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HomeMy WebLinkAboutMiscellaneous - 265 HAY MEADOW ROAD 4/30/2018 (2)00 Cj X ®R It lit 2D 0 LL. o W UJI W nj w w 49 1 z 0 cr u * a. 41 ir *' Zib 0,9 fj -Z LL to 0 7Z K -Z 4 -Z IL 7Z ®R It lit 2D 0 LL. o W UJI W nj w w 49 1 z 0 cr u * a. 41 ir *' Zib 0,9 fj -Z 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 Add Owner's Name: , :)Z�U461=Z219 Owner's Address: Date of Inspection: Name of Inspector: (please print)�_�L Company Name: Mailing Address: Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: Inspector's Signature: V -'*Passes Conditionally Passes Needs Fuo, er Evaluation by the Local Approving Authority Date: Z— The system inspector shallAubmit a copy of this inspection report'(o the Approving Authority (Board of Health or DEP) within 30 days of c'ornpleting 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 Page 2 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:Ao�—� Z32f Owner: —5? Date of Inspection: 6Z&4/1Zz—�—Z- / X Inspection Summary: Check A,B,CD or E / ALWAYS Complete all of Section D A. System Passes: L/—I 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: 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 followin- 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): - . .. ;4 7 T 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): 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.�i4�5— Owner: 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 protecupublic health, Wetyland the envirohment: — 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 lesf ari 5 plim, pr6vided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ,�-5-- 1,115) 1 Owner: Se4wil)II-) Date of Inspection: IV� 2 D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: Yes No ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool 1!joe/��/Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or - —L/logged SAS or cesspbol' –Sltatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or / cesspool V Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2day flow — 4zRequired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped — ��A"y portion of the SAS, cesspool or privy is below high ground water elevation. ny portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. — y portion of a cesspool or privy is within a Zone I of a public well. y 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 5 0 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: 4 To be considered?a lirie system the s*ystem must serve a[ facility with a desik'n' 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 – IATA) 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 6C 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 3 10 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 4 , s Page 5 of I I A* '41 61� '*' OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner:5&Kn?. Date of Inspection: �4W-- Check if the following have been done. You must indicate '�yes" or "no" as to each of the following: Y 0 Pumping information was provided by the owner, occupant, or Board of Health /We're any of the sy"stem"components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period ? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out ? Were all system components, excluding the SAS, located on site ? jz_ 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 ? --I/— Was the facilitv owner (and occupants if different from owner) provided with information on the proper maintenance of subsurfac� sewage disposal systems '.1 The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes no J,,-*" Existing information. For example, a plan at the Board of Health. _JZ 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(3)(b)] 5 Page 6 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:'�'_�_I_ ,A4 Owner: Date of Inspection: 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): Number of current residents: Does residence have a garbage grinder (yes or no):&O Is laundry on a separate sewage system (yes or no)��if yes separate inspection required] Laundry sy�teqi inspected (yes orno): Seasonal use: (yes or noWe Water meter readings, if available (last 2 years usage (gpd)): Sump pump (yes or no) -/Pb Last date of occupancy4i� �Co� j e COMMERCIAVINDUSTRIAL Type of establishment: Design flow (based on 3 10 CMR 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 ;71 Source of information: 5�t_ pf) fn 10 Was system pumped as part of the insp ction (yes or no)kle'S If yes, volume pumped eallons -- How ;pas�&� pumped determined? Reason for pumping: /,IoVS -C2_oe 1— 47 Ad f �" � V TrY IF SYSTEM L,- eptic tank, distribution box, soil absoiption "-m — 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 coTponents, date installed (if known) and source of information: Were sewage odors d;tected when arriving at the site (yes or no)AV40 Page 7 of I I As OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: 0; i! A40 Date of Inspection: BUILDING SEWER (locate on site plan) Depth below grade: Materials of constructio� 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: ��(Iocate on site plan) Depth below grade: Material of constructi , on: P-1cloncrete —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: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 0 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottornap.9 outlet tee or baffle/ How were dimensions determined: 774 av /%P— Comments (on pumping recommenda'tions/mlet and outlet tee or Saffle condition, structural integrity liquid levels asjS!aWd et invert videnc of le e, etc.): 4a outl i 77,&;r,4­,� VM,�P- /A/ ellod-W ��AOY'o GREASE TRAP: _(locate on site plan) Depth below grade: Material of construcii7o—n: —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 Address Al, Owner: S!! 2, e -t z7ii Date of Inspection: 101, TIGHT or HOLDING TANK: _ (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: —concrete —metal —fiberglass ____polyethylene other(explain): Dimensions: Capacity: allons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: JZ(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of le nto or out of box- eta.l: C- /)'01— Z) / C 7— AM (0a If fadm—e r 01 PUMP CHAMBER: (locate on site plan) Pumps in working order (yes or no): Alarms in working order (yes or no): Comments (note copditi p of pymp chamber, condition of pumps and appurtenan�es,;,e tc.)- 8 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-�;&'-' Owner: 40-tzl' Date of Inspection: /z2A1;1 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: 4. Type leaching pits, number: leaching chambers, number: leaching galleries, number: f :j�j<:eaching trenches, number, length: 410 leaching fields, number, dimensions: overflow cesspool, number: innovative/alternative 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): 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, -41 -5— �eZ6�jelfll 14 �91 Owner: -5�V,11r_1110 Date of Inspection: 72�7//-7-7 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 .-M.* - . - 0 . 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 -A Owner: Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells feet Estimated depth to ground water Please indicate (check) all methods used to determine the high ground water elevation: 00 V60btained from system de"sign plans on record - If checked, date of design plan reviewed: 67 - 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. mus-Ldescribe how you e tablished the high d water elevation: /1Z? IAJ Aj Ix 1-1 V5, A_"elec et Inj lk"' J A.1 0 N William F. Weld Governor Tlud Xe S.ret ' ..y%EA David B. Struhs Commissioner TOWN OF NORTH ANDOVER/ H. F TH BOARD F Commonwealth of Massachusetts Execufive Office of EmAronmental Affairs APR 17 PQ; Department of Environmental Protection SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A JERTIFICP?/� Aj- /)J-/ 0 ek-, Property Address: C;t N4 e aq drg-J Address of Owner: Date of Inspection: 0!7 (if different) Name of Inspector: A4 Company Name, Address and Telephone Number- Iq /'/ t) 0 1/ t V 4 .1 ej'-T CERTIFICATI—ON STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was per -formed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: am,'. AA� Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing 665 inspection, If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the systern owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES:_ t. //, h One or . more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is 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. (revised 8/15/95) 1 One Winter Street e Boston, Massachusefts 02108 0 FAX (617) 556-1049 9 Telephone (617) 292-55W 0 Printed on Recyded Paper / AV & - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (con inued) IL/ W4n 640' Xv Property Address: Owner: Lv Date of Inspection: � 4, III SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(5). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed Cl 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 the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soii absorption system and is within 100 feet to a surface water suppi-y or tributar� to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system hab a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 D] SYSTEM FAILS: ppm. 1-14 I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. — Backup of sewage into facility or system component due to an overloaded or dogged 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. (revised 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 1114-1 CERTIFICATION (continued) Property Address: Owner: e -o Date of Inspection: '3— D) SYSTEM FAILS (continued): 9-40 — Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. — Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design f1mv 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: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: led - Owner: -e tv Date of Inspection: 1-3- �/- Check if the following have been done: '.1 �Pr" — Pumping information was requested of the owner, occupant, and Board of Health. �- 4one of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates du�ing that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. s uilt plans have been obtained and examined. Note if they are not available with N/A. The facility or �welling was inspected for signs of sewage back-up. 4 T e system does not receive non -sanitary or industrial waste flow 5�_ T site was inspected for signs of breakout. All tem components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or t s, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. Th size and location of the Soil Absorption System on the site has been determined based on existing information or 1z prox imated by non -intrusive methods. The facilit) o-,�nc. (and occupants, if different frorn owner) were provided with information on the proper maintenance of Sub - Surface Disposal System. n (revised 8/15/95) 4 r A '.� 0 Property Address: Owner: Date of Inspection: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORtAATJON ,�2 6 AIJ e .2 IA-.., P-cf FLOW CONDITIONS RESIDENTIAL: Design flow: gall 5 ' 102 Number of bedrooms: Number of current residents: Garbage grinder (yes or ): no Laundry connected to syste(yes or no): e Seasonal use (yes or no): Water meter readings, if a4lable: S I Last date of occupancy:—&e(/P/ ie a COMMERCIAIJINDUSTRIAL: Type of establishment: Design flow: allons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no) Non -sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and sour�c of information - 57,',W.2 System pumped as part of inspection: (yes or no4e If yes, volume pumped �allons Reason for pumping: 4-ovie -ro. ell TYPE OF SYSTEM I....0 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) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: &o-ws' dr 4�O Sewage odors detected when arriving at the site: (yes or no) do (revised 8/15/95) Property Address: Owner: Date of Inspection: 0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM I?4jDRMATION (continued) .2 /-70-/ ILI 9 SEPTIC TANK: to Y, (locate on site nlan) of Depth below grade: Material of construct rete —metal _FRP —other(explain) Dimensions: 4 04 Sludge depth: r ly " Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 0 Distance from top of scum to top of outlet tee or baffle- 7 Distance from bottom of scum to bottom of outlet tee or baffle__�j Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) GREASE TRAP:— (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 bottorn ot From t- bottom of outlet tee or battle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) I (revised 8/15/95) 6 N" SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: /t/ - Owner: Date of Inspection: TIGHT OR HOLDING TANK:_ (locate on site plan) N. �- - Depth below grade: Material of construction: —concrete —metal —FRP —other(explain) Dimensions: Capacity: _gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distr;but:--n equa!, evidence of sohd, carryover, evidence of leakage into or out of box, etc.) QOY o PUMP CHAMBER:— (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFO" ,TION (continued) Property Address: C� a Owner: e P__-, Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excav tion �ot required, but may be approximated by non -intrusive methods) If not determined to be present, explain: vel(ee�wn'- d /V Type: leaching pits, number: leaching chambers, number: leaching galleries, number: leaching trenches, number,Te—ngth: 1/ #2 IX;r leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) A/0 3,/.5 CESSPOOLS: (locate on site plan) Number and configuration: Depth -top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater. inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of poncling, 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.) (revised 8/15/95) 00 Property Address: Owner: Date of Inspection: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMAT�q-hl (continue�, -e"000, 9W eo.2wnk, Ala 0 V SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' ccol 1-9 It ,4 -7 () C let 137-0 1c -.-.0 (� s 3d- /S- A DEPTH TO GROUNDWATER Depth to groundwater: _k_jeet method of determination or approximation: 011�lNal 110-Aw (revised 8/15/95) 9 Mara oi- iieatn INorth Andover,,Yass APPROVIM Providedi Title V Reg 2.5 Reg 6 Reg 10. 2 Reg 10.4 SPO 'V SUBSURFACE DI, sa DEsrGN cocK Lis? 777 d- Vio DISAPPROVO DATE Reasons: LOT IL2;_� I 'I -?, T) � Z-2 M' - I- / - '�� V r9�Z e submitted plan st show as a Minim=: '117 the lot to be served -area A lie ,pdizensions lot # abutters location and log deep observation Mes-di "Stance to ties location and results Pezvolation tests -distance to ties design calculations & calculations showing requireA leaching area (4) location and dimensions of Syriltem-including L-eserve area M existing and prcposed contours (9) location any wet areas within 1001 of sewage disposal system or disclaimer -check wetlands mapping surface and subsurface drains within loot of sewage disposal system or disclaimer i) location any drainage easements vAthin 3.00, of sesage disposal il ,J) systwa or disclaimer-PlawdMg Board f . es known sources of %-&ter suPPly within 200, of sewage disposal 'k) system or disclaimer location of any proposed wen to serve lot -loo, from leaching facility ,l) location of water lines on property -lot from leaching facility V location of benchmark 'it) driveways p� garbage disposals p no PVC to be used in construction q) profile of iystem-elevations of basement., plumb, pipe.. septic tarl� distribution box inlets and Outletsm distribution field piping a' btber elevations r) maximam ground -water elevation in area seuage disposal system s) plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Aqptic Tanks caPacitU—s--150% of flaw, water table,, tees,, depth of tees., ,�accessO pumping cleanout C)1101 from cellar wall or inground swimming pool NO 251 from subsurface drains Distribution Boxes a) slo-pe gr �ter �thm 0.08 b) 20ARD 0�' S5 34-3 4"mit5v T) i <A i2o 17^ L -o -r �,2 wy/w-A- pmo A'�PL( 0 oJELL APR�NW6 AoTlioi-�)Py PEAA) V651 6A.) Pax) P14 TC CollivIT-0,05 2-7 '5fpr(6 :516T67M pjs-v4ud-Tlo" C'l-X4V4T(o.,AJ U13TC- 'Nzo-V AWITIoMAL, jojj5 DISAPPJ�O\j6p DId T-C-- J�C,/J,so N5', 0 1945S - E] F41L- AWNDVIlUG AUTHORa"y -6�kl ) tJ-DT4U&�� 40,qlAK) RA L A PPI;0VA L 10-542 Appw\n&)6 /6u -lHogi A 1, Commonwealth of Massachusetts _PME'Filo No. 24 —413 (To be pfovided by DEQE) North AndoV.et"' City[Town Applicant Michael & Elizabeth Marino Order of Conditions Massachusetts Wetlands Protection Act c. 13 1, § 4.0 and under the Town -of North Andover ' Bylaw, Chapter 3.5 A & B From North Andoyer Conservation Commission Michael & Elizabeth Marino To (Name of Applicant) 731 Winter Street North Andover, MA Address This Order �s issued and delivered as follows: D 1by hand d*elivery to applicant or representative on Same (Nz. ne of property owner) Same Address— (date) 0 by certified mail, return receipt requested on 171 19A7 (date) This project is located at Lots 60A -62A -64A Hay Meadow Road The property is recorded at the Registry of Northern Essex Boo Page & Certificate (if registered) The Notice of Intent for this project was.filed on may 6, 1987 (date) The public hearing was closed on _May 27, 1987 (date) Findings The North Andover Conse-rvation Commission. has reiiewed*the above-referen . ced Notice of Intent and plans and has held a poblic'hearing on the project. Bas�ed or 'the'information available to the NACC at this time, the NACC has determined that. the area on WHO the proposed work Is to be done Is significant to the Pbllowlng Interests In accordance with the Presumptions of Significance set forth In the regulations for each Amia Subject to Protection Undler the Act (check as appropriate): to/ Public water supply 10 St6rm I damage prbvention U/ Private water supply 19 Prevention of pollution' NI I/ Ground wa I ter suppi I y 0' Land containing shellfish 0 Fisheries Flood control — 1 — 242— Therefore. the NACC hereby finds that the following conditions are necessary, in accordance.with the Performance Standards set forth in the regulations. to protect those inter- ests checked above. The --NAC—C orders that all work shall be performe inaccordance with sai'd conditions and with the Notice of Intent referenced above. To the extent that the fol-'," lowing conditions modif . y or differ ' from the plans, specifications or othcr proposals submitted with the Notice of Intent. the conditions shall control. c-,cncral Conditions 1 Failu'rc to comply wit . h all'conditio ns stated fie rein, and with all related sta tutes and other regulatory meas- urcs, shall be deemed cause to revoke or modify thin Order. 2. This Order does not gr� nt any property rights orany exchisivc privileges'. it does not authorize any injury to private property or invasion of private rights. 3. This Order does not relieve the permittee or any other person of the necessity of complying with all othcrapplicable fedd(nl, state or local statutes, ordinances, by-laws or regulations. 4. The work authorized hereunder shall be compleldd with.i.n three years from the date of this Order unless either of the following apply: (a) the work is a maintenance dredging.proicct as provided for in the Act; or (b) the timr- for completion,has been ext�nded to a specified date more than three years, but less thar five years. from the date of issuanccand both that dato and the special circumstances warranting the cx!cndcd time period are set forth in this Order. 5. This Order may be extended by the i,ssuing authority for one or rnorc periods of up t(;Lthree years each upon application to the issuing authorilyat least 30 (lays prior to the expiration date of - the Order. 6. Any fill used in connection With this project shall be clean fill, containing no trash, refuse rubbish or de- bris. including but not limited to lumber. bricks, plaster, wire, lath. paper, cardboard, pipe, tires. ashes. refrigerators, motor vehicles or parts of any of the foregoing. 7,-. No work shall be undertaken until all administrative appeal periods.Rom.lhis Order have elapsed or, if such an appeal has been filed. until all proceedings before the Dcpartm ent have been completed. 8. No work shall be undertaken until the Final Ordar has been recorded in the Registry of Deeds or the Land Court for the district in which the land is located, within the chain of title of the affected property. In the cas I c of recorded land, the Final Order shall also be noted in the Registry's Grantor Index under the name of the owner of the land upon which the proposed work is to be done. In the case of registered land. the Final Order shall also be noted on the Land Court Certificate of Title of the owner of the land upon which the,proposed work is.to. be done. The recording information shall be submitted to the NACC on the form at the end of this Order prior to commencement of the work. 9. A sign shall be dispi . aycd at the site not less tha.n two square feet or more than three square feet in -size bearing the words, "Massachusetts Department of Environmental Quality Engineering, File Number 242— L1_3 10. Where tiie DepartmeM of Environmental Quality Engineering Is roquested to make a determination and to issue a Superseding Order, the C-onservition.Cornmission shall be a party to all agency proceedings and hearing$ before the D'epartment. ant shall for-thwith request in writing that a 11. Upon completion.of the work describeq herqin, [tic applic, Certificate of Compliance be issued stating that the work huas been satisfactorily completed. k hall conform to the following pinns nnd specinl conditions:: 12. The work s Page 3 ORDER OF CONDITIONS Lots 60A, 62A, 64A Hay Meadow Road DEQE #242-413 12. The work shall conform to the following plans and additional conditions: a. Notice of Intent submitted by Michael and Elizabeth Marino of 731 Winter Street, North Andover, Mass., prepared by John F. McQuilkin, Jr. of Yankee Engineers, 110 Jackson Street, Methuen, Mass., dated May 5, 1987 and received by the NACC on May 6, 1987. b. Plan entitled "Site Plan of Land Prepared for Marino Custom Homes locted in North Andover, Mass.," prepared by Yankee Engineers and dated May 1. 1987. 13. The extensive siltation that has occurred on the southeasterly side of the crossing along the stream shall be removed and the area stabilized. The erosion controls on the northeasterly side of the crossing which have been covered by boulders and dirt shall be re-established. 14. Detailed plaris for the driveway crossing and headwall construction shall be submitted to the NACC for review and approval prior to start of construction. 15. In advance of any work on this project, the applicant shall notify the NACC, and at the request of the NACC, shall arrange an on-site conference among the NACC, the contractor and the applicant to ensure that all of the conditions of this Order are understood. This Order also shall be made a part of the contractor's written contract. 16. The applicant, or its successors, shall notify the NACC in writing of the identity of the on-site construction supervisor hired to coordinate construction during the work on the site and to ensure compliance with this Order. 17. Commencing with the issuance of this Order, and continuing through the existence of same, the applicant shall submit to the NACC a written progress report every 4 months detailing what work has been done in or near resource areas. 18. Prior to construction of the crossing extension, a filter fabric fence or a double row of staked hay bales shall be placed between all construciton areas and wetland areas. This barrier shall be inspected and approved by the NACC prior to the start of construction. This row of hay bales of filter bafric shall remain intact until all disturbed areas have been mulched, seeded and stabilized to prevent erosion. 19. The applicant shall have on hand at the start of any soil disturbance, removal or stockpiling, a minimum of twenty-five (25) hay bales and sufficient stakes for staking these bales. Said bales shall be used only for the control of emergency erosion problems, and shall not be used for the normal control of erosion, as described in the Erosion Control Plan submitted with the Notice of Intent or the hay bale barrier described in Conditions 13 and 17. Page 4 ORDER OF CONDITIONS Lots 60A, 62A, and 64A -Hay Meadow Road DEQE #242-413 20. Upon completion of construction and grading, all disturbed areas located outside resource areas shall be stabilized permanently against erosion. This shall be done either by sodding, or by loaming, seeding, and mulching according to Soil Conservation Service standards. If the latter course is chosen, stabilization will be considered once the surface shows complete vegetative cover has been achieved. 21. After proper grading, all disturbed areas located within a resource area, except those areas designated as compensatory wetlands, shall be loamed and seeded with not less than four (4) inches of good quality loam. Before seeding, ground limestone shall be applied at a rate sufficient to bring the soil test to pH 6.5. In addition, 10-6-4 fertilizer, or its equivalent, shall be applied at a rate of fifteen (15) pounds per one thousand (1000) square feet, in accordance with Soil Conservation Service guidelines. 22. No earthen embankment in the buffer zone shall have a slope steeper than 2.1. 23. All erosion prevention and sedimentation protection measures found necessary during construction by the NACC will be implemented at the direction of the NACC. 24. There shall be no stockpiling of soil or other materials within twenty- five (25) feet of any resource area. 25. During and after work on this project, there shall be no discharge or spillage of fuel, oil, or other pollutants into any resource area. 26. Any changes in the submitted plans, Notice of Intent or resulting from the aforementioned conditions must be submitted to the NACC for approval prior to implementation. If the NACC finds, by majority vote, said changes to be significant and/or deviate from the original plans, Notice of Intent or this Order of Conditions to such an extent that the interests of the Wetlands Protection Act and Bylaw cannot be protected by this Order of Conditions and would best be served by the issuance of additional conditions, then the NACC will call for another public hearing within 21 days, at the expense of the applicant, in order to take testimony from all interested parties. Within -21 days of the close of said public hwearing, the NACC will issue an amended or new Order of Conditions. 27. Any errors found in the plans or information submitted by the applicant shall be considered as changes, and procedures outlined above for changes shall be followed. 28. In conjunction with the sale of any lot within a resource area, the applicant shall submit to the NACC a signed statement by the buyer that he is aware of an outstanding Order of Conditions on the development and has received notice under Conditon #32 below. 29. The NACC shall be notified in writing of any lot line or lot number changes with a copy of a plan showing these changes prior to any work on these lots. ORDER OF CONDITIONS Page 5 LOTS 60A, 62A and 64A Hay Meadow Road DEQE #242-413 30. Members of the NACC shall have the right to enter upon and inspect the premises to evaluate compliance with this Order of Conditions. 31. Accepted engineering and construction standards and procedures shall be followed in the completion of the project. 32. Prior to the issuance of a Certificate of Compliance, the applicant shall submit a letter to the NACC from a registered professional engineer certifying that the work i's in compliance with the plans referenced above and all conditions hereof. 33. The provisions of the Or - der shall apply to and be binding upon the applicant, its employees, and all successors and assigns in interest or control. 34. Issuance of these conditions does -not in any way imply or certify that the site or downstream areas will not be subject to flooding, storm damage, or any other form of damage due to wetness. 35. A proper bond or the deposit of money or negotiable securities sufficient in the opinion of the Commission to secure the performance of the Conditions and observance of the safeguards of such Order of Conditions running to the town of North Andover shall be provided in the amount of $2,000.00. Such bond or security, if filed or deposited shall be approved as to form and manner of e�xecution by Town Counsel and/or the Town Treasurer, shall be posted with the Treasurer of the Town of North Andover before commencement of work. Said bond or deposit of money or negotiable security shall be conditioned upon the completion of all conditions hereof, shall be signed by a party or parties satisfactory to the NACC, has been made for performance of any conditons which are of a continuing nature. This condition is issued under the Authority of the Town of North Andover Wetlands Protection Bylaw. 36. This Order of Conditions is issued in addition to those issued under File #242-16 and in substitution for those issued under File #242-263. �' A A Lot 6 62,64 Haymeadow Road 242-413 Issued By-' 'No-rth Andover Conservation Commission Signature(: V This Order must be signed by a majority of the Conservation Commission. On this 10th _ day of 11 'PQ I _19- 87 . before me personally appeare North Andover Consprunfinn —.tomeknoWntobethe person described In and who executed the foregoing Instrument and acknowledged that he/she executed the same as his/her free act and deed. Notary Public My commission ex . p s The applicant. the owner, any person aggrloved by this Order. any owner of land abutting the land upon which the proposec?work 13 10 be done or any ton residents of the city or town In which such land Isiocated are hereby notified of their right to request the Department of Environmental Ouality Engineering to Issue a Superseding Order. providing the request Is made by cerlified mail or hand delivery to - the Department withln ton days from the datoof Issuance of this Order. A copy of the (equost shall at the same time be sent by certified mail or hand delivery to the Conservation Commission and the applicant. If you wish to appeal this decision uNder the Town By Law, a complaint must be filed in -Superior Court. Detach on dotted line and submit to the prior to commencement 01 work. . .... . ..... . ................. . ................ . ...................................................................................................................................... . . TL� Issuing Authority Please be advised that the Order of Conditions for the project at File Number 2w— - hu been recorded all'thaPeolatry of and has been noted In the chain of tide of the affected property In accordance with General Condition 8 on It recorded land. the Instrument number which Identifle3 this transaction Is 11 registered land, the document number which Identities this transaction Is Applicant. LL (9 C9 to op 72 7Z —Z %Xl w 0 w cr al w Ix a. -Z , .3 % X 73 z t4 4 7Z (9 C9 to op 72 7Z —Z %Xl w 0 w cr al w Ix a.