HomeMy WebLinkAboutMiscellaneous - 260 SUMMER STREET 4/30/2018 (3)C>1
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Town of North Andover
HEALTH DEPARTMENT
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CHECK #: DATE: /2-
LOCATION:7-1
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H/O NAME:
CONTRACTOR NAME:Jzi
TyRe
of Permit or License: (Check box)
0
Animal
11
Body Art Establishment
1:1
Body Art Practitioner
$
0
Dumpster
0
Food Service - Type:
0
Funeral Directors
$
13
Massage Establishment
$
0
Massage Practice
$
0
Offal (Septic) Hauler
$
0
Recreational Camp
$
0
Sun tanning
0
Swimming Pool
$
0
Tobacco
$
0
TrashlSolid Waste Hauler
0
Well Construction
$
SEP77C Sy tems:
0 Septic - Soil Testing $
0 Septic - Design Approval
$
0 Septic Disposal Works Construction (DWC)
0 Septic Disposal Works Installers (DWl)
0 Title 5 Inspector $
Title 5 Report $
0 Other (Indicate) $
Health gent.Initials
White -Applicant Yellow -Health Pink -Treasurer
Owner
information is
required for every
page�
Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
VQ
Commonwealth of Massachusetts rRECEIVED
Title 5 Official Inspection Form Ur
J
Subsurface Sewage Disposal System Form - Not for Voluntary Assessmen AUG 0,
260 Summer St I TOWN OF MMTH
L�Hlwim vipAi
Property Address
Hal G Worsham
Owner's Name
No Andover Ma
City/Town State
01845 7/25/2012
Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. General Information
Inspector:
John DiVincenzo
Name of Inspector
Stewart Septic Service
Company Name
58 South Kimball
Company Address
Bradford Ma 01835
City/Town
978-372-7471
Telephone Number
B. Certification
State
S113386
License Number
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:
F] Passes Conditionally Passes F] Fails
N Needs Further E uati the Local Approving Authority
eed s
I �ns r's S i ature Date
syst
e 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 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
Property Address
Hal G Worsham
uwner s i,4ame
o Andover
City/Town
B. Certification (cont.)
Ma 01845
State Zip Code
7/25/2012
Date of Inspection
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes:
F1 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� Y [I N El ND (Explain below):
Sins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Su
-P— bsurface Sewage Disposal System Form Not for Voluntary Assessments
A, 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
B. Certification (cont.)
B) System Conditionally Passes (cont.):
Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if (with approval of Board of Health):
Z broken pipe(s) are replaced
[I obstruction is removed
E Y El N El ND (Explain below):
El Y R N El ND (Explain below):
Z distribution box is leveled or replaced [E Y R N El ND (Explain below):
Dist. box Deteratated needs to be replaced.
F1 The system required pumping more than 4 times a year due to broken or obstructed pipi The
system will pass inspection if (with approval of the Board of Health):
El broken pipe(s) are replaced 0 Y El N [I ND (Explain below):
El obstruction is removed El Y El N El ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
F] 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
IN
Owner
information is
required for every
page.
t5ins - 11/10
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
dwn`e�—sN�—me—
No Andover
Cityrrown
B. Certification (cont.)
Ma
State
01845 7/25/2012
Zip Code 6a—teof Inspection
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
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.
[I 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 I water
supply well.
El The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
El M
Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
0
Liquid depth in cesspool is less than 6" below invert or available volume is less
than % day flow
Title 5 Official Inspection Form: SUbsurface Sewage Disposal System - Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
260 Summer St
Property Address
Hal G Worsham
Owner Owner's Name
information i's
required for every N,o Andover Ma 01845 7/25/2012
page. City/Town State Zip Code Date of lnspect"iori---
B. Certification (cont.)
Yes No
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.
Ej Z Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
El 0 Any portion of a cesspool or privy is within a Zone 1 of a public well.
E] n/1 Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
El Z The system is a cesspool serving a facility with a design flow of 2000gpd-
1 0,000gpd.
E] 0 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
F-1
El
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area — IWPA) or a mapped Zone 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 CIVIR 15.304. The system owner should contact the appropriate
regional office of the Department.
(5ins - 11/10 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
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
N 0
260 Summer St
El N
Property Address
Z 0
Hal G Worsham
Owner
Owner's Name
information is
required for every
No Andover Ma 01845
page.
Cityrrown State Zip Code
C. Checklist
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
N 0
Pumping information was provided by the owner, occupant, or Board of Health
El N
Were any of the system components pumped out in the previous two weeks?
Z 0
Has the system received normal flows in the previous two week period?
El E
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?
E El
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?
M F]
Was the facility owner (and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
Existing information. For example, a plan at the Board of Health.
Z n
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): 3 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 330
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
Property Address
Hal G Worsham
Owner Owner's Name
information is
required for every No Andover
page. City/Town
D. System Information
Description:
Number of current residents:
Does residence have a garbage grinder?
Ma 01845 7/25/2012
State Zip Code Date of Inspection
Is laundry on a separate sewage system? [if yes separate inspection required]
Laundry system inspected?
Seasonaluse?
4
0
Yes
No
El
Yes
No
F�
Yes
F-1
No
0
Yes
[E
No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? EJ Yes 0 No
Last date of occupancy.- occupied
Date
Comm erciallIndustrial 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 7 No
Industrial waste holding tank present? EJ Yes F1 No
Non -sanitary waste discharged to the Title 5 system? Yes [:1 No
Water meter readings, if available:
15ins - 11 /10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17
I
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.)
Last date of occupancy/use:
Other (describe below):
Pumping Records:
Source of information:
Ma 01845 7/25/2012
State Zip Code Date of Inspection
General Information
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Type of System:
Date
Andover Septic
gallons
N Yes R No
E Septic tank, distribution box, soil absorption system
D Single cesspool
11 Overflow cesspool
0 Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
El 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
El Tight tank. Attach a copy of the DEP approval.
El Other (describe):
15ins - 11 /10 Title 5 Official inspection Form: Subsurface Sewage Disposal System - Page 8 of 17
Commonwealth of Massachusefts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
260 -Summer St
D. System Information (cont.)
Ma 01845 7/25/2012
State Zip Code Date of Inspection
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)
El Yes [Z No
Depth below grade.- 181,
feet
Material of construction:
M cast iron F� 40 PVC other (explain):
Distance from private water supply well or suction line:
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-1 metal
a
feet
Ej fiberglass [] polyethylene 0 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:
D Yes El No
t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17
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 7/25/2012
State Zip Code Date of Inspection
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)
El Yes [Z No
Depth below grade.- 181,
feet
Material of construction:
M cast iron F� 40 PVC other (explain):
Distance from private water supply well or suction line:
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-1 metal
a
feet
Ej fiberglass [] polyethylene 0 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:
D Yes El No
t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17
( t\ co
mmonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top Of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
7/25/2012
5-ateof inspection
No Baffle
_2�slop�e..._
0
No baffle
How were dimensions determined? Slope juclqE�,
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 away needs replacinq
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
0 concrete 1 0 metal El fiberglass El 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:
t5ins - 11/10
Date
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17
260 Summer St
�roperty Acldre�s
H al G Worsham
Owner
6wner's Name -
information i's
required for every
'No Andover Ma 01845
page.
City/Town State Tip Eode
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top Of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
7/25/2012
5-ateof inspection
No Baffle
_2�slop�e..._
0
No baffle
How were dimensions determined? Slope juclqE�,
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 away needs replacinq
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
0 concrete 1 0 metal El fiberglass El 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:
t5ins - 11/10
Date
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
260 Summer St
Property Address
Hal G Worsham
Owner Owner's Name
information is
required for every No Andover
page. City/Town
Ma 01845 7/25/2012
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 F� metal El fiberglass
Dimensions:
Capacity:
Design Flow:
Alarm present:
Alarm level:
gallons
El polyethylene El other (explain):
gallons per day
El Yes El N 0
Alarm in working order: F� Yes 0 No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
* Attach copy of current pumping contract (required). Is copy attached? El Yes [I No
(5ins - 11 /10 Title 5 Official Inspection Fornni Subsurface Sewage Disposal System - Page 11 of 17
-commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
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. 6_t�/_T�_w_n_ State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Dist Box needs replacina detached concreate pipe from outlet baffle to D -box needs replacinq.
Pump Chamber (locate on site plan):
Pumps in working order: D Yes El No
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
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. '6 7it `y/T Tow n __
t5ins - 11/10
D. System Information (cont.)
Type:
Ma 01845
State Zip Code
7/25/2012
Date of Inspection
1-1 leaching pits number:
El leaching chambers number: —
leaching galleries number:
leaching trenches number, length: 3-60'
El leaching fields number, dimensions:
F overflow cesspool numb er:
F] innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
no Hydraulic failure no siqns of nondina.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth — top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow Yes No
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17
'Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
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 (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 poncling, condition of vegetation,
etc.):
t5ins - 11 /10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 17
L
Commonwealth of Massachusefts
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 i's . .
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:
[11/hand-sketch in the area below
0 drawing attached separately
C.- 10
15ins - 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
page. CitylTown
D. System Information (cont.)
Site Exam:
Check Slope
Surface water
Check cellar
0 Shallow wells
Ma 01845
State Zip Code
7/25/2012
Date of Inspection
Estimated depth to high ground water: 4'
feet
Please indicate all methods used to determine the high ground water elevation:
E] Obtained from system design plans on record
If checked, date of design plan reviewed: application May 1 196�_
Date
E] Observed site (abutting p rope rty/observatio n hole within 150 feet of SAS)
Checked with local Board of Health - explain:
pulled file on property
Checked with local excavators, installers - (attach documentation)
Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
Cellar �s 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 - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17
tomm onwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
260 Summer St
01845
Zip Code
7/25/2012
Date of Inspection
Inspection Summary: A, B, C, D, or E checked
Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
System information — Estimated depth to high groundwater
Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins - 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.
Cityrrown State
E. Report Completeness Checklist
01845
Zip Code
7/25/2012
Date of Inspection
Inspection Summary: A, B, C, D, or E checked
Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
System information — Estimated depth to high groundwater
Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17
BOARD OF HEALTH OF NORTH ANDOVER7 MASSACHUSETTS
SEWAGE DISPOSAL
DATE February 12, 190-6
NAME OF APPLICANT_ GeorEe Farr
LOCATION Lot #6, Farnham. St.
Address of-l-ot -no.
BUILDING: Dwellin x -Other
SYSTEM: New x —Repair
GENERAL DESCRIPTION OF LAND Hiah
SUBSOIL: Clay Gravel Sand Y-Cln,�r X
PERCOLATION TEST minutes per inch.
MINI MUM INSTALLATION RECOMMENDATIONS
CONCRETE SEPTIC TANK 1000 gallon capacity.
LEACH FIELD 180 —lineal feet of drain pipe.
�1'lliam J D4sjcoll, Engine-ep
Board of kealtil
BOARD OF HEALTH 04�
TOWN OF NORTH ANDOVER, MASS. A 6'.
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1. NAME DATE 2
2. ADDRESS ff 15' c le LOT NO. TEL. eb"
3. NO. OF BEDROOMS__:� 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 /Yp
8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL
9. NON-10-CKTI-0�--A'-N'D--I)ISTA-NC-E-OF-�WELL-r-ROM�---SEWERAGE--S-YS-T.-EM u
10. SHOW � -LOCA-TION---OF--BROOKS STREAMS- --.DITCH-ES-'-'L-EDGE,- OUT
CROP,, -ETC.
11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE
NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY.
Farr., George
Lot # 6) Colonial Acre
APPLICATION FOR SEWAGE DISPOSAL INSTALLATION su=vrr St.
HEALTH DEPARTMENT - NORTH ANDOVER, MASS. Fa V -'M
I hereby make application for a permit for a sewage disposal installation at
Colonial Acresj_Lot 6y Sumner Sto * I will install this system in ac-
cordance with alll 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 inchesi 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 Salt in size. A manhole (s) permitting easy cleaning
will be provided with- *cover (s) of iron or concrete within 12 inches of
.removable
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 __lgo lineal (square) feet of effective absorption'areas
The pipes will be laid on a 9 -"Inch 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 1/811 to 1/4" (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 tocover any -portion of this installation until apEroved by,the
inspection officer, as provided below, and to incorporate any additional requirements
that may be attached to the permit. Plot Plans must be submitted with application.
DATE41 &U
;;K kl_
Sipature of Applicant
I hereby issue the above permit for the Board of Health of the Town of North
Andover, Massachusetts.
DATE�-
. X,
Vignature-of Health Agent
I have inspected the uncovered system indicat ed above and find everything done
as described.
PATE
J
L
Signature o" specting Offiber
Percolation Test 5 mjn�
Garbage Grinder
1 11
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Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
RECEIVED
AU ro' 0 4 2 014
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CM R 15.351.
A. Facility Information
1. System Location:
_�( 'o 5o rn M er- 5�7-
Address
North Andover
City1Town
2. System Owner:
— Vq 116?rn gz) / c e—
Name
Address (if different from location)
City/Town
Ma
State
State
Telephone Number
01886
Zip Code
Zip Code
B. Pumping Record
7�7
// L/ 06
1. Date of Pumping Date 1 2. Quantity Pumped: Gallons
3. Type of system: Cesspool(s) 5171 Septic Tank El Tight Tank Grease Trap
F1 Other (describe):
4. Effluent Tee Filter present? 0 Yes 0 No
5. Condition of System:
6. System Pumped By-,
1 f[yes, was it cleaned? E] Yes [] No
Name — I Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler
Date
Signature of Receiving Facility Date
t5form4.doc- 03/06
System Pumping Record - Page 1 of 1