HomeMy WebLinkAboutMiscellaneous - 260 CARLTON LANE 4/30/2018 (2)1R .-,
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P m
Commonwealth of Massachusetts
City/Town of
System Pumping Record RECEIVED
Form 4
DEP has provided this form for use by local Boards of Health. Other rms AA&4eP91ut the
information must be substantially the same as that provided here. Be re using this fo ith your
ub
local Board of Health to determine the form they use. The System PUZI itted to
the local Board of Health or other approving authority. HEA
A. Facility Information
1 . System Location: Left side of houso Right side off house, eft front of house, Right front of house,
..�ig�
Left rear of house, Right rear of house.
Address
Q C' e) L—V\,
City/Town State Zip Code
2. System Owner:
Name
Address (if different from location)
Cityrrown
B. Pumping Record
1. Date of Pumping
3. Type of system: 11
F1 Other (describe):
St t
Telephone Number
IR
<
Date Quantity Pumped:
Cesspool(s)
Gallons
E:1 Tight Tank
4. Effluent Tee Filter present? Yes 4�� �No If yes, was it cleaned? E] Yes F1 No
5. Condition of System:
y \,0 rWl-aA
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
t-- . �$D Lowell Waste Water
Vehicle License Number F5821
Date
t5form4.doc- 06/03 System Pumping Record - Page I of 1
COMMONWEALTH OF MASSACHUSETTS
OFFICE OF ENVIRONMENTAL AFFAIRS
DRi3ARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: �2 6 6 C A 11,7 L zzaz i-
wolelyp 11C 2 1 2004
Owner's Name: YNI A5 14J S 9-7-'
Owner's Address: .24 C -M �=7—MN LAIVE I TC)..
Date of Inspection: �:/ �-70 V
Name of Inspector: (please print) A6-,t1A1t1iWM&2
Company Name: 1116XOIX4
S7- A'V111X0V#9A,7XZ-
Mailing Address: 7 S7
/910y1Vt1-z4S WA 019.22
Telephone Number: 72F-769 - S -VO -r (C)
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true. accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to S t' 15 340 of Title 5 (310 CMR 15.000). The system:
Passes
Conditionallv Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date:
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or
DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page I
10
-Page 2 of I I
OFFICIAL INSPECTIO FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE AGE DISPOSAL SYSTEM INSPECTION FORM
PART A
7 CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
Inspection Summary: Check A,B,C,D or E /ALWAYS complete all of Section D .
A. System Passes:
LXI have not found any information which indicates that any of the failure criteria described in 3 10 CMR
15.303 or in 3 10 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
fs 79/" 14 �, S n"c e- 0101-14 9 S
B. System Conditionally Passes:
/V/4
One or more system components as described in the "Conditional Pass" section need to be replaced or
repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass.
Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please
explain.
— The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pAss inspection if the.
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 time's a year due to broken or obstructed pipe(s). The system will
pass inspection if (with approval of the Board of Health):
ND explain:
broken pipe(s) are replaced
obstruction is removed
2
Page 3 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: e-1'W4V-2A) 1-14A4C
.41v,9,9t1Ke_
Owner: YAIIJ-F-k)S,'-,7-
Date of Inspection:' 2- /2 lei
C. Further Evaluation is Required by the Board of Health: *1.4
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b) that the
system is not functioning in a manner which will protect public health, safety and the environment:
— Cesspool or privy is within 50 feet of a surface water
— Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the
system is functioning in a manner that protects the public health, safety and environment:
— The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
— The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
— The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
— The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this forin.
3. Other:
Page4ofli
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: .2-60 CA41-7-oAl 1-,41t,��
"47Y 1fA1V0V1E1z-
Owner: VN ITaAl!�7 /< z
Date of Inspection: 12-17
I f I
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or "no" to each of the following for all inspections:
Yes No
— _LZ 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
— vRequired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped
— we"�y portion of the SAS, cesspool or privy is below high ground water elevation.
MAE Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
All,�P Any portion of a cesspool or privy is within a Zone I of a public well.
— Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compominds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
(Y(s-/No
�e system fails. I have determined that one or more of the above failure criteria exist as
described in 3 10 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: /4/
To be considered a large s/tthe system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either "yes" or "no" to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a inapped
Zone 11 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
44yes" 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 3 10 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
. 'Page 5 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 2f' -'e9
1122,6 77-1 41kOnIr-le-
Owner: YWIZT-110SAI—1
Date of Inspection: / 2—Z2 LO
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 ?
L.-' 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 pt�oper
maintenance of subsurface sewage disposal systems '.1
The size and location of the Soil Absorption System (SAS) on the site has been determined based on:
Yes no
Existing information. For example, a plan at the Board of Health.
Determined in th e field (if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [3 10 CMR 15.302(3)(b)]
Page 6 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 2e�o c,41zjrol_� 1-4160
Owner:
Date of Inspection: 1 -2 -
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): Number of bedrooms (actual):
DESIGN flow based on 3 10 CMR 15.203 (for example: I 10 gpd x # of bedrooms): e t t 2 A!— 7- 7- t t- E_
Number of current residents:
Does residence have a garbage grinder (yes or no):
Is laundry on a separate sewage system (yes or no): A/ [if yes separate inspection required]
Laundry system inspected ( r no):
Seasonal use: (yes or no): 7
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump (yes or no): A/
Last date of occupancy: 6 0/1 ASW7—
COMMERCIALANDUSTRIAL
Type of establishment: IVIA
Design flow (based on 3 10 CN4R 15.203)� _gpd
Basis of design flow (seats/persons/sqft,etc.):
Grease trap present (yes or no): _
Industrial waste holding tank present (yes or no):
Non -sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER (describe):
GENERAL INFORMATION
Pumping Records
Source of information: 11e1MXre_v1u6R 1,s7-z1w_,,4fzr.5
Was system pumped as part of the inspection (yes or no): Y
If yes, volume pumped: /5-00 gallons -- How was quantity pumped determined?
Reason for pumping: IA-17-514AI&_ IxjsRs c- 7-,1oA,1 —
TYP��QF 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)
— Tight tank _ Attach a copy of the DEP approval
— Other (describe):
Approximate age of all components, date installed (if known) and source of information:
2- 0 Y4 -5
Were sewage odors detected when arriving at the site (yes or no): NO
4 ' Page 7 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM EWORMATION (continued)
Property Address: Ze-'o 6,41LI,7-0 4 4AVz-
Owner:
Date of Inspection:
BUILDING SEWER (locate on site plan)
Depth below grade: 15
Materials of construction: —cast iron 40 PVC —other (explain):
Distance from private water supply well or suction line:
Comments (on condition ofjoints, venting, evidence of leakage, etc.):
SEPTIC TANK: I
(locate on site plan)
Depth below grade: 3
Material of construction: :,eon�crete —metal _fiberglass __polyethylene
—other(explain)
If tank is metal list age: zo"41s age confirmed by a Certificate of Compliance (yes or no): (attach a copy of
certificate) t I
Dimensions: A -X K evr,� /%r-
Sludgedepth: 4
Distance from top of sludge to bottom of outlet tee or baffle: 2 K
Scum thickness: / "
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined: irt b e) /3 .5,0,0 U/4
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
6, cen -/-�> r e- A-, /--� , -r—,, e) A./
A14(
GREASE TRAP- / locate on site plan)
Depth below grade:
Material of construction: —concrete —metal _fiberglass __polyethylene —other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
7
0 IPage 8 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 2-6e e'144?t- 7,olu 44tl,�L
Owner: YIVI,-rF- W Z 7Z/ 4,V4041�-e—
Date of Inspection: VI --7-T,"4.1_
TIGHT or HOLDING TANK: ±!/,4(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:
Alarm present (yes or no):
Alarm level: Alarm in working order (yes or no):
Date of last pumping: I
Comments (condition of alarm and float switches, etc.):
DISTRIBUTION BOX: Zof present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: C
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box, etc.):
PUMP CHAMBER: A0 (locate on site plan)
Pumps in working order (yes or no):
Alarms in working order (yes or no):
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
0 Page 9 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C.
SYSTEM INFORMATION (continued)
Property Address: 2-60 C,401-;r0A1 I-Atic-
Owner: Al
Date of Inspection: h /I y
SOIL ABSORPTION SYSTEM (SAS): _ (locate on site plan, excavation not required)
If SAS not located explain why:
Type
leaching pits, number:
leaching chambers, number:
leaching galleries, number:
eaching trenches, number, length:
:Z'leaching fields, number, dimensions: e, r /e
overflow cesspool, number:
innovative/altemative system Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
CESSPOOLS: Al ZP (cesspool must be pumped as part of inspect ion)(1 ocate on site plan)
Number and configuration:
Depth - top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow (yes or no.):
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
9
Page 10 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM'INFORMATION (continued)
Property Address: 2*0 e-A&z-7-f),V 4,4,41,,,
401e-1-71
Owner: YV 12,r-- Uj 5 *� /
Date of Inspection: / 2- 17Z4
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
10
2-
Page I I of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 2-4 o r A 12 z- 7-,,--)/(/ I-AIIIA-7
Owner: YAll�-91UStQ
Date of Inspection: _ "7- / 7 /0
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water � feet
Please indicate (check) all methods used to determine the high ground water elevation:
Obtained from system design plans on record - If checked, date of design plan reviewed:
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health -explain:
(attach documentation)
Phecked.with local excavators, installers
L-1 Accessed USGS database -explain: 0-- 7?
You must describe bow you established the high ground water elevation:
- 0" (1. - r > 4,
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:
Owner's Name: -
Owner's Address:
Date of Inspection:
Name of InspectoAr:1ease
print 16 b/A W511-62
Company Name:
Mailing Address:
Telephone Number:
L�7e-
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant t S ion 15.340 of Title 5 (310 CMR 15.000). The system:
��es
Inspector's Signature:
by the Local Approving Authority
71? / / -) ?-
/- 7
The system inspector shall,obmit a copy of this inspection report to i6e Approving Authority (Board of Health or
DEP) within 3 0 days of cofnpleting this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments
****This report only describes conditions at the time inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page I
Page 2 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Date of Inspection:
Inspection Summary: Clieck A,B,C,D or E / ALWAYS complete all of Section D
A. System Passes:
KII have not found any information which indicates that any of the failure criteria described in 3 10 CMR
53 or in 3 10 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the "Conditional Pass" section need to be replaced or
repaired.* The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass.
Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please
explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed -
ND explain:
Page 3 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address,��C,, &� /6) 612
Owner:
AP /r/
Date of Inspection:
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b) that the
system is not functioning in a manner which will protect public health, safety and the environment:
— Cesspool or privy is within 50 feet of a surface water
— Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the
system is functioning in a manner that protects the public health, safety and environment:
— The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
. The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
— The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more fi-om a
private water supply well". Method used to determine distance
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen' and nitrate nitro�en is equal to or less than 5 ppm, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
!!, I Page 4 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
��o /�
Property Address L
Owner:
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or "no" to each of the following for all inspections:
Yes No
VBackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
— :ZDischarge or ponding of effluent to the surface of the ground o� surface waters due to an overloaded or
clogged SAS or cesspool
— _VO'Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
,cesspo"00f)
Liq�� d �ipth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow
—Aelkei4—Ared pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
" of times pumped _.
t,," Any portion of the SAS, cesspool or privy is below high ground water elevation.
ow
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
t-l"'Any portion of a cesspool or privy is within a Zone I of a public well.
oo*�ny portion of a cesspool or privy is within 50 feet of a private water supply well.
_jZAny portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
(Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as
described in 3 10 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 s erve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either "Yes" or "no" tovach of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
— — the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a nWped
Zone 11 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
Ccyes" 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 3 10 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
W " 4 Page 5 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 0;�0/0
111-2,
Owner:
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
V"Were any of the system components pumped out in the previous two weeks ?
Has the system received normal flows in the previous two week period ?
_je-'Ohave 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 ?
loo"' Was the site inspected for signs of break out ?
to,' 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 ?
4.--" Was the facility owner (and occupants if different from owner) provided with information on the proper
maintenance of subsurface sewage disposal systems ?
The size and location of the Soil Absorption System (SAS) on the site has been determined based on -
Yes no
__L,.- _ Existing information. For example, a plan at the Board of Health.
Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [3 10 CMR 15.3 02(3)(b))
5
4 .
Page 6 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address-:_1�0(�9/ Azvy 6/2102,
Owner:
Date of Inspection:
FLOWCONDITIONS
RESIDENTIAL
Number of bedrooms (design): Number of bedrooms (actual):
DESIGN flow based on 3 10 CMR 15.203 (for example: I 10 gpd x # of bedrooms):
Number of current residents: a_
Does residence have a garbage grinder (yes or no):/VO
Is laundry on a separate sewage system (yes or no),�VO [if yes separate inspection required]
Laundry system inspected (yes or no):
r no)/V
Seasonal use: (yes o 10
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump (yes or no) -.AO
Last date of occupancy: 19C C, JZ 101 e al
I
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow (based on 3 10 CMR 15.203): gnd
Basis of design flow (seats/persons/sqft,etc.):
Grease trap present (yes or no): _
Industrial waste holding tank present (yes or no):
Non -sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER (describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as parf of th� insp ction (yes or no):
If yes, volume pumped:Z
00gallons How was quann pumped determined9
Reason for pumping: f—,
TYPEgF SYSTEM
_�,�p ic tank, distribution box, soil absorption system
— Single cesspool
Overflow cesspool
— Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be
obtained from system owner)
— Tight tank — Attach a copy of the DEP approval
— Other (describe):
of all co onents, date installed (if known) and source of information:
9mP –
Were sewage odors detected when arriving at the site (yes or no).A/40
Page 7 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Add ressA.�q��
Owner:
Date of Inspection:
BUILDING SEWER (locate on site plan)
Depth below grade: A�
Materials of construction: _L,,,�ttst iron 40 PVC --Other (explain):
Distance from private water supply well or suction line:
Comments (on condition ofjoints, venting, evidence of leakage, etc.):
SEPTIC TANK: —,.--<Ocate on site plan)
Depth below grade: �� 41
Material of construction: 4��oncrete _metal _fiberglass ___polyethylene
___other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance (yes or no): (attach a copy of
certificate)
Dimensions: X /0
Sludge depth: 1,0
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: 2 /'
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom outlet tee or baffle: IX
How were dimensions determined: -//I 'e? -0 mo! 92 CC < C
Comments (on pumping recommendations, 4nl�ti and'outlef tee or baffle condition, sirucc�turamtejleiquid levels
as� reLated to outlet invert, evoence of leakage, etc.): If — I
et
GREASE TRAP: _(locate on site plan)
Depth below grade:
Material of construction: concrete —metal _fiberglass __polyethylene other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Page 8 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Addrew-�6a �'qt /'/r/ / zX/
-1 1/
Owner-.1/79/1�40W16/_1
Date of Inspection:
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 olyethylenie _other(explain):
Dimensions:
Capacity: gallons
DesignFlow:____ allons/day
Alarm present (yes or no):
Alarm level: Alarm in working order (yes or no):
Date of last pumping:
Comments (condition of alarm and float switches, etc.):
DISTRIBUTION BOX: jeo(oifopresent 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
le��Se into or out of box
etc.):
PUMP CHAMBER: . (locate on site plan)
Pumps in working order (yes or no):
Alarms in working order (yes or no):
Comments (note condition of pump chamber, condition of pumps and appurtepances, etc.):
8
0 . 0 # Page 9 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C.
SYSTEM INFORMATION (continued)
Property Address: C;;�/ A 0
Owner:,.��� Z417
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS): _ (locate on site plan, excavation not required)
If SAS not located explain why:
Type
leaching pits, number..
leaching chambers, number:
leaching galleries, number:
__,,leaching trenches, number, length:
W leaching fields, number, dimensions: —L-4411 7 0
overflow cesspool, number:
innovative/altemative system Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level oif ponding, damp soil, condition of vegetation,
CESSPOOLS: _ (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth — top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow (yes or no.):
Comment s (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
f
PRIVY: (locate on site plan)
Materials of construction:
Dimensions. -
Depth of solids:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
9
.0 . 0 0 Page 10 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM'INFORMATION (continued)
Property AddressA6e,�o(-//,V-,12 4��S-
If Ir)
,4
Owner:
Date of Inspection: -7/3'
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
-P� 0 1- 7- 'kx
10
Z," 2
:2
Page I I of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: -:zrir4.
Owner: 7
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate (check) all methods used to determine the high ground water elevation:
0
V'-O-*"btained from system design plans on record - If checked, date of design plan reviewed:
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health -explain:
Checked.with local excavators, installers- (attach documentation)
Accessed USGS database -explain:
You must desc;ibe ho you established the high ground water elevation:
TOWN OF NORTH ANDOVER
SYSTEM PUMPINGRECORD
D.ATF: 2z In, Q
"�'STEINJ OWNER & ADDRESS
c:::266
SYSTEM LOCATION
(example: left front of house)
46, n+ rt�T� S*11k
D,,�-TE OF PUMPING:.fz6D �Ir� QUANTITY PUMPED GALLONS
CPS S 11 0 0 L: N 0 YES SEPTIC TANK: NO YES L.//_
NATURE OF SERVICE: ROUTINE EMERGENCY
013SERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SYSTEIN1 PUMIPIEI) BY:
(-'O.N INI E N T S:
CONTENTS TRANSFERREDTO:
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
0
PETER F. REILLY
AFFILIATED WITH F.P. REILLY AND SONS, INC.,-,-.,.
206 ANDOVER STREET, SUITE 1 1
ANDOVER, MA 01810
(978) 475-4370
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION
Property Address:
Address of Owner (if different):
Name of Inspector:
Company Name, Address, Phone #
CERTIFICATION STATEMENT
260 Carlton Lane, North Andover, MA 0 1810
N/A
Peter F. Reilly
0 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
F.P. Reilly & Sons, 206 Andover St., Suite 11
Andover, MA 01810 (978) 475-1237 / (978) 475-4370
I certify that I have personally inspected the sewage disposal system at this address and that the information
is true, accurate and complete as of the time of inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on-site sewage disposal systems. The
system:
Passes
N/A Conditionally Passes
N/A Needs Further Evaluation By the Local Approving Authority
N/A Fails
Inspector's Signature: A_C___r4 - Date: May 13, 1998
Peter F. Reill �� 1� I
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 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.
INSPECTION SUMMARY:
A. SYSTEM PASSES: Check A, B, C or D
I have not found any information which indicates that the system violates any of the failure criteria as
defined in 310 CIVIR 15.303. Any failure criteria not evaluated are indicated below.
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FORM U -10—T'RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary approval s/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any a - pplicable or requirements.
**********APPLICA-NT fiLLS OUT THIS SECTION
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APPLICANT_aci�
LOCATION: Assess&S Map Number_, _0 IDL—
SUBDIVISION
S T R E E T
PHONE
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ST. NUMBER _C-QL 0
USE ONLY C V
RECOMMENDATIONS OF TOWN AGENTS: 5 f <I + 3
CONSERVATION ADMINISTRATOR
COMMENTS
TOWN PLANNER
COMMENTS
FOOD INSPECTOR -HEALTH
PECTOR-HEALTH
COMMENTS
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED.
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PUBLIC WORKS - SEWERfWATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR DATE_
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PETER F. REILLY
AFFILIATED WITH F.P. REILLY AND SONS, INC.
206 ANDOVER STREET, SUITEA'i
ANDOVER, MA 01810
(978) 475-4370 MAY
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION
Property Address:
Address of Owner (if different):
Name of Inspector:
Company Name, Address, Phone #
CERTIFICATION STATEMENT
260 Carlton Lane, North Andover, MA 01810
N/A
Peter F. Reilly
V am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
F.P. Reilly & Sons, 206 Andover St., Suite 11
Andover, MA 01810 (978) 475-1237 / (978) 475-4370
I certify that I have personally inspected the sewage disposal system at this address and that the information
is true, accurate and complete as of the time of inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on-site sewage disposal systems. The
system:
Passes
N/A Conditionally Passes
N/A Needs Further Evaluation By the Local Approving Authority
N/A Fails
Inspector's Signature: Date: May 13, 1998
Peter F. Reilly
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 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.
INSPECTION SUMMARY:
A. SYSTEM PASSES: Check A, B, C or D
I have not found any information which indicates that the system violates any of the failure criteria as
defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION (continued)
Property Address: 260 Carlton Lane, North Andover, MA
Owner's Name: Kenneth Brown
Date of Inspection: 5/13/98
B. SYSTEM CONDITIONALLY PASSES:
N/A 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, ND). Describe basis of determination in all instances. If "not determined",
explain why not)
N The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure
is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
N Sewage backup or breakout or static high water level observed in the distribution box is due to broken or
obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with
approval of the Board of Health):
N/A broken pipe(s) are replaced
N/A obstruction is removed
N/A distribution box is leveled 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):
N/A broken pipe(s) are replaced
N/A obstruction is removed
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing
to protect the public health, safety and environment.
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:
N/A Cesspool of privy is within 50 feet of a surface water
N/A Cesspool or privy is within 50 feet of a bordering vegetated wetland or 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:
N/A 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.
N/A The system has a septic tank and soil absorption and is within a Zone I of a public water supply well.
N/A The system has a septic tank and soil absorption and is less than 100 feet but 50 feet or more from a
private water supply well, unless a water well water analysis for coliform bacteria and volatile organic
compounds indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance N/A
(approximation not valid).
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION (continued)
Property Address- — -260 1 Carlton Lane, North Andover, MA
Owner's Name: Kenneth Brown
Date of Inspection: 5/13/98
D. SYSTEM FAILS:
N/A 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.
N Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
N Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool.
N Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool.
N/A Liquid depth in cesspool < 6" below invert or available volume < 1/2 day flow.
N required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped: none
N Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
N/A Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
N/A Any portion of a cesspool or privy is within a Zone I of a private water supply well.
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well.
N/A 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:
The following criteria apply to a large system in addition to the criteria above.
N/A The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
N The system is within 400 feet of a surface drinking water supply
N The system is within 200 feet of a tributary to a surface drinking water supply
N The system is located in a nitrogen sensitive area (interim Wellhead Area (IWPA) or a mapped Zone 11 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 CIVIR 5.00 and 6.00. Please consult the local regional office of the DEP for further
information.
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART B - CHECKLIST
Property Address: 260 Carlton Lane, North Andover, MA
Owner's Name: Kenneth Brown
Date of Inspection: 4/18/98
Check if the following have been done:
Pumping information was requested of the owner, occupant and Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving
normal flow rates during that period. Large volumes of water have not been introduced into the system recently
or as part of this inspection.
As built plans have been obtained and examined. Note they are not available with N/A.
The facility or dwelling was inspected for signs of sewage backup.
V The system does not receive non -sanitary or industrial waste flow.
The site was inspected for signs of breakout.
All system components, excluding the SAS, have been located on the site.
V/ The septic tank manholes were uncovered, opened and the interior of the septic tank was inspected for condition
of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The facility owner (and occupants, if different from owner) were provided with information on the proper
maintenance of SSDS.
The size and location of the SAS on the site has been determined based on:
Existing information (Example: Plan at BOH). DESIGN PLAN / "AS -BUILT" PLAN
N/A Determined in the field if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable [15.302(3)(b)].
PART C - SYSTEM INFORMATION
FLOW CONDITIONS
RESIDENTIAL:
Design Flow (gpd/bedroom for SAS):
Number of bedrooms:
Current residents:
Garbage grinder:
Laundry connected to system:
Seasonaluse:
Water meter readings, if available:
Sump Pump (yes or no):
Last date of occupancy:
COMMERCIAL/lINDUSTRIAL:
Type of Establishment:
Design Flow:
Grease trap present:
Industrial waste holding tank
Non -sanitary waste discharged the Title 5 system
Water meter readings, if available:
Last date of occupancy:
OTHER:
Describe:
Last date of occupancy:
500 gallons/day (per design plan)
3
2
no
yes
no
154,500 gal. 1996-97 / 212 gpd
no
current
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 260 Carlton Lane, North Andover, MA
Owner's Name: Kenneth Brown
Date of Inspection: 5/13/98
GENERAL INFORMATION
PUMPING RECORDS and source of information:
last pumping: not since new according to owner
System pumped as part of inspection: no
if yes, volume pumped: N/A gallons
Reason for pumping: N/A
TYPE OF SYSTEM
V Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
NO Shared system (yes or no - if yes, attach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other (explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information:
System was installed when house was constructed in 1985
Sewage odors detected when arriving at the site NO
BUILDING SEWER: (locate on site plan)
Depth below grade: 8"-10"
material of construction: V cast iron 40 PVC other (explain)
Distance from private water supply well or suction line N/A
Diameter: 4"
Comments: Condition of joints, venting, evidence of leakage, etc.)
Building sewer was watertight and appeared sound.
SEPTIC TANK: / (locate on site plan)
Depth below grade: 4"
material of construction: V concrete metal FRP other (explain)
Dimensions: rectangular - 1,500 gallons
2-4" sludge depth
32" distance from top of sludge to bottom of outlet tee or baffle
1-2" scum thickness
7" distance from top of scum to top of outlet tee or baffle
15" distance from bottom of scum to bottom of outlet tee or baffle
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, recommendations for repairs, etc.)
Tank was watertight and functioning properly. Outlet baffle was deteriorated and was replaced following inspection.
1P
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 260 Carlton Lane, North Andover, MA
Owner's Name: Kenneth Brown
Date of Inspection: 5/13/98
GREASE TRAP: N/A (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, recommendations for repairs, etc.)
N/A
TIGHT OR HOLDING TANK: N/A (locate on site plan)
Depth below grade:
material of construction: concrete metal FRP other (explain)
Dimensions: N/A
Capacity: N/A gallons per day
Design Flow: N/A gallons per day
Alarm level: N/A Alarm in working order N/A
Date of previous pumping: N/A
Comments: (condition of inlet tee, condition of alarm and float switches, etc.)
N/A
DISTRIBUTION BOX: v/ (locate on site plan)
011 depth of liquid above outlet invert
Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box,
recommendation for repairs, etc.)
The d -box was level and functioning properly. Four lines leaving box. Minimal evidence of solids carryover.
PUMP CHAMBER: N/A (locate on site plan)
N/A Pumps in working order (yes or no)
N/A Alarms in working order (yes or no)
Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance
or repairs, etc.)
N/A
a
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 260 Carlton Lane, North Andover, MA
Owner's Name: Kenneth Brown
Date of Inspection: 5/13/98
SOIL ABSORPTION SYSTEM (SAS): / (locate on site plan, if possible; excavation not required, but may be
approximated by non -intrusive methods)
If not determined to be present, explain: not applicable
Type
leaching pits and number
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions
overflow cesspool, number
alternative system (name of technology)
N/A
N/A
N/A
N/A
one field, size 1,380 s.f., four lines (per "as built" plan)
N/A
N/A
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations
for maintenance, repairs, etc.)
Soils over leaching area were good, no evidence of breakout.
CESSPOOLS: N/A (locate on site plan)
number and configuration
N/A
depth -top of liquid to inlet invert
N/A
depth of solids layer
N/A
depth of scum layer
N/A
dimensions of cesspool
N/A
materials of construction
N/A
indication of groundwater inflow (cesspool
must be pumped as part of inspection)
N/A
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations
for maintenance or repairs, etc.)
not applicable
PRIVY: N/A (locate on site plan)
materials of construction
dimensions
depth of solids
N/A
N/A
N/A
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations
for maintenance or repairs, etc.)
not applicable
16
r
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 260 Carlton Lane, North Andover, MA
Owner's Name: Kenneth Brown
Date of Inspection: 5/13/98
SKETCH OF SEWAGE DISPOSAL SYSTEM:
indicate at least two permanent references, landmarks, or benchmarks
locate where public water system enters house
locate all wells within 100' N/A
/ 3E t>
hae 4;*
-rile / 4
57jale-
Yq r
19 14 C
Xco
ivq i-er
t �-rc
1DX
5ervice-
+,A)lk
SEPTIC TANK TIES: A to Inlet (1)
15-5"
B to Inlet
25'6"
A to Center (C)
18'8 "
B to Center
28'0"
A to Outlet (0)
22'0"
B to Outlet
3 0'6 "
D -BOX TIES: A to Box
4410"
B to Box
52'0"
NOTE: The system is in the side yard (northerly
side).
/ 3E t>
hae 4;*
-rile / 4
r
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 260 Carlton Lane, North Andover, MA
Owner's Name: Kenneth Brown
Date of Inspection: 5/13/98
DEPTH TO GROUNDWATER
Depth to Groundwater 4' (below bottom of SAS)
Indicate all methods used to determine High Groundwater Elevation:
Y Obtained from Design Plans on record
Y Observation of Site (abutting property, observation hole, basement sump, etc.)
Y Determined from local conditions
Y Check with Local BOH
N Check FEMA Maps
N Check pumping records
Y Check local excavators, installers
N Use USGS Data
Describe in words how High Groundwater Elevation was established:
Four feet separation indicated on septic design plan. Grade changes in the area
indicated no groundwater in the SAS.
41
V
DISCLAIMER
This passing septic inspection under Massachusetts Title V in no way
guarantees the septic system. The inspection is a "snapshot in time" and
does not constitute a complete assessment of the quality or potential
longevity of the septic system. The pass/fail criteria are specific and
outlined in detail in this report. Under the limited criteria of a Title V
inspection, it is impossible to determine how long any septic system will
last. The inspector made a diligent effort to certify the septic system based
on the criteria required under Title V.
Under Massachusetts Title V, soil evaluation is the accepted method of
determining the high groundwater elevation. This inspector is not a
certified soil evaluator and is therefore not qualified under Title V to
determine or establish the high groundwater elevation. The method used
to estimate the high groundwater for this inspection was based on the
public records and methods of observation described on the previous page.
Groundwater levels can vary greatly from season to season, year to year
and soil evaluation is considered the most reliable method of groundwater
determination under Title V.
Peter F. Reilly
Inspector
May 13, 1998
j�oa_rd of Health
North AnOOVer.,MiSse
PROM DATE DIWPROM
R;-ammst
OK
[6,1T
I 10-T
BEMC SISTEM
INSTALLATICK CM30K LISr
LOT`�_jZ4 4�0
_'EX(�AHVATTILCOK OK AIL
1. Distance Tot
a. Wetlands
b. Drains
c.. Wen
2,--- W,;;iAr Ti -Location
lane
3- No PM Pipe
4. 'Septic Tank.
A.' Tees --Length & To Clean Out Covers
b. b6ment-Pipe to Tank On -,Both Sides'.,6.f� Tank
5. Distribution Box
a, -:-Cover's & Box - No Cracks
b , All . Lines Flo-rAng Equal knounts
c. No Back Flow
6.- Leach Field, or Tj�enclh
a. Dimensions
b. Stone Depth
co Capped 'Eads
cl. Clem Double Washed Stone
7. Leach Pits
a. Dimensions
b. Stone Depth
c. Splash Pads
d. Tees
e. Cement Pipe to Pit. - Bo th Sides
-------- DOU61e Washed Stone
?To Garbage Disposal
9. -Final Grading Inspection
10. Barricading Covered System
11. As Built Submitted
ie_ tot Location
b. Dimensions of System
c. Location with Regard -to Perc Test
d. Elevations
e.' Water Table
. --t
Board of Health
Nor -11 "indover,, Mass
MBSURFACE DISPOSAL DESIGN CHECK LisT
LOT
APPROM DM ._Z- 3L
q DISAPPROM DATE
Provid6d:
Reasonsi
TOP <&L. FOR
471owip 1304AA-)
Title V An cK
Reg 2.5 The submitted plan mut show as a mimilmim:
I a)
b)
the lot to be served -areas dimensions lot # abutters
location and log deep observation hoie.-die'tance to ties
c
and results percolation tests -distance to ties
d�location
design calculations & calculations showing required leaching area
(e)
location and dimensions of system -including reserve area
f)
existing and proposed contours
(g)
location any vet, areas within 100, of sewage disposal system or
disclaimer -check wetlands mapping
h)
surface and subsurface drains wit -bin 1001 of sewage disposal
system or disclaimer
W
location any drainage easements vithin 1001 of sevage disposal
system or disclaimer -Planning Board files
(J)
knova sources of -water supply within 200, of sewage disposal
system or disclaimer
(k)
location of any proposed well to serve lot -loot from leaching facilit,
(1)
_(m)
location of water lines on property -101 from leaching facility
location of benchmark
-(n)-driveways
(o)
garbage disposals
F(P)
no PVC to be used in construction
(q)
-profile- of-- system-elevationB of basement.-, - plpmb., pipe., septic tank,
I.
distribution- box inlets - and'outl:et6,9 die-t-fibution-field piping and
Otter elevations
(r)
mudxmm ground water elevation in area sewage --disposal system
'Plan
(S)
mast be prepared by a Professional Engineer or other
professional authorized by law to prepare swh- plans
Reg 6
Septic Tanks
(a)
capacities -150% of flow., water table., tees., depth of tees.,
access.t pumping
(b)
cleanout
(c)
101 from cellar imll or inground s -Waring pool
(d)
25, from subsurface drains
Reg 10.2
Distribution Boxes
(a)
slope greater- fl� 0.08
Reg 10. 4 b)
suzop
TO: NORTH ANDOVER, MASS 0 9
BOARD OF HEALTH
FROM: D . ESIGN ENGINEER Re: Soil Absorption Sewage
System Inspection
This is to certify that, 1. have inspected the.construction of the said disposal system at
/q P- Z- -/-0 �v AIVE North Andover, Mass.
SIFE LOCA1 ION
The gra'des,and construction are as specified in rny plans and specifications dated
19 --6,!
...... . ... .. . ..... .... . JAN 0
".4ro ..G 200
TOWN OF NORTH ANDOVE'p,
DA Vh SYSTEM PUMPINO R.ECOFL)
SYSTEM OW)4ER & �ADDRESS
u r) i I UeW5 I .
6?619 & r i -�4 L�4-17 e-
/t/v, #n OA,�*e-
SYSTEM LD��A710N����
3
DATE OF PVMpjNQ:_.j
-Q()ANnTY PUMPED:
k:LSSPOOL: NO--.... YES— SOPUC Tank: NU. YE I s
NA rURE OF SERVICE: Kou-rINE.
ObSF-RVA,rioNs:
WOD CONDI'rIolq FULL'Ty-) covER
HEAVY ORWE BAFFLES IN PLACL
ROOTS LWKPlELD RUNBACK
BXCESSIVE SOLIDS.- FLOODED
SOLID CAKRYOVEp,,_. OTHER EXPLAIN
Systvm Pump -W by
177a
�-'UMMENTS.
�-:UN ItNT.5 rKAN3FbRK5D Il)
L�l
Comm'pnwealth of Massachusetts
City/76wn of NORTH AN MASSACHUSETTS
DOVER.
Sys
01 tem Pumping Record
Form 4
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
1 . System Location:
A 4-64
Address
CityfTown
2. Syster;n Owner:
Address (if different —from
CityfTown
State Zip Code
State
Telephone Number
B. Pumping, Record
1 Date of Pumping
Date 2. Quantity Pumped
3. Type of system: El Cesspool(s) U-S�eptic Tank
E] Other (describe):
If yes, was it cleaned? -,� �Yes F� No
4. Effluent Tee Filter present? 2/Yes [:1 No
5. Condition of System:.
06c)
6. SyAtem Pumped By:
Lt&tA' Ktc4A
Name
Company
7. Location where contents were disposed:
W 0--r o' I I A s4e
Signature of Hauler
http,://www.mass.gov/d6p/water/approvaIs/t5forms,htm#inspect
Zip Code
Gallons
El Tight Tank
U -32 -
Vehicle License
�1�
MM
Date
t5form4.doc- 06/03
System Pumping Record - Page 1 of 1