HomeMy WebLinkAboutMiscellaneous - 271 CAMPBELL ROAD 4/30/2018I
1p
C, Im
w m
—, --U—
�,ysu ) wn I I
Y",
1 p " N G RE C OJ3.D--i
FOPN 4 -SYS
Commonwealth of MassachUSet�s ins
'�-Y'\, Massachusells
ystenz Pum in Record I -T H IDF-
yslem ocation
3eH (CV
i
. Lq�787
!S�- 61
T- y pe Emergency Routine y
CCSSP( )1� yes C] S,.ptic Tartk: zr /
t Quantivy pumped:
Pumpin2:
Date (
SVS(el�. Pumped by (Company): ORACZEK).S.
I ---------------
Con�( is (rusfeacd io:
C,Nnt. iLs disposed ar
D
Pumper Sinanire
Con( ition of sysiei-TVoLher comments:
ki
C,N<b. to
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
City/Town of. d-- . . A- OV�?'
System Pu'mping Record
Form 4
RECEIVED
APR 15 2009
I TOWN OF NORTH �,NDOVER I
DEP has provided this form for use by local Boards of Health. Other . MOW the
informabon 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.
A. Facility Information
I.' System Location:
-- . 1-71 60,
Address
City/Town
2. System Owner:
LIN)
Name
Address (if different from location)
Cityfrown
B. Pumping Record
1. Date of Pumping
3. Type of system: E-]
El Other (describe):
— IRA
State Zip Code
state Zip Code
— 1_ q? Z_ 6.6� 3'.
Telephone Number
2-2/-O� 2. Quantity Pumped:
Date
/SM
Gallons
Cesspool(s) Septic Tank Tight Tank
4. Effluent Tee Filter present? E] Yes x No
5. Condition of
6. System Pumped By:
1VL
Name
Company
7. Location where contents were disposed:
If yes, was it cleaned? [] Yes E] No
Vehicle License Number
Date
t5form4.doc- 06/03 System Pumping Record - Page I of 1
Town of North Andover
Health Department Date.
Location:
(Indicate Address, if Residential, oAfame oo . �Business)
Check #:
T"e of Permit or License: (Circv
;-2�7 ��
> Animal $
> Dumpster $
> Food Service - Type._ $-
> Funeral Directors $
> Massage Establishment $
> Massage Practice $
> Offal (Septic) Hauler $
> Recreational Camp $
> SEPTIC PERMITS:
El Septic - Soil Testing $
El Septic - Design Approval $
El Septic Disposal Works Construction (DWO $
Q Septic Disposal Works Installers (E)WI) $—
> Sun tanning $
> Swimming Pool $
> Tobacco $
> TrashlSolid Waste Hauler $—
> Well Construction $
OTHER- (Indicate)
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
.7- .-
416
NEW ENGLAND ENGINEERING SERVICES
lk INC
February 6, 2006
Ms. Susan Sawyer
North Andover Board of Health
400 Osgood Street
North Andover, MA 0 1845
EIVED
FEB 0 7 200
To
WN N RTH AND VER
__H , EA DEPARTMENT
RE: TME V REPORT: 271 Campbeff Road, North Andover, MA
Dear Ms. Sawyer:
Enclosed is the Title 5 Report for the above referenced property. The system PASSES
the inspection.
if there are any questions please call me at my office, 686-1768.
Sincerely,
Benj n C. Osgo , Jr.
Certified Title 5 Inspector
60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099
I of
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 271 Campbell Road No. Andover 0 1845
Owner's Name: Chris Ritondo
Owner's Address: 271 Campbell Road No. Andover 0 1845
Date of Inspection: January 26. 2006
Name of Inspector: (please print) Benjamin C. Osgood, Jr. Certified Title 5 Inspector
Company Name: New England Engineering Services Inc.
Mailing Address: 60 Beechwood Drive North Andover, MA 01845
Telephone Number: 978-686-1768
CERTIFICATION STATENENT
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 fimction and maintenance of the on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section
15340 of Title 5 (310 CNM 15.000). The system:
Passes
Conditionally Passes
—Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: 0—=,, (,- /,5> -4 Date: :2)&)06
The system inspection shall submit a copy of this espection. report to the Approving Authority ( Board of Health. or DEP) within 30
days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and
the system owner shall submit the report to the appropriate regional office of the DER The original should be sent to the system
owner and copies sent to the buyer, if applicable, and the approving authority.
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.
2 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 271 Campbell Road No. Andover 01845
Owner'sName: Chris Ritondo
Date of Inspection: January 26. 2006
Inspection Summary: Check A, B, C, D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 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:
1v,j One or more system components as described in the "Conditional Pase 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,NND) in the for the following statements. If "not determined" please explain.
—The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits
substantial infiltration or exfiltration or tank failure is imminen . System will pass inspection if the existing tank is replaced with a
complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the
tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health):
Broken pipe(s) are replaced
Obstruction is removed
Distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if
(with approval of the Board of Health):
—Broken pipe(s) are replaced
Obstruction is removed
ND explain:
3 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 271 Campbell Road No. Andover 0 1845
Owner'sName: Chris Ritondo
Date of Inspection: January 26. 2006
C. Further Evaluation is Required by the Board of Health:
NO — Conditions exist which require ftuther 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 (SAS) Soil Absorption System and the (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 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 organize compourids 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 5ppm, provided that no other failure criteria are
triggered. A copy of the analysis must be attached to this form.
3. Other:
4 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 271 Campbell Road No. Andover 0 1845
Owner's Name: Chris Ritondo
Date of Inspection: January 26. 2006
D. System Criteria applicable to all systems:
You must indicate "yes or No" to each of the following for all inspections:
Yes No
%1� Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
t-- Discharge or ponding of effluent to the surface of the ground or surface waters due to an overload or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overload or clogged SAS or cesspool
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2day 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 SAS, cesspool or privy is below high ground water elevation.
Any portion. of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. ( this system passes if the well water analysis, performed at a DEP certified laboratory for
colfform bacteria and volatile organic compounds indicates that the weH is firee from pollution from that facility and the
presence of ammonia nitrogen and nitrogen is equal to or less than 5ppm, provided that no other failure criteria are
triggered. A copy of the analysis must be attached to this form.)
A/ 0 - (YestNo) The system fails. I have determined that one or more of the above failure criteria exist as described in
3 10 CNM 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be
necessary to correct the fitilure.
E. 1,arge 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 "yee' 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 in 400 feet of a surface drinking water supply
The system is within 200 of a tributary to a surr . ing water supply
system is located in a nitrogen e area (interim Wellhead Protection Area — IWPA) or a mapped Zone R
of a public water supply well
If you answered "yes" to any que§ticd—m Section E the system is consider�mignificant threat, or answered "yes" in Section D above
the large system has fa@�e owner or operator of any large system consi er&I-Asigaificant threat under Section E or failed under
Section D s4j�a e the system in accordance with 3 10 CMR 15.304. The system-bw�ould contact the appropriate regional
office of the Denartment.
5 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 271 Campbell Road No. Andover 0 1845
Owner's Name: Chris Ritondo
Date of Inspection: January 26. 2006
Check if the followinz have been done. You must indicate "Yes" or "no" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health
Were any of the system components pumped out in the previous two weeks-?
V/ 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 an 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 sign of break out9
Were all system components, excluding the SAS, located on site?
Were all 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 fitcility owner ( and occupants if difference from owner) provided with information on the proper
maintenance of the subsurfiLce sewage disposal systems9
The size and location of the Soft Absorption System (SAS) on the site has been determined based on:
Yes No
Existing information. For example, a plan at the Board of Health.
Determined in the field (if any of the fitilure criteria related to Part C is at issue approximation of distance is
unacceptable) [3 10 CMR 15.302(3)(b)]
6 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 271 Campbell Road No. Andover 0 1845
Owner'sName: Chris Ritondo
Date of Inspection: January 26. 2006
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design)__�:__ Number of bedrooms (actual):
DESIGN flow based in 3 10 CMR 15.203 for example: I 10 gpd x 9 of bedrooms):
Number of current residents:
Does residence have a garbage grinder (yes or no): _�A C�'
Is laundry on a separate sewage system (yes or no): Al 0 [if yes separate inspection required]
Laundry system inspected ( yes or no): —
Seasonal use: Cyes or no): 1yo .
Water meter readings, if available Oast 2 years usage (gpd): ZC,5- &FP I #'j
Sump Pump (yes or no): !3 j� �, .
Last date of occupancy__LLLLt,-�-
COA01ERCIAL/MUSTRIAL
Type of establishment:
Design flow (based on 3 10 CNIR 15.203): gpd
Basis of design flow (seats/persons/sqt 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: M 0 A, -FH -�, VC: - I'Z 0 I-V X9� �2-
Was system pumped as part of the inspectio� (yes or no): A10
If yes, volume purnped-.________gallons — How was quantity pumped determined?
Reason for pumping:
T!-�� 0-�' ti -0
TYPE OF SYSTEM
Septic tank, distibution box, soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from
system owner)
Tight tank Attached a copy of the DEP approval
Other (describe):
Approximate age of all components, date installed (if known) and source of information:
�� ,-) I L;-,— lq5c-
Were sewage odors detected wen arriving at the site (yes or no): A/2 .
7 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 271 Campbell Road No. Andover 0 1845
Owner'sName: Chris Ritondo
Date of Inspection: January 26. 2006
BURDING SEWER (locate on site plan)
Depth below grade: 12- "
Materials of construction: -"" cast iron 40 PVC other (explain)
Distance from private water supply well or suction line: Al �It'
Comments (on condition ofjoints, venting, evidence of leakage, etc.):
V) i'c I -Z-0 V--,, &-Co-o� I AJ 13 ft-&&I'A e -A -j-1
SEPTIC TANK: (locate on site plan)
Depth below grade:
Material of construction: concrete—metal—fiberglass _polyethylene
Other
If tank is metal list age: Is age confirmed by a Certificate of Compliance (yes or no): a copy of certificate)
Dimensions: 1,5oo &ft t- L-0 AJ
Sludge depth: -:?>
Distance fivm top of sludge to bottom of outlet tee or baffle:
Scum thickness:,
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle 1-1
How were dimensions determined: lincAsog-e- ,--n c V,
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet
invert, evidence of leakage, etc.):
A) L/rc- 0 CIO "-rr-> I 1'\ 0 A, co z'y-t 6 1
GREASE TRAP: Al (locate on site plan)
Depth below grade:
Materials 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 sludge 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.
8ofll '
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 271 Campbell Road No. Andover 01845
Owner's Name: Chris Ritondo
Date of Inspection: January 26. 2006
TTGHT OR HOLDING TANK (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Materials of construction: concrete metal fiberglass other
(explain)
Dimensions:
Capacity: gallons
Design Flow: gallonstday
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- (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert- 0 '
Comments (note if box is level and distribution to outlets equal, any evidnence of solids carryover, any evidence of leakage into or
out of box, etc.):
P-, 0'X ( f'/ 0 V, e 0 tj 1> - TwN " , g t.�- e--,z--s cu ) 6 (—\ F
&-1Z Fr D G- O -D D ED OS ro<-7-1 or I All -C P F -C-7-7 0 �v
PUMT CHAMBER: A� 11 A (locate on sire plan)
Pumps in working order (yes or no)
Alarms in working order (yes or no)_.
Comments (note condition of pump chamber� condition of pumps and appurtenances, etc.):
90f1l *
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 271 Campbell Road No. Andover 0 1845
Owner's Name: Chris Ritondo
Date of Inspection: January 26. 2006
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not reg
If SAS not located explain why
TYPE
leaching pits number
leaching chambers, number
leaching galleries number
leaching trenches, number in length
leaching fields, number, dimensions:
overflow cesspool, number:
innovativetalternative system Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, Level of ponding, damp soil, condition of vegetation, etc)
01f P J-73 ;--0 6),V, Ajo k^ -q 4 '-
CESSPOOLS: Alli4 (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: —41J-1-0ocate on site plan)
Material of construction:
Dimensions:
Depth of solids
Comments (note condition of soil signs of hydraulic failure, level of ponding, condition of vegetation, etc.
100f 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 271 Campbell Road No. Andover 0 1845
Owner's Name: Chris Ritondo
Date of Inspection: January 26. 2006
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.
11,0f11 ,
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner's Name:
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
271 Campbell Road No. Andover 01845
Chris Ritondo
January 26. 2006
Estimated depth to ground water feet
Please indicate (check) all methods used to determine the high ground water elevation:
v-- 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 excavator, installers — (attach documentation)
V- Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
6,j�-re VVA e -,-
t J9
P.T-5
F C,
4��t- AS 13 wc 14, 16e, i-0 +5b--iTb A� 0 F'1 7 -S
O� i-ORTH ANJG .1/
pr6f—) SIF HEACM
TO" OF NORTH ' ANDOVER NOV - 4 f2C%02
SYSTEM PUMPING R-ECORD
OWNER & ADDRESS I SYSTEM LOC.ATION
(mimpit: lef( from or hou�t).
r OF PUMPINC�- QUANTITY PUMPED 150-�
�Si'00L: NO YES SEPTIC' TANK� NO
OF SERVICE: ROUTINE EMERCENCY
)H�FRV,:\TIONS:
COOD CONDITION
HFAVY CREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
-�� -) I L'm PUMI)CI) BY
., ;j �) M F N T S:
U *� 1 I -,'N 1'� TRA N S F E R R E D TO:
FULL TO COVEI�
BAFFLES IN P1 - , A C I"
LEACHFIELD
FLOODED
O�HFR (EXPLAIN)
��, 1� lle,14 t / � , — - ---z
-OCT
To
OF. 3200,
01M
NORTH AND ER
sysprM
Mot'
A
..... . . . . . .
j tv, M
I f, -!i' 4. o
do
SYSTEM 7LUCATIO
-fMat of houn)
/00,
W.0
." 740
QVANTM PUWED
GALLONS
o
............... ..............
C TANX: NO
YES
...... ...... -v
CakGgNCY
. . . . . . . . . . ........
TO CovzR
LAMM IN PLACE
saw
LEACHFIELD RUNBACIC
CARRYOVXR"mm"""!.*
FLOODED
EXPLARO'
"ITA? 4J.;. 4�;
-,A 4
ip
&
LI
W -01A 7R.
Vi
fj: 91,:0-19 A'A"IP
fin^
-TIVI
NEW ENGLAND ENGINEERING SERVICES
lk INC
North Andover Board of Health
Town Hall Annex
27 Charles Street
North Andover, MA 0 1845
RE: TITLE V REPORT: 271 Campbelll Road, North Andover, MA
Dear Sirs:
September 23, 2003
Enclosed is a copy of the Title V report for the above referenced property. The system PASSED
our inspection.
If there are any questions please call me at my office, 686-1768.
Sincerely
B4a n C. (Osgooe, Jr.
60 BEECHWOOD DRIVE -NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645- FAX (978) 685-1099
COMMONWEALTH OF MASSACHUSETTS
ExECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: ,;Z I I C -Am? eg,-. R-,;:>
Owner's Name:
Owner's Address:
Date of inspection:
Name of Inspector: (please print) -Benjamin C. Osgood, Jr.
CompanyName:New England Engineering Services Inc.
Mailing Address: 60 Beechwood Drive, --
ljorth Andover- MA 01945
Telephone Number: 978-686-1768
03 -7?
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 fitriction 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:.
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: —3— C 0--,, 1 Date: q/.tC//`;-3
The system inspector shall submit a copy of this inspeZion report to the Approving Authority (Board of Health or
DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shalt submit the report to the appropriate regional office of the
DEP. 1he 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.
Page 2 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: Z -7 C AAj e p
,>ELL_ -o
Owner:
Date of Ins 11: q) 1q) --� 3
Inspection Summary: Check ABCD or E / ALWAYS complete all of Section D
A. . System Passes:
have not found any information which indicates that any of the fitilure criteria described in 3 10 CMR
15.303 or in 3 10 CMR 15.304 exist. Any Witure 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 . epla or
r%='e& 1he system, upon completion Of the replacement or repair, as approved by the of Health, will pass.
Ansver yes, no or determined (YNND) in the for the following AM= If "not determinecr please
t erm
explain -
The septic tank is m and over 20 years old* or the septic tank (whether metal or not) is structurally
it trat.
ibi st i
unsound, exhibits tsubstantial on or exfiltration or tank fitilure 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 inspedign if it is structurally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 y�s old is available'.
ND explain:
Observation of sewage back-up orU;i�k oui\or,�igli static water level in the distribution box due to broken or
bb�—cted pipe(s) or due to a brokensldided or uneven -di*ibution box. System will pass inspection if (with
approval of Board of Health): z
broken pipe(s) are rep
'a
obstruction is removed
distribution box is leveledd o"r rep�la
ND ext)lain: Z
(Me system required pumping more than 4 times a year due to broken or ot;�tructed pipc(s). 1he system will
pass inspection if (with approval of the Board of Health): 7
broken pipe(s) are replaced
obstruction is removed
ND explain:
Pagel of it
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENT9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: P- -7 1 C 4,%,,, p 13 CLj- pp
Owner: pHJJ
,T
Date. of Inspection: q. Q--;;
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require fiirther evaluation by the Board of Health in order to determine if.tl�e' system
is - failing to protect public health, safety or the environment.
L 'SP, tem will pan unless Board of Health determines in accordance with 310 CMR 15:303(l)(b) that the
4;4eml. is not functioning in a manner which will protect public health, safety and'ihe environment:
— Cessl)001 or Privy is within 50 feet of a surface water / /
— CesSP061,,0r Privy is within 50 feet of a bordering vegetated wetland or -salt marsh
2. System will fail unless the BQ�W of Health (and Public Water Supplier, if any) determines that the
system is functioning in a manner thitfrOtects the Publkiealth, safety and environment:
— The system has a septic tank and
Surface water supply or tributary to a!
- The system has a septic tank and
— ne system has a septic tank
di system (SAS) and the SAS is within 100 fed of a
supply-
is within a Zone I of a public water supply.
and the SASJs within 50 feet of a private wate . r supply well.
I
— The system has a septic tank and SAS and the SAS is fess than 100 feet but 50 feet or more from a
Private water supply well",1Aethod used to determine distw6e
"This system passes if the Well water analysis, performed at a DEP certified laboratory, for coliform
bacteria mid volatile-6rganic; 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 criter 'are triggered- A copy of the analysis must be attached to �'
'ja ffii�.form.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address; - 2.71 C/+A4 P '�, Ff- L
Owner:
:ToYtO
Date of Inspection: ef I Lcjjz� I
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or "no" to each of the following for Ell inspections:
Yes No
-.I::f Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the groutid or surface waters due to an overloaded or
.clogged SAS or cesspool
Static liquid level m 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
Required pumping more than 4 times in the last year ?j0T due to clogged or obstructed pipe(s). Number
of times pumped
Any portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion of cesspool of 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. Rlis 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.]
AIJ (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 (5M—R- 15.303, therefore the system fitils. 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 mustlidlicate either "yes" or "noP to each of the following:
(The followmjb#j�ia apply to large systems in addition to the criteria above)
yes no.
— — the system is within
— — the system is within 200 feet
of a surface drinking
a surface drkddng water supply
the system is located in a nitrogen sensitive (Interim Wellhead Protection Area - IWPA) or a mapped
-'br tl im
Zone 11 of a public.waier supply well
tem
consid'
If you have ans "yee' to any question in Section E the system considered a significartt threat, or answered
V�ves 0 or or 4
W� F! 1) a ra e
"yes" in S 'on D above the large system has failed. The owner or " r of any large system considered a
significant threat under Section E or failed under Section D shall upgrad system in accordance with 3 10 CNIR
15.304. The system owner should contact the appropriate regional office of the'Department.
Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: - a 71 eAmP 06LL (1b
0 MT14 A^)000evt
Owner:
Date of Inspection:
Check if the E01192*9 have been done. You must indicate "yef or "noP as to each of the following:
Yes No
— PumPinginfOrmation was Provided by the Owner, occupant, or Board of Health
ZWere any of the system components pumped out in the previous two weeks
Has the system received normal flows in the pr evious two week period ?
100" Have large volumes of water been introduced to the system recently or as part of this inspection ?
Z Were as built plans of the system Obtained and examined? (If they were not available note as N/A)
v**'00- Was the fitcility or dwelling fiLTected 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 ?
vo'- Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition
-�Rhi�-aiffles or tees, m aterial of construction, dimensions, depth of liquid, depth of sludge and depth of scum 7
- vo'- — 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 Son Absorption System (SAS) on the site has been determined based on:
Yes no
v -f Existing information. For example, a plan at the Board of He a*1th.
— ±:!!�' Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [3 10 CMR 15.302(3)(b)]
Page 6 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 7- '11
J009 -pt Awpo�.ee�'
Owner: ji -Ij
Date of Inspection: ----
RESIDENTIAL FLOW CONDITIONS
Number of bedrooms (design): Number of bedrooms (actual):
DESIGN flow based on 3 10 CMR 15.203 (for example: 110 gpd x #of bedrooms):
Number of current residents: q
Does residence have a garbage grinder (yes or no): qe
Is laundry on a separate sewage system (yes or no) �
lAundry system inspected (yes or no): — 1v 0 [if yes separate inspection required]
Seasonal use: (yes or no)- A/,;p
Water meter readings, if available Oast 2 years usage (gpd)):
Sump pump (yes or no):
List date of occupancy:
COMMERCIALIINDUSTRIAL
Type of establishment:
Design flow (based on 3 10 CMR 15.263): gpd
Basis of design flow (seats/persons1sqketc.):
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:
OTIIER (describe):
Pumping Records GENERAL INFORMATION
Source of information: I �je.-,t ct!50 Pet- e)'-ne'a
Was system pumped as part of the ��ion (yes or no):A.40—
If yes, volume pumped: ---gallons — How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic ta* distribution box, soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
InnOvativeJAItemative technology. Attach a copy of the cment operation and maintenance contract (to be
obtained from system owner)
Tighttank Attach a copy of the DEP approval
Other (describe):
Approximate age of all components, date installed (if Imown) and source of information:
Were sewage odors detected when arriving at the site (yes or no): /t/O
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: 7- 7,1 C-A'VlrbtFi�t-
100 0-714 X- 0 oj�E-
Owner. :77-0 dAl Q I 5,T15 -F AWD
Date of Inspection: -Ilig/14r,
'BUILDING SEWER 0ocate on site plan)
Deptk below grade: (72'
Matdi& of construction: _V cast iron 40 PVC o&er ('explain):
Distance from private water supply well or suction line:
Comments (on condition ofjoints, venting, evidence of leakage, etc.):
t L-4z)c) jj"� &,cjo v' I -P -a 4 -C �C'A. (� ^;T
SEPTIC TANK: — (locate on site plan)
Depth below grade:
Material of construction: voconcrete metal —fiberglass polyethylene
If tank is metal list age: Is age confirmed by a Certificate of Compliance (yes or no): (attach a copy of
certfficate)
Dimensions: _57-C) &AL'L-0?j
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thicktiess; r
Distance from top of Scurn to top of outlet tee or baffle:
'Distance from bottom of scum to bottom of outlet tee or baffle: A
How were dimensions determined: -4,t C' -A.5 L/ Itzi -1 ), r e -e'
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
A, ,./ &0 0 C 0.'j P 01-2 L) t\). --xc r e-
a -I)o �Ike
GREASE TRAP:/D"ocate on site plan)
Depth below grade:
Material of construction: —concrete metal _fiberglass
(explain):- other
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: .9--7t
Owner: P,-, a-Tve
Date of ins
11GHT or HOLDING TANK.. 1�6q (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: _
Material Of construction: concrete metal fiberglass ----polyethylene ____9ther(explain):
Dimensions:
Capacity- gallons
Design Flow: gallions/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.):
DIMMUTION BOX: — (if Present must be Opened)(locate on site plan)
Depth of liquid level above outlet invert
Comments (note if box is level and ' —
leakage into or out of box, etc.): distribution to outlets equal, any evidence of solids carryover, any evidence of
10vo
-L-stpe,tuc- C>jQ'
PUMIP CHAMBEIL- 1Vj9 (locate on site plan)
Pumps in working order (yes or no):
Alarms in working order (yes or no):
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Page 9 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: Z-1 I c Am o ig
Owner,.
Date of Inspection.:
SOIL ABSORI'TION SYSTEM (SAS): — (locate on site plan, excavation not required)
If SAS not located explain why:
Type leaching . pits, number: 3 5 �i , .
leaching chambers, number:
leaching galleries, number:
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:
innoyativetalternative system TypeJname of technology:
�=ents (note condition Of soil, signs Of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
- #W– "--6 0 F�
CESSPOOIS: A�A-(Mspool must be pumped as part of inspectionXiocate 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: _/Vk(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.):
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: 7-71 e6mP0C(-L- RAO
�jo "I
Owner. -1 Wkl D 15 —iE-FO " o
Date of Inspection: !YL/e/o-s
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.
Page 11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: Z7 I C z,�,
P o a1l-e Aej:�-> c:>,j rA
Owner: "FOHN i�->js—IrF4�vo
Date of Inspection: q//2�Los
SUE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 6 feet
Please indicate (check) all methods used to determine the high ground water elevation:
v" 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-explam:
Checked with local excavators, installers- (atGc-h —documentation)
oZAccessed USGS databaso-explain: _
You must describe how You established the high ground water elevation:
I
V1 LF j? agaue-
V-S C- 5 AA IAJDIC#q T
)9-�E4,s I " r�e,,- -v & pzoj^l
..
13 a7fi) e%4 0/- P 11-3
(D
0 -0
(D
u
0
En
CD
M
El
-V
cu
LC
0
> 0 a
0 0)
ei ry
(D
h
a lcoLmo
(D
0 -0
(D
u
0
En
CD
M
El
-V
cu
LC
0
... ... ...
12 -� 0 -,9 S-
ZO
I
BOARD OF HEALTH
No.Andover, maz;s.
APPROVED DATE
Provided:
SUBSURFACE DISPOSAL DESIGN CHECK LIST
DISAPPROVED
Reasonsi
5
.5VW6
DATE
LOT #
TU/77�
Title V An
F
Reg 2.5 The submitted plan must show as a minimum:
a) the lot to be served-area.,d1menBions lot # abutters
—'b location and log deep observation Mes-dis*tance to ties
_�c location and results percolation tests -distance to ties
di design calculations & calculations showing required leaching area
'(e) location and dimensions of system -including reserve area
(f) existing and proposed contours
(g) location any wet areas Athin 1001 of sewage disposal system or
. disclaimer -check wetlands mapping
(h) surface and subsurface drains within 1001 of sewage disposal
system or disclaimer
(i) location any drainage easements vithin 1001 of sesage disposal
system or disclaimer -Planning Board files
(J) kno-,= sources of water supply within 200t of sewage disposal
system or disclaimer
(k) location of any. proposed well to serve lot -1001 from leaching facility
(1) location of water lines on property -101 from leaching facilit7
'(m) location of benchmark
'(n) driveways
_(o) garbage disposals
(p no PVC to be used in construction
'(q) profile of system- el evationa of basement., plumb., pipe,, septic tank,,
distribution box inlets and outlets., distribution field piping and
othei elevations
(r) maAmam ground water elevation in area sewage disposal system
___�(s) plan mast be prepared by a Professional Engineer or other
professional authorized by law to prepare such plans
Reg 6 Septic Tank.
(a) capacities -150% of flowp water table., tees., depth of tees.,
acceBs., punping
(b) cleanout
c) 101 from cellar vall or inground sulmming pool
1(d) 251 from subfrurface drains
Reg 10.2 Distribution Boxes
I 1(�a) slope greater �U= 0.08
Reg 10.4
J(b) suM
Boa.4. of �Health. -
North And.o_ver,M."S.
APPRovED DATE
Reas.onst
OK
5ZMC SISTEH
INSTAILATICK CHBCK LISr
2
LOT"
-'ffX(,'AVA
1. Distance Tot
a. Wetlands
b. Drains
C.. well
2. Water Line Location
3. No PVC Pipe
4. Septic Tank
a. -Tees �-_Length & To Clean Out Covers
b. Cement Pipe to Tank - On Both Sf&es of Tank
5. Distribution Box
a. Covers & Box - No Cracks
b. All Lines Flo-Ang Equal Amounts
c. No Back Flow
6. Leach Field or Trench
a. Dimensions
b. Stone Depth
a 0, Capped Eads
d. Clean Double, Washed Stone
7. Leach Pits
a. Dimensions
b. Stone Depth
c. Splash Pads
d. Tees
e. Ceirrant Pipe to Pi t Both Sides
f . Clean Double Washed Stone
8. No Garbage Disposal
9. -Anal Grading Inspection
10. Barricading Covered System
11. As Built Submitted
a. Lot Location
b. Dimensions of System
c. Location with Regard -to Pere Test
'd. Elevations
e.* -Water Table
- 1 7 -
OK FAI
A
v
—S86[ -r-g—L 4jpnjq5j uo
JO/�@A,AnS fiPW4bL[j
J@@ULbu3
JUPDL[ddV
/,ql[P@H 40 PAeoq
PJPOO 5ULuuQ[d :DD
WgIdl 31OV3 3DN3�MVJ @q4 UL @Duo und
UPWJLeqo
,PU5PA[29 -V :Aq
.4U8W4ULoddP 4q jo Wd
00:� 04 uov 00--;,L woAj /�epsanj uo VW ',A@AOPUV qlAON '4@aJqS ULPW O�L
'6ULPLpq UMOJ ;aDLIJO UOLSS�WWO3 UOL42AJDSUOJ aq; qP @LqPL�PAP @JP suPLd
-auoZ ja44nq aqq UL bupeAbaj
PUP 'swD47, Lpsodsp fijp4pps buM24s4 4o E)soajnd aq4 jol sPqPL4am
,M�4P4@ bu�jaqLp 'SPUPLIEW E)A�4p4ab8A SSOJOP SfiPM@ALjp UOWWOD bUL
-LLe4SUL '(LPL4U@P�SGJ aLbULS) S40L ZE 04 SSaDOP @P�AoAd o4 sAemppoi
oml buponj4suoD jo sasodind aq4 jo4 E)ALAa uppIsanU3 PUP @[DJL)
PLUOOPI 4P PUPL J@4LP 04 �MUUej WPL
LL�M PUP E)P�H q4aUt�@N
:SJaUMO 'fi4Lead Sa4eLOOSSV S@4P;s3 UeLJ4sanb3 40 4ua4uI 40
aOL40N aq4 uO VW 'JaAOPUV q4JON '4@aA4S ULPW OZL 'Wood 6UL4@@W
bULPLpg umol aq; qP 'W'd 00:8 4e S86L 102 �jenjqaj uo
UOL4pnUL4UO3 6ULJPaH DLLqnd e PlOq Mm UOLSSLWWO3 UOLIPAJaSUO) J@AOPUV
aq; Imel fiq UOL40@4OJd PuPL;@M S,J@AOPUV q;JON 40 umOl aq4 PUP
'PAOUMP SP 'Ot UOLIO@S 'M ja;deq) SmPI LeJauaO sq4asnqoess?W
'4-'' UOL4:)a4OJd, sPuPL4aM aq4 so k4poqqne aqq ol quensAnd
NOISSIW"'OD NOIiVAd3SNOO
JO 3DIJJO
S113snHDVSSVW 'd3AOGNV HIHON JO NMOI
SOIL PROFILE LPERC21ATION tSST DATA
Town/Cj-4��We- — No.&Street
Lot No. 2
Loc./Subdiv. pi a Owner
- —*z
Observer_
SOIL.-P92F;US-DATE
Elev. Elev. J* Elev. 4 l-Elev.
0 fl -4 Z! 0
0 0
2 2 2
3 3 3
4 4
1
2
3
4
5 5 5
6 6 6
7
7 7
8 --8 -8
9 9
10
10
0 10
Benchmark Location
'Elevation Datum
Percolat4on..Tests-Date
--M/7 7
P it Number
1 2 3 4 5
S tart -Saturation ..
Soak-mlins.
.. .......
Start'Test-Time
Drop of 311 -Time
DrOP of 611 -Time'
Mins. lst -Y'Dro—
p
Mins.2nd 3"Dro,p
'.D&ez(;nes on bacK F k C
e
�,n -.�elinas & Associates, North And.
C�4
all
VA
V) � I
r-
rv-
i9i
N -N 4�
q
% Nr -
i I
ct
ba
IL
Tw
AN
17t
cj!
tk
zz V:� A
,qqi *:�k Qi
(ZS
ta
0
IV
"R- -4
4Q1
i I
ct
ba
IL
Tw
AN
17t
cj!
tk
zz V:� A
,qqi *:�k Qi
(ZS
ta
0
5),
to
riew
f
i
LINI
ILI
f0000
C,
-Ar
Vol,
Nt
ItV
74
-e. i. I.— U. :a
�t Ui
13
0
3
0
or
44
If
Lf-
,ey ct
%3
19
ir
do
f
i
LINI
ILI
f0000
C,
-Ar
Vol,
Nt
ItV
74
-e. i. I.— U. :a
�t Ui
to
Au
13
0
3
0
or
44
If
Lf-
,ey ct
to
Au
If
Lf-
%3
19
ir
It <r
rz
S7� P
CZ�
QN
7,p
'�- -'V — -\ I
Julius Kay, M.D., Chairman
R. George Caron
Edward J. Scanlon
BOARD OF HEALTH
NORTH ANDOVER
MASSACHUSETTS
01845
Mr. Richard Zielinski
326 Canpbell PA - .
No.Andover, Mass.
Dear Mr. Zielinski:
Nov 14, 1977
ORTH
01 4-c
0
SACHIJ5
TEL. 682-6400
Re: Lot 2 Cam, bell Rd.
An exc ation-inspectIon-on-Lot 2 CaM Rd.._wa.s-
be] 1
made by Leonard Philj:1p2 of this—qf fice qn-.noXe el�- ., 1 �3 .
p]k 7 _ 9 -7._
At the time of this inspection., it was noted that crushed stone
had been installed.
Inspection on-November-ll,-�9 U
-77-indicatedjha�_the
entire si�e-had-been, backfilled., but no final inspection of the
RE arface sewage disposal system could be made. NTithout this
inspection, the entire system is in violation of Title 5 of the
State Environmental Code and the No. Andover Regulations for Soil
Absorption Sewage Disposal Systems. Furthermore, no occupancy
permit from the building inspector shall be issued. ,
The entire system shall be uncovered of all soil
and 3-e-. inch crushed stone to permit an inspection of the perforated
pipe in the absorption bed., the distribution box and the septic
tank. Upon coirpletion of this work., the Board of Health shall be
notified so a final inspection can be made.
Very truly your
O�
Leonard E. Phillips, Engineer
No -.Andover Board of Health
mj
cc: Bldg Insp
King Sewer Service
Julius Kay, M.D., Chairman
R. George Caron
Edward J. Scanlon'
BOARD OF HEALTH
NORTH ANDOVER
MASSACHUSETTS
01845
Mr. Richard Zielinski
326 Cpxpbell Rd '.
No.Andover, Mass.
Dear Mr. Zielinski:
Nov 14, 1977
"ORTH
0
's SA
TEL. 682-6400
Re: Lot 2 Cam. bell Rd.
An excavation inspection on Lot 2 Campbell Rd. was
made by Leom�rd Phillips of this office on November 7. 1977.
At the time of this inspection, it was noted that crushed stone
had been installed.
Inspection on November 11., 1977 indicated that the
entire site had been backfilled., but no final inspection of the
subsurface sewage disposal system could be made. Without this
C,
inspection., the entire system is in violation of Title 5 of the
State Environmental Code and the No. Andover Regulations for Soil
Absorption Sewage Disposal Systems. Fkirthermore,, no occupancy
permit from the building inspector shall be issued. I
1 The entire system shall be unco-vered of all soil
and e- inch crushed stone to permit an inspection of the perforated
pipe in the absorption bed, the distribution box and the septic
ttlank. Upon completion of this work, the Board of Health shall be
notified so'a final inspection can be made.
Ve truly your,
ry u'r
Leonard E. Phillips, Engineer
No.Andover Board of Health
mj
cc: Bldg Insp
King Sewer Service
NORTH A-hTXV-M BO�_RD OF MMTH
iNSTAULA'.11TON CHEFfK LTST
APPROVED DI SAPPROV ED
Date:- Date:
Reason:
3
1. BUlt Submitted
Check: Lot location., dimensi ons of system, location in regard to
percolation tests., depth of system, i.,rater table
EXCAVATION OK
2. Distance to Wetland Areas, Drains., Street & House, Drainage Easement and Wells.
3. Water Line Location
4. (NEo PVC Pipe
ipe
5. Septic Tank - Tees., Cement -Pipe to Tank -Joints on bo
4A4
6. Distribution Box - No cracks in box or cov r. all lines flow equally from box.
7. Leach Fields - Dimensions, Stone Depths, Capped ends., Clean double -washed stone
8. Leach Pits - Dimensions, Depth of Stone, Splash pac�tees) Cement -pipe toltank-
joints on both sides of tank-, Clean double-i%rashed stone
13
9. No Garbage Disposals
10. Final Grading k'�'barricading of sub -surface system.)
14�4�
................
12—
a
tAORTH
"'.0 ,
BOARD OF HEALTH
Julius Kay, AD'., Chairman 0
NORTHANDOVER
R. George Caron
MASSACHUSETTS
Edward J. Scanlon
01845
"�SA US
TEL. 682-6400
January.10., 1978
1
Mr. Wil I iam King
King Flexible Sewer Service Re: Lot 2 Campbell Rd.
2 Conte Drive
Methuen, Mass
Dear Mr. King:
Due to your failure to appear before this Board as
requested on January 9. 1978 " this Board voted to not renew your
Disposal Works Installer Permilt,, or your perriat to transport Offal
until the violations on Lot 2 Campbell Rd are corrected. The vio-
lations are as follows:
1. Systet was covered before final inspection by
this Boa -rd.
9. Entire system was covered before final inspection
by the designer.
3. FVC pipe was used in the installation.
4. The system is too close to the house.
The owner of this house cannot be issued an occupancy
permit until this system has been corrected and approved.
Very,truly yours,
R.George 2ron
Acting Chairman
1p;mj
cc: Owner R.Zielinski
Building Inspector 111017 F
1-f �/
J,
110 40RTil
BOARD OF HEALTH
Julius Kay, M.D., Chairman 0
NORTH ANDOVER #
R. George Caron
MASSACHUSETTS
Edward J. Scanlon
o
01845 o
CHU
TEL. 682-6400
December 20, 1977
Mr. William King
King Flexible Sewer Service
2 Conte Drive
Methuen, Mass.
Dear Sir:
Re: Lot 2 Campbell Rd.
According to our records the sub—surface
sewerage disposal system on the above—mentioned lot is in violation
of Title V of the State Sanitaxy Code and the North Andover Rules
and Regulations for Sewerage Disposal Systems. The violation pertains
to the following:
1. The system was covered before final inspection was made by this
office.
2. The entire system was covered before final inspection by
the designer. p
3. PVC pipe was used in the installation.
4. The system is too close to the house.
I L You are hereby ordered to appeax before this
Board at a heaxing,on January 9, 1978 at 6:45 P -M- to show good and
sufficient reasons as to why the above—mentioned violations occurred
and why the Board of Health should not revoke your Disposal Works
Installer's Permit.
1; mj
cc: Richaxd Zielinski
Building Inspector
- Ae_,�e
Very truly yours,
Julius Kay, M.D.
Chairman
IORTH .1
4,
6
BOARD OF HEALTH 0
Julius Kay, M.D., Chairman 0 Q
NORTHANDOVER 1 a
R. George Caron � 01
MASSACHUSETTS _7
Edward J. Scanlon
01845 0
SSACHUS
TEL. 682-6400
December 20, 1977
Mr. Richard Zielinski
326 Campbell Rd. Re: Lot 2 Campbell Rd.
No.Andover, Mass.
Deax Sir:
The sewerage disposal system for your
house on the above-mentioned lot is in violation of Title V
of the State Sanitary Code and the North Andover Rules and
Regulations for Sub -surface Disposal Systems.
Consequently an occupancy permit cannot be
approved and because the home is not fit for habitation, your home
owners insurance may be invalidated.
A copy of a letter to your installer is
enclosed for your information. If you wish, you may attend the
installer's hearing before this Board.
Ve, truly yours,
ITY
Julius Kay, M.D.
Chairman
1; mj
cc:Bldg Insp
THE MAIN LINE
For All Your Transportation Needs
HOME OFFICUCHARLOTTE, N. C.
7"
y f
Rsrl-
0-v
m
0
THE MAIN LINE
For All Your Transportation Needs
HOME OFFICUCHARLOTTE, N. C.
7"
y f
i
tkORTN
BOARD OF HEALTH
Julius Kay, M.D., Chairman
NORTH ANDOVER
R. George Caron MASSACHUSETTS
Edward J. Scanlon
01845
-r.D
CHU
TEL. 682-6400
December 9, 1977
Mr. William King
King Flexible Sewer Service 0 0 ?-f
2 Cnnte Drive Re: Lot 2 Campbell Rd.
Methuen, Mass.
Dear Mr. King:
According to our records the sub -surface sewerage
disposal system on Lot 2 Campbell Rd is in violation of Title 5 of
the State Sanitary Code and the No. Andover Regulations for Sewerage
Disposal Systems. You are hereby ordered to correct the situation
by December 16, 1977.
The violation pertains to the covering over of the
system before final inspection. It will be necessary for you to make
excavations so that a final inspection of the system can be completed-.
If you feel this judgment is unfair you have the
right to reouest a hearing with the Board of Health with seven days.
cc:Mr.Zielinski
Very truly yours,
Leonard Phillips, Inspector
Board of Health
lb
Julius Kay, M.D., Chairman
R. George Caron
Edward J. Scanlon
BOARD OF HEALTH
NORTHANDOVER
MASSACHUSETTS
01845
Mr. William King
King Flexible Sewer Service
2 Cnnte Drive
Methuen, Mass.
Dear Mr. King:
December 9, 1977
Re: Lot 2 Campbell Rd.
According to our records the sub -surface sewerage
disposal system on Lot 2 Campbell Rd is in violation of Title 5 of
the State Sanitary Code and the No. Andover Regulations for Sewerage
Disposal Systems. You are hereby ordered to correct the situation
by December 16, 1977.
t4ORTtl
*A,. 0-0411
ACHU
TEL. 682-6400
The violation pertains to the covering over of the
system before final inspection. It will be necessary for you to make
excavations so that a final inspection of the system can be completed.
If you feel this judgment is unfair you have the
right to reouest a hearing with the Board of Health with seven days.
cc:Mr.Zielinski
Very truly yours,
Leonard Phillips, Inspector
Board of Health
L
1_4
Julius Kay, M.D., Chairman
R. George Caron
Edward J. Scanlon
BOARD OF HEALTH
NORTHANDOVER
MASSACHUSETTS
01845
Mr. William King
King Flexible Sewer Service
2 Cnnte Drive
Methuen., Mass.
Dear Mr. King:
December 9, 1977
Re: Lot 2 Carnpbell Rd.
According to our records the sub -surface sewerage
disposal system on Lot 2 Caupbell Rd is in violation of Title 5 of
the State Sanitary Code and the No. Andover Regulations for Sewerage
Disposal Systems. You are hereby ordered to correct the situation
by December 16, 1977.
HORTN
SS
CHU
TEL. 682-6400
The violation pertains to the covering over of the
system before final inspection. It will be necessary for you to make
excavations so that a final inspection of the system can be cornpleted.
If you feel this judgment is unfair you have the
right to reouest a hearing with the Board of Health with seven days.
cc:Mr.Zielinski
Very truly yours.,
Leonard Phillips� Inspector
Board of Health
e.
LONWEALTH OF MMSACHUSETTS
TTM"TV n=n n P nxnt x-vxTrr A T A -mn A T
X IN V
DEPARTMENT OF ENVIRONMENTAL Pk6TECT1'ON
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: ;2 -71 c0ime&"
/vc[M-i /AA�)0000(4-
Owner's Name: *Tot 4 A) V 1 -6- Tr- r-AA10
Owner's Address: Z-71 C0Mf*RCLL- )ZO
IV c, ilTw A-�ooL)e(L
Date of Inspection: qj) )co
13
Name of Inspector: (please print) &-13o9A4,A.1 C Os& -c,,) "Z -
Company Name: IV E -Vu* ��k;&L#4mP CjV&-1N e-FI?14i
Mailing Address: (o o SCIFcH L,00�— jP41 VF
IVO 4TH ' A�v o oviFt2 iAt4 0 15 Vs -
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, ac6urate and complete as of the time of the inspection. 'Me inspectioA was perform! ed 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 15340 of Title 5 (310 CMR 15.000). Th6 system:
--V—/Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signaturp Date: 0
;, ff &1 0---7 g "12 'i
71be system inspector shall submit a copy of this insj�ection report to the Approving Authority (Board of Health or
I
DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP-The original should 6e sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments
14
****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 1
N
Page 2 of I I
OFFICIAL INSPECT -ION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBS,.URFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
PROPERTY ADDRESS: 271 Campbell Rd.
North Andover, MA
OWNER: John Distefano
DATE OF INSPECTION: 9/12/00
Inspection Summary: Check AB,C,D or E ALWAYS complete all of Section D
A. System Passes:
,a/ 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 systen-4 upon completion of the replacement or repair, as approved by the Board of Health, will pass.
Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please
explain.
The septic tank is metal and over 20 years old* or the septic tank (wheiher 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 Hea Ith.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance
indicating that the tafik 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) oridue to a broken, settled or uneven distributionbox. System will pags inspection if (with
Approval of Board of Health):
broken pipe(s) are replaced
obstruction is -removed
distribution box is leveled or replaced
ND explain:
- Tlie 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): f
broken pipe(s) are replaced
obstruction is removed
ND explain:
Title 5 Inspection Form 6/15/2000 2
Page 3 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACESEWAGE DISPOSAL SYSTEM INSPECTION FORM
'I PART A
PROPERTY ADDRESS: 271 Campbell Rd. ",,RTIFICATION (continued)
North Andover, MA
OWNER: John Distefano
DATE OF INSPECTION: 9/11/00
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order. to de e if the system
is faili o protect public health, safety or the environment.
f H Ith i Ord t d n
r' m
1. Syste pass unless Board of Health determines in accordance /withCMR 15-303(l)(b) that the
M
systemisn functioning in a manner which will protect public healt safety and the environment:
Cesspoolor ivy is within 50 feet of a surface water
Cesspool or pn
i—Eis within 50 feet of a bordering vegetate etland or a salt marsh
2. System will fail unless the Board k!1thid Public Water Supplier, if any) determines that the
0 Ile I
e
system is functioning in a manner that�rrol4tk the public health, safety and environment:
The system has a septic tank and oil absorp n system (SAS) and the SAS is within 100 feet of a
surface water supply or tributary to surface water s ly.
'o
water
n
S
rp SYS te
Y. m
(SAS) and the S
m
The system has a septic and SAS and the SAS is 'thin a Zone I of a public water supply.
f
S thin f t f a
The system has a s c tank and SAS and the SAS is within feet of a private water supply well.
S 1 0 t I
r Thesysternh aseptictank and SAS andtheSAS is less than 10 eetbut50feetormorefroma
I Is
t c
private water su ly well". Method used to determine distance
"This SYS passes if the well water analysis, performed at a DEP certified lab tory, for coliform
11 t ryf 4
bacteria d volatile organic compounds indicatesthat the well is free from poX11utionom that facility and
ppm, 'd �4
the p ence of ammonia nitrogen and nitrate niq�gen is equal to or less than 5 ppm, pro that no other
fai e criteria are trigger 6!&A copy of the analysis must be attached to this form.
3. Other:
Title 5 Inspection Form 6/15/2000 3
Page 4:of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE WSPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
PROPERTY ADDRESS: 271 Campbcll Rd.
North Aodover, MA
OWNER: John Distdano
DATE OF INSPECTION: 9/12100
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or "no" to each of the following for all inspections:
Yes No
%/ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
%7 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 '/2day 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 SAS, cesspool or privy is below high ground water elevation.
V Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply. . I
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic 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 deteirmined 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: : , V I V I
f
considered a large system the system Must serve a facility wit esign flow of '10,000 gpd to 15,000
lw��o *li
gpd-
f
t 'n o the ollow
c r "y " or , 0,
You mus�t i1ridic ither "-yes" or "no" to each of -the follow,
10 in it t I iti
(The following criteria to large systems in additi o the crifteria above)
yes no,
the system is within 400 fe a s drinking water supply
inkin
to a s e
t syst
the system is *i 00 feet of a tributary to a s e ing water supply
1 w
un
the syst is located in a nitrogen sensitive area (Interim We Protection Area - IWPA) or a mapped
Zo 0 lic w t r suPP13 11
of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a signific-diftt threat, or answered
"yes" 'in Section D above the large system has failed. 'Me 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.
Title 5 Inspection Form 6/15/2000 4
F7iN77m- �!.,
Page 5 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
StBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
PROPERTY ADDRESS: 271 Campbell Rd.
North Andover, MA
OWNER: John Distefano
DATE OF, INSPECTION: 9/12/00
Check if the following have been done. You must indicate "yes" or'�no" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health
Were any of the system components pumped out in the previous two weeks ?
Has the system received normal flows in the previous two week period ?
Have large volumes of water been introduced to the system recently or as part of this inspection ?
Were as built plans of the system obtained and examined? (If they were not available note as N/A)
Was the ficility 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 ?
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 ?
Ile size and location of the Soil Absorption System (SAS) on the site has been determined based on:
.Yes no Existing information. For example, a plan at the Board of Health.
/Determined in the field (if any of the failure cr I iteria related to Part C is at issue approximation of distance
is unacceptable) [3 10 CMR 15.302(3)(b)]
Title 5 Inspection Form 6/15/2000 5
Page 6 of I I
OFFICIAL INSPECTION FORM,- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
PROPERTY ADDRESS: 271 Campbell Rd. SYSTEM INFORMATION
North Andover, MA
OWNER: John bis*tefano
DATE OF INSPECTION: 9/12/00
.vLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): Number of bedrooms (actual):
DESIGN flow based on 3 10 CMR 15.203 (for example: 110 gpd x # of bedrooms):
Number of current residents: q
Does residence have a garbage grinder (yes or no):
Is laundry on a separate sewage system (yes or no): ffa [if yes separate inspection required]
Laundry system inspected (yes or no): —
Seasonal use: (yes or no): 0
Water meter readings, if available (last 2 years usage (gpd)): —
Sump pump (yes or no): _!��
Last date of occupancy: jqrj-cn
CONMIERCIALAENDUSTRUL
Type of establishment:
Design flow (based on 3 10 CMR 15.203): gi)d
Basis of design !flow �seats/persons/sqf�etc.):
Grease trap present (yes or no): _
Industrialwaste holding tank present (yes or no):
Non-sanitdry waste discharged to the Title 5 system (yes or no):
Water meter readings, if available:
]Last date of occupancy/use:
OTHER (describe):
GENERAL INFORMATION
Pumpin� Records
9
Source ofinformation:— I �deaa AL -<2 PCJZ 0 IA.) A) E -/-Z
Was system pumped as part ofthe inspection (yes or no): 4�2
If yes, volume pumped: allons -- How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
_�K Septic tank, disqibution box, soil absorption 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
obtained from system owner)
_ Tight tank — Attach a copy of the DEP appiroval
Other (describe):
Approxim ate age of all componen�, date installed (if kriown) and source of information:
1!el 3p�' c.
Were sewage odors detected when arriving at the site (yes or no): "
Title 5 Inspection Form 6/15/2000 6
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: 271,Csmpbell Rd.
North Andover, MA
OWNER: John Distefano
DATE OF INSPECTION: 9/12/00
BUELDING SEWER (locate on site plan)
Depth below grade: 12
Materials of construction: , 0
_.,/cast iron 40 PVC --' ther (explain):
Distance from private water supply well or suction line: - AIA
Comments (on condition ofjoints, venting, evidence of leakage, etc.):
?I 17r- k -c' () y- 5. C', 6 ;' I AJ &Is eA^eAiT
SEPTIC TANK: _ (locate on site plan)
Depth below grade: q')
Material of construction: Vconcrete —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: 6 -OL &,-O.pj
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: Z
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: — I
Distance from bottom of scum to bottom ofoutlet tee or baffle: AkL
How were dimensions determined: 4 %k
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakaie, etc.):
-rAk) 9, A/ 6-roo 1- 4 0-4) 3) O'n oAJ 0 �j e 1z IF IF
C 0 t- 1> %TN 0 tj.
GREASE TRAP-A�&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:
Cornments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Title 5 Inspection Form 6/15/2000 7
IA
Page 8 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
PROPERTY ADDRESS: 271 Ca n1pbC11 Rd.
North Andover, MA
OW14ER: John Dig:tefano
DATE OF INSPECTION: 9/12/00
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 olyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: jzallons/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: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 4.
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.):
eox I A) S. I?C(-FC P VV L-rtA camte aig, Op VC no ZIF� M pj�
c #J Ai 6-0oo 1. 0 Aj
PUMP CHAMIBER: Am (locate on site plan)'
Pumps in working order (yes or no):
Alarms in working order (yes or no):
Comments (note condition of pump phamber, condition of pumps and appurtenances, etc.):
Title 5 Inspection Form 6/15/2000
8
Page 9 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS;
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
PROPERTY ADDRESS: 271 Campbell Rd. SYSTEM INFORMATION (continued)
North Andover, I�A
OWNER: John Distefano
DATE OF INSPECTION: 9/12/00
SOIL ABSORPTION SYSTEM (SAz): (locate on site plan, excavation not required)
If SAS not located explain why:
Type
— leaching pits, number: -3 5HAL-t-0
- leaching chambers, number:
leaching galleries, number:
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:
innovative/alternative system Type/name of technology:
Commei its (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
r- P1 rs /Vo (L ,-L A L%
CESSPOOLS: JVR (cesspool must be pumped as part of inspection)(locate on site plan)
a
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):
C�mments (note condition of soil, signs of hydraulic failure, level o.iponding, condition of vegetation, etc.):
PRIVY: 4A(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.):
Title 5 Inspection Form 6/15/2000 9
Page 10 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSME
NTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
PROPERTY ADDRESS: 271 Campbell Rd.
North Andover, MA
OWNER: John Distefano
DATE OF INSPECTION: 9/12/00
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.
Title 5 Inspection Form 6/15/2000 10
Page 11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
: A PART C
SYSTEM INFORMATION (continued)
PROPERTY ADDRESS: 271 Campbell Rd.
North Andover, MA
DWNEi: John Distefano
DATE OF INSPECTION: 9/12100
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:
v, 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)
v" Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
:5 -15 -,-e -- D f_:; ( 6- A.$ T 0 q ' P" i3b 0 J� W A -1,1F IL
VS 6-5c. 21 C ATE a > &-40JA) D
LJ FTL-A Aj P>. Ar��"5 _c 7- &6'0 —1 T -L 0+^./ L3 J> L\F P%7-5
LV 1?p 'n 7-D or P k T-� z! Ge,
Title 5 Inspection Form 6/15/2000
R* Ei 0. f
Q YA.-T
UISKR
I R
AA
Y hl PW
I-': J4*i
. Ni
20
m p fro n I Qf
0 UA-NTI TY P
iS�
v m
S p IQ
y P
,Y,:ROQTIN
ER 0 E N'C y.
O'CO Y C. k.
A C"
�'O' 0 D'.
XP A -IN)
71 b-,
0 y
")4A
..........
... .......
SYSTEM -PI
FORM 4
D
sa. OCT 14 2 Oil
commomvealth of Ma� 'c uset s
Mass'achus.e'M TOWN OF NOR . TH ANDO R
ALJj-j De T E
CQ
Re
slem Coq4tion
-4- r
�Yste n U ier
vi a- N
a"7 c f -"Z)
Type- Emergency 0 Rouflne,�-e 'N o yes
cesspc ok No E] yes S(.ptic Tank:
QuantiN Pumped -
Date c.'POmping:
0-RAGZEKI.'*.'..,
Permit
Svsjej:: Pumped by (Company):
Date Pumper Signawre
Con(:Iiion.of systen-L/oLher corrLments:
DEY AYFROVED MPLM 1110719S