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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: > 17)#MMd~ > �4�MF4WW > 17*RhpiW TO,, > 0&4md > L7Fw*Whyandwnwxw > LY&*wft A 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: > L7AsA?MuW > L7rw*pmd > L7&rA,&fvwwdxnrw# > Ekryowiw n Nr� 0&wke qp ris for 01" q0f8SfVr&f 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� ?VLL flu cc) CA KA YQ n�'- Qrrf ER -EX P L,� . . �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 4- 0 Q) 0) 03 5 5 E H (4-.- 0 (1) 4-J z -.q V91 cn 0 U a) ra n. Q 4-J CU 4-- u 0 00 CD. E = 0 4-J m :Lj F- 0 t 14 E :3 0 0, t 0 m Z fu ia_ ru 0 'R ca 0 p 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 Qq_ i A/) 5u 9LJ ,4 - Ll rb 47 w 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 _01, Aa:�skhusetts M Z� M, h. �"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 NW��R r= ACM R pp- AUG 2 2-007' OT VIM TOWN OF NORTH ANDOVER HEALT-;-i DEPA E �RTME' 4 Rhai Oidildid tfilf f u i4L NT for foru6ohyie%t,,aR,%nrj su n b'114id t�'thq,jocafftard of Health or other approving authority, -FaCIIItY..,Inf9rm t 4 Ion Wo 8ystoni, oca on: 0* M tab.key to move your." do pQ1 -use' w '4` Y, QWner!�` ;ji Pam# Aw (it difforgrit from location) ZJp Pods ord must tit p Code Telephone Number !XE "R "JUMPIn 29 -- IV$ a*otPump1ngj1i--­; , 1 , .,. — owantity Pumped: 2. Gallons :J f. cesspool 3"' ".Typ , 9 9f SyCom" htTank (s) ptic Tank Tig. At If ye ad? T so FlItor Oont?-- D 0 s, was It clean Yes []'No C 1%-� �wli C, VONC40 Ucen4e Number "'d n W pro, 1posed. V. al 9 of How ------- Dots M ati OV/d e pl.wa to A0 MOMOrms,hhMnspect W-003 System Pumping Record Page i of I 1h5 B R -AA -My P * H DEC 0 5 2008 - (9P- NWUH E 77 0:7) p - Pv mping ., . tpq L -e <50 oc T'an., EMOM Too F18 0( ptp)enr? y ".0 It 7 J' 7. - Lou on J V4 m a Q y -' '- -A ' �� 7 719ni Ta�% L VA Lon 01 V14 rl 1.11m � le� Pv mping ., . tpq L -e <50 oc T'an., EMOM Too F18 0( ptp)enr? y ".0 It 7 J' 7. - Lou on J V4 m a Q y -' '- -A ' �� 7 719ni Ta�% 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