HomeMy WebLinkAboutMiscellaneous - 27 EAST PASTURE CIRCLE 4/30/2018rn
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CONDITIONS
WATER SUPPLY: WELL
WELL PERMIT--,,
WELL TESTS CHEMICAL DAJE APPROVED
BACTE-RIA I
DAIE (IPPRUVED
BACTERIA II DATE nPPROVEl)
COMMENTS:
FORM U APPROVAL: APPROVAL TO ISSU- NU
DATE ISSUED
CONDITIONS:
FINAL APPROVAL:.
ALL PERMITS PAID YES NO
WELL CONSTRUCTION APPROVAL YES NU
SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO
OTHER YES NU
ANY VARIANCE NEEDED YES NO
FINAL BOARD OF HEALTH APPROVAL: DATE:
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MAP #
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PARCEL #
STREET
HAS PLAN REVIEW
FEE.E)EEN PAID? YES
NO
PLAN APPROVAL:
DATE
DESIGNER:
4/4 PLAN
DA,rE.
CONDITIONS
WATER SUPPLY: WELL
WELL PERMIT--,,
WELL TESTS CHEMICAL DAJE APPROVED
BACTE-RIA I
DAIE (IPPRUVED
BACTERIA II DATE nPPROVEl)
COMMENTS:
FORM U APPROVAL: APPROVAL TO ISSU- NU
DATE ISSUED
CONDITIONS:
FINAL APPROVAL:.
ALL PERMITS PAID YES NO
WELL CONSTRUCTION APPROVAL YES NU
SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO
OTHER YES NU
ANY VARIANCE NEEDED YES NO
FINAL BOARD OF HEALTH APPROVAL: DATE:
6IZ3 1_q
5EPII Q T 15j D
a4LE Mq
'IS 'THE'INSTALLER LICENSED?.,;..-.''.. YES NO
.:�TYPE. OF -CONSTRUCTIO
REPAIR*
:d i
-,.,_._,.:'-.NEW CONSTRUCTION: : -CERTIFIED PLOT -PLAN REVIEW
:e YES NO
CONDITIONS OF..APPROVAL
YES NO
(FROM FORM U)
-ISSUANCE OF DWC PERMIT.
�. - �YES NO
DWC 'PERM1 T NO. INSTALLER:
BEG I N ..I NSPECT I ON NO:
INSPECTION: ;NEEDED:
ASSED BY
—CONSTRUCTION INSPECTION: NEEDEDz
7
AS BUILT PLAN SATISFACTOR Y
TO.BACKFILL: DATE: B Y
..,APPROVAL
..�FINAL,GRADING APPROVA L: DATE BY—
DATE: 6/0
Y 44
FINAL CONSTRUCTION APPROVAL:
i .7.
Owner
informati on i's
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.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
27 East Pasture 0 (a
Property Address
Anthony Pizzimenti
Owner's Name
North Andover
City/Town
MA 01845 02/23/17
State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. General Information
1. Inspector:
Robert Herrick
Name of Inspector
Wind River Environmental
Company Name
163 Western Avenue
Company Address
Gloucester
City/Town
(978) 282-7315
Telephone Number
B. Certification
RECEIVED
MAR � U LU I I
-TOWN OF NURT' -ANDOVEP—
H ALTH I)EpARTMENT
EJ -
MA 01930
State Zip Code
SI 13758
License Number
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
E Passes D Conditionally Passes F-1 Fails
0 Needs Further Evaluation by the Local Approving Authority
02/23/17
4-n&pecto , =ig�� Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system 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.doc - rev. 6/16 Title 5 Official Inspection Form. Subsurface Sewage Disposal System - Page 1 of 17
"I I MINE:
L
.4 M -
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
2 7 East Pasture
Property Address
Anthony Pizzimenti
Owner's Name
—orth Andover
City/Town
B. Certification (cont.)
MA 01845
State Zip Code
02/23/17
Date of Inspection
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes:
1 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.
El Y F1 N El ND (Explain below):
t5ins.doc - rev, 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
27 East Pasture
Property Address
Anthony Pizzimenti
Owner Owner's Name
information is
required for every North Andover
page. City/Town
B. Certification (cont.)
MA 01845 02/23/17
State Zip Code Date of Inspection
El Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
F1 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):
El broken pipe(s) are replaced 0 Y El N El ND (Explain below):
0 obstruction is removed El Y El N El ND (Explain below):
F1 distribution box is leveled or replaced El Y R N 0 ND (Explain below):
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). -
F1 broken pipe(s) are replaced 0 Y F-1 N 0 ND (Explain below):
0 obstruction is removed El Y El N F-1 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 doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 3 of 17
IP Ems,
A P.M
M
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
27 East Pasture
Property Address
A
Owner's Name
North Andover MA 01845 02/23/17
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.
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
El
0
Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
El
E
Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2day flow
t5ins.doc - rev. 6/16
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
27 East Pasture
Property Address
Anthony Pizzimenti
Owner Owner's Name
information is
required for every North Andover MA 01845 02/23/17
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped: _.
El E Any portion of the SAS, cesspool or privy is below high ground water elevation.
El Z Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
0 z Any portion of a cesspool or privy is within a Zone 1 of a public well.
El E Any portion of a cesspool or privy is within 50 feet of a private water supply well.
El E 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.]
EJ 0 The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
El Fq 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
El El the system is within 200 feet of a tributary to a surface drinking water supply
El 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.
t5ins doc - rev. 6/16 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
27 East Pasture
Property Address
Anthony Pizzimenti
Owner Owner's Name
information is
required for every North Andover MA 01845 02/23/17
page. CityrTown State Zip Code Date of Inspection
t5ins.doc - rev. 6/16
C. Checklist
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
N El
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?
E 1:1
Has the system received normal flows in the previous two week period?
El 0
Have large volumes of water been introduced to the system recently or as part of
this inspection?
N El
Were as built plans of the system obtained and examined? (if they were not
available note as N/A)
N E]
Was the facility or dwelling inspected for signs of sewage back up?
E El
Was the site inspected for signs of break out?
N El
Were all system components, excluding the SAS, located on site?
N 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?
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:
2 El
Existing information. For example, a plan at the Board of Health.
Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 — Number of bedrooms (actual): 4 -
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 660 gpd
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
S Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
27 East Pasture
Property Address
Anthony Pizzimenti
Owner Owner's Name
information is
required for every North Andover MA 01845
page. City/Town State Zip Code
02/23/17
Date of Inspection
D. System Information
Description:
This syste is made up of a tank, distribution box and soil absorption system.
Number of current residents:
Does residence have a garbage grinder?
Is laundry on a separate sewage system? (include laundry system inspection
information in this report.)
Laundry system inspected?
Seasonaluse?
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump?
Last date of occupancy:
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present?
Industrial waste holding tank present?
Non -sanitary waste discharged to the Title 5 system?
Water meter readings, if available:
Gallons per day (gpd)
El
Yes
2
No
El
Yes
0
No
El
Yes
N
No
El
Yes
H
No
N/A
El Yes E No
Occupied
Date
M
Yes
El
No
El
Yes
El
No
El
Yes
El
No
t5ins doc - rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
27 East Pasture
Property Address
A
Owner Owner's Name
information is
required for every North Andover MA 01845 02/23/17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
General Information
Pumping Records:
Date
Source of information: Board of Health
Was system pumped as part of the inspection?
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
H Septic tank, distribution box, soil absorption system
E] Single cesspool
El Overflow cesspool
0 Privy
El 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
Tight tank. Attach a copy of the DEP approval.
El Other (describe):
El Yes 0 No
t5ins.doc -rev 6116 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
27 East Pasture
Property Address
A
Owner Owner's Name
information is
required for every North Andover MA 01845 02/23/17
page. City/Town State Zip Code Date of Inspection
t5ins.doc - rev. 6/16
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1996-, Plans on File with the Board of Health
Were sewage odors detected when arriving at the site? El Yes [Z No
Building Sewer (locate on site plan):
Depth below grade: 18"
feet
Material of construction:
El cast iron E 40 PVC El other (explain):
Distance from private water supply well or suction line: Town Water
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
All joints are solid. There are no signs of leakage and the ventingls vent.
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
E concrete El metal
12"
feet
0 fiberglass El polyethylene El other (explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes El No
Dimensions: 1010" x 5'8" x 58"
Sludge depth: 3"
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
27 East Pasture
Property Address
Anthony Pizzimenti
Owner Owner's Name
information is
required for every North Andover
page. City/Town
t5ins.doc - rev. 6/16
State Zip Code
02/23/17
Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle 30"
Scum thickness 3"
Distance from top of scum to top of outlet tee or baffle 6"
Distance from bottom of scum to bottom of outlet tee or baffle 14"
How were dimensions determined? Tape Measure & Sludge 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.):
Recommend pumping early. The inlet and outlet are solid. There am nogi ns of carryover or
leakage in or out of the box and liquid level is OK in relation to the inverts.
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
0 concrete F-1 metal El fiberglass
feet
El polyethylene El 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: 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
27 East Pasture
Property Address
Anthony Pizzimenti
Owner Owner's Name
information is
required for every North Andover MA 01845 02/23/17
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 El fiberglass polyethylene El other (explain):
Dimensions
Capacity: gallons
Design Flow: gallons per day
Alarm present: El Yes El N o
Alarm level: 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? El Yes El No
(5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
27 East Pasture
Property Address
Anthony Pizzimenti
Owner Owner's Name
information is
required for every North Andover
page. City/Town
State
01845
Zip Code
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
n
02/23/17
Date of Inspection
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 leakage into or out of box, etc.):
The distribution box is solid and there are no signs of leakage or carryover in or out of the box.
Pump Chamber (locate on site plan):
Pumps in working order: El Yes El No*
Alarms in working order: El Yes El No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.)-.
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins.doc - rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Insp
Subsurface Sewage Disposal System Fo
27 East Pasture
D. System Information (cont.)
Type:
ection
Form
leaching pits
number:
rm - Not for Voluntary
Assessments
number:
11
leaching galleries
number:
El
Property Address
number, length:
leaching fields
Anthony Pizzimenti
overflow cesspool
Owner
Owner's Name
innovative/alternative system
information is
required for every
North Andover
MA
01845 02/23/17
page,
City/Town
State
Zip Code Date of Inspection
D. System Information (cont.)
Type:
El
leaching pits
number:
El
leaching chambers
number:
11
leaching galleries
number:
El
leaching trenches
number, length:
leaching fields
number, dimensions:
overflow cesspool
number:
El
innovative/alternative system
I @ 65' x 30'
Type/name of technology -
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
There are no signs of hydraulic failure, no ponding and the soil isdg. The vegetation 'is normal for
the area.
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 F1 N o
t5ins.doc - rev. 6116 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
D. System Information (cont.)
01845 02/23/17
Zip Code 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.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 17
27 East Pasture
Property Address
Anthony Pizzimenti
Owner
Owner's Name
information is
required for every
North Andover MA
page.
City/Town State
D. System Information (cont.)
01845 02/23/17
Zip Code 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.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 17
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
27 East Pasture
Property Address
AnthonV Pizzimenti
Owner's �ame
—orth Andover MA 01845
CityrTown State Zip Code
D. System Information (cont.)
02/23/17
Date of Inspection
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:
El hand -sketch in the area below
Z drawing attached separately
t5ins.doc - rev. 6/16 Title 5 Official Inspection Form Subsurface Sewage Disposal System - Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Insip
Subsurface Sewage Disposal System Fo
27 East Pasture.
D. System Information (cont.)
Site Exam:
Check Slope
ection
Form
rm - Not for Voluntary Assessments
Shallow wells
Property Address
Anthony Pizzimenti
Owner
Owner's Name
information is
required for every
North Andover
MA
01845 02/23/17
page.
City/Town
State
Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
Estimated depth to high ground water: 6'
feet
Please indicate all methods used to determine the high ground water elevation:
041
I
I
Obtained from system design plans on record
If checked, date of design plan reviewed. 2001
Date
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health - explain:
Checked with local excavators, installers - (attach documentation)
Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
Obtained the estimated qround water from the plans on file with the Board of Health.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17
Check Slope
Surface water
Check cellar
Shallow wells
Estimated depth to high ground water: 6'
feet
Please indicate all methods used to determine the high ground water elevation:
041
I
I
Obtained from system design plans on record
If checked, date of design plan reviewed. 2001
Date
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health - explain:
Checked with local excavators, installers - (attach documentation)
Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
Obtained the estimated qround water from the plans on file with the Board of Health.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
27 East Pasture
Property Address
Anthony Pizzimenti
Owner Owner's Name
information is
required for every —orth Andover MA 01845
page. City[Town State Zip Code
E. Report Completeness Checklist
02/23/17
Date of Inspection
Z Inspection Summary: A, B, C, D, or E checked
Z Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
Z System information — Estimated depth to high groundwater
Z Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17
V,ORT#1
7793
0 0
Town of North Andover
HEALTH DEPARTMEN
CHECK#: DATE -
LOCATION:
H/ONAME:
CONTRACTOR NAME:
Type of Permit or License: (�heck box)
• Animal
$
• Body Art Establishment
$
• Body Art Practitioner
$
0 Dumpster
$
0 Food Service - Type:
$
0 Funeral Directors
$
0 Massage Establishment
$
0 Massage Practice
$
• Offal (Septic) Hauler
$
• Recreational Camp
$
0 Sun tanning
$
0 Swimming Pool
$
0 Tobacco
$
• TrashlSolid Waste Hauler
$-
• Well Construction
$
SEP77C Systems:
• Septic - Soil Testing $
• Septic - Design Approval $
0 Septic Disposal Works Construction (DWQ $
0 Septic Disposal Works Installers (DW[) $
0 Title 5 Inspector $
Title 5 Report $
0 Other (Indicate)
4@
HeaffiLAgent Initials
White - Applicant Yellow - Health Pink - Treasurer
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40
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FORK U - IA)T P,=ASE FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT:
Phone _(V
LOCATION:
Assessor's Map Number
Parcel
ols-Z-3)
Subdivision 6 LtaT k6_-aMEL_Q CS-A�� Lot (s)
Street _Q__ Ed A P -1a St. Number
************************Official Use Only************************
RECOMMEMATIONS OF TOWN AGENTS:
.' Conservation Administ-ramor
Comments
Town Planner
Comments
Date Approved
Date Rejected
Date Approved
Date Rejected
Date Approved
Food Inspector -Health Date Rejected
,<I�Date Approved
L__,-LLLY=2
SeT:�t c Inspector -Health Date Rejected
Comments
Public Works - sewer/water connections
- driveway permit
Fire Department
Received by Building Inspector 0 1 3_1 Date
OLS LO a4 IS-
NORTH ANDOVER BOARD OF HEALTH
DESIGN REVIEW REPORT
FEE: PERMIT # 00// DATE RECEIVED
APPLICANT 1304) MAP PARCEL
ADDRESS -5 7e -AJ A/ LOT # 4 -
ENG. �5 STREET
ADDRESS. Ife-:!5 0
PLAN DATE 3 REV. DATE
CONDITIONS OF APPROVAL
APPROVED
REASONS FOR DISAPPROVAL:
DISAPPROVED A—
ot�- �61e_ 7-25;-6,7-,5 007- 0/—� Z)197�57-
5
-7-
UO.7
O,c 4, A107 -C-,, OQXBIQ 66- A -)OT
7-17L"- eC- /9-1V Y (-5 &0 7
�5)/
Town of North Andover
0*
OMCE OF OZ.
0
COMMUNITY DEVELOPMENT AND SERVICES
146 Main Street
North Andover, Massachusetts 0 1845 CHU50-
(508) 688-9533
February 1, 1996
Hayes Engineering
603 Salem Street
Wakefield, MA 01880
Re: Lot #4 East Pasture Circle
To whom it May Concern:
This is to inform you that the proposed plans for the site
referenced above have been disapproved for the following reasons:
1) Elevations of perc tests missing.
2) Soil tests out of date.
3) Benchmark not within 75 feet of system.
4) Note: garbage grinder not allowed.
5) Are there any wells within 150 feet of the system?
If you have any questions, please do not hesitate to call the Board
of Health Office at the number below.
Sincerely,
Sandra Starr, R.S.
Health Administrator
SS/cjp
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
Julie Parrino, D. Robert Nioetta Nfichael Howard Sandra Starr Kathleen Bradley Colwell
PLAN REVIEW CHECKLIST
ADDRESS ENGINEER
GENERAL
3 COPIES STAMP' LOCUS L,-' NORTH ARROW SCALE
CONTOURS PROFILE SECTION BENCHMARKN' SOIL &
PERCS S
ELEVATIONS,
WETS. DISCLAIMER WELLS & WETS
WATERSHED? DRIVEWAY_��Elev) WATER LINE C--' FDN DRAIN
SCH40 L,--- TESTS CURRENT? lq�Z- SOIL EVAL
SEPTIC TANK
MIN 150OG .17 INVERT DROP GARB. GRINDERA/0(+200% EDF)
251 TO CELLAR &,'-' MANHOLE ELEV GW # COMPS.
D -BOX
SIZE # LINES 4- FIRST 21 LEVEL STATEMENT
INLET lq-54,1,6) - OUTLET-/-qj.-5(ff 17 (211 OR .17 FT) TEE REQ I D? A/6
LEACHING
MIN 660 GPD? RESERVE AREA L11 4' FROM PRIMARY?L,-' 2% SLOPE
-r
1001 TO WETLANDS 1001 TO WELLS 41 TO S.H.Gil (51>2M/IN)
35' TO FND & INTRCPTR DRAINSI--� 3251 TO SURFACE H20 SUPP
41 PERM. SOIL BELOW FACILITY' MIN 12-1 COVER t,� FILL? (251
if above natural elev; 101if below) BREAKOUT MET?
TRENCHES
MIN 660 gpd X SLOPE (min .005 or 611/1001) L-"" SIDEWALL DIST. 3X EFF.
W OR D (MIN 61) L"-� RESERVE BETWEEN TRENCHES? /�d/ IN FILL? MUST
BE 101 MIN. 4 11 PEA STONE? L -----VENT? L--�- (>31 COVER; LINES >501)
BOT (9/6 + SIDE /085 X LDNG 34- = TOT
(L x W x (DxLx2x#F (G/ft2)
Copyright@ 1995 by S.L. Starr
FORM U - LOT RELEASE FORM
INSTRUCTIONS: iTh "s form is used to verify that all necessary approvals/permits from
Boards and Departfr,6nts having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
*****************************APPLICA-NT OUT THIS SECTION***********************
f,
APPLICANT PHONE
(J
LOCATION: Assessor's Map Number PARCEL
SUBDIVISION_ LOT (S)
STREET ST. NUMBER-L:��
RECOMMENDATIONS OF TOWN AGENTS:
CONSERVATION ADMINISTRATOR
COMMENTS- ........
TOWN PLANNER
COMMENTS
FOOD INSPECTOR -HEALTH
SEPTIC JN-9PV0'OR-HEALT
COMMENTS
USE
DATE APPROVED
DATE REJECTED.
DATE APPROVED
DATE REJECTED.
DATE APPROVED
DATE REJECTED.
DATE APPROVED
DATE REJECTED -
PUBLIC WORKS - SEWER[WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUJLDING 4NSPECTOR
Revised 9\97 jM
00 1
DATE
"OWN OF ORI'll AN DOV EP,
L) A 11 SYS'M MPINQ R.ECORI)
SYSTEM 0 ADDRESS
f rzz"-/ DATE OF 0"ut"ki
SYS EM LOCATION
*44 -A-
--QUANTITY PUMPED:
11:LSSPOOL: NOJo,-..-yBs- ScPdcl'ank: NU� YES,6,-,
NA rURE OF SERVICE Rou-rINE�/ I�MER(
ObSERVATIONS:
GOOD CONDITION FULLTO covER DEC 0 7 2004
�vy oill;,��E BAMES IN PLACL
ROOTS
LEACKFIELD RUN BACK
BXCUSIVE SOLIE)S..__. FLOODED
SOLM CAkRYOV'ER,_.....,_.. OTHER EXPLAIN
SysLomp,umpodby
Po / n�. L5
WMMENTS.
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No. FEE $ 60.00
THE COMMONWEALTH OF MASSACHUSETTS
North Andover —,MASSACHUSETTS
�Njjpliration for Disposal *Votrra Toustrurtion 11jerntit
Application is hereby made for a Permit to Construct (X) or Repair ( ) an On-site Sewage Disposal System at:
Location Address or Lot No.
Owner's Name, Address and Tel. No.
East Pasture Circle - Lot 4
Donald Johnston 1-508-682-1619
North Andover, NA 01845
114 Boston St., North Andover, MA
Installer's Name, Address, and Tel.No.
Designer's Name, Address and Tel. No.
Hayes Engineering, Inc. 617-246-2800
603 Salem St., Wakefield, MA 01880
Type of Building:
Dwelling
Other
No. of Bedrooms
Type of Building
Other Fixtures —
4
Garbage Grinder M
No. per Persons — Showers Cafeteria
Design Flow 165 - gallons per day. Calculated daily flow 660 gallons.
Plan Date March 31, 1995 - Number of sheets one — Revision Date
Title Septic SVstem Desi�n in North Andover., Mass,
Description of Soil See soil log on plan.
Nature of Repairs or Alterations (Answer when applicable) -
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site sewage disposal
system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a
Certificate of Compliance has been issued by this Board of Health.
Signed
Application Approved by
Application Disapproved for the following reasons
Permit No.
Date Issued
Date
Date
THE COMMONWEALTH OF MASSACHUSETTS
, MASSACHUSETTS
(fertifirate of VI-1,11raptiattre
THIS IS TO CERTIFY that the On-site Sewage Disposal System installed or repaired/ replaced on
by for
at has been constructed in
accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
. Use of this system is conditioned on compliance with the provisions set forth below:
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. This
Certificate expires on
DATE
No.
Inspector
THE COMMONWEALTH OF MASSACHUSETTS
, MASSACHUSETTS
,Vioyveial *Vstera 10-11anstrurtion jhrrnit
Permission is hereby granted to
to construct ( ) or repair ( ) an On-site Sewage System located at
FEE
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her
duty to comply with Title 5 and the following local provisions or special conditions.
All construction must be completed within three years of the date below.
DATF
FORM 1255 Re�. 3/95 A.M. SULKIN CO. - BOSTON, MA
Approved by
V
TO" OF NORTH ANDOVER
SYSTEM PUMPINC RECORD
),OR 7 2003
'�O M OWNER & ADDRESS
�YSTEM LOCATION
(MMple: lef( from of hou�t)
1� p
-1,a4qL fS In re-av-
u-\TE 0 F PUMPINC:. QUANTITY I PUMPED 0 /� L L
NO YES SEPTIC TANK: NO YES
'�-\TURE OF SERVICE: ROUTINE 6"�EMERCENCY
COOD CONDITION- FULL TO COVEk
HFAVY CREASE BAFFLE'S IN PLACE
ROOTS LEACHFIELD RUNOACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER O�jHER (EXPLAIN)
�)T L'm P U M P C D 0 Y:
� UNI.M r N T S:
T) � A N S F E I Z I � ED TO:
US 2,7 S....'.
J I LJ
spo
Cos 0 qo\,N
E P h P r Q'� I d d 14.'fo`rm'f
o r u a o b Y 10cdl Boards of Health. The .3 t OM Pumping
be subml�e'd to thQ IQCAI'E30ard of Health or
CD y 0 0
other approving au(hQrSIY
ty,
A,, Fac Y.'InIoN,ation
I ------
Nin Qvt I..." 8Y$�m.L6,uUon:"'.'.
22
Addrm
L-� MOYO xQu.1 .
W-4 L6# I M.
X3 OM Okor,':
4'.
7-7-77-1 M
. .......
Rme,—
AW
9 zi
let_
of PUMPIng,
Quan�
jb ad:
J I LJ
spo
Cos 0 qo\,N
..........
7
CD y 0 0
L
'�M 1'.
ftrri#lnspec�
IIJ—i
CD Tight Tank
If yes, W83 N c'leaned? E) yes
SXI(em Pumping ROWM
z
Commonwealth of Massachusetts
City/Town of
ystem Pumping Record NORTH ANDOVER
Form 4
�1
1�ffl -7 ZU11
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 CIVIR 15.351.
5. Condition of System:
6. System Pumped By:
GQOW4
Name Vehicle License Number
Company
7. Location where contents were disposed:
Ipswich Water
Signatu�e-of—Ha6l�-r---"'Il-re-alffi-6ft":Iqa-n'U— Date
Signatwe--of—R—ecJe, QW)UPhl Date
t5form4.doc- 03/06 System Pumping Record - Page 1 of 1
A. Facility Information
Important:
When filling out
forms on the
1 . System Location:
Eq�5A a5lwt C
computer, use
only the tab key
to move your
Address
NocAb
C),
cursor - do not
Cityrrown
State
Zip Code
use the return
key.
2. System Owner:
?i
Name
Address different from location)
(if
City[Town
Z—i
p Code
Telephone Number
B. Pumping Record
1 . Date of Pumping 2.
Date
Quantity Pumped:
1500
Gallons
3. Type of system: Cesspool(s) [/Septic Tank Tight Tank
F1 Grease Trap
F-1 Other (describe):
4. Effluent Tee Filter present? 0 Yes [/No
If yes, was it cleaned?
0 Yes 2/No
5. Condition of System:
6. System Pumped By:
GQOW4
Name Vehicle License Number
Company
7. Location where contents were disposed:
Ipswich Water
Signatu�e-of—Ha6l�-r---"'Il-re-alffi-6ft":Iqa-n'U— Date
Signatwe--of—R—ecJe, QW)UPhl Date
t5form4.doc- 03/06 System Pumping Record - Page 1 of 1
L�- Commonwealth of Massachusetts RECIEWED
City/Town of
j,�'a 2 0 2013
System Pumping Record NORTH ANDOVE
TOWN OF NORTH ANDOVER
Form 4
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms ma—y5e usect, but Me
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 CIVIR 15.351.
A. Facility information
Important:
When filling out
forms on the
computer, use
only the tab Rey
to move your
cursor - do not
use the return
key.
dll-�
V� --�
1. System Location'.
Address
State Zip Code
Cityi i own
2. System Owner:
Name
)�d—dre��SiTf di ieiV iror� location)
own
6—tyrr
State Zip Code
Telephone Number
B. Pumping Record
/_5700
2. Quantity Pumpedi dallo—ns
e-14�1
1. Date of Pumping Date
3. Type of system: Cesspool(s) Pq-0-S3eptjc,Tank 0 Tight Tank, E] Grease Trap
n Other (describe):
4. Effluent Tee Filter present? Yes [?-T"No If yes, was it cleaned? 0 Yes El No
5. Condition of System:
6. System Pumped By:
Vehicle License Number
Company
7. Location where contents were disposed:
GI.S.D.-
-NOrthAndover, MA.
'§—gnZure of Hauler bate
-§ign,Tu-,�-�-f—R—ece--iving Facility Date
l5form4.doc- 03106 System Pumping Record - Page I of 1
COMMON*EALTH OF MASSACHUSE'ITS
ExEcuTivE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: J)?�3-S7- R?-Sl-lle?
IVOe WA)a',oaPPE,
Owner's Name: O/Vt 4,
Owner's Address:
Date of Inspection:
Name of Inspector4e;se IIA;—' C- ^-LO
, Zrint) �Jokj
Company Name:
Mailing Address:
Telephone Number !F
,_2
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:
"'o
VIPasses
Conditionally Passes
ee s er Ev luation by the Local Approving Authority
Fai
Inspector's Signature:
a1z__,,07 Date:
The system inspector sha�/ggbmit a copy of this inspection repoff to the Approving Authority (Board of Health or
DEP) within 30 days oQQ(hpleting this inspection. If the system is a shared system or has adesign flow of 10,000
gpd or greater, the insp66or 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 bu�prjf applicable, and the approving
authority.
Notes and Comments
""This report only describes conditions at the time of inspection and �r
time. This inspection does not address how the system will perform In the
conditions of use.
Title 5 Inspection Form 6/15/2000
page I
vo
'1--000
.�itions of use at that
under the same or different
V
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:J? 6,
Owner
: �/ re z
Date of Inspection:
Inspection Summary: Check A,B,CD or E / ALWAYS complete all of Section D
2 Passes:
�e 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 bvaluated: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 followinc, 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 c fitribution box! due to broken or
obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if (with approval of the Board of Health):
ND explain:
broken pipe(s) are replaced
obstruction is removed
i 4 - Page 3 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
04 Vrof-Zf Cj�-
Property Address: ,( /
,IV or '0C
Owner: alillez�
Date of Inspection:
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b) that the
system is not functioning in a manner which will protect public health, safety and the environment:
— Cesspool or privy is within 50 feet of a surface water
— Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the
system is functioning in a manner that protects the public health, safety and environment:
— The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
— The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
— The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passe� if the well water analysis, performled at a DEP certifiM laboratory;'f6r 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.
3. Other:
4�
Page 4 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: cV e. #00 �7 /jA0
00"01
Owner: — 0M e L.
Date of Inspection: 3 -,P
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or "no" to each of the following for all inspections:
Yes No
— �4peckup of sewage into facility or system component due to ovefl6aded or clogged SAS or cesspool
— T/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
,^esspool
::��iquid 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
��f times pumped
Aw 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.
�ky 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.
:�?�y portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compoirads
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.1
Al 6 (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as
described in 3 10 CMR 15.303. therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either "yes" or "no" to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
— — the system is within 400 feet ofa 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 nyapped
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
14yes" 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.
Page 5 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
14
Property Address:L-99 f,
' Zf-11 A&/57410
Owner: Ob"
Date of Inspection:
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
VNo %t
_ Pumping information was provided by the owner, occupant, or goard of iiealth
VWere any of the system components pumped out in the previous two weeks ?
V- Has the system received normal flows in the previous two week period ?
_I/Have large volumes of water been introduced to the system recently or as part of this inspection ?
-vowere 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 ?
o'0� Were the septic tank manholes uncovered. opened, and the interior of the tank inspected for the condition
th baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ?
Was the facility owner (and occupants if different from owner) provided with information on the p�oper
maintenance of subsurfac� sewage disposal systems ?
The size and 10"cation of ihe Soil Absorpt'ion System (SAS) on the S!i& 1�as be�n determined based on:
Yes no
Existing inforina lion. For example, a plan at the Board of Health.
Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [3 10 CMR 4 5.302(3)(b)]
0
Page 6 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Addressc�'/70' kl<7Vfle
I?Z
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: I "
A
Does residence have a garbage jinder (yes or no)�;' 11#1 11 1 �)'
Is laundry on a separate sewage system (yes or no): -S [if yes separate inspection required]
Laundry system inspected (y s or no):
Seasonal use: (yes or no))Vi
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump (yes or no): MP -
Last date of occupancy: I ed
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
Source of information: ��e 4-jor I C_
Was system pumped as part of the inspection (yes or no): ' le
If yes, volume pumped: gallons --How whs upt,)toy- p�unlped determined?
Reason for pumping: J�KJS(Re_gr'
TYPE SYSTEM
eeptic tank, distribution box, soil absorpticn system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Innovative/Altemative technology. Attach a copy of the current operation and maintenance contract (to be
�btained from system owner)
— Tight tank _ Attach a copy of the DEP approval
— Other (describe):
of all com Dnents, date installed (if known) and source of information:
e_Q 9
V ' /-I
Were sewage odors detected when arriving at the site (yes or no).&C-)
Page 7 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: C4 C- I ft
Owner: 0/%j i -e
Date of Inspection:
BUILDING SEWER (locate on site plan)
Depth below grade:
Materials of constru�-- iron 40 PVC other (explain):
Distance from private water supoly well or suctiohlline: 210
Comments (on condition ofjoints, venting, evidence of leakage, etc.):
SEPTIC TANK: i�41ocate on site plan)
Depth below grade:
Material of construcii�rete —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: 5-Ts-
Sludgedepth: -:r'v
Distance from top of slpdge to bottom of outlet tee or baffle:
Scum thickness: / " JAY
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottop�.of outlet tee or baffle:
How were dimensions determined-. /aOjo /AZ t? -5 -15 e -
Comments (on pumping recommendatiods, inlet ind outlet tee or baffle conditid'n, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.j-
71- a,( -.,7-z 4 7- 7-e-ev<, IA -1 Teno al
GREASE TRAP: _(locate on site plan)
Depth below grade:
Material of construction: —concrete __metal _fiberglass __polyethylene —other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Page8 ofil
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
0.
Property Address: r) ) t,' R57;(Ifie— C-1
"
Owner: 1,e
Date of Inspection:
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: _ 1
Material of constructiot concrete metal -4 fiberglass other(explain5
_�ipoly6$hylene _
Dimensions:
Capacity: gallons
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: jee(Oi0fop" resent must be opened)(locate on site plan)
Depth of liquid level above outlet invert:,&'Orpa J-4
Comments (note if box is level and distribution to outlets equa �,any evidence of solids carryover, any evidence of
1.
leakage into or ourof Dpx, etc.):
1*0 SQL&�� A-0 or PaPud1,,,!ic
PUMP CHAMBER*/
#(locate on site plan)
Pumps in working order (yes or no):
I
Alarms in working order (Yes or no)-'
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
4
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: 2Z Ja2vvyu c;
% /I/10
Owner:0.1vre c --
Date of Inspection: '1;=V17-6Pj
SOIL ABSORPTION SYSTEM (SAS): _ (locate on site plan, excavation not required)
If SAS not located explain why: !� i I I
Type
leaching pits, number:
leaching chambers, number:
leaching galleries, number:
a?'hing trenches, number, length:
Ieacching fields, number, dimensions:
overflow cesspool, number:
innovative/alternative system Type/name of technology:
Comments (note condition of soil, sips of hydraulic failure, level of 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 ififlow (yes or no.):, V0
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.):
r.
Page 10 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM'INFORMATION (continued)
17-1,0 Q'sn' C�, n
Property Address: z
Owner: 0 /,j I
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
wells witfiih 100 feet. Lobate where public Water shpply enterithe building.
benchmarks. Locate aq
Wo
off
10
Page 11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFkCE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address-q�?
% &IN)
Owner: i eK.
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate (check) all methods used to determine the high ground water elevation:
Obtained from system design plans on record - If checked, date of design plan reviewed:
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health -explain:
Checked.with local excavators, installers- (attach documentation)
Accessed USGS database -explain:
Youzyt descsrOe hpw you estaMshed the high ground Nater elevation:
jc>y / L_ /7�:r/7L-e 040 ^Z K.9
a
Town of North Andover, Massachusetts
BOARD OF HEALTH
,AOf?T)q 19-1—
KS CONSTRUCTION PERMIT
DISPOSAL WOR
—0
E
Applicant L Vu ALA)Kt�Zl
NAMt
Site Location 7
struct ��or Repair an individual Soil Absorption
Permission is hereby granted to Con
the Design Approval S.S.
Sewage Disposal System as shown on
,;;'� �CHAI�RMAN,�BORD�OFHEA�LTH
D.W.C. No.
F e e
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE: (OL � 1�6 — CURRENT INSTALLER'S LICENSE#
LOCATION: F 4-1—
LICENSED INSTALLER:
(50)
SIGNATURE: LEPHONE#
0 -7
CHECK ONE:
REPAIR: NEW CONSTRUCTION:
IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUr_LT.
Administrative Use Only
$75.00 Fee Attached? Yes No
Foundation As -Built? Yes No ob
Approval Date:
')OVER/
__70_WN 6V-
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