ❑ the system is in 400 feet surface drinking water supply ❑ ❑ the system is with' 0 t of a tributary to a surface drinking water supply ❑ ❑ the syste ' located in a nitroge ensitive area (Interim Wellhead Protection Are PA) or a mapped Zone II o ublic water supply well If you have answer "yes" to any question in Section E the system ' considered a significant threat, or answered " in Section D above the large system has failed. The er or operator of any large system con ' ered a significant threat under Section E or failed under Sectioshall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact t appropriate regional office of the Department. t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 254 Lacey Street Property Address Beninato Owner's Name North Andover City/Town C. Checklist MA 01845 September 24, 2013 State Zip Code Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): A 440 gpd t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 '-<C' Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 254 Lacey Street Property Address Beninato Owner Owner's Name required fo is North Andover MA 01845 September 24, 2013 required for P every page. City/Town State Zip Code Date of Inspection D. System Information Description: owner and town Number of current residents: 2 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: `f, J ViIIc.- CJ eA k p n 1LC- S ri k7-- Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type o ablishment: U Design flow (based 10 CMR 15.203): Basis of design flow (seatsJpers sq.ft., etc.): Grease trap present? Industrial waste holding tan sent? Non -sanitary w discharged to the Title 5 system? readings, if available: Gallons_W-d—ay (gpd) ❑ Yes ® No Current Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Pa-gqaf 17 ' Commonwealth of Massachusetts . Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w„ 254 Lacey Street Property Address Beninato Owner Owners Name information is North Andover MA 01845 September 24, 2013 required for p every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Las cupancy/use: Date Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Pumped on average every yr - owner IN gallons No need at this time 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 a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 254 Lacey Street Property Address Beninato Owner's Name North Andover Cityrrown D. System Information (cont.) MA 01845 State Zip Code September 24, 2013 Date of Inspection Approximate age of all components, date installed (if known) and source of information: System was installed in 1978 - 35 years old - town records Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): / Depth below grade: Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): 1' feet Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Main line and joints are in very good condition. I1111MOR� Septic Tank (locate on site plan): Depth below grade: 4 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) Precast rectangular - 1000 gallons ank is metal, list age: n irmed by a Certificate of Compliance? (attach a copy of certificate) es Dimensions: 5' x 5' x 8' - 1000 gallons Sludge depth: 1" t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 254 Lacey Street Property Address Beninato Owner information is required for every page. �j t5ins • 3113 Owners Name North Andover City/Town D. System Information (cont.) Septic Tank (cont.) State 01845 September 24, 2013 Zip Code Date of Inspection Distance from top of sludge to bottom of outlet tee or baffle 34" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? sticks and tape measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The septic tank and baffles are in very good condition. The liquid in the tank is running at it's correct working heigth. The solids in the tank are very light and do not require pumping at this time. Trap (locate on site plan): Depth belo ade: Material of constructio ❑ concrete ❑ Dimensions: Scum thickness feet ❑ fiberglass ❑ Distance from top of scum to of outlet tee or baffle scum to bottom of outlet tee or baffle Distance from bottgrp Date of lad umping: ❑ other (explain): Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • ge 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 254 Lacey Street Property Address Beninato Owner information is required for every page. Owner's Name North Andover City/Town State Zip Code September 24, 2013 Date of Inspection D. System Information (cont.) Comme n pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as -r#tated to outlet invert, evidence of leakage, etc.): Ti ht or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth elow grade: Material of nstruction: �J ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene other (explain): Dimensions: 1Z Capacity: gallons Design Flow: Ilons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: �' 13"ate Comments (condition of alar and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 254 Lacey Street Property Address Beninato Owner's Name North Andover City/Town D. System Information (cont.) MA 01845 September 24, 2013 State Zip Code Date of Inspection Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Zero Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The d -box is 2' below grade and is 24" x 24" square. The d -box is level and in good general condition. The liquid in the d -box is running at it's correct working heigth. The soil in this area is clean and dry with no signs of any problems. Pu Chamber (locate on site plan): Pumps in working o ❑ Yes ❑ No* rl Alarms in working order: o* V Comments (note condition of pump chamber, con mps and appurtenances, etc.): l * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: The SAS was located by asbuilt drawings and previous title v. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 254 Lacey Street Property Address Beninato Owner Owner's Name information is required for NorthP Andover MA 01845 September 24, 2013 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1 - 20'x 45' ❑ 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.): The SAS is in good general condition with no signs of any problems. The soil in this area is clean and dry with no signs of ponding or breakout. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number a configuration Depth — top of liquid nlet invert U Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of ndwater inflow Yes ❑ No t5ins • 3/13,� Title 5 Official Inspection Form: Subsurface Sewage Di sal System - Page 13 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w„ 254 Lacey Street Property Address Beninato Owner Owner's Name information is required for North Andover MA 01845 September 24, 2013 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comme ote condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 1� r✓ P ' locate on site plan): 91 Materials of con ction: V Dimensions Depth of solids Comments (note condition of soil, signs of hydr ilure, level of ponding, condition of vegetation, etc.): t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 254 Lacey Street Property Address Beninato Owner Owner's Name information is required for NorthP Andover MA 01845 September 24, 2013 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below O Iwell ❑ drawing attached separately W tv / LY�' /ll. A�a✓cvel �• � wall( Wit X D -e01( t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 254 Lacey Street Property Address Beninato Owner's Name North Andover MA 01845 September 24, 2013 City/Town D. System Information (cont.) Site Exam: /, ® Check Slope �--[�p ® Surface water No - State Zip Code Date of Inspection ® Check cellar 1) rr o Stti� h p� r►� p l ® Shallow wells / 0r a Estimated depth to high ground water: 6'fo1-- feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Asbuilt and previous title v and pumping records ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: The basement is 5' below grade with no sump pump. There is a wetland areas about 100' away which is 10'+/- below the qrade of this yard. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 • ` Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 254 Lacey Street Owner information is required for every page. Property Address Beninato Owner's Name North Andover Cityrrown State E. Report Completeness Checklist 01845 September 24, 2013 Zip Code Date of Inspection ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 Commonwealth of Massachusetts — City/Town of NORTH ANDOVER MASSAC U "Fi,. , System Pumping Record MAY 1 9 2008 y` Form 4 TOWN OF NORTH ANDOVER DEP has provided this form for use by local Boards of Health. Th NWT R'Rord must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Location: forms on the d f computer, use only the tab key Address to move your cursor - do not use the return Cityrrown State Zip Code key. 2. S tem Owner: faro IV Name Address (if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Gall Pumped: Date ons I Type of system: ❑ Cesspooi(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes / No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6..Sf�: 'stem Pumped By: ame Vehicle License Number16 F XU 4 Company 7. Location where contents were disposed: Is" 14-4-15 Date http://www.mass-gov/dep/Water/approvals/t5forms.htm#inspect t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 c W L CU HP Fax K1220xi Log for NORTH ANDOVER 9786889542 Jan 23 2004 4:O1pm Last 30 Transactions Date Time Twe Identification Duration Pales Result Jan 21 11:49pm Received M. V . Cham 0:47 1 OK Jan 22 8:42am Received 0:39 0 No fax Jan 22 8:45am Received 19785212224 0:33 2 OK Jan 22 9:05am Received 2:33 7 OK Jan 22 9:15am Received discount vacations 1:32 1 OK Jan 22 9:40am Received 0:39 0 No fax Jan 22 9:52am Fax Sent 556 0:50 2 OK Jan 22 11:42am Received 0:41 4 OK Jan 22 12:42pm Received Corporate Travel 1:31 1 OK Jan 22 12:47pm Received 978 532 8410 0:26 1 OK Jan 22 1:07pm Fax Sent 89786850521 3:46 3 OK Jan 22 2:59pm Fax Sent 89785578633 2:24 4 OK Jan 22 3:07pm Fax Sent 816174261457 0:30 2 OK Jan 22 3:30pm Received 0:42 1 OK Jan 22 3:51pm Received 9786850049 0:53 3 OK Jan 22 4:15pm Fax Sent 89784591333 0:45 2 OK Jan 22 4:16pm Fax Sent 89784591333 0:32 1 OK Jan 22 4:28pm Received 0:47 5 OK Jan 22 4:42pm Fax Sent 89788518547 0:21 1 OK Jan 22 4:53pm Received 148 687 6808 0:40 2 OK Jan 22 5:04pm Received 19788518547 0:32 1 OK Jan 23 9:15am Received 1:20 2 OK Jan 23 10:26am Received 9783886779 1:10 2 OK Jan 23 11:35am Received 978 688 3211 0:55 2 OK Jan 23 12:15pm Fax Sent 89782511211 2:15 3 OK Jan 23 1:43pm Received 6173382662 1:16 2 OK Jan 23 2:01pm Fax Sent 819787776363 6:31 7 Jan 23 3:50pm Fax Sent 816172694221 7:01 VOK _,�9-�� Error 345 Jan 23 3:58pm Fax Sent 89787942500 1:18 2 OK Jan 23 4:OOpm Fax Sent 816172694221 0:51 1 OK , William F. Weld Governor Argeo Paul Celluccl U. Governor Commonwealth of Massachusetts Executive Office of Environmental Affairs ®epcartment of Environmental Protection SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 2-,T+ LArcx-- Y ST., 1 o • ArjI>0V 12_ Address of Owner. of Inspection: H_A; fz ,t4 11 1.1 Q (v (If different) Name of Inspector• M A-QTI N FA i P— Company Name, Address and Telephone Number. WAizn N Fk1 Rr iZ�. +D - t4t.mi Tz WA,, . SfEI.EN t"1 Old (5-08) '?-+- 051,9 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: A�Passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority —Fails Inspector's signature: ��j-- 7 Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. Trudy Coxe secretary David B. Struhs Comrniz er INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMH 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: 6 One or more system components.need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration,.or tank failure is in„ninent. The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 One Winter Street • Boston, Massachusetts 02108 • FAX (617) 556-1049 A zi Printed on Recycled Paper • Telephone (617) 292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 7_5+ LJ4L6`f!Sr., N oe�r4 kw voq t-_ - Owner. JOt+IJ SrhMfq Date of Inspection: P k_a_ -F 1 , 1 q q (i Bj SYSTEM CONDITIONALLY PASSES (continued) _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(a) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N O _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet .of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER. IF APPROPRIATE) 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 and'is within 100 feet to a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.— _ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is flee from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 3) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) PropertyAddreas: 25+ LA-e-� ST. , NoQ.-rF� �'1-100vel2 Owner.�p �r4 —s4i RbY Date of Inspection: �+.} (1 I f{ q (, D] SYSTEM FAILS: N1 O I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: NIA The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 GWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information." (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 254 L Acer S -r, ,. tv o • Aw oovam Owner. j O 1 +J'A Date of Inspection: W *ac -H 1, 19910 Check if the following have been done: V Pumping information was requested of the owner, occupant, and Board of Health. L/�1one of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. V As built plans have been obtained and examined. Note if they are not available with N/A. Z'The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non -sanitary or industrial waste flow The site was inspected for signs of breakout. /All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. ZThe size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non -intrusive methods. _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub - Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Z5+ LAe-sq Sr., No• A-Nmve2- Owner. Jo w4 �►�� %`( Date of Inspection: f-4 A'i2C.H. 11 lqq (o FLOW CONDITIONS RESIDENTIAL.• Design flow: gallons Number of bedrooms: Number of current residents: Z Garbage grinder (yea or no):Ye5 Laundry connected to system (yes or no): `�' 6s Seasonal use (yes or no):O Water meter readings, if available: t-4 e 1je A VA7 (LARd .j DYVftLj N(. P5 5C2.✓&`D RH A �W fu— Last date of occupancy: Ue LJ( Q(LU PI eD COMMERCIAL/INDUSTRIAL.• KLA Type of establishment: Design flow:_gallons/day 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: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: IZ_S+F►.2 Ey....___SA-1 D_F}�_._�i-A-D_ 'T1fl�- SY15f'ISM ?VM Pfd Y"�'Ot1T Z yo--r'A G.D "r4f--1 Pel w PED rsyE2y Z`ea t' o V e--2- T -►t C.A-sr 8 Y" System pumped as part of inspection: (yes or no) L o If yes, volume pumped: gallons Reason for pumping: TYPE�F SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yea or no) (if yea, attach previous inspection records, if any) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: 01,7-A-►NE�D Sewage odors detected when arriving at the site: (yes or no) �v v (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 2-5 4 LAC ey ,Jr . , tAo . A t4 Dove 2 Owner. t–jo 4N yH)REX Date of Inspection: HA-2LA J 1qq (o SEPTIC TANK -JO -S, (locate on site plan) �r Depth below grade:_ Material of construction: ✓ concrete _metal _FRP _other(ezplain) Dimensions: S9' W'C g L X 4AD Sludge depth: G •r ' g,� Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 0" � /A Distance from top of scum to top of outlet tee or baffle: Distance frobottom of scum to bottom of outlet tee or baffle: NIA m Comments: di(recommendation for pumping, contion of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) GREASE TRAP O (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —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: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFFORMATION (continued) Property Address; Z54 L.�cE� �r:l 00. �}NDoVEi2. Owner. o ► i K SFH 2eY Date. of Inspection: HA -904 (t (q 9 (o TIGHT OR HOLDING TANK:—KO (locate on site plan) Depth below grade: Material of construction: _concrete _metal —FRP —other(explain) ' Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments:, (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOY --Y6-5 (locate on site plan) Depth of liquid level above outlet invert:�C7� Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, 'etc.) t aTt21 psvn 0 nl t S E�Qy /a, -L T+€¢ -r- i S Ar St.y r A 21 N tn„ ArQou N D T}t-r_- fScac Ar -1- -t-H-tr-L W- 7-1 O t.l O F TNrr-y 1 til V C4--r'S ¢ O l�Tt.ETS PUMP CHAMBER: N 0 - (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address 7-54 l A SY 51--j N o • n►ood �Z Owner. V o H N s H i 2,EY Date of Inspection: �-A At-aC-H I I I99lo SOIL ABSORPTION SYSTEM (SAS):--�3)E�5 (locate on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods) If not determined to be present, explain: tl7� leaching pits, number:_ leaching chambers, number:_ ' leaching galleries, number: leaching trenches, number,length: „ leaching fields, number, dimensions: OWF--L T " AFS IN Cq oUND PL-Arhl VQT-A- t4C-D F2UM TH6 overflow cesspool, number: BSD o F 4+*A-t-T74 1N Ot c ATES -rU& EXISTENCE. OF- A ZO'W x 4S'L F►ELDi_T4e-1 ooTL4N6 CF W Cj-T1LD SNOvJ INDILATES AT 111 Vge9' Comments: (note condition of soil, signs of hydrauc faillevel of ponding,condition of vegetation, o etc.) 1J a FVt 0"C.—e- OF FA-IWQ6 WkS Q P26 6W-VArD. CESSPOOLS: NO (locate on site plan) Number and configuration: Depth -top of liquid to inlet invert: Depth of solids layer. Depth of scum layer. Dimensions of cesspool; Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY. NO (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.) (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: LS4- L,6� 1 14o¢r4 A poVE1Z Owner. J O .—'5}{y ;ZSy Date of Inspection: F( A-aC-k+ I) I q q (0 SKETCH OF SEWAGE DISPOSAL. SYSTEM: NTS• include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' DEPTH TO GROUNDWATER Depth to groundwater.--j-(o _feet =: A -1: 1 = 2-0. 51 A_- - D 44• o_' sem- r✓ _ __ . 48 . �-' . F-5 (.E -PT 12EA 2 WA -c —__ a r- 40-vsL, SS'4,FRoM soft, so2P - Tt 0 N S�?s►�t ( , method of determination or approximation: T, W CA_UN 63 IS A -T- Tia t" OF KN OL 11-4 G i.Oy lel D M O 2R.h-1 N 6 . MI -S F0vNQJVMOW WA-, 2.51 of 2 veAl- W1ri4 A 7- S` Povg- Cwt A-2 sL- -a 1S .51 G.R.ti-De< Alin N -Ars 110 twmP PUHP. Box t5 -sl ry uN a4--norl . TW:961 s ice` �� err /4c264 hCeo5S TH'fr 6T4�'r Ab0U-r 1001 ArWA-q-) W FFSGI-} 15 ->_ (0' i�0-rjee- %hl (Pdi%$S) TH-A✓N Cm gA-06 01V7' T -A-6 So , t— 9 A -3S o R?Ti O Q 544-vr i. _1��E5T wA R D eiR Ala GLIB /N E,ZF V4 77/ 0,A1 S �p�E�E.E 7c�a�gc /N /a a �S 2 ITAiVg QLA*- /ua-.2 7 ,8oX /N 7 7�y I I. I' ' IIS 5 I I i•I I I h 1 1 ExiS7/NG- z wt///NG 4APR ak• 0 r �I r 7%v S•fr 43E0 j L000 - / r_ f i4NK a O Qom - 137-17 coMti10co r;z 9c a / 7 FORM U TOWN OF NORTH ANDOVER LOT RELEASE FORM .' ASSESSORS MAP SUBDIVISION LOT(S) PERMANENT ADDRESS (ASSIGNED BY D.P.W. STREET Jr) LQ Cu S1- N• A'1eJ,), )o= YT, 01 FAN S APPLICANT PHONE qq5'a`703 DATE OF APPLICATION 67,-00-90 PLANNING BOARD TOWN PLANNER CONSER ATIONCOT S CONSERVATION ADMIN. BOARD OF ALT HEALTH SANITARIAN TOWN USE BELOW THIS LINE DATE APPROVED DATE REJECTED ON /J D f(APPROVED l� 1 ATE REJECTED DEPARTMENT OF PUBLIC WORKS ,. DRIVEWAY PERMIT SEWER/WATER CONNECTIONS DATE APPROVED DATE REJECTED RECEIVED BY BUILDING INSPECTION DATE This form shall be signed by the agents of the Planning and Health Boards, the Conservation Commission prior to the issuance of any building permits for the subject lot. This form shall not releive the applicant from the compliance of any applicable Town requirement or Bylaw. I� ,yam �.r�•—� J �TATtMtTfT FLEXIBLE SEWER & SEPTIC SERVICE, Inc. �. II CONTE DRIVE METHUEN. MASSACHUSETTS 01844 SEWERS CLEANED ELECTRICALLY OWNED d OPERATED N NEW SEWERS INSTALLED OVER ao I_ 66 0024 EXPERIENCE WILLIAM F. KING d SONS TEL. SSS.0044 SEPTIC TANKS CLEANED AND INSTALLED FILE Y J� r Per your request, an inspection was made of thesubsurfacedisposal system located at S7�. "J rr ' on C/ ,5' _1P4'F and it was found that said system is not malfunctioning at the present time. The approval at this time shall not be construed as a guarantee as to how long said system will function properly and is not a• certification that this system is installed in accordance with Title 5 of the State Environmental Code. Copy Sent To: BOARD of HEALTH in City or Town that Inspection is performed in. Recommendations: YQurs truly MICHAEL J. KING 7 Licensed Massachusetts Disposal Works Installer - Methuen, Lawrence, Andover, North Andover, Dracut and Haverhill N.H. License No. 902 05/11/2000 15:57 5083736611 STEWART/ANDOVER PAGE 02 A/647 AIVI)6ver Q -o. 4. 1a� Mqn St Na !Iti A neav�.- U-c.u/ Lac )rl /) Llc 91TWART ' s SEPr.TC TM, SERvrcE 47 RAILROAD STRZer BRADFORD, MA 01835 978-372-7471 MONM OF - •-�'�. MONIULY REJPO T FOR TOWN OF DATE ADDRESS Ll y y I 3L Z21 30 6 �J r.• re � o a En o d. 1-3 O' 0M o z til n dn jn H am`' C V' V" V" �I� y W� ro w3czz no .1- ID O M y trj (� •�H O drn z 1-3 t,- mi k z cnO0 H�JH � H O z