HomeMy WebLinkAboutMiscellaneous - 260 SUMMER STREET 4/30/2018I
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&*---h
Commonwealth of Massachusetts
- " - i
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessment AU't, 28
'rOK/,#V
260 Summer St
Property Address
Hal G Worsham
Owner's Name
No Andover
City/Town
Ma 01845
State Zip Code
7/25/2012
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:
John DiVincenzo
Name ot Inspector
Stewart Septic Service
Company Name
58 South Kimball
Company Address
Bradford
City/Town
978-372-7471
Felephone Number
B. Certification
Ma
State
S113386
License Number
01835
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:
0 Passes El Conditionally Passes El Fails
NTeds Fvrthe
,f-fvaluatipn by the Local Approving Authority
re
7-25-2012
Date
The system inspector shall sukmit a
,hopy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 day§-ofcompleting 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 DER 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 - 11/10 Title 5 Official 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
260 Summer St
r-rupeny Aclaress
Hal G Worsham
uwner S Name
No Andover Ma 01845 7/25/2012
Cityrrown 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:
Replace d -box, 20 feet of pipe, and put hew baffle
13) System Conditionally Passes:
El 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.
[I Y M N El ND (Explain below):
t5ins - 11 /10
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17
Owner
information is
required for every
page.
02 ---� .1
Commonwealth of Massachusetts
Title 5 Official Inspection For
U�?
Subsurface Sewage Disposal System Form Not for Voluntary Asse Lyo%ts
3g OF
t4 ep�
740ft
'IRV260 Summer St SP RT&jr. - R
Property Address
Hal G Worsham
Owner's Name
No Andover
City/Town
Ma 01845
State Zip Code
7/25/2012
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.
Impoirtant: When
A. General Information
filling out forms
on the computer,
use only the tab
1 Inspector:
key to move your
cursor - do not
John DiVincenzo
use the return
key.
Name of Inspector
Stewart Septic Service
Company Name
58 South Kimball
Company Address
Bradford
CitylTown
978-372-7471
Telephone Number
B. Certification
Ma
State
S113386
License Number
01835
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:
El Passes 0 Conditionally Passes F� Fails
El Njeds Furtpr Eyauation/by the Local Approving Authority
X/(:/ r�' T2S-42
r's Signature /1" ) Date
The system inspector shal s mit a copy of this inspection report to the Approving Authority (Board
6W6
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 DER 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 - 11110 Title 5 Official 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
260 Summer St
Property Address
Hal G Worsham
Uwner's Name
No Andover Ma 01845 7/25/2012
City/Town 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:
El 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:
El 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.
F-1 Y 0 N El ND (Explain below):
t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 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
260 Summer St
Property Address
Hal G Worsham
Owner's Name
No Andover Ma 01845 7/25/2012
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
F-1 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):
N broken pipe(s) are replaced
El obstruction is removed
JZ Y El N El ND (Explain below):
El Y El N El ND (Explain below):
distribution box is leveled or replaced Z Y El N Ej ND (Explain below):
Dist. box Deteratated needs to be
El 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):
El broken pipe(s) are replaced El Y El N 0 ND (Explain below):
0 obstruction is removed El Y El N El ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
El 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:
El Cesspool or privy is within 50 feet of a surface water
El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins - 11 /10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 3 of 17
-R -
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
260 Summer St
Property Address
Hal G Worsham
Owner's Name
No Andover Ma 01845 7/25/2012
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
El 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.
El The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
El 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
El 0 Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
El 0 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
El 0 Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2day flow
t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17
Commonwealth of Massachusetts
Yes No
t5ins - 11/10
El 0
Title 5 Official
Inspection
Form
o
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
g5
260 Summer St
tributary to a surface water supply.
Property Address
El Z
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
El N
Hal G Worsham
from a private water supply well with no acceptable water quality analysis. [This
Owner
Owner's Name
laboratory, for fecal coliform bacteria indicates absent and the presence
information is
required for every
No Andover
Ma
01845 7/25/2012
page.
Cityrrown
State
Zip Code Date of Inspection
B. Certification (cont.)
t5ins - 11/10
El 0
Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
El N
Any portion of the SAS, cesspool or privy is below high ground water elevation.
El M
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.
El Z
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
El N
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.]
0 z 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
El El the system is within 400 feet of a surface drinking water supply
E] El the system is within 200 feet of a tributary to a surface drinking water supply
El D the system is located in a nitrogen sensitive area (interim Wellhead Protection
Area — IWPA) or a mapped 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 "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.
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
260 Summer St
C. Checklist
Ma 01845
State Zip Code
7/25/2012
Date of Inspection
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
0 D
Property Address
El 0
Hal G Worsham
Owner
Owner's Name
information is
required for every
No Andover
page.
CityfTown
C. Checklist
Ma 01845
State Zip Code
7/25/2012
Date of Inspection
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
0 D
Pumping information was provided by the owner, occupant, or Board of Health
El 0
Were any of the system components pumped out in the previous two weeks?
E El
Has the system received normal flows in the previous two week period?
El 1Z
Have large volumes of water been introduced to the system recently or as part of
this inspection?
Z R
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?
1Z El
Were all system components, excluding the SAS, located on site?
E El
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?
E El
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:
1Z 0
Existing information. For example, a plan at the Board of Health.
0 EJ
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):
Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms):
t5ins - 11/10 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
260 Summer St
D. System Information
Description:
R A -
01845
Zip Code
7/25/2012
Date of Inspection
Number of current residents: 1
Does residence have a garbage grinder? Yes F No
Is laundry on a separate sewage system? [if yes separate inspection required] El Yes N No
Laundry system inspected? El Yes F1 No
Seasonaluse? El Yes [E� ANN
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
I Xkwx
Sump pump? Yes No
Last date of occupancy: occupied
Date
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203): Gallons per day (gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? El Yes F No
Industrial waste holding tank present? El Yes El No
Non -sanitary waste discharged to the Title 5 system? Yes [I No
Water meter readings, if available:
t5ins - 11 /10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17
Property Address
Hal G Worsham
Owner
Owner's Name
information is
required for every
_o Andover
page.
City/Town
D. System Information
Description:
R A -
01845
Zip Code
7/25/2012
Date of Inspection
Number of current residents: 1
Does residence have a garbage grinder? Yes F No
Is laundry on a separate sewage system? [if yes separate inspection required] El Yes N No
Laundry system inspected? El Yes F1 No
Seasonaluse? El Yes [E� ANN
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
I Xkwx
Sump pump? Yes No
Last date of occupancy: occupied
Date
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203): Gallons per day (gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? El Yes F No
Industrial waste holding tank present? El Yes El No
Non -sanitary waste discharged to the Title 5 system? Yes [I No
Water meter readings, if available:
t5ins - 11 /10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17
L
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
260 Summer St
Property Address
Hal IS Worsham
Owner Owner's Name
information is
required for every No Andover
page. CityfTown
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
Pumping Records:
Source of information:
Ma 01845
State Zip Code
General Information
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Andover
gallons
Date
Type of System:
Septic tank, distribution box, soil absorption system
Single cesspool
7/25/2012
Date of Inspection
0 Yes El No
Overflow cesspool
Privy
E] 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
E] Tight tank. Attach a copy of the DEP approval.
1:1 Other (describe):
t5ins - 11/10 '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
260 Summer St
Property Address
Hal G Worsham
Owner Owner's Name
information is
required for every No Andover Ma 01845 7/25/2012
page. CityfTown 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?
Building Sewer (locate on site plan):
Depth below grade:
Material of construction:
H cast iron [140 PVC other (explain):
Distance from private water supply well or suction line:
18"
feet
feet
Comments (on condition of joints, venting, evidence of leakage, etc.)-.
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
0 concrete F� metal
0 Yes E No
611
feet
El fiberglass 0 polyethylene El other (explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate)
Dimensions:
Sludge depth:
0 Yes 0 No
t5ins - 11/10 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
260 Summer St
Property Address
Hal G Worsham
Owner Owner's Name
information is
required for every No Andover Ma 01845 7/25/2012
page. CityfTown 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 No Baffle
Scum thickness 0 6" Slope
Distance from top of scum to top of outlet tee or baffle 0
Distance from bottom of scum to bottom of outlet tee or baffle No baffle
How were dimensions determined? Slope judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Inlet baffle ok outlet baffle not there concreate detereated awav needs replacinq
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
0 concrete [I metal
Dimensions:
Scum thickness
feet
El fiberglass El polyethylene [] other (explain):
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 - 11110
Date
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17
I via
L
LVI.Mil
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
260 Summer St
Property Address
Hal G Worsham
Owner Owner's Name
information is
required for every No Andover Ma 01845 7/25/2012
page. City/Town 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'.
El concrete El metal fiberglass
Dimensions:
Capacity:
Design Flow:
Alarm present:
Alarm level:
gallons
El polyethylene El other (explain):
gallons per day
El Yes E-1 N o
Alarm in working order: El Yes El No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
* Attach copy of current pumping contract (required). Is copy attached? 0 Yes El No
t5ins - 11 /10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17
IMUNI`
L 'j
W"IM I ,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
260 Summer St
D. System Information (cont.)
01845 7/25/2012
Zip Code Date of Inspection
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
1
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.):
Dist Box needs replacing detached concreate pipe from outlet baffle to D -box needs replacing.
Pump Chamber (locate on site plan):
Pumps in working order:
Property Address
Yes
Hal G Worsham
Owner
Owner's Name
information is
No Andover Ma
required for every
No
page.
City/Town State
D. System Information (cont.)
01845 7/25/2012
Zip Code Date of Inspection
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
1
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.):
Dist Box needs replacing detached concreate pipe from outlet baffle to D -box needs replacing.
Pump Chamber (locate on site plan):
Pumps in working order:
D
Yes
F-1
N o
Alarms in working order:
El
Yes
F�
No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins - 11110 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 Assess
260 Summer St
Property Address
Hal G Worsham
Owner Owner's Name
information is
required for every —o Andover
page. City/Town
D. System Information (cont.)
State
01845
Zip Code
7/25/2012
Date of Inspection
Type:
El
leaching pits
number:
El
leaching chambers
number:
El
leaching galleries
number:
N
leaching trenches
number, length:
El
leaching fields
number, dimensions:
M
overflow cesspool
number:
El
innovative/alternative system
3-60'
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
no Hydraulic failure no sians of Dondina.
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 0 Yes [:1 N o
t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17
z
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
260 Summer St
Property Address
Hal G Worsham
Owner Owner's Name
information is
required for every No Andover
page. City/Town
D. System Information (cont.)
Ma 01845
State Zip Code
7/25/2012
Date of Inspection
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 17
I'LIJ
Commonwealth of Massachusetts
Title 5 Official. Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
260 Summer St
Property Address
Hal G Worsham
Owner Owner's Name
information is
required for every No Andover Ma 01845 7/25/2012
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:
EKhand-sketch in the area below
El drawing attached separately
B-0
t5ins - 11/10 Title 5 Official 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
260 Summer St
Property Address
Hal G Worsham
Owner Owner's Name
information is
required for every No Andover Ma 01845 7/25/2012
page. CityrTown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
N Check Slope
El Surface water
0 Check cellar
0 Shallow wells
Estimated depth to high ground water: 4'
feet
Please indicate all methods used to determine the high ground water elevation:
El Obtained from system design plans on record
If checked, date of design plan reviewed: application May 1 1966
Date
El Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health - explain:
pulled file on Dror)ertv
El Checked with local excavators, installers - (attach documentation)
El Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
Cellar is dry no pump in cellar. cellar floor aprox 5' below bottom of stone.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins - I I /10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17
0
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
260 Summer St
2 Inspection Summary: A, B, C, D, or E checked
01845
Zip Code
7/25/2012
Date of Inspection
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 - 11/10 Title 5 Official inspection Form: Subsurface Sewage Disposal System - Page 17 of 17
Property Address
Hal G Worsham
Owner
Owner's Name
information is
required for every
No Andover Ma
page.
City/Town State
E. Report Completeness Checklist
2 Inspection Summary: A, B, C, D, or E checked
01845
Zip Code
7/25/2012
Date of Inspection
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 - 11/10 Title 5 Official inspection Form: Subsurface Sewage Disposal System - Page 17 of 17
North Andover Health Department
(ommunity Development Division
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: -2— 0 :5�->
INSTALLER:
DESIGNER
PLAN DATE:
BOH APPROVAL 6ATE ON PLAN:
MAP: LOT:
INSPECTIONS
TANK INSPECTION.
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
Comments:
SEPTIC TANK
0 Contractor reports any changes to design plan
El Existing septic tank properly abandoned
El Internal plumbing all to one building sewer
El Topography not appreciably altered
El Building sewer in continuous grade, on
compacted firm base
Cleanouts per plan
El Bottom of tank hole has 6" stone base
E] Weep hole plugged
El gallon tank has been installed
loading
E] Monolithic tank construction
Water tightness of tank has been achieved by
testing
Tn—iettee installed, centered under access port
>C
AA&
Outlet tee installed, centered under access port
(gas baffle/effluent filter)
inch cover to within 6" of final grade
installed over one access port
El
Hydraulic cement around inlet & outlet
Comments:
PUMPCHAMBER
E]
B'ottom of tank hole has 6" stone base
El
Weep hole plugged
gallon Pump Chamber installed
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
El
cover at final grade installed over pump
access port
Water tightness of tank has been achieved by
testing
Hydraulic cement around inlet & outlet
Comments:
CONTROLPANEL
El
Alarm & Pump are on separate circuits
El
Alarm sounds when float is tripped
Location of control panel: basement
El
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)
Comments:
6210
T
Town of North Andover
HEALTH DEPARTMENT
3 CHUS
CHECK4: D T E:
LOCATION:
H/O NAME:
CONTRACTOR NAME: Z /1//
Type
of Permit or License: fCheck box)
0
Animal
$
0
Body Art Establishment
0
Body Art Practitioner
$
0
Dumpster
$
0
Food Service - Type.
$
0
Funera I Directors
$
0
Massage Establishment
$
0
Massage Practice
$
0
Offal (Septic) Hauler
$
0
Recreational Camp
$_
0
Sun tanning
$
0
Swimming Pool
$
0
Tobacco
$
0
Trash/SoUd Waste Hauler
$_
13
Well Construction
$
SEPTIC Systems:
0 Septic - Soil Testing
0 Septic -Design Approval,,?,
Disposal Works Constru 0� $
&Ise-Ptic
0 Septic Disposal Works Installers (DWl) $
0 Title 5 Inspector $
0 Title 5 Report $
0 Other (Indicate) $
Ith Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
1,2
Application for Swtic Disposal System 53�
4 Xonstruction Permit - TOWN OF TOI
$ 250.00 — Full Repair
ORTH ANDOVER, MA 01845
C $125.00 - Component',
Important: Avialication is hereby made for a permit to:
When filling out El Construct a new on-site sewage disposal sys;
forms on the tem*
computer, use El Repair or replace an existing on-site sewage disposal system*
only the tab key
to move your P<epair or replace an existing system component — What?
cursor - do not
use the return
key- A. Facility Information
;?,�a
Address or Lot #
Ive eV)Ve&7Le,,r
City/Town RECEIVED -
01
20
2
_C
2, *TYPE Of SEPTIC SYSTEW: U
El Pump [4 -Gravity (choose one) [FAUG 0 2012
***If pump system, attach copy of electrical permit to application *TOWN OF NORTH ANDOVER
LT P TM
HEALTH DEPARTMENT
VConventional System (pipe and stone system)
[:] Infiltrator or Biodiff user (Gravel -Less) (Attach a copy of your certification to install this type of system.
El Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement)
E] Pressure Dosed (D -Box Present) S.A.S.,
2. Owner Information
(, - alo
Name
Address (if different from above)
City[Town State Zip Code
Telephone Number
3. Installer. Information
?&V,) ,v M tv2A )—Ar_
Name Name of Company
��F.
Address
Nl-,z
City[Town State Zip Code
Telephone Number (Cell Phone # if possible please)
4. Desiciner Information
Name Name of Company
Address
City/Town
_§tate Zip Code
Telephone Number (Best # to Reach)
Application for Disposal System Construction Permit - Page 1 of 2
_4
ion for S stem
Applicat eptic Disposal Sv
-Construction Permit —TOWN OF TODAY'S DATE
$ 250.00 - Full Repair
ORTH ANDOVER MA 01845
$126.00 - Component
C
PAGE 2 OF 2
A. Facility Information continued....
5. Type of Buildina: JResidential Dwelling or nCommercial
B. Agreement
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
EnviVnmental Co��, as well as the Local Subsurface Disposal Regulations for the Town of
No dov r, a . ot to place the system in operation until a Certificate of Compliance has
beliluediv tris toarylof Health.
Date
App7licati WApproved "'(Board of Health Representative)
A—L, f — z�_ IL
Narfie- Date
Application Disapprove /�orthe following reasons:
For Office Use Only:
L Fee AttachedP Yes L11 No
2. Project Manager ObEgation Form Attacbed? Yes I/ No
I Pump &—stem? ff so, A ttach coQE of Electrical Permit
4. Foundation As -Built? (new construction ronly):
(Same scale as approvedplan)
9. Floor Plans? (new construction only):
Yes NoLI1
Yes No
Yes No
Application for Disposal System Construction Permit - Page 2 of 2
SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North dover licensed installer for the construction for the septic system for the property at:
121 -
(Address of septic system) For plans by
Relative to the application of 7s_ 6 k 0 L �, V I it) c e !y>,b And dated
(Installer's name)
Dated �g // / / -L—
J � I oclay- s clate)
Widi revisions dated
I understand the following obligations for management of this project:
�Engineer)
(Original date)
(Last revised date)
1. As the installer, I am obligated to obtain all pen -nits and Board of Health approved plans pjjor to
performing any work on a site. I must have the a1212roved 121ans 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 ke4LaLons maj result in a $50.00 fi�e being levied against me and/o
M�E comany.
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 Inspectio — Engineer must first do their inspection for elevations, des, etc.
As -built of verbal OK (or e-mail to: healthdel?tQtownofnorthandover.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 (otbertban 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 sel2dc systems in North Andover can constitute
reasons for denial of the system and/or revocation or susp �sion'of my license to ol)erate in the Town of
North Andover, significant fines to all 12ersons 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 theproper elevation of the excavation has been reached.
b. Inspection of the sand and stone to be ased.
c. Final inspection by Board of Health staff or consmitant.
d. Installation of tank, D-Boxpoes, stone, ventpmmp chamber, retaining wall and other
comPonents.
6. As the installer, I understand that I am solLly resi2onsible for the installation of the system as 12er the
a1212roved 121ans. No instructions by the homeownen general contractor, or any other persons shall absob
me of this obligation.
Undersigned Licensed Septic Installer: (Today's Date) i/w/P _Z_
r
—7a—m—e — Signed)
(Name — Print)
Farr, George
Lot # 61 Colonial Acres
APPLICATION FOR SEWAGE DISPOSAL INSTALLATION SU=%9r- St.
HEALTH DEPARTMENT - NORTH ANDOVER, MASS.
Fa k -
I hereby make application for a permit for a sewage disposal installation at
Colonial Acre§j_ Lot 61 Summer St, - I will install this system in ac-
cordance with all the laws -of the Commonwealth of Massachusetts and regulations of
the Board of Health of the Town of North Andover.
Further, I will construct the house sewer of bell and spigot pipe, the minimum
diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre -
ceding the septic tank, where the grade shall not exceed eo. I will install a con-
crete septic tank of 1000 g!l* in size. A manhole (s) permitting easy cleaning
will be provided with emovable a -over (s) of iron or concrete within 12 inches of
the ground surface. I will provide subsurface disposal field with 4 inch perforated
or open jointed pipe and laid in a series of trenches, the bottom of which will pro-
vide a minimum of __180 lineal (square) feet of effective absorption'area.
The pipes will be laid on a 9-In—ch layer of washed gravel or crushed stone ranging
in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar
material to a height of 2 inches above the crown of the pipe. The joints of these
pipes will be protected from clogging and before filling the trench, 2 inches of
gravel or stone 1/8" to 1A" (dia.) will be placed over the course gravel or stone.
The disposal field will be installed at a grade of 4 to 6 inches/100.feet. No single
tile line will exceed 100 feet in length and in any case, two lines of tile will be
installed. A minimum of 6 feet will be maintained between the center lines of the
disposal field trenches and the average depth of trench shall not exceed 36 inches.
No part of the installation will be less than 100 feet from any private water supply,
25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line.
Ifurther agree not to cover any portion of this installation until approved by the
inspection officer, as provided below, and to incorporate any additional requirements
that m be attached to the permit. Plot Plans must be submitted with application.
DATE4�22 A -w
SiKaturi* of Applicant
I hereby issue the above permit for the Board of Health of the Town of North
Andover, Massachusetts.
DA
4�?22A
6Zignature of Health Agent
I have inspected the uncovered system indicated above and find everything done
as described.
DATE
Signature ot nspecting Offiber
Percolation Test 15 min. - J_ . - X
Garbage Grinder ?
BOARD OF HEALTH 0
TOWN OF NORTH ANDOVER, MASS. ca Aq e� lei A
ff 0:1e
30+ —
'30
m
1. NAME r Lae --r
DATE
2. ADDRESS. -e/5- LOT NO. Q -'V TEL. 45�
3. NO. OF BEDROOMS.- -3 DEN YES NO
4. GARBAGE GRINDER YES NO
5. SHOW DIMENSIONS OF HOUSE
6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES
7. SHOW DIMENSIONS OF LOT
8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL
9. NOTE-MM'TIONAND DTST-A-Na--OF-w�FLL-F-ROM-SFWERA-GB--&yS-T-EM
10. SHOW-LOCA-T-I-0N--0E-B�OOKq,_ STREA-M-s-,-DI-TC-H-ES,—L-EDGE-OUTCROP-,-ETC.
11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE
NOTE. LOCAL REGULATIONS SHOULD BE READ CAREFULLY.
q V
BOARD OF HEALTH OF NORTH ANDOVER, MASSACHUSETTS
SEWAGE DISPOSAL
DATE February 12, 966
NAME OF APPLICANT Geor6e Farr
LOCATION— Lot #6, Farnham I -St.
Address of lot no.
BUILDING: Dwelling__j _ Other
SYSTEM: New x Repair
GENERAL DESCRIPTION OF LAND Hilp;�h
SUBSOIL: Clay Gravel Sand_yZflay X
PERCOLATION TEST 5 minutes per inch.
MINIMUM INSTALLATION RECOMMENDATIONS
CONCRETE SEPTIC TANK
1000
gallon
capacity.
LEACH FIELD 180
—lineal
feet of
drain pipe.
,U],
Villiam, J Drfi-slc6ll, Engin_eeji�_
Board of keal�q
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
'-)'YSTEM OWNER & ADDRESS
0 k:
A 116 .
-SYSTEM LOCATION
(example: left front of house)
9�jr_ 04 W Pic V69
DATE'OF PUMPING: QUANTITY PUMPED G A L L ONS
C4'.S.SPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF S ERV I CE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION---��'FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
,, S)"STEM PUMPED BY:
CON 1.,N/1 E N T S:
ONTE'NTS TRA N S F E R R E D TO
14
GALLONS
QUANTITY PUMPED. 65�E
NO X YE
58POOL"
S-
SEPTICTANK:No
YES
Tm OF
:,ROUTjNj9
X EMERGENCY
SIRVA
TIOINS'�'
GOOD
N
FULL TO COVER
HEAVY GREAs
E
ROOTS
]3A]FFLES IN PLACE
-BACK
LEACHFIELD RUN
EXCESSIVE SOLIDS
FLOODED
S
-SO1M CARRYOVER
wi
A OTHER (EXPLAIN)
"j, i
01
-------------
NORTH ANDOVER
SYSTEM P UMPING n "Con,
14
GALLONS
QUANTITY PUMPED. 65�E
NO X YE
58POOL"
S-
SEPTICTANK:No
YES
Tm OF
:,ROUTjNj9
X EMERGENCY
SIRVA
TIOINS'�'
GOOD
N
FULL TO COVER
HEAVY GREAs
E
ROOTS
]3A]FFLES IN PLACE
-BACK
LEACHFIELD RUN
EXCESSIVE SOLIDS
FLOODED
S
-SO1M CARRYOVER
wi
A OTHER (EXPLAIN)
"j, i
01
jt�
(YR,�'A
T0WN'.oFp,4bZTH AND
OVE
ORry
-SYSTP, U�VJN(3 rE
et
DATE Jun e -
DATE V
AD�RIS
RESS SY bM LUCATION
0. /V/)
DATE OF PUMP 'PQWE
_qUANTITY D
CESSPOOL NO_YflS:
!SEPTIC TANY, No YES
NATURE OF SERVlC9;""R9-'YT -'ENEROENCY
OBSERVATIONS:
GOOD CONDi T�Io� FULL TO COVER
4AVY GREASE BAFFLES IN'LACE
.,ROOTS LEACHRIELD RVNBACK
EXCESSIVE SOLIDS -FLOODED
SOLED CARRYOVER OTHER EXPLAIN
SYSTEMPUNQEDBY
COMNfENTS:
COIMNTS TRANSFERRED TO
SACHUSETT
R CE
Mifform for., 6PA
P. ha rdvl 4
.1. USO by 10C41 Boards of Heal Th tL $71
be Isklub; to' Qjq4 ng Record must
0 .10691'130ard of Health or other approving Buthority,
TOWN 0
�,,Fqc111ty.1nfqrmqt1on
�n
only the tab.key Mdros$
to move your.*6.;,,
do rtQt
U 1)WI.......
34
return Still Zjp PQ<iOL
4
-fio-
��":-Addrw (If different M location)
$tat*
p Code
Telephone Number
30(yhli 0,
/,.Zp C)
2. Qu'
Dots/
antlty Pumped:
Gallon3
ype ?f t cesspool($) C�—�eptic Tank Tight Tank
ir (describ#`�
"int? Yes
wis -13
Jee Filter C3 If yes, was It 61ea'
ned? C Yes No
06,
A:
66�
ed
AM
toot
Vehicle n4e Number
w AA lid
i` A,
j"
y
pposed:
ad
1; -YA4
Anwo of How Dots
rms,h1tm#Inspect
----------
14
SY$t$m Pumping Record - Page I of
177
. .... . . ....
U-1
ke
P.
SrIpM
L
WE
mon pissachusefts TOWN OF NORTH ANDOVER
HEALTH DEPARTMENt
�,',=Wpf,N
THANDOV
5F
ER, MASSACrju, =TTS
hill
8 t 61 M P U, ng ecord
DEP has provided this form for use by lopal Boards of Health. The system Pumping Record mwil-'
be submitted to the local Board of Health or other approving authority,
A.. Facill Information
ty
:Ut 1. System Locatl
on,
Ad k
at
v4rytlown State
p Code
2, System Owner,
Ann
'Nams
A�dress (if different hm locatlon)
M/twn State ZJ0 Code
Telephone Number
B. Purnpin" Record
I Date of Pumpin�
2. Quantity Pumped:
0�alloni
. 3 Type of system: Cesspool(s) Septic Tank Tight Tank
Other (describe):
.4, Effluient Tee Filter present? C3 Yes Ej No lf'�e
$,*Vvas It cleaned? E] Yes C] No
Condition of System:
CC)
6 SpLem Pumped By:
Vehlcle Llcense Number
0
rwecompany
7, Locatlo where contents were disposed,
--------------
Hauler -
no ure of Date
'-ss-gov/depM.'ate'r-/-*':
4PPrQ.Va1sA5forms,;htm#lnspect P
'J 3 -
Sy3tem Pumping Recorti - page
1 of I
'k