HomeMy WebLinkAboutMiscellaneous - 271 CANDLESTICK ROAD 4/30/2018rn
ll�
MAP # LOT #
PARCEL # STREET
CONSTRUCTION N iR
HAS PLAN REVIEW FEE BEEN PAID? YES. NO
PLAN APPROVAL: DATE Ile ZAQ3 PP. BY
DESIGNER: Alf" PLAN DATE.
CONDITIONS—N&&,b 'r"/- -e:7&)c 1je,1_ _X- 7-,f:57 ? "/o 7 0 e__4W*,7'j_
WATER SUPPLY: WELL
WELL PERMIT
WELL TESTS: CHEMICAL DAIE APPROVED
8nc,rERIA I DAI E (11"PRUVED
DA J'E APPROVED
BACTEA71A., I I
COMMENTS:
FORM U APPROVAL: APPROVAL TO ISSUE ES (:N:6�)
DATE lSSUED,3z1/_6/yo___BY . .....
CONDITIONS:
FINAL APPROVAL:.
ALL PERMITS PAID NO
WELL CONSTRUCTION APPROVAL NO
SEPTIC SYSTEM CONSTRUCTION APPROVAL YES No
OTHER YES NO
ANY*VARIANCE NEEDED YES NO
FINAL BOARD OF HEALTH APPROVAL: DA l'E:....
Commonwealth of Massachusetts
Q RX, City/Town of JRREC�V- ED
S Mem Pumping Record
YS SEp 2 � 2014
U Form 4 TOWN OF NORTH ANDOVER
DEP has provided this fbrm'for use�by local Boards of Health. Other f&A"a1§-%97is&-11M-Tthj
information must be substantially the same as that provided here. Before using Ahis 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
1. System Location: Left ht front of hous; , Left / Right rear of house, Left / right side of house, Left
6 Nig inio Ob L
Right side of building, Left / Ri uildihg, Left / Right rear of building, Under deck
ACICIrM
Cityfrown
2. System Owner
Name'
Address (9 different from location)
Myrrown
B. Pumping Record
1. Date of Pumping
3. Type -of system,- [:]
0 Other (describe):
State
Zip Code
state Zip Code
Telephone Number
ly
2. Quantity Pumped:
Date Gallo
Cesspool(s) , B-9-e—ptic Tank El Tight Tank
4. Effluent Tee Filter present? Yes If yes, was it cleaned? E] Yes F� No
5. Condition pf System:
ZA V
6.. System Pumped By -
Nell Batesbn
Name
Bateson Enterprises Inc-
-dompany
7. Loca��e contents were disposed:
Waste Water
F5821
Vehicle License Number
f
Date
t5form4.doc- 06/03 SYstem Pumping Record - Page I of I
_C\ Commonwealth of Massachusetts
City/Town of
System pumping Record NORTH ANDOVER
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, b . Ut the
s that provided here. Before using this form, �,heck with your
information must be substantially the same a e submitted to
ine the form they use. The System Pumping Record must b
local Board of Health to determ I -
authority within 14 days from the pumping date in
the local Board of Health or other approving
accordance with 310 CMR 15.351.
A. Facility Information
ImportaDt: System Location:
When filling out
forms on the 2 '71
computer, use
only the tab key Address
to move your zip Code
cursor - do not State
use the return
key. 2. System Owner:
Z/11 -1 Z '7 ee
!Wr�e
�Ff,�,ff�,ent from location)
zip Go : de
Telephone Number
B. pumping Record
? - 2. Quantity Pumped� "dallon . s
1. Date of Pumping -15at'e""-'
3. Type of system! CeSspool(s) E35_eptic Tank Tight Tank �Grease Trap
Other (describe)�
4. Effluent Tee Filter present? 0 Yes ES -140 if yes, was it cleaned? E] Yes No
5. Condition of System�
6. System Pumped By�
scle License Num er
N ame
01F
Company G.L.S.D.
7, Location where contents were dN6ftAnd0v(-"
----- ------- Date
Sigrtature of Hauler
-of Receiving Facility
System PumPin Record - Page I of 1
9
l5fofm,l�doc' 03/06
Ov�mo
information is
required for every
page.
Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
Commonwealth of Massachusetts
Title 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
271 Candlestick Rd.
Property Address
Scarangelo
Owner's Name
N. Andover MA 01845 4/8/2013
CityfTown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms
way. Please see completeness checklist at the end of the form.
A. General Information MAY 0 7 2013
1. Inspector:
Chad Jablonski
Name of Inspector
CJ Jablonski Septic Inspection & Repair
Company Name
237 Merrimac St.
TOWN OF NORTH ANDOVER
HEALTH DEPARTAA;:Krr
Company Address
Newburyport MA 01950
City/Town State Zip Code
978-360-9358 4574
Telephone Number
B. Certification
License Number
h.-IIN
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 CM R 15.000). The system:
0 Passes E] Conditionally Passes El Fails
El Needs fj4herj��aluation by the Local Approving Authority
e-1 /I /Z-61 i '�
Date
The syste7rins
#-ctor shall submit a copy of this inspection report to the Approving Authority (Board
of HealtVor PEP) within 30 days of completing this inspection. If the system is a shared system or
has a dd&io flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 1 of 17
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
271 Candlestick Rd.
Property Address
Owner's Name
N. Andover MA 01845 4/8/2013
CityfTown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E /always complete all of Section D
A) System Passes:
I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
SAS and all components in good working order.
13) System Conditionally Passes:
40
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- 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Off idal lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
271 Candlestick Rd.
Property Address
Scarangelo
Owner's Name
N. Andover
Cityrrown
B. Certification (cont.)
B) System Conditionally Passes (i
KAA ni RAr,
QLCLLU /-1P %,UUU
4/8/2013
Date of Inspection
El 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
F1
F1
broken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
El Y
El Y
E] Y
El N
El N
[I N
El
El
0
ND (Explain below):
ND (Explain below):
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):
El broken pipe(s) are replaced 0 Y El N El ND (Explain below):
0 obstruction is removed El Y F1 N F1 ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
El Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(l)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
El Cesspool or privy is within 50 feet of a surface water
El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 3 of 17
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
271 Candlestick Rd.
Property Address
Scarangelo
Owner's Name
N. Andover MA 01845 4/8/2013
CityfTown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fall 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:
F] The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
El The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
El The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes
No
Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
El
E
Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2 day flow
t5ins - 11/10
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official lnsp
Subsurface Sewage Disposal System Fo
271 Candlestick Rd.
Property Address
Scarangelo
Owner Owner's Name
nformation is
required for every N. Andover
page. City/Town
B. Certification (cont.)
Yes No
E]
0
ection
Form
n
rm - Not for Voluntary Assessments
El
E
Any portion of the SAS, cesspool or privy is below high ground water elevation.
E]
0
Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
El
E
Any portion of a cesspool or privy is within a Zone 1 of a public well.
MA
01845 4/8/2013
State
Zip Code Date of Inspection
E]
0
Required pumping more than 4 times in the last year NOTdue to clogged or
El
n
obstructed pipe(s). Number of times pumped:
El
E
Any portion of the SAS, cesspool or privy is below high ground water elevation.
E]
0
Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
El
E
Any portion of a cesspool or privy is within a Zone 1 of a public well.
El 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well.
El N Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
1:1 z The system is a cesspool serving a facility with a design flow of 2000gpd-
1 0,000gpd.
E] z 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
n
the system is within 400 feet of a surface drinking water supply
El
0
the system is within 200 feet of a tributary to a surface drinking water supply
1:1
E]
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 "yes7 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 - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
271 Candlestick Rd.
Property Address
Scarangelo
Owner Owner's Name
information is
required for every N. Andover MA 01845
page. CityfTown State Zip Code
C. Checklist
4/8/2013
Date of Inspection
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
M E]
Pumping information was provided by the owner, occupant, or Board of Health
El E
Were any of the system components pumped out in the previous two weeks?
E F-1
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?
• El
Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
• El
Was the facility or dwelling inspected for signs of sewage back up?
M 0
Was the site inspected for signs of break out?
E EJ
Were all system components, excluding the SAS, located on site?
Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
M E]
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:
N El
Existing information. For example, a plan at the Board of Health.
El 0
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): 440
t5ins- 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17
Commonwealth of Massachusetts
Title, 5 Official lnspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
271 Candlestick Rd.
Property Address
Scarangelo
Owner Owner's Name
information is
required for every N. Andover MA 01845 4/8/2013
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 5
Does residence have a garbage grinder? 0 Yes El No
Is laundry on a separate sewage system? [if yes separate inspection required] El Yes E No
Laundry system inspected? E Yes El No
Seasonaluse? El Yes E No
Water meter readings, if available (last 2 years usage (gpd)): Attached
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?
Gallons per day (gpd)
El Yes 0 No
Occupied
Date
Ej Yes [:1 No
El Yes El No
Non -sanitary waste discharged to the Title 5 system? El Yes Ej No
Water meter readings, if available:
t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official �nspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
271 Candlestick Rd.
Property Address
Scarangelo
Owner Owner's Name
information is
required for every N. Andover MA 01845 4/8/2013
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:
Source of information:
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Date
North Andover BoH
El Yes E No
na
gallons
na
na
Type of System:
E Septic tank, distribution box, soil absorption system
El Single cesspool
El Overflow cesspool
F1 Privy
E] 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
E-1 Tight tank. Attach a copy of the DEP approval.
El Other (describe):
t5ins- 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
271 Candlestick Rd.
Property Address
Scarangelo
Owner Owner's Name
information is
required for every N. Andover MA 01845
page. CityfTown State Zip Code
D. System Information (cont.)
4/8/2013
Date of Inspection
Approximate age of all components, date installed (if known) and source of information:
18 years, as -built plans
Were sewage odors detected when arriving at the site?
Building Sewer (locate on site plan):
Depth below grade: 1011
f eet
Material of construction:
E cast iron E] 40 PVC El other (explain):
Distance from private water supply well or suction line: f eet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Watertiaht at foundation
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
Z concrete El metal
311
f eet
El Yes 0 No
El fiberglass n polyethylene [:1 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: 10.5 x 5.5 x 5.5
Sludge depth:
411
t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
271 Candlestick Rd.
Property Address
Scarangelo
Owner Owner's Name
information is
required for every N. Andover MA 01845
page. City/Town State Zip Code
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
2811
ill
511
1411
4/8/2013
Date of Inspection
How were dimensions determined? measuring stick
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is structurally sound, inlet and outlet baffle in good working order.
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
0 concrete El metal
Dimensions:
Scum thickness
f eet
El fiberglass [-] polyethylene [-] other (explain):
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
t5ins - 11/10
Date
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
271 Candlestick Rd.
Property Address
Scarangelo
Owner Owner's Name
information is
required for every N. Andover MA 01845
page. City/Town State Zip Code
4/8/2013
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:
R concrete El metal El fiberglass El polyethylene El other (explain):
Dimensions:
Capacity:
Design Flow:
Alarm present:
Alarm level:
gallons
gallons per day
El Yes El No
Alarm in working order:
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
El Yes F1 No
* Attach copy of current pumping contract (required). Is copy attached? El Yes El No
t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official �n.spection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
271 Candlestick Rd.
Property Address
Scarangelo
Owner Owner's Name
information is
required for every N. Andover MA 01845
page. CityfTown State Zip Code
D. System Information (cont.)
4/8/2013
Date of Inspection
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert Oil
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.):
Box is level and distributi
Pump Chamber (locate on site plan):
Pumps in working order: El Yes El No
Alarms in working order: El Yes EJ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17
.,f
Commonwealth of Massachusetts
T0 00"
itle 5 ufficial Mspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
271 Candlestick Rd.
D. System Information (cont.)
Type:
MA 01845 4/8/2013
State Zip Code Date of Inspection
El leaching pits
Property Address
El leaching chambers
Scarangelo
Owner
Owner's Name
information is
N. Andover
required for every
number, dimensions: 1- 20'x 45'
page.
Cityrrown
D. System Information (cont.)
Type:
MA 01845 4/8/2013
State Zip Code Date of Inspection
El leaching pits
number:
El leaching chambers
number:
El leaching galleries
number:
leaching trenches
number, length:
leaching fields
number, dimensions: 1- 20'x 45'
El overflow cesspool
number:
El innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
No sion of hvdraulic failure or Dondina.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth — top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow El Yes Ej No
15ins - 11/10 Title 5 Officid Inspection Form: Subsurface Sewage Disposal System - Page 13 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
271 Candlestick Rd.
Property Address
Scarangelo
Owner's Name
N. Andover MA 01845 4/8/2013
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of poncling, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins - 11/10 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
271 Candlestick Rd.
�_roper_ty_4d1�r_esS_
P�eg and Maryann Scaranqelo
_c�ry
Owner's Name
North Andover
City[Town
D. System Information (cont.)
�P/
MA 01845 i Qi2 _2'420D9_
State Zip Code 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:
9 hand -sketch in the area below
E] drawing attached separately
E 5;7- C K
13 -AT L�?).q
_j>
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17
Commonwealth of Massachusetts
Title 5 ufficial �nspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
271 Candlestick Rd.
Property Address
Owner Owner's Name
information is
required for every N. Andover
page. CityfTown
D. System Information (cont.)
Site Exam:
Z
Check Slope
0
Surface water
Z
Check cellar
Z
Shallow wells
MA 01845
State Zip Code
4/8/2013
Date of Inspection
Estimated depth to high ground water: 8611
feet
Please indicate all methods used to determine the high ground water elevation:
a
10
Obtained from system design plans on record
If checked, date of design plan reviewed: 11/10/1992
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:
Soils test performed 6/19/1992 by Neve Associates and witnessed by the North Andover BoH
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17
Commonwealth of Massachusetts
Title 5 Off icial Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
271 Candlestick Rd.
Property Address
Scarangelo
Owner Owner's Name
information is
required for every N. Andover MA 01845 4/8/2013
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Inspection Summary: A, B, C, D, or E checked
Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
System Information — Estimated depth to high groundwater
Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17
Summary Record Card generated on 3/26/2013 2:22:19 PM by Karen Hanlon
Town of North Andover
Tax Map # 210-106.A-0235-0000.0
Parcel ld 17380
271 CANDLESTICK ROAD
GREGORY & MARYANNE SCARANGELLO
271 CANDLESTICK ROAD
NORTH ANDOVER, MA 01845
Page I
Class 101 Single Family Property Type 1 Residential
Zoning2 1 Residential Zoning3 1 Residential
Size Total 1.24 Acres
FY 2013
UB Mailina Index
Name/Address
Type Loan Number
Activelinact.
From
GREGORY & MARYANNE SCARANGELLO
Owner
3/13/2013
1219
271 CANDLESTICK ROAD
1191
9/13/2012
1165
NORTH ANDOVER, MA 01845
1092
3/14/2012
1054
WILTSE, DEAN
Previous Customer
Inactive
7/22/2004
271 CANDLESTICK ROAD
934
3/8/2011
909
NO.ANDOVER,MA
884
9/10/2010
839
01845
660
3/9/2010
621
DOUGLAS & STACY KORN
Previous Customer
Inactive
6/26/2006
271 CANDLESTICK ROAD
518
3/16/2009
474
NORTH ANDOVER, MA 01845
449
7/20/2011
-2%
PRUDENTIAL RELOCATION
Previous Customer
Inactive
8/30/2006
16260 71 ST STREET
45
1/12/2011
-73%
SCOTTSDALE, AZ
179
10/15/2010
335%
UB Account Maint.
Account No Cycle Occupant Name Active/Inactive
Bldg Id. 17761.0 - 271 CANDLESTICK ROAD Last Billing Date 1/3/2013
3170322 03 Cycle 03 Active
UB Services Maint.
Account No. 3170322
Service Code Rate Charge Multiplier/Users
MISCFEE ADMIN FEE 0.635/8 7.82 1/
WTR WATER 01 ALL METER bIZE 109.30 /1
UB Meter Maintenance
Account No. 3170322
Serial No
Status
33132492
a Active
Date
Reading
3/13/2013
1219
1211112012
1191
9/13/2012
1165
6/12/2012
1092
3/14/2012
1054
12/12/2011
1023
9/12/2011
1002
6/7/2011
934
3/8/2011
909
12/9/2010
884
9/10/2010
839
6/7/2010
660
3/9/2010
621
12/8/2009
595
9/9/2009
566
6/8/2009
518
3/16/2009
474
12/9/2008
449
Until
Location
Brand
Type Size
YTD Cons
ERT HH
b Badger
w Water 0.630.63
891
Code
Consumption
Posted Date
Variance
a Actual
28
4%
a Actual
26
1/9/2013
-63%
a Actual
73
10/15/2012
86%
a Actual
38
7/16/2012
27%
a Actual
31
4/14/2012
44%
a Actual
21
1/17/2012
-67%
a Actual
68
10/13/2011
155%
a Actual
25
7/20/2011
-2%
a Actual
25
4/13/2011
-44%
a Actual
45
1/12/2011
-73%
a Actual
179
10/15/2010
335%
a Actual
39
7/15/2010
52%
a Actual
26
4/14/2010
-11%
a Actual
29
1/12/2010
-38%
a Actual
48
10/15/2009
-1%
a Actual
44
7/20/2009
103%
a Actual
25
4/29/2009
-24%
a Actual
31
1/20/2009
-62%
Summary Record Card generated on 3/26/2013 2:22:19 PM by Karen Hanlon
Town of North Andover
Tax Map # 210-106.A-0235-0000.0
Parcel Id 17380
271 CANDLESTICK ROAD
GREGORY & MARYANNE SCARANGELLO
271 CANDLESTICK ROAD
NORTH ANDOVER, MA 01845
Page 2
Class 101 Single Family Property Type 1 Residential
Zoning2 1 Residential Zoning3 1 Residential
Size Total 1.24 Acres
FY 2013
9/8/2008
6/6/2008
317/2008
12/11/2007
9/5/2007
6/18/2007
3/14/2007
12/8/2006
9/12/2006
8/25/2006
6/23/2006
6/23/2006
6/22/2006
3/812006
Trouble Code:03
12/21./2005
Trouble Code:03
9/20/2005
Trouble Code:03
6/13/2005
3/25/2005
12/14/2004
Trouble Code:03
9/24/2004
7/19/2004
4/15/2004
Trouble Code:03
12/15/2003
418
a Actual
335
a Actual
300
a Actual
271
a Actual
242
a Actual
140
a Actual
108
a Actual
81
a Actual
58
a Actual
29
f Final Bill
0
n New Meter
2591
r Replacement
2591
f Final Bill
2552
a Actual
2533
a Actual
2475
a Actual
2316
a Actual
2277
m Manual estimate
2257
a Actual
2236
a Actual
2212
f Final Bill
2168
a Actual
2139 n New Meter
83 10/10/2008
35 7/16/2008
29 4/11/2008
29 1/22/2008
102 10112/2007
32 7/20/2007
27 4/16/2007
23 1/19/2007
29 10/20/2006
29 8/25/2006
0 7/10/2006
0 7/10/2006
39 6/22/2006
19 4/17/2006
58 1117/2006
159 10/14/2005
39 7/15/2005
20 4/5/2005
21 1/14/2005
24 10/8/2004
44 7/19/2004
29 5/17/2004
0 12/15/2003
130%
15%
11%
-77%
287%
19%
6%
-84%
250%
-100%
-100%
-100%
49%
-61%
-61%
229%
146%
-24%
-28%
-23%
95%
0%
0%
,AORTh
0 -Z
'A
Town of North Andover
E TH DEPARTMENT
CH t I
CHECK#: DATE:
LOCATION-
H/O NAM
CONTRACTOR NAM�-
jyRe
of Permit or License: (Check box)
11
Animal
1:1
Body Art Establishment
0
Body Art Practitioner
0
Dumpster
El
Food Service - Type.
0
Funeral Directors
0
Massage Establishment
0
Massage Practice
0
Offal (Septic) Hauler
0
Recreational Camp
0
Sun tanning
0
Swimming Pool
11
Tobacco
0
TrashlSolid Waste Hauler
11
Well Construction
SEPTIC Systems:
0
Septic - Soil Testing
11
Septic - Design Approval
0
Septic Disposal Works Construction (DWQ
0
Septic Disposal Works Installers (DW)
0
Title 5 Inspector
Title 5 Report
11 Other (Indicate) s-
----------------
Health Agent Initials
%%ite - Applicant Yellow- Health Pink - Treasurer
T
0
Town of North Andover
cb4u
HEALTH DEPARTMENT
CHECK#: D A T E:
LOCATION:
1-1/0 N
CONTRACTOR NAME:
Type of Permit or License: (Check
0 Animal
0 Body Art Establishment
0 Body Art Practitioner
0 Dumpster
0 Food Service - Type:
0 Funeral Directors
0 Massage Establishment
0 Massage Practice
0 Offal (Septic) Hauler
0 Recreational Camp
0 Sun tanning
0 Swimming Pool
• Tobacco
• TrashlSolid Waste Hauler
0 Well Construction
SEP77C Systems:
0 Septic - Soil Testing
0 Septic - Design Approval
0 Septic Disposal Works Construction (DWQ
0 Septic Disposal Works Installers (DW[)
0 Title 5 Inspector
0, Affle 5 Report
4 0 0
9A, ,
0 Other (Indicate) $
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
Owner
information is
required for every
page.
Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
Commonwe'alth of Massachusetts
Title 5 Official lnspectio� orm
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
271 Candlestick Rd.
Property Address
C— ki f,' —
C-z;�AQ--
Gregory and Maryann Scarangelo
Owner's Name
North Andover
Cityrrown
MA 01845
State Zip Code
10/22/2009
Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. General Information
Inspector:
Chad Jablonski
Name of Inspector
Jablonski & Sons, Inc.
Company Name
1,67 Willow Ave.
Company Address
Haverhill MA 01835
Cityrrown State Zip Code
978-360-9358 4574
Telephone Number
B. Certification
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:
Z Passes Conditionally Passes Fails
0 Needs Further Evaluation by the Local Approving Authority
I a / -&�: If "
Date
The systeKi. nsp�26r shall submit a copy of this inspection report to the Approving Authority (Board
of Health&��) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DER The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t51ns - 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page I of 17
M L
11"N'.1241,
Owner
information is
required for every
page.
Commonwbalth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
271 Candlestick Rd.
Property Address
Gregory and Maryann Scarangelo
Owner's Name
North Andover
City/Town
B. Certification (cont.)
MA 01845
State Zip Code
10/22/2009
Date of Inspection
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes:
I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
SAS and all components in good working order
13) System Conditionally Passes:
El one or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
F-1 Y El N El ND (Explain below):
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17
(,�N Commonwealth of Massachusetts;
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
271 Candlestick Rd.
Property Address
Gregory and Maryann Scarangelo
Owner Owner's Name
information is
required for every North Andover MA 01845 10/22/2009
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
13) System Conditionally Passes (cont.):
Observation of sewage backup or b - reak 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 El Y El N F1 ND (Explain below):
El obstruction is removed 0 Y F] N 0 ND (Explain below):
distribution box is leveled or replaced E] Y E] N F1 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):
El broken pipe(s) are replaced F1 Y F1 N [I ND (Explain below):
Fj obstruction is removed [:1 Y 0 N [I ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
F-1 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
E] Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 3 of 17
L
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
271 Candlestick Rd
Property Address
Gregory and Maryann Scarangelo ......
Owner's Name
North Andover
City/Town
B. Certification (cont.)
Foll
MA 01845 10/22/2009
State Zip Code Date of Inspection
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
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.
Fj The system has a septic tank and SAS and the SAS is within a Zone I of a public water
supply.
El The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for 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
z
Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
El
Z
Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged. SAS or cesspool
1:1
z
Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2day flow
t5ins - 09/08
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
271 Candlestick Rd.
Property Address
Gregory and Ma ann Scarangelo
Owner Owner's Name
information i's
required for every North Andover
MA 01845 10/22/2009
page. Cityrrown
State Zip Code Date of Inspection
B. Certification (cont.)
Yes
No
El
z Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
El
z 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.
1:1
z Any portion of a cesspool or privy is within a Zone 1 of a public well.
El
Z Any portion of a cesspool or privy is within 50 feet of a private water supply well.
1:1
z Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
El
Z The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
z 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 0 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 - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17
Commonwe�alth of Massachusetts
Title 5 Official Insp
Subsurface Sewage Disposal System Fo
271 Candlestick Rd.
Property Address
Gregory and Maryann Scarangelo
Owner Owner's Name
information i's North Andover
required for every
page. City[Town
C. Checklist
Check if the following have been done.
Yes No
F1 Pumping informati
Z Were any of the sy
Has the system re
Have large volume
El Z this inspection?
Were as built plan
E El available note as �
Z El Was the facility or
Was the site inspe
Z Were all system c
Z El Were the septic ta
inspected for the c
dimensions, depth
Was the facility ow
Z 11 information on the
The size and loca
been determined t
Z E-] Existing informatio
0 Z Determined in the
approximation of d
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17
ection Form
rm - Not for Voluntary Assessments
MA 01845 10/22/2009
State Zip Code Date of Inspection
You must indicate "yes" or "no" as to each of the following:
on was provided by the owner, occupant, or Board of Health
stem components pumped out in the previous two weeks?
ceived normal flows in the previous two week period?
s of water been introduced to the system recently or as part of
s of the system obtained and examined? (If they were not
/A)
dwelling inspected for signs of sewage back up?
cted for signs of break out?
omponents, excluding the SAS, located on site?
nk manholes uncovered, opened, and the interior of the tank
ondition of the baffles or tees, material of construction,
of liquid, depth of sludge and depth of scum?
ner (and occupants if different from owner) provided with
proper maintenance of subsurface sewage disposal systems?
tion of the Soil Absorption System (SAS) on the site has
ased on:
n. For example, a plan at the Board of Health.
field (if any of the failure criteria related to Part C is at issue
istance is unacceptable) [310 CMR 15.302(5)]
Number of bedrooms (design): 4 Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17
_n
Commonwbalth of Massachusefts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
271 Candlestick Rd.
I-roperty Address
Gregory and Maryann Scarangelo
Owner Owner's Name
information is
required for every North Andover MA 01845 10/22/2009
page. Cityrrown State Zip Code Date of Inspection
t5ins - 09/08
D. System Information
Description:
Number of current residents:
Does residence have a garbage grinder?
Is laundry on a separate sewage system? [if yes separate inspection required]
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?
Gallons per day (gpd)
r,
El Yes 0 No
1� Yes/M No
El Yes 0 No
Attached
El Yes E No
Occupied
Date
EJ Yes El No
El Yes F� No
Non -sanitary waste discharged to the Title 5 system? 0 Yes E] No
Water meter readings, if available:
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17
Commonweikith of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
971 Cniridlestick Rd.
Property ddress
Grego�y and Maryann.Scarangelo
Owner Owner's Name
information i's 10/22/2009
required for every North Andover MA 01845 —
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
7-- Me.
na
gallons
na
na
Date
011M.211110
Type of System:
z Septic tank, distribution box, soil absorption system
0 Single cesspool
F� Overflow cesspool
D Privy
El Shared system (yes or no) (if yes, attach previous inspection records, if any)
D 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
EJ Tight tank. Attach a copy of the DEP approval.
El Other (describe):
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17
CC_
I � - Fwaill
Commonwdalth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
271 Candlestick Rd
Property Address
Gregory and Maryann Scarangelo
Owner Owner's Name
information is
required for every North Andover MA 01845 10/22/2009
page. City[Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
15 vrs determined by as -built plans
Were sewage odors detected when arriving at the site? El Yes 0 No
Building Sewer (locate on site plan):
1011
Depth below grade: feet
Material of construction:
E cast iron E] 40 PVC E] other (explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Waterticiht at foundation
Septic -Tank (locate on site plan):
Depth below grade:
Material of construction:
Z concrete EJ metal
31'
feet
fiberglass F-1 polyethylene El other (explain)
na
iT tanK is meiai, iist age: years
is age confirmed by a Certificate of Compliance? (attach a copy of certificate)
10x5x5
Dimensions:
Sludge depth:
3"
F-1 Yes El No
t5ins - 09/08 Title 5 Official inspection Form: Subsurface Sewage Disposal System - Page 9 of 17
S- vi
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
271 Candlestick Rd
Property Address
Gre ory and Maryann Scarangelo
Owner's Name
North Andover MA 01845 10/22/2009
City/Town State — Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
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
How were dimensions determined?
Measuring tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank structurally sound, sli
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
[:] concrete El metal
Dimensions:
Scum thickness
feet
[-] fiberglass E] polyethylene [:] other (explain):
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
t5ins - 09/08 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
271 Candlestick Rd.
Property Address
Gregory and Maryann Scarangelo
Owner owner's Name
information is
required for every North Andover MA 01845 10/22/2009
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:
EJ concrete El metal E] fiberglass El polyethylene El other (explain):
Dimensions:
Capacity:
Design Flow:
Alarm present:
Alarm level:
Date of last pumping:
gallons
gallons per day
El Yes El No
Alarm in working order:
Date
Comments (condition of alarm and float switches, etc.):
El Yes El No
* Attach copy of current pumping contract (required). Is copy attached? [] Yes El No
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 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
271 Candlestick Rd.
Property Address
Gregory and Maryann Scarangelo
Owner's Name
North Andover MA 01845 10/22/2009
Cityf'rown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
A
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.):
Box is level and distributing equally
Pump Chamber (locate on site plan):
Pumps in working order: D Yes E] No
Alarms in working order: El Yes 0 No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17
<L
Commonw6alth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form Not for Voluntary Assessments
271 Candlestick Rd.
Property Address
Gregory and Maryann Scarangelo
Owner Owner's Name
information is North Andover MA 01845 10/22/2009
required for every State Zip Code Date of Inspection
page. Cityrrown
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: 1- 20'x 45'
overflow cesspool
number:
0 innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
No sign of hydraulic failure or ponding
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 El Yes 0 No
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17
L MAU
11
7NIW�-.J,
Commonw�alth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
271 Candlestick Rd.
Property Address
Gregory and Maryann Scarangelo
Owner Owner's Name
information is North Andover MA 01845 10/22/2009
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 17
z
Commonwl6alth of Massachusefts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 271 Candlestick Rd.
Property Address
Gregory and Maryann Scarangelo
Owner Owner's Name
information is
required for every North Andover MA 01845 10/22/2009
page. CityrTown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
Fj hand -sketch in the area below
El drawing attached separately
C Z 5;-r K
Lf.
-4T t-(S_q'
P
T-7,> GO-
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
271 Candlestick Rd
Property Address
Gregory and Maryann Scarangelo
Owner Owner's Name
information i's
required for every North Andover MA 01845 10/22/2009
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
Check Slope
Surface water
Check cellar
Shallow wells
M
Estimated depin to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
z Obtained from system design plans on record
If checked, date of design plan reviewed: 11/10/92
Date
F-1 Observed site (abutting property/observation hole within 150 feet of SAS)
F-1 Checked with local Board of Health - explain:
I
Checked with local excavators, installers - (attach documentation)
Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
Perc test performed 6/19/92 by Neve Associates Witnessed by the the North Andover BoH
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins - 09/08 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
271 Candlestick Rd
Property Address
Gregory and Maryann Scarangelo
Owner Owner's Name
information is North Andover MA 01845 10/22/2009
required for every
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
• Inspection Summary: A, B, C, D, or E checked
• Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
• System Information — Estimated depth to high groundwater
• Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins - 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17
> OTHER. (Indicate)
1443 Health Agent Initials
White -Applicant Yellow -Health Pink -Treasurer
Town of No rth Andover
Health Depirtment Date:
Location:
(Indicate Address, if Residential, or
Name of Busi
Check #: "C;—, /
��_
Type of Permit or License: (Circle)
> Animal
$
> Dumpster
$
> Food Service - Type._
$
> Funeral Directors
$
> Massage Establishment
$
> Massage Practice
$
> Offal (Septic) Hauler
$
> Recreational Camp
> SEP77C PERMITS:
L) Septic - Soil Testing
$
El Septic - Design Approval
$
L1 Septic Disposal Works Construction (DWC) $
0 Septic Disposal Works Installers (DW[) $
> Sun tanning
$
> Swimming Pool
$
> Tobacco
$
> TrasWSolid Waste Hauler
$
> Well Construction
$
> OTHER. (Indicate)
1443 Health Agent Initials
White -Applicant Yellow -Health Pink -Treasurer
TRANSMISSION VERIFICATION REPORT
TIME 08/15/2006 12:04
NAME HEALTH
FAX 9786888476
TEL 9786888476
SER.# 000B4J120960
DATEJIME
08/15 12:02
FAX NO./NAME
89784755101
DURATION
00:02:02
PAGE(S)
10
RESULT
OK
MODE
STANDARD
ECM
North Andov r-Roalth Denartment
1600 Osgood Street
Building 20, Suite 2.36
North Andover, MA 01845
978-688.9540 - Phone
978.688.8476 — Fox
healthd, t0Wn0fnnr4hRftfj.%"a. - E-mail
www-to-w—mohorthoy - Website
... dover.com
.Fox:
Letter of Transmittal.
page / of /'�
DATE.,
FROM: Pamela DefleChiaie,
jFE; Z-71-1171
We irm sending you: I_76pyoflefter 0ftns 47 Other Ifillig below)
These are transmitted as checked below:
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Department Assistant
L7&v&,n# qji?sfar
>
North Andover Health Department
1600 Osgood Street
Building 20, Suite 2-36
North Andover, MA 0 1845
978.688.9540 - Phone
978.688.8476 — Fax
healthdeptO-townofnorthandover.com - E-mail
www.townofnorthandover.com - Website
A
Letter of Transmittal,
of 1-5
Page
VtORTH
01
+ 0
0 Z.
Argo
TO: 47 r
DATE:
COMPANY:
FROM: Parnein DefleChouie, Health Department Assistant
Phone:
RE: �e 117
X6 /I
Fax:
COPY TO:
Veorese,7dingyou.- 06pyofletter 17PIons /7 Other Ifill M below)
These are transmitted as checked below:
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REMARKS:
(OPY TO:
COPY TO:
SIGNED:
COPY TO:
NEW ENGLAND ENGINEERING SERVICES
INC
March 2, 2006
Ms. Susan Sawyer
North Andover Board of Health
400 Osgood Street
North Andover, MA 01845
D
-106
MAR 0 6 2006,
TOWN
V,li OFN
L-rt� ORT�;i�DdV-j
A DEF
--�����ENT
RE: IME V REPORT: 271 Candlestick Rd No 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,
j�� C 0 /
Benja��,C. Osgood, Jr.
Certified Title 5 Inspector
,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 ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 271 Candlestick Road No Andover, MA 01945
Owner's Name: Doug Kom
ownees Address: 271 Candlestick Road No Andover, MA 01845
Date of Inspection: 3/l/2006
Name of Inspector. (plem print) Benjamin C. Osgood, Jr. Certified Title 5 Inspector
Company Name: New England Engineering Services Inc.
MWfing Address: 60 Beechwood Drive North Andover, MA 0 1945
Telephone Number. 978-686-1768
CERTWICATION STATEMENT
I certify that I have personally inspected. the sewage disposal system at this address and that the infbimation. 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 the on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section
15340 of Title 5 (3 10 CMR 15.000). The system:
_ZPasses
Conditionally Passes
— Needs Further Evaluation by the Local Approving Authority
Fails
Inspectoes Signature: (��7 K5) Date:—,31--?1C&
V
The system inspection shall submit a copy of this inspection report to the Approving Authority ( Board of Health or DEP) within 30
days of completing this inspection. If the system is a shared.system or has a design flow of 10,000 gpd or greater, the inspector and
the system owner shall submit the report to the appropriate regional office of the DEP. The origin& 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.
26f 11
OFkCIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CER CATION (continued)
Property Address: 271 Candlestick Road No Andover, MA 01845
Owner's Name: Doug Korn
Date of Inspection: 311/2006
Inspection Summary: Check A, B, C, D or E/&W_AYS complete all of Section D
A., System Passes:
EE�5 _ 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:
IL System Conditionally Passes:
�J 0 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 (YNND) in the for the following statements. If "not determined" please explam.
-.....-The septic tank is metal and over 20 years o1d* or the septic tank (whether metal or not) is structurally unsound, exhibits
substantial iriffitration. or exfiltration or tank bilure is imminent. System will pass inspection if the existing tank is replaced with a
complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the
tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health):
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):
_-Proken pipe(s) are replaced
Obstruction is removed
ND explaik.
36f 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 271 Candlestick Road No Andover, MA 01845
Owner's Name: Doug Kom
Date of Inspection: 3/l/2006
C. Further Evaluation is Required by the Board of Health:
A) 0 Conditions exist which require finther evaluation by the Board of Health in order to determine if the system is failing to protect
public health, sakty 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 widiin 50 feet of a bordering vegetated wedand 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, systern 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 certifted laboratory, for coliform bacteria and
volatile organize compounds indicates that the well is free from pollution fi-om 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 Candlestick Road No Andover, MA 01845
Owner's Name: Doug Kom
Date of Inspection: 3/l/2006
D. System Criteria applicable to all systems:
You must indicate "yes or No" to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or. clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an 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
)K 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.
e 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 well is free 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 foruL)
1VJ (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in
3 10 CUR 15.303, therefore the system fads. 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 . di
, in cate either "yes7 or "nor to each of the following:
(rhe followin& criteria apply to large systems in addition to the criteria above)
Yes No
The system is -within 400 feet of a surface drinking water Supply
1-1
The system is within 2 t of a tributary to a water supply
The system is located in a nii area (Interim Wellhead Protection Area — IWPA) or a mapped Zone H
of a public water supply well
If you answered "Yes" to an on in �ection E the system is idered a significant threat or answered "yes" in Section D above
the large system The owner or operator of any haurge nsi er a si
large 'd ed 'gnificant threat under Section E or failed under
Section upgrade the system in accordance with 3 10 15. 0 . system owner should contact the appropriate regional
office of the Department
5 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 271 Candlestick Road No Andover, MA 01845
Owner's Name: Doug Kom
Date of Inspection: 3/l/2006
Check if thefollowing have been done. You must indicate "yes" or "no" as to each of the, followbaAr.
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 sips of sewage back up
Was the site inspected for sign of break out?
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 facility owner (and occupants if difference from owner) provided with information on the proper
maintenance of the subsurface sewage disposal system?
The size and location of the Soil Absorption System (SAS) on the site has been determined based on:
Yes No
t-- — Existing information. For example, a plan at the Board of Health.
Determined in the field ff any of the failure criteria related to Part C is at issue approximation of distance- is
unacceptable) [3 10 CMR 15.302(3)(b)]
6of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
i
PART C
SYSTEM INFORMATION
Property Address: 271 Candlestick Road No Andover, MA 01845
Owner's Name: DougKorn
Date of Inspection: 3/1/2006
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design)_�_ Number of bedrooms (actual)_�_
DESIGN flow based, in 310 CMR. 15.203 (for example: 110 gpd x #of bedroomsh
Number of cuff ent residents:
Does residence have a garbage grin er (yes or no):
Is laundry on a separate sewage system (yes or no): /y o [if yes separate inspection required]
Laundry system inspected (yes or no)* —
Seasonal use: (yes or no): X-C).
Water meter readings, if available (last 2 years usage (gpd): > L5-) z 3� 3 T o I z) z I K -
Sump Pump (yes or no): AJ 0
Last date of occupancy -.a )
COAMIERCIAL/INDUSTRL&L
Type of establishment:
Design flow (based on 3 10 CMR 15.203): gpd
Basis of design flow (seats/personstsqk etc�_
Grease trap present (yes or nol__
Industrial waste holding tank present (yes or no):
Non-sandary waste discharged to the Title 5 system (yes or no)_
Water meter readings, if available:
Last date of occupancy/use:
OTIIER (describe):
GENERAL INFORMATION
Pumping Records
Source of information: 0 C -1v S uz- 2 0 4�) _—�
Was system pumped as part of the inspection (yes or no): A/ 0
If yes, volume pumped: ---gallons - How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank distribution box, soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
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:
S) 61 L�
Were sewage odors detected wen arriving at the site (yes or no): N 0 .
7 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 271 Candlestick Road No Andover, MA 01945
Owner's Name: Doug Kom
Date of Inspection: 3/112006
BUILDING SEWER (locate on site plan)
Depth below grade: 1 -2-
Materials of construction:- past iron -,/40 PVC___pther (explainj
Distance from private water supply well or suction line:
Comments (on condition ofjoints, venting, evidence of leakage, etc,):
�7) p r L-;20) t -11, cz:2Dz) I 1,-r , 0, Ate 4
SEPTIC TANK:_Oocate on site plan)
Depth below grade:
Material of construction: ne
If tank is metal list age: s ago confirmed by a Certificate of Compliance Ores or no): _(attach a copy of certificate)
Dimensions: I <-,, 0 C-14fL-L4f) tJ --�-
Sludge depth: 41
Distance from top of sludge to bottom of outlet tee or baffle: Z
Scum thickness:. Z- 1 0/
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle__j -
How were dimensions determined: -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.):
-7-jQeJ I,( I f1j 6-ro e) 7) %3 A.,% ee> tj c 12 e 77�-6�� i 6�- 0-c> COA/D
GREASE TRAP: A) /,f _(locate on site plan)
Depth below grade:
Materials of construction: concrete inetal fiberglass. ----polyethylene other
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.
TRANSMISSION VERIFICATION REPORT
TIME
08/17/2006 14:19
NAME
HEALTH
FAX
9786888476
TEL
9786888476
SER.#
000B4J120960
DATEJIME
08/17 14:19
FAX NO./NAME
89784755101
DURATION
00:00:37
PAGE(S)
03
RESULT
OK
MODE
STANDARD
ECM
a Of 11
otncLAL wspEenoN FORM — NOT FOP. VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC'11ON FORM
PART C
SYSTEM INFORMAIMON (continued)
PrupertyAddrm: 271 C=dlcsdck Road No Andover, MA 01945
OwncrJsName. DougKom
Dsft of Inspection.. 311/2006
PnGHT OR HOLDING TAN1L-_&g_(t=k must bee putnpcd at time of inV�on)oocate on site plan.)
Depth below grade:
Materials of consftction: __q0nCretq_meta1 -Aberglass -poiyethyle= —other
(evlaia) - -
Dimensions:
capcitr
Desigrk Fl(YwL--_ gallons/day
Almm prmw (yet or no).
Almm level: Almm w woAmg order (Yes or no):_
Date of last pumping:
CommeW (wndition of *rm and f 1,oat switches, etc.):
DISTRIBUTION BOX:—(if Fvmni must be ope%W)Oocate on Site pl=)
Depth of hquW level above outlet � , 0 " , .
Commem (note if box is level and distribution to outlets quat my evidnence of solids carryover, any cvidcnce aC lealow into or
out of box, etc.):
�'2C
,'yo , i-ZI-4 0"ID-.P AJ &FC%JA-1-
PUW CHAMMR.- A � I IA-:_00cate on dre p1m)
Pww in w0flums onler 0= or no)--,—�
Almms in woffing order om or no)_.
Comments (ome condition of pump chamber, condWon of pumps and appurtemanoes, etc.)*
8 of 11'
010FICL&L INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 271 Candlestick Road No Andover, MA 01845
Owner's Name: Doug Kom
Date of Inspection: 311/2006
TIGHT OR HOLDING TANK 4
—L�L--(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Materials of constniction: concrete metal fiberglass _polyethylene -------other
(explain)
Dimensions:
Capacity: gallons
Design Flow_,. galloWday
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.):
DISTRIBUTIONBOX (if present must be opened)(locate on site plan)
Depth of liqutd 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.):
J3 -,?c t OL/ Q 0 AA /yC Z-C411,H6-F j^ -j (D (Z 0,1 -j
Al',D
PUMP CHAMBEIL A) I � . (locate on sire plan)
Pumps in working order (yes or
Alarms m working order (yes or no)_.
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
. 9 of If
. 4
oihncL4,L INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 271 Candlestick Road No Andover, MA 01845
Owner's Name: Doug Kom
Date of Inspection: 3/1/2006
SOEL ABSORPTION SYSTEM (SAS): gocate on site Wan, excavation not veguired
If SAS not located explain why
TYPE
-leaching pits number
__jeacbing chambers, number
___leaching galleries number�_.
leaching venches, number in length
X —leaching fields, number, dimensions: 20' x -v,!;-' o' --i C- P
overflow cesspool, number:
innovativetaltemative system Typetname of technology:
Comments (note condition of soil, signs of hydraulic failure. Level of ponding, damp soil, condition of vegetation, etc)
.0-OeA r/ C -e j:> -00,2
L) tj L)
CESSPOOLS:/L) I yq- (cesspool must be pumped as part of inspection) (locate on site plan)
Nuniber and configuration:
Depth — top of liquid to inlet invert
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of
Indication of groundwater inflow (yes or
Comments(note condition of soil, signs of hydraulic failure, level of pondmg, condition of vegetation, etc.):
PRIVY:_&),d�_Oocate 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.
10 of 11
oi�nciALINSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 271 Candlestick Road No Andover, MA 01845
Owner's Name: Doug Kom
Date of Inspection: 3/l/2006
SNETCH 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.
-P � (L) 0-
L�L)
A -T
& -T
1-1 a 1 61 1
A--
-ns7
1.1 of ii
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 271 Candlestick Road No Andover, MA 01845
Owner's Name: Doug Kom
Date of Inspection: 3/l/2006
SUE 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 excavator, installers – (attach documentation)
Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
L -5- H 4,4 D
i�llov - C
TOWN
U -A �YSTBN-j p P I N Q R2 C 0
S YS TT
QUANTITY PLIWPCC,
X�C)
y �3. �Vpwc
NA rVKI5 Op MKyIC
t; h tO�
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CA KA YQ n�'-
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. . �UNI'tNj'� TmtWtK&bo I-( (�3 D _0 � 060j-
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Add ressa -7
...AV
br7ft)L t��rhA zVer
Owner's Name: N./\,e % \46e
Owner's Address: S 4 All C_
Date of Inspection:,j5—a 4— naz,
Name of Inspector: (please print) 4—�a rf\ —1�usn
Ic
Company Name: -S=eQd4, su
Mailing Address: ar-, S Y -Y\,*\
, I :S+(e4
Telephone Number: _��5,-
97a— -7q7j
To
130ARD OF HEALTJ
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:
1-113 Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
II -fails
Inspector's Signature: Jaw Al� C- 1—/ Date: C)
.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 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 -O-f inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page I
Page 2 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
11
Property Address: COVIA?GVie-k 'V�kd
�t r
Owner: V\./ 1\ -Irse-
Date of Inspection: R— --CR
Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D
A. System Passes: I -e -S
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:
9. if.
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 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.
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:
']Page 3 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: CG
')VC�Vr\ 'A rN-�f > r
Owner: Iv-\/ Vkf� P -
Date of lnspection:—r� — &L4—cR
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 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.
3. Other:
Page 4 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: <Qn k C�o M I C �
'\ 6aro-fit Acvipyrr
Owner: \4-,/ X AE—!, e
Date of Inspection
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or "no" to each of the following for all inspections:
Yes No
— Ll�Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
— v"bischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
V`� Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
,,cesspool
'--' Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow
--Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped
:��y 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
(Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as
described in 3 10 CMR 15.303. therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. LargeSystems: �1' Art
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.4ach of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area – 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 3 10 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
1�
Page 5 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: Cf—A-1 k CG"Ao44�1 <�� �46
Owner:
Date of Inspection:
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Y
Pumping information was provided by the owner, occupant, or Board of Health
----W'ere any of the system components pumped out in the previous two weeks?
N, Has the system received normal flows in the previous two week period?
-'�Have large volumes of water been introduced to the system recently or as part of this inspection ?
Were as built plans of the system obtained and examined? (If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up .9
Was the site inspected for signs of break out ?
Were all system components, excluding the SAS, located on site ?
L/ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition
;-f—the —baffies 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 pz�pper
maintenance of subsurface sewage disposal systems?
The 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 criteria related to Part C is at issue approximation of distance
is unacceptable) [3 10 CNM 15.302(3)(b)]
o, Page 6 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: Cn lf_G�tck q6
N A/b -A A62AE (I
Owner: \r\l � �2 _,P
Date of Inspection: S;-6 L4—<Z)3r
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): 4 Number of bedrooms (actual):
DESIGN flow based on 3 10 CMR 15.203 (for example: 110 gpd x # oFb—edrooms):
Number of current residents:
Does residence have a garbage grinder (yes or no):
Is laundry on a separate sewage system (yes or no): [if yes separate inspection required]
Laundry system inspected (ye or no):
Seasonal use: (ye's or no): 42
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump (yes or no): /I/
Last date of occupancy: /I (,' 0 01 P C,
COMMERCIALMiDUSTRIAL
Type of establishment: /k/. A,
Design flow (based on 3 10 CUR 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: ,�, / a y -
Was system pumped as part of thi inspection (yes or no):
If yes, volume pumped: Llb 0 gallons -- How was quantirr umped determined? 716 e, 1-e Pet
Reason for pumping: -S;rz 0 c- 1 4/ tze_
OF SYSTEM
Septic tank, distribution box, soil absorpfm system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
fimovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be
�b__tained from system owner)
Tight tank _ Attach a copy of the DEP approval
Other (describe):
Approximate age of all components, date installed (if known) and source of information:
/0 vo
Were sewage odors detected when arriving at the site (yes or no): 1�
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: C-6 n/i i VP0
q �K� K
Owner:
Date of Inspection: —a
BUILDING SEWER (locate on site plan)
Depth below grade: 3 1`
Materials of construction: L -cast iron 40 PVC other (explain):
Distance from private water supply well or suction line:
Comments (on condi ion ofjoints, venting, evidence of leakage, etc.):
161ti-Ir � /7/ 7—/o Al
SEPTIC TANK: YPS (locate on site plan)
Depth below grade:
Material of construci7io—n- —L --'concrete —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) I of
Dimensions: /0 S 5 -
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: — (a
Distance from bottom of scum to bottom of outlet tee or baffle: IV
How were dimensions determined: 0�-/ -S / 1-,6'
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
g4l��,t
-, S + 7-;�q 04,)< 6"to o o eo-A-lo� r/u,�-/
IvA-
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.):
0 Page8 ofll
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: a--7 � (f 0 M leg <A
Owner: W \ - le
Date of Inspection: G—c& 4 —o—�
Y14i
TIGHT or HOLDING TANK: _ (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass ___polyethylene _other(explain):
Dimensions:
Capacity: 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.):
61STPJBUTION BOX:Yf--S (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:��Ud
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.):
9p,1
PUMP CHAMBER: (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 10 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM'INFORMATION (continued)
Property Address:
A,K---)C+h AM 1 Wr
Owner: Ase
Date of Inspection: ak W Q-9
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.
9
-2 V,
,z U
i
,Page I I of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: ca od C64�"
, ' h
Owner:
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:
You must.describe how you est#blished the high ground water elevation:
/,) 411 190 to) Al 1� ' V - - 19 d —/ J- /k -/L) ka,4r/�� OA 5:1',eVv"I
I I
Commonwealth of Massachusetts
A
Executive Off ice of Environmental Affairs
Department of
D E Environmental Protectio
William F. Weld
Governor
Trud
S.r,ly Xe
. %EA
David B. Struhs
Comminioner
/-, 1, ep 0 S
L
Property Address: d 14 //, 5�r-f c jl'o-j Address of Owner: U
Date of Inspection: (if different)
Name of Inspector: 47ot /3 (154
Company Name, Address and Telephone Number:
/),-/ /) 6, (1 Y,�, Ac ro c�'- -2 /2 - Ir
CERTIFICATION STATEMENT
I certif�, that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site se ge disposal systems. The system:
Y_w
Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
TOO�NOF N
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
IJUN 9 1998
Inspector's Signatu�re- Date: b,
The System ln� /e�orashWall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing ithips
inspection If the systen) i� a shared system or has a design flow of 10,000 gpd or greater, the inspeclor and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be vni ie !I)r, wstem o\vner and copies sent to the buyer, if applicable and the approvilig dU1110111�.
INSPECTION SUMMARY:
Check A, B, C, or D
A] SYSTEM PASSES:�
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
Bj SYSTEM CONDITIONALLY PASSES: 1 -1;4 -
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not)
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
(revised 8/15/95)
One Winter Street 0 Boston, Massachusetts 02108 a FAX (617) 556-1049 o Telephone (617) 292-5500
40 Printed on Recycled Paper
7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property A�dr ess: 0 5,)r,(c ec—
Owner:
Date of Inspection:
B) SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the
Board of Health);
broken pipe(s) are replaced
obstruction is removed
distriUution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if (with approval of the Board of Health):
i
broken pipe(s) are replaced
obstruction is removed
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD Of HEALTH: 1,44
1
Conditions exist which require further evaluation b the Board of Health in order to determine if the system is failing to protect the
public health, safety and the erivironment.
1) SYSTEM WILL PASS UNLESS BOAkD:OF HEALTH DETTIMNES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH �Nl) 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.
j)�j
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
I he w;tem nas aseptic tank and so i I absorption system and is w I I I iiii 100 feti kid surifdLt� water supply or tribotary tc, a
surface water supply.
The systern ha-- a septic tank -and soil absorption system and is within a Zone 1,.of.a publicwater supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system ha�, a septic tank and soil absorption system and is less than 100 feet but 50 feet,or more from a private water
supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is
free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm.
D) SYSTEM FAILS: P 4.
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to; determine what will be necessary to correct
the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool..
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged'SAS or
cesspool.
(revised 8/15/95) 2
M
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection: e
DI SYSTEM FAILS (continued): H,
Static liquid level in the' distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or,obstructed pipe(s).
Numberof times pump* t,
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The design flov� of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety
and the environment because one or more of the following conditions exist:
— the system is within 400 feet of a surface drinking water supply
— the system is within 200 feet of a tributary to a surface drinking water supply
T
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone 11 of a
public wdter supply welh
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 8/15/95) 3
.4 -
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 0 dks rt re "9- /9--l'ou L)
Owner:
Date of Inspection: 7-ktom cps
Check if the following have been done
We Pumping infon�nation was: re� ested qtth� owner,.vccupantN,a4'Board of Fiealth.
None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
V-1, 'A -f t I (IV I r --
As built plans have been obtained and examined. Note if they are not available with N/A.
V"'Tl* facility or dwelling was. inspected for signs of sewage back-up.
C4T system does not receive non -sanitary or industrial waste flow
/The site was inspected for signs of breakout.
system components, excluding the Soil Absorption System, have been located on t he site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees ' material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
/The size and location of he Soil Absorption System on the site has been determined based on existing information or
approximated by non -intrusive methods.
The faciht� cj,%;-.c, (and occupant,�, if differen! frcm owner) were provided with information on the proper maintenance of Sub -
Surface Disposal System.
(revised 8/15/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: it it/e .5-,f le -&—
Owner:
Date of Inspection: e' 414
FLOW CONDITIONS
RESIDENTIAL:
Design flow: gallons
Number of bedrooms:
Number of current res dents:
Garbage grinder (yes or no): -W
Laundry connected to system ( es or no):—�Ops
Seasonal use (yes or no):7:z
Waier"Oeter readings,, if available: A-1,4*%' V.,
Last date of occupancy: 6� I �f �'
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: allons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)
Non -sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
PUMPING RECORDS and source of information:
GENERAL INFORMATION
-'; /'-J'
System pumped as part of inspection: (yes or no)—Vops,
11,yes, volume pu ped all
m ons
Reason for pumping. C, C re, HI L -
TYPE F SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Other (explain)
a -/ 0 -2 P -j -
APPROXIMATE AGE of all components, date installed (if known) and source of information: f -�-
Sewage odors detected when arriving at the site: (yes or no) A
/6
(revised 8/15/95) 5
00
Property Address:
Owner:
Date of Inspection:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM.INFORMATION (continued)
SEPTIC TANK:— k/
(locate on site plan)
Depth below grade:
Material of construction:
—concrete —metal _FRP —other(explain)
Dimensi6ns:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: Z,�5
Scum thickness: ; I f
Distance from top of scum to top of outlet tee or baffle: 'r
Distance from bottom of scum to bottom of outlet tee or baffle: / q
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
GREASE TRAP:
(locate on site �_Ian)
Depth belo", grade:
Material of construction: —concrete —metal _FRP —other(explain)
Dimensions:
Scum thickness.
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom ot rum v, hottorr of outlet tee or battle-
-Commentsi
(recommendation for pump;ng, -condition of i nlet and outlet tees or baffles, depth of liquid level in r1elation to outlet invert, structural
integrity, evidence of leakaFe, etc.)
(revised 8/15/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
tj VIC
Property Address:
Owner:
Date of Inspection: I A nx
TIGHT OR HOLDING TANK:_
(locate on site plan)
Depth below grade
Material of construction: —concrete —metal —FRP —other(explain)
Dimensions:
Capacity: _gal Ions
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: 14P5
(locate on site plan)
Depth of liquid level above outlet invert: ') I
Comments:
(note if 1c% c! and ev;dence of cn! id� evidi-nce of leakage into or out of box, etc.)
PUMP CHAMBER:
(locate on site plan)
cull V 6 A i 7AIJ
J-/ '.6 Z- e-j� /1,- :1, C -e
Pum�s in working order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 8/15/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: le-&_
Owner:
Date of Inspection: I-- . S
SOIL ABSORPTION SYSTEM (SAS): —
(locate on site plan, if possible; excavation nVt (e0q5ired, but may be approximated by non -intrusive methods)
If not determined to be present, explain:
Type:
14eaching pits,, number:
leaching chambers, number:
leaching galleries, number:
leaching trenches, number,Tength:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
V4z oc""l-f C_
4e Aa CJ M A4 0'
CESSPOOLS:
(locate on site plan)
Number and configuration:
Depth -top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater.
inflow (cesspool must be pumped as part of inspection)
J T
Comments: (n�te condi'tion of soil, signs of hydrliulic failure, level of ponding, concl;iti�n of vegetation , etc.)
PRIVY:
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 8/15/95) 8
:_ e"
0
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: le-&_
Owner:
Date of Inspection: I-- . S
SOIL ABSORPTION SYSTEM (SAS): —
(locate on site plan, if possible; excavation nVt (e0q5ired, but may be approximated by non -intrusive methods)
If not determined to be present, explain:
Type:
14eaching pits,, number:
leaching chambers, number:
leaching galleries, number:
leaching trenches, number,Tength:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
V4z oc""l-f C_
4e Aa CJ M A4 0'
CESSPOOLS:
(locate on site plan)
Number and configuration:
Depth -top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater.
inflow (cesspool must be pumped as part of inspection)
J T
Comments: (n�te condi'tion of soil, signs of hydrliulic failure, level of ponding, concl;iti�n of vegetation , etc.)
PRIVY:
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 8/15/95) 8
:_ e"
Property Address:
Owner:
Date of Inspection:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
j "..
,;z 7/
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
11)6 it C
DEPTH TO GROUNDWATER
Depth to groundwater: 6 '�- feet,
method of determination or approximation: 19V C, 0-4, -f 4) -J�
AIL) ve.1—
Af., a s-
lrevise.d 8/15/95) 9
Form No. 2
Town of North Andover, Massachusetts
BOARD OF HEALT
DESIGN APPROVAL FOR
SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Test No.
Applicant
Site Location
Reference Plans and 511)ecs. ENGINEER DLSIUN DATE
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations o . f Board of Health.
I M A �t4 R O�D 0 F �HE A L T �H
CHAIRMAN, BOAR
Fee— Site System Permit,No.-53—��—
1 0
DATE_Z,� �,3 �,7��
Sheet of
BOARD OF HEALTH
TOWN OF NORTH ANDOVER
SUB; ICE DISPOSAL DESIGN REVIEW
FEE �� A -.PERMIT # Qf_5�5- — DATE RECEIVED__��//Z-5�/93
APPLICANT Zq&Z) 5- e ASSESSOR'S MAP
ADDRESS
ENGINEER
ADDRESS -44 0 4 b 865 EON RD
PLAN DATE ////0 1177.
CONDITIONS OF APPROVAL:
APPROVED
DISAPPROVED
PARCEL #
LOT #
STREET
7_,� 115,,c71&zo 0128,3
REVISION DATE
MINIMUM 906 1-7-1 1`61e ze�,961YIN6 134-b
No IN /v "g. k c- 6. 5 &Iev c- /4 -� 50
t 1,Ck5
0/-- V)
-7 loe,9 OR 2
(/V/g. /6, 6
A. )U5r 8,6 7Z)
e'07-
56�7_
eON67��ZIC7_101V - M05 7- _73C_ <3/v '-'07-
( /Y, 12.
6 ry-,
M 0 5 7' Y A10.rC
INrO IV197_alP�,l _P&�f 1116U�; A4A7-,-1?1,Q�- 7
(/l/ 1-2,
EIVD5 0/.:7- 015�7,_ x_INS-5 r -O 8` '1`611ve�9 NO2-e-5- o1V
?1_1,q1v5 CIYI�9 19-64)
-5 Q/-
7) lx�ep IVF -W 7-e5 7L
IV, 119 0 7)
PLAN REVIEW CHECKLIST
ADDRESS -Z -ENGINEER. 761'4
GENERAL
3 COPIES L,-' STAMP LOCUS 1-,� NORTH ARROW e-� SCALE -/--
6 /L
CONTOURS PROFILE 1-� SECTION BENCHMARK4/>7- SOIL &
PERC INFO ELEVATIONS WETS. DISCLAIMER L� WELLS &
WETLANDS WATERSHED? DRIVEWAYL-.--' (Elev) WATER LINE,��
FDN DRAIN_k_ SCH40 TESTS CURRENT?—
SEPTIC TANK
MIN 1500G. .17 INVERT DROP GARB. GRINDER/V6 (+200% EDF)
251 TO CELLAR�-� MANHOLE TO GRADE ELEV 61C GW 0,1!f
D -BOX
SIZE
LINESA7'
FIRST 21
LEVEL STATEMENT
INLET
OUTLET (2".
OR .17 FT)
TEE REQID?—
LEACHING
RESERVE AREA --' 4' FROM PRIMARY? L,-' 100' TO WETLANDS 2% SLOPE
100' TO WELLS ---- 35' TO FND & INTRCPTR DRAINS t--� 41 TO S.H.GW
3251 TO SURFACE H20 SUPP---- 4' PERM. SOIL BELOW FACILITY 6--'
MIN 12" COVER L�-' FILL?L-- ((25�)if above natural elev; 10fif below)
BREAKOUT MET? /VC;r,6, 01V �rCpLl. IA17-0 -XWf&Nr 5614 --�-
TRENCHES
MIN 660 gpd_ SLOPE (min .005 or 611/1001)_ >31 COVER? - VENT_
SIDEWALL DIST. 2X EFF. W OR D.(MIN 61)_ IS RESERVE BETWEEN
TRENCHES? IN FILL? MUST BE 101 MIN. 411 PEA STONE?--�--
BOT X LDNG_2 + SIDE X LDNG TOT
(L x W x (G/ft ) (DxLx2x#)
PITS
MIN 660 LEACHING GW MIN 41 BELOW BOTTOM MANHOLE/PIT,
EXCAV 2x EFF W OR D 1211-48" STONE SURROUNDING
BOT + SIDE— x LOAD
(L x W X (2 x (L+W) x D X #)
CHAMBERS
COVER >3 FT - VENT
FIELDS
= TOTAL
A'jk
MIN 900 ft2 LEACHING -,K PERC RATE FASTER THAN 20M/IN GW MIN
41 BELOW BOTTOM OF FIELD PIPE ENDS JOINED W/NON-PERF. PIPE?
4" PEA STONE? DIST LINE SLOPE .005? >31 COVER - VENT
SCH 40 L ----MIN 12" COVER L x W = T x LDNG > DESIGN FLOW?
-6R 660 0 0
Lzr:5,�-,,e V Lx Dc-516N&D /-
DOSING TANKS AND PUMPS
DIMENSIONS x x PUMP CAPACITY gpm
—W —W Vol.
DISCHARGE SIZE DISCHARGE RATE DISCHARGE TIME
gpm
MANHOLES TO GRADE ALARM SEP. CIRC. GW (Min. 11 below
inlet) HWL LWL CHECK VALVE BLEEDER HOLE MANUAL
OP. SWITCH
Town of North Andover, Massachusetts Form No. I
BOARD OF HEALTH
ON kA e'de-,
APPLICATION FOR SITE TESTING/[ NSPECTION
Appli
�ite Location
Engineer
Test/inspection Date and Time
R
CHAIRMAN, BOARD OF HEALTH
Fee Test No. q —) q
S.S. Permit No.-D.W.C. No.-C.C. Date-Plbg. Permit No.
Town of North Andover, Massachusetts Form No.1
,�XORTH BOARD OF HEALTH
.0 '�r, -
0 19
APPLICATION FOR SITE TEST I NG/I NSPECTI ON
Applicant - � 'f �— � j
NAME ADDRESS TELEPHONE
Site Location 1 -�� -i , , A-
A.
Engineer NAME ADDRESS TELEPHONE
Test/Inspection Date and Time
.4
Fee
CHAIRMAN, BOARD OF HEALTH
-N
Test No. ' L , L
S.S. Permit No.-D.W.C. No.-C.C. Date-P1bg. Permit No.
ZS
BOARD OF HEALTH
Neve Associates
447 Old Boston Road
Topsfield, MA 01983
120 MAIN STREET ,
NORTH ANDOVER, MASS. 01845
TEL. 682-6483
Ext. 32
January 11, 1993
RE: Lots 25 and 27 Candlestick, and Lot 28A Sugarcane Lane
Dear Tom:
This is to notify you that the proposed septic plans for the
above -referenced lots have been disapproved. Please see the
enclosed design review sheets for explanations.
If you have any questions, please do not hesitate to call me
any Monday, Wednesday or Friday.
Sincerely,
Sandra Starr
Health Agent
cc: Karen Nelson
BOH file
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FORM U - LOT RELEASE FCRM
INSTRUCTIONS: -7-nis' form, is used to verify that all nec--s:sary apprcvals/perrmits frorm-
Ecards and Departments having jurisdiction have been obtained. T�,is does not reHeve
the applicant andlor landowner from ccmplianc-- with any applic-,:ble or requirements.
AFFLICANT FILLS OUT T"H,14'- SECTICN-"
uu - It
A P P L I CANT Y -C,
e� _Dg- a - b k e,
LC CA TIG M: As-zesscr's Map Numter / 0 (, Iq
SUECIVI:SICN
ST7RAE-27 Lv-�
PHONE 7Z 5--33J4
P.4 R C = . n �2-3
LOT (:S)
ST. NUMSER-,1 -7
--------------- —OFFICIAL
F—RECOMMENDATICN-5 OF TOWNAGENTS:
;r�l,;,17 134,sf
CCN-<ERVA7TCN ADMINISTRATOR CATE APPROVED
il CATE RE-JECTED
COMMENTS
TOWN PLANNER
CCMMENTS
CATE APPROVED
CATE REJEC71EM
FOOD IN -SPECT
��EAL7H CATBAPPROVED
) CAT7z R.EJECTIM
OR-HEAL7H
COMMENTS
4
CATH APPROVED 0 'n
CATE REJECTED
PUELIC WORKS - SEINER1WATIER CONNECTIONS
DRIVE -NAY PERMIT
-IFF- DEPARTMENT
RE EY E U I LID ING ii',I:S F EC'7C R
evised S�97 im
DATE
a
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5u
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47
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Form No. 3
Town of North Andover, Massachusetts
BOARD OF HEALTH
14ORTPI
61 19 qq
0
DISPOSAL WORKS CONSTRUCTION PERMIT
Applicant_ 6 TELEPHONE
NAME ADDRESS
site Location WT- ,
Permission is hereby granted to Construct Py � or Repair an Individual Soil Absorption
V\1
Sewage Disposal System as shown on the Design Approval S.S. No.
CHAIRMAN, BOARD OF HEALTH
Fee, �b D.W.C. No. C 6 Y
I i .
FORM U - LOT RELEASE 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 sec . on*****************
I
APPLICANT: felA421- 71-1,10WAx4o A)la)�6- hone
LOCATION: Assessor's Map Number /6 ) i�/� Parcel
Subdivision P,.46g: Lot(s)
Street
el eVA St. Number
************************Official Use Only************************
RECOMMENDATIONS OF TOWN AGENTS:
Date Approved
Conservation Administrator Date Rejected
Comments
Y� 9) C.L�d � Q -
Town Planner
Comments
Food Inspector -Health
J �JILI�
Septic Inspector -Health
Comments
Public Works - sewer/water connections
- driveway permit
Fire Department
Date Approved
Date Rejected
Date Approved
Date Rejected
Date Approved
Date Rejected
Received by Building Inspector Date
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
27 CHARLES STREET
NORTH ANDOVER, MASSACHUSETTS 01845
Sandra Starr, R.S., C -H-0. (978) 688-9540 - Telephone
Public Health Director -
(978) 688-9542 - Fax
TOC From:
C --
Fax:
Pages:
Phone. Date:
'51—a -,-;, /e�7
Re: CC:
0 Urgent 0 For Review 0 Please Comment 0 Please Reply 0 Please Recycle
Please call 978-688-9540 for assistance with any questions. Thank you.
Xc: Address File
Chrono File
Pools & Septic Systems HD -02
Why do I need this approval? Unless the
Board of Health approves the location of the
proposed pool, the Building Department will not
issue a building permit. The Board of Health
reviews all applications for residential pools that
are proposed for sites with septic systems to
make sure that the pool is not being placed on
top of the septic system components, on or in
the leach area or on or in the reserve area. In
addition there are certain setbacks to the septic
system and any well on site that must be
maintained.
What do I neecl� For the Health Department
review you will need the following documents:
• Scaled plot plan with house and septic
system accurately located;
• Plan location of your proposed pool at
the correct scale added to the plot plan
If you do not have this information in your own
files, the Board of Health may be able to help you
by p roviding a copy of yoursepticAs-,6uilt plan.
Who do I see? To obtain a copy of your As -Built
(the plan that shows your lot, house and septic
system as it was buil4, you may request a copy to
be made at the Health Department if one is on
file. If you cannot obtain a scaled copy, you may
want to request that your septic tank pumper
come out and locate the septic system
componenis. A Civil Engineer may also locate
the system and can then prepare a certified plot
plan.. Once you have the plot plan and are ready
to site the pool, there are a few rules you need t o
keep in mind. They are:
In -ground pools must be at least 20 feet
from the septic system leach area and at
least 10 feet from the septic tank.
Aboveground pools must be at least 10
feet from both the leach area and the
septic tank.
If there is a well on the property, regardless of
the well's use, then:
Both types of pools must be at least 15
feet from the well.
These setbacks include all parts of the pool, such
as fences, decks, cement walkways and grading.
How do I do this? To start the process you
must first go to the Building Department and
apply for a permit to install a pool. You will pay
a fee and receive some paperwork. You will
have to go through the Conservation
Commission if you have wetlands on or near
your property. It is always wise to check with
the Conservation Department whenever you
are planning an outside project that will result
in excavation of soil or removal of trees. You
can , at the same time you are working with
Conservation, submit your paperwork to the
Health Department for review and approval. if
there is a problem with the application or if
information is missing, you will be contacted
and asked to supply additional paperwork or
clarify something on your application. A final
approval and issuance of a building permit will
depend on the approval of all pertinent
departments.
Other References:
3 10 CMR 15-000 of the State
Environmental Code, Title 5
(Download a copy online at
vvvvvv.state.ma.us/dep/brpZwvvm/t
5pubs.htm)
Town of North Andover Minimum
Requirements for the Subsurface
Disposal of Sanitary Sewage
• #CD--Ol Notice of Intent (NOI)
brochure
• #PD -0 I Watershed Permit brochure
Town of North Andover Health Department - Community Development & Services Division
ThIs brochure Is Intended as education of the localpermittin_q process on6l It does not cover al1junsdIctlons or
scenarios thatyourpermitapplIcation maybe subject to Ferm./tapplIcatlons are site specific
Pools Septic Systems
Why do I need this approval? Unless the
Board of Health approves the location of the
proposed pool, the Building Department will not
issue a building permit. The Board of Health
reviews all applications for residential pools that
are proposed for sites with septic systems to
make sure that the pool is not being placed on
top of the septic system components, on or in
the leach area or on or in the reserve area. In
addition there are certain setbacks to the septic
system and any well on site that must be
maintained.
What do I need? For the Health Department
review you will need the following documents:
• Scaled plot plan with house and septic
system accurately located;
• Plan location of your proposed pool at
the correct scale added to the plot plan
If you do not have this information in your own
files, the Board of Health may be able to help you
by providing a copy of your septic As-Ruilt plan.
Who do I see? To obtain a copy of your As -Built
(the plan that shows your lot, house and septic
system as it was buil4, you may request a copy to
be made at the Health Department if one is on
file. If you cannot obtain a scaled copy, you may
want to request that your septic tank pumper
come out and locate the septic system
components. A Civil Engineer may also locate
the system and can then prepare a certified plot
plan.. Once you have the plot plan and are ready
to site the pool, there are a few rules you need to
keep in mind. They are:
In -ground pools must be at least 20 feet
from the septic system leach area and at
least 10 feet from the septic tank.
Aboveground pools must be at least 10
feet from both the leach area and the
septic tank,
If there is a well on the property, regardless of
the well's use, then:
Both types of pools must be at least 15
feet from the well.
# HD -02
These setbacks include all parts of the pool, such
as fences, decks, cement walkways and grading.
How do I do this? To start the process you
must first go to the Building Department and
apply for a permit to install a pool. You will pay
a fee and receive some paperwork. You will
have to go through the Conservation
Commission if you have wetlands on or near
your property. It is always wise to check with
the Conservation Department whenever you
are planning an outside project that will result
in excavation of soil or removal of trees. You
can, at the same time you are working with
Conservation, submit your paperwork to the
Health Department for review and approval. If
there is a problem with the application or if
information is missing, you will be contacted
and asked to supply additional paperwork or
clarify something on your application. A final
approval and issuance of a building permit will
depend on the approval of all pertinent
departments.
Other References:
3 10 CMR 15.000 of the State
Environmental Code, Title 5
(Download a copy online at
www.state.ma.usZdep/brp/wwMLt
5pubs.htm)
Town of North Andover Minimum
Requirements for the Subsurface
Disposal of Sanitary Sewage
#CD- 0 1 Notice of Intent (NOI)
brochure
#PD -0 1 Watershed Permit brochure
Town of North Andover Health Department — Community Development & Services Division
This brochure Is Intended as education of the localpermitting process on6l It does not cover al1junsdIctlons or
scenarlds thatyourpermitapplIcatlon maybe subject to PermitapplIcatlons are sitespedfic
A
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Aa:�skhusetts
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�"a`;NORTKAN DOVER, MA
SSA0HUM
.,by. iem..Fumping K cora NO V 13 2006
im: -4
: _; � ._ , , , . ... . OF
TOWN
DER has provided this form for use by local Boards of Health. T
be submitted to the.local'Board of Health or other approving authority.
'4)V,
State
Zip Code
state Zip Code
Telephone Number
B. Puffiping Record
ID6 )6(17�
Date- of Pumping Date 2. Quantity Pumped,
Gillons
Tight Tank
3. 'Type of system:. F-1 Cesspool(s) �Ileptic.Tank
Other (describe):
Effluent Tee Filter present? 0 Yes Y!�� If yes, was it cleaned? Yes E].No
must
t5form4.doc--06103 System Pumping Record - Page 1 of 1
A. Facility Information
tmj)ortant:
-...When'filUng out
1. System Location'.
foh-ns on the
comOuter, use.,
only the tab key
Address ............
to move your
cursor - do not ,
tAe the return.
Cityrrown
key.'�
2 System Owner
Name.
Address (if different from location)
city/Town
'4)V,
State
Zip Code
state Zip Code
Telephone Number
B. Puffiping Record
ID6 )6(17�
Date- of Pumping Date 2. Quantity Pumped,
Gillons
Tight Tank
3. 'Type of system:. F-1 Cesspool(s) �Ileptic.Tank
Other (describe):
Effluent Tee Filter present? 0 Yes Y!�� If yes, was it cleaned? Yes E].No
must
t5form4.doc--06103 System Pumping Record - Page 1 of 1
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Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
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.
A. Facility Information
Important:
When filling out
1 . System Location:
forms on the
computer, use
only the tab key
Address
to move your
No.Andover
cursor - do not
City/Town
use the return
key.
2. System Owner:
C'A
Name
Address (if different from location)
City/Town
Ma
State
State
Telephone Number
OCT 18 &11
TOWN OF NORTH ANDOVER
01845
Zip Code
Zip Code
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped- Gallons -
3. Type of system: El Cesspool(s) Septic Tank El Tight Tank El Grease Trap
F� Other (describe):
4. Effluent Tee Filter present? 0 Yes 0 No
5. Condition of System:
6. 1,5ystem Pumped By: I I
Z)L�Ac-P "ef
Name
Stewart's Septic Service
Company
7—. -Location where contents were disposed:
8�wart's Pre-treatment Plant, 20 Sp. Mill B
Signature of Haulg I
U -
Signature of Receivi*Lictlity
If yes, was it cleaned? E] Yes El No
Vehicle License Number
Ma 01835
Date
— () �' ' -�o . I I
Date
t5form4.doc- 03/06 System Pumping Record - Page 1 of 1
Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
,\\\j
KRER�l
5 2313
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.
A. Facility Information
Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
2
System Location:
Address
North Andover
City/Town
System Owner: n 10.
Name J
Address (if different from location)
Ma
State
01845
Zip Code
City/Town State Zip Code
Telephone Number
B. Pumping Record
? j/ /
�34'�
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of System: El Cesspool(s) Septic Tank Tight Tank Grease Trap
El Other (describe):
4. Effluent Tee Filter present? F1 Yes No If yes, was it cleaned? El Yes El No
5. Condition of System:
qr\, -s
Cx A
6. System Pumped By
lfC\fhIl2,
'Nam�i— Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewarfa-REe--fteatment Plant, 20 So. Mill Bradford. Ma 01835
re of H
Signature
-Date
Da4
t5form4.doc- 03/06 System Pumping Record - Page 1 of 1
7
�L\ Commonwealth of Massachusetts JIJ t
MEMO= City/Town of TOWN OF NORTH N�4DOVER
System Pumping Record NORTH ANDOVER HEALTH DEPARI MENT
Form 4
DEP ha:t provided this. form for use by local Boards of Health. Other forms may be used, but the
information must t)e substantially the same as that provided here. Before using this form, check wilh your
local Board of Health to determine the form they use. The System Pumping Record must be submiftted to
the local Board of Heatth or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15,3511 -
A. Facility Information
Important:
When, filling out
form$ on the
I , System Location:
Computer. Use
only the tab key
to move your
A00ress
C,
cursor - do not
Use the return
cityrTown
state
Zip Code
key.
2. System Owner:
Name
�(if from location)
Addresi$ cifferent
State Zip Coce
7
Teli�h--ne Number
13. Pumping Record
1, Date of Pumping 2.
Date
Quantity Pumped:
Gallons
3. Type of system: 0 CesspoolM �ep�tic
-rank Tight Tank
El Grea5e Tmp
El Other (describe)'
4, Effluent Tee Fitter present? 0 Yes
If yes, was it cleaned?
Yes C] No
5. Condition o,�,fSyste
6. SysteM Pumped By'.
Nanw
Company
7. Location where contents were disposed,
Signat6r Hauler
Signature of Receiving FaciJ4
Vehicle Lic7e�nse umber
t5forM4.d00- 03106 3y:stern Pumping Record - Page I of I