HomeMy WebLinkAboutMiscellaneous - 272 SUMMER STREET 4/30/2018 (2)0 m
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PUBLIC HEALTH DEPARTMENT
Community Development Division
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To: All North Andover Residents with SeDtic Systems and Garbage Grinders
Please note that due to recent reviews of Title 5 Reports, your property has been identified as
maintaining a working garbage grinder that is being used in conjunction with a septic system.
The Health Department is concerned for the Ion evity of your septic system.
9
Garbage grinders are never recommended where septic systems are used, but if they are installed,
the system must be specifically designed to handle the waste from them; your system can not
handle the waste as designed. Please note that continued use of this grinder could quickly cause
a pre -mature failure of your septic system, resulting in a large expenditure to replace it. The
North Andover Health Department recommends that you remove it from your home as soon as
possible.
Some information regarding regular maintenance of your septic system is attached. Please call
the Health Department -at 978.688.9540 if you have any questions, or e-mail your questions to:
healtlidepta
,townofnorthandover.com.
Thank you,for taking the time to consider the impact that your current setup has on your septic
system and'the environment.
Sincerely,
Susan Y. Sawy-er, RE.Hsl�'
Public Health Director
/pfd
Enc: Septic System Information: http://www.mass.gov/dep/water/wastewater/dodont.htm
1600, Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fox 978.688.8476 Web http://www.townofnorthafidover.com
6716
0
Town of North Andover
HEALTH DEPARTMENT
S CHU
CHECK #:
LOCATION
H/0 NAME:
CONTRACTOR N
TYRe of Permit or License: (Check box)
Septic - Soil Testing
0 Animal
$
0 Body Art Establishment
$
0 Body Art Practitioner
$
0 Dumpster
$
11 Food Service - Type.4
$
11 Funeral Directors
$
0 Massage Establishment
$
0 Massage Practice
$
0 Offal (Septic) Hauler
$
0 Recreational Camp
$-
0 Sun tanning
$
0 Swimming Pool
$
13 Tobacco
$
0 TrasWolid Waste Hauler
$-
0 Well Construction
$
SEPTIC Sustems:
0
Septic - Soil Testing
$
0
Septic - Design Approval
$
0
Septic Disposal Works Construction (DW0
0
Septic Disposal Works Installers (DWI)
0
Title 5 Inspector
$
4
Title 5 Report
0
Other. (Indicate)
$
[E)
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
PAUL & DIANE SPENCER
Property Address
272 SUMMER STREET
Owner Owner's Name
information is
required for every NORTH ANDOVER MA 01845 3/21/14
page. City/Town State Zip Code Date of Inspection
Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
VQ
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. General Information
1 Inspector:
hAR Z 5 2014
JAMES H CURRIER 11
TOWN OF NCRTJ H ANDOVER
Name of Inspector
L_2tALI��ULPAKIMtNlf 'I
J'S SEPTIC & DRAIN
Company Name
131 FOREST ST
Company Address
MIDDLETON
MA 01949
City/Town
State Zip Code
978-774-6685
S12327
Telephone Number
License Number
B. Certification
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:
0 Passes El Conditionally Passes El Fails
Ej Needs Further Evaluation by the Local Approving Authority
®re
, 201:
v,
3/21/14
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system 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.
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 1 of 17
ff17 MFEf� �--
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
PAUL & DIANE SPENCER
Property Address
272 SUMMER STREET
Owner's Name
NORTH ANDOVER MA 01845 3/21/14
City/Town 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:
1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
SYSTEM WORKING PROPERLY
B) System Conditionally Passes:
El one or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
F1 Y [-] N F1 ND (Explain below):
t5ins - 3/13 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 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
PAUL & DIANE SPENCER
Property Address
272 SUMMER STREET
Owner's Name
NORTH ANDOVER
City[Town
B. Certification (cont.)
MA 01845
State Zip Code
3/21/14
Date of Inspection
El Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
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 broken pipe(s) are replaced El Y F� N [j ND (Explain below):
F1 obstruction is removed F-1 Y F1 N El ND (Explain below):
El distribution box is leveled or replaced 0 Y El 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):
F-1 broken pipe(s) are replaced El Y El N F1 ND (Explain below):
F-1 obstruction is removed El Y El N El ND (Explain below):
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:
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 - 3/13 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
PAUL & DIANE SPENCER
Property Address
272 SUMMER STREET
Owner's Name
NORTH ANDOVER MA 01845 3/21/14
CityfTown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
El The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
El The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
El The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes
No
El
0
Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
1:1
z
Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El
El
Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2day flow
t5ins - 3/13
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Insp
Subsurface Sewage Disposal System Fo
PAUL & DIANE SPENCER
Property Address
272 SUMMER STREET
Owner Owner's Name
nformation is
required for every NORTH ANDOVER
page. City/Town
B. Certification (cont.)
Yes No
El El Any portion of a cesspool or privy is within 50 feet of a private water supply well.
El EJ 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.]
Z The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
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
ection
Form
F
rm - Not for Voluntary
Assessments
0
Any portion of the SAS, cesspool or privy is below high ground water elevation.
E]
E]
Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
[I
El
Any portion of a cesspool or privy is within a Zone 1 of a public well.
MA
01845 3/21/14
State
Zip Code Date of Inspection
El El Any portion of a cesspool or privy is within 50 feet of a private water supply well.
El EJ 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.]
Z The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
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
Required pumping more than 4 times in the last year NOT due to clogged or
El
F
obstructed pipe(s). Number of times pumped:
El
0
Any portion of the SAS, cesspool or privy is below high ground water elevation.
E]
E]
Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
[I
El
Any portion of a cesspool or privy is within a Zone 1 of a public well.
El El Any portion of a cesspool or privy is within 50 feet of a private water supply well.
El EJ 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.]
Z The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
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
F
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
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 "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 - 3/13 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
PAUL & DIANE SPENCER
Property Address
272 SUMMER STREET
Owner Owner's Name
information is
required for every NORTH ANDOVER MA 01845
page. Cityrrown State Zip Code
C. Checklist
3/21/14
Date of Inspection
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
E El Pumping information was provided by the owner, occupant, or Board of Health
11 E
Were any of the system components pumped out in the previous two weeks?
E El
Has the system received normal flows in the previous two week period?
El Z
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?
Was the site inspected for signs of break out?
were all system components, excluding the SAS, located on site?
E El
Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
Was the facility owner (and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
Existing information. For example, a plan at the Board of Healt h.
El E
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): 600 GPD
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
PAUL & DIANE SPENCER
Property Address
272 SUMMER STREET
Owner Owner's Name
information is
required for every NORTH ANDOVER
page. City/Town
MA 01845
State Zip Code
3/21/14
Date of Inspection
D. System Information
Yes
El
No
Description:
Yes
E]
No
El
Yes
[:1
No
Number of current residents:
2
Does residence have a garbage grinder?
Yes
No
Is laundry on a separate sewage system? (Include laundry system inspection
El
Yes
No
information in this report.)
Laundry system inspected?
El
Yes
F No
Seasonaluse?
D
Yes
E No
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 holdin� tank present?
Non -sanitary waste discharged to the Title 5 system?
Water meter readings, if available:
Gallons per day (gpd)
El Yes E No
CURRENT
Date
El
Yes
El
No
Ej
Yes
E]
No
El
Yes
[:1
No
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
PAUL & DIANE SPENCER
Property Address
272 SUMMER STREET
Owner Owner's Name
information is
required for every NORTH ANDOVER
page. City/Town
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
MA 01845
State Zip Code
Date
General Information
Pumping Records:
Source of information:
I
Wa's system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
I
Reason for pumping:
i
Type of System:
LPID 10/31/13
gallons
E Septic tank, distribution box, soil absorption system
Single cesspool
E-1 Overflow cesspool
E-1 Privy
3/21/14
Date of Inspection
El Yes 0 No
Li 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) and a copy of latest
inspection of the I/A system by system operator under contract
Tight tank. Attach a copy of the DEP approval.
El Other (describe):
I
t5ins - 3/13 1 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 Assilissments
PAUL & DIANE SPENCER
Property Address
272 SUMMER STREET
Owner Owner's Name
information is
required for every NORTH ANDOVER MA 01845 3/21/14
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:
AS BUILT DATED 7/25/85
Were sewage odors detected when arriving at the site?
Building Sewer (locate on site plan):
0 Yes E No
Depth below grade: 1411
feet
Material of construction:
E cast iron El 40 PVC El other (explain):
Distance from private water supply well or suction line: PUBLIC H20
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
E concrete El metal
J -1i
feet
El fiberglass E:1 polyethylene El other (explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes El No
Dimensions: 10'X5'X4' 1500 GALLON
Sludge depth: 311-411
t5ins - 3113 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
PAUL & DIANE SPENCER
Property Address
272 SUMMER STREET
Owner Owner's Name
information is
required for every NORTH ANDOVER
page. City[Town
D. System Information (cont.)
State Zip Code
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
3/21/14
Date of Inspection
3011
1/211-111
811
1511
How were dimensions determined? SLUDGE JUDGE & TANK
MEASURE
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 DOES NOT NEED PUMPING AT THIS TIME. INLET BAFFLE IN PLACE, OUTLET PVC TEE
IN PLACE. LIQUID LEVEL CORRECT.
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
F] concrete F1 metal
Dimensions:
Scum thickness
feet
El fiberglass El polyethylene El 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 - 3/13
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
PAUL & DIANE SPENCER
Property Address
272 SUMMER STREET
Owner Owner's Name
information is
required for every NORTH ANDOVER MA 01845 3/21/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
El concrete D metal El fiberglass El polyethylene other (explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: El Yes El No
Alarm level: Alarm in working order: El Yes No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
* Attach copy of current pumping contract (required). Is copy attached? El Yes [—] No
t5ins - 3/13 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
Subs irface Sewage Disposal System Form - Not for Voluntary Assessments
PAUL�i & DIANE SPENCER
Property Address
272S UMMER STREET
Owner's Name
NORTH ANDOVER MA 01845 3/21/14
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
j
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
9
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
ev�idence of leakage into or out of box, etc.):
BOX LEVEL AND WORKING PROPERLY, LIQUID LEVEL CORRECT, NO EVIDENCE OF SOLID
cARRYOVER. BOX 36" BELOW GRADE.
Pump Chamber (locate on site plan):
Pu mps in working order:
I
El Yes El No*
Alarms in working order: El Yes No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If.pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If S I AS not located, explain why:
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
PAUL & DIANE SPENCER
Property Address
272 SUMMER STREET
Owner Owner's Name
information is
required for every NORTH ANDOVER
page. City/Town
MA 01845 3/21/14
State Zip Code Date of Inspection
D. System Information (cont.)
Type:
El
leacl�ing pits
number:
El
leaching chambers
number:
El
leaching galleries
number:
z
leaching trenches
number, length: (2)45-
(1)25 -
El
leaching fields
number, dimensions:
11
overflow cesspool
number:
El
innovative/alternative syster�
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
SOILS DRY, VEGETATION APPEARS NORMAL, WINTER CONDITIONS, NO SIGN OF
HYDRAULIC FAILURE.
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 g , roundwater inflow El Yes [:1 N o
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
PAUL & DIANE SPENCER
Property Address
272 SUMMER STREET
Owner Owner's Name
information is
required for every NORTH ANDOVER
page. City/Town
State Zip Code
3/21/14
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 - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsllrface Sewage Disposal System Form Not for Voluntary Assessments
I
PAUL & DIANE SPENCER
Property Address
272 SUMMER STREET
Owner Owner's Name
information is
required for every NORTH ANDOVER MA 01845 3/21/14
page. City/Town State Zip Code Date of Inspection
D. S�ystern 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:
hand -sketch in the area below
drawing attached separately
t5ins - 3/13 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
PAUL & DIANE SPENCER
Property Address
272 SUMMER STREET
Owner Owner's Name
information is
required for every NORTH ANDOVER
page. City/Town
D. System Information (cont.)
Site Exam:
El
Check Slope
El
Surface water
El
Check cellar
El
Shallow wells
MA 01845 3/21/14
State Zip Code Date of Inspection
Estimated depth to high ground water: 41
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. 4/23/85
Date
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health - explain:
I
El Checked with local excavators, installers - (attach documentation)
El Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
TEST PIT DATA, TEST PITS PERFORMED 1985.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins - 3/13 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
PAUL & DIANE SPENCER
Property Address
272 SUMMER STREET
Owner Owner's Name
info rmation is
required for every NORTH ANDOVER
page. Cityrrown
MA 01845 3/21/14
State Zip Code Date of Inspection
E. Report Completeness Checklist
Z inspection Summary: A, B, C, D, or E checked
Z Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
Z System Information — Estimated depth to high groundwater
Z Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17
Class W S;rigle ramIly
zo*02 I Ros dontial
SizoTotal i Ao:
FY 2014
U0 Mallina Index
Town of North Andover
Tax Map # 210-107.A.0224-0000.0
Parcel ld 17989
272 SUMMER STREET
SPENCER, PAUL & DIANE
272 SUMMER STREET
.N. ANDOVER, MA
01846
Property Typo
zoninvi
V -T J i
(" -.v F100 i
Re3idential
Norria/Addross
Type
Loan Rumba*
Active/inact. From
unt(i
SPENCER, PAUL & DIANE
Payor
272 SUMMER STREET
N, ANDOVER, MA
0160
AccountNo
Cycle
Oocupant Name
Act;vefinsotive
Bldg Id, 14249.0 - 272 SU MhOlb'K V REET
Last Bgl!!"g Date 12110/21013
2100244 1
02 Cycle 32
Active
U8 Serylgo0alol,
AtcoUnt No, 2100244
son'144 Coft
Rato
Charge
Mwitipilarlusem
MISCFEE ADMIN FEE
0.63 618
7.82
1/
WTA WATtR
01 ALL k'1F4R SIZE 50,80
11
US Motor MlLn�
Acmunt No. 2100244
sarlai No status
Location
Brand
Type Size
YTD Cons
32421948 a Active
ERT HH
b Sadgar
w Water 01630.63
403
Dato
ftwing
C000
Consumption
Post*d Date
Variance
2A/2014
939
a Actwsi
16
111%
101112013-.-
524
a ActuM
-1 ff
12012013
2%
8/1/2013
WS
a Acitual
-46 -
0118120113
SO/6
0/2013
$93
a Actual
-1 ' 4.
Oil EY20 13
-16%
217/2013
579
a Acitual
- ig.
3/1131203
190/0
10130012
$60
a Actun!
1.4
121`1212012
V/2
802012
54a
s Acit'Jal
14
M8/20i 2
12%
W/2012
21Y2012
$32
520
a ActjG!
a Actual
2 -
5
6020012
M412012
-16%
21%
I I m2ol 1-�'/
506
a AcN21
12 12118/20111
-14%
81212011
493
a Am*
14,1'
9114/2011
130/0
5&2011
479
a Aewl
12
5MV1011
-380/6
V4120i 1
487
a Actual
2`1
3116/2011
- 14%
1 ill 12010
446
a Actual
2$
12il 312010
81312010
423
a AtUal
23
9/11312010
$13/2010
400
a Actual
2s
6/912010
10%
2/112010
377
a Actual
21
3/11112010
-6%
I , 1/212009
356
a Aotual
22
12111009
0%
liwooq
334
a Actual
22
9/1112009
0%
5/412009
312
a Autual
22
611612009
0%
=009
290
a Actual
22
3/le/29009
0%
111312008
268
a Aotual
22
12110/2008
-911h
81AV2006
246
a Actial
25
OMV2003
-10/0
5=008
221
a Actual
23
611812008
8%
202008
19a
a AdJ21
24
3�14/20()B
-7010
11 J1/22007
174
a AoUsil
24
111512008
6%
W200V
IiZ
a Actual
23
W14/2007
14%
SW2007
127
o Actual
15
012e/2007
I bVA
V21/2007
Ill
a Actual
�9
312312007
22%
SUOSURFACE.-SEW4GE PISPPS4 SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
p/
PropetlY Address:
potg of Inspection:
SKETtH Of SEW�rw PISPOSAL SYSTEM:
include ties to 4t least two permanent references landmarks or benchmarks
locate all wells within i00' (Locate where public water supply comes into house)
<�� a15
�,-VCD LA
-3
Ao
C -A)
�3 0
of 10
ft
WILLIANI F. WELD
Ponmo;
ARGEO PAUL CELLUCCI
Lt. Goy;mor
CO? L�
COMMON-WrEALTH OF MASSAC14USETTS
EXECUTIVE OFFICE OF ]ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON. MA 02108 617-292-5500
TRUDY COXT
30 Sccrctar)
DAVID B. STRUHS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioncr
PART A
CERTIFICATION
PropertY Address; SV lsk- NOO'A AAft Iress of Owner:
Date I of InspP00 (if different)
'Q: to C
N#Me o' spe
of In , ct F:
I arn DEP_ a d s
_ A pp 9ve , ystern inspector pursuant to SectjqIL1 5.340 of Title 5 (310 CMR 15.000)
Commy Nome'! . �.'�=&&�Lnr- C%_')r,�
I L1. It ?rv—v- oj
Mailing AOorps: ttcl M 0 lli�)
Telephone N4171ber: Yn El G
CERTIFICATION STATEMENT
I certif curate
,y that I have personally inspected the sewage disposal system at this address and that the information reported below is true, ac
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 sewage disposal systems. The system:
Passarr-
T�onditionally Passes
Needs Further Evaluation By the Local Approving Authority
a 5
Inspectorfs Signature: Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 r repor; to the appropriate regional office of the Department of EOvironmental. Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SPMMARY: Check A, 8, C, or D: �
A] SYSTEM PASSES:
I ha - t. .303.
ve not found any informa ion which indicates that the system violates any of the failure criteria as defined in 310 CMR 15
Any failure criteria not evaluated are indicated below.
COMMENTS:
81 SYSTEM C DITIONALLY PASSES:
=One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
cQLnpletin of the replacement or rep_air, as proved by khe Board of Health, will pass.
r,
VPA ce�_-4
Indicate yes, no, or not determined (Y, N, or ND). bescribe basis of determination in all instances. If "not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiitration, or tank
failure is imminent. The system will pass inspectign if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(r4�yisod 04/2$/97) pagq I of 10
DEP on the World Me Yftb: http:/h~.rnagnet-state.rna.uS/deP
Printed on RecvcJed Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property. Address: D ww'Aej�-
Owner;
Date of Inspection: C)
81 SySTftA. �PN
IDI
,TIONALLY PASSES (contin
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
neven distribution box. The system will pass inspection if (with approval of the
pipe(s) or due'to a broken, settled or U
Board of Health)T Pescribe o0seryalticins:
broken pipe(s) are replaced
obstruction is removed
r re laced
distribution box is levelled o, p
year due to broken or obstructed pipe(s). The system will pass
The systo
in required pumping more than four times 0
inspection if (with approval of the Board of Health);
, broken pi*s) are replaced
obstruction is removed
Cl f URT"gg W
Akp4TION 15 REQUIRED BY THE BOARD OF HEALTH:
rotect the
on b the Board of Health in order to determine if the system is failing to p
Conditions exist which require .,
furthe r evaluati I Y1.
public he#ith,, safety and the environment.
LTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
1) SYSTEM WILL PASS UNLESS BOARD OF HEA
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is Within 50 feet of a bordering vegetated wetland or a salt marsh.
HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
2) 6YSTEM WILL FAIL UNLESS THE BOARD -CIF ECTS THE PUBLIC HE r ALTH AND SAFETY AND THE
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROT
ENVIRONMENT:
The system has ia septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to 4 Surface water supply.
The system has a septic tank and soil absor ion system and the SAS is within a Zone I of a public water supply well
pt
m and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorpO06 syste
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
pounds indicates that
private water supply well, unless a well water analysis for coliform bacteria and volatile organic corn
at to or
pollp ion from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equ
the well is free from t etermine distance (approximation. not valid).
less than 5 ppm. Method used to d
3) pTHER
po 0 2 of 10
r�
SUBSVRF�CE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Aodr"s: SU Mywe,�-
OwIrigr:
Date of Inspection:
P) SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
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.
Yes No
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.
Static liquid level in lhe 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.
Re
quired 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 $oil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspo ol or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a c
or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or priq Is less them 100 feet Out greater then 50 feet from a private water supply well with no
acceptable water quality analysis. if the well has been analyzed to be acceptable, attach copy of well water analysis lot
cohiorm bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E) LARGE SYSTEM IFAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility With 0 design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (interim Wellhead Protection Area - IWPA) or a mapped Zone 11 of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(rovised 04/;$/97) P&9* 3 of 10
ft
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property A Oress: Dia 3QlV'A*Xe-1lZ-
Owner:
Date o6rispe0ion; 4V CLA-k
to
Check . if . hi following have been done: You Must indicate either "Yes" or 'No" as to each of the following:
(Foyii#pO P4/25/97) Vage 4 of 10
Yes .1�90
P nt, or Board of Health.
..ping information was provided by the owner, occupa
for at least two weeks and the system has bee al
None of the system components have been pumped n receiving norm
flow rates during that period. Large volumes of water have not been introduced into the system recently or
As part of this inspection.
As bu . ilt plans have been obtained and examined. Note if they are not available with N/A.
-up.
The facility or dwelling was inspected for signs of sewage b#ck
The system does not receive non -sanitary or industrial wage flow.
The site Was inspected for signs of breakout.
All systeFn components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were qncovered, 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 the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants,. if different from owner) were provided with information on the -proper maintenance of
Sub -Surface Disposal System.
L�/ Existing information. Ex. Plan at B.O.H.
Oetermined in the field (if any of the failure criteria related to Part C is at issue, approximatio
n of distance is
unacceptable) [15.302(3)(b))
6
I
SPOSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property A idd,res' s a SV M� WwAr �jo 0�'
Owner:
Date pf llr�s 000q: Rluo-&A
FLOW CONDITIONS
RESIDENTIAL:
' - " "'
Design 49w: -p.d./bedroom for S.A.S.
Number of c res I idents:
4rren!
Glorbagq grinder (yo o n
Laundry connected- to system (yes or �o)'.��
Seas r!41 4se j yes or no):
Water meter readi
if yailable (last tw r usage (gpd):
q (2) yea
Sump Pymp (yes or no 00
Last date o ccupancy:CUV'AXA-
. If P ,
COtdMERCIALJINDUSTRIAL:
-Type of establishment:
Design fipw:-�gallons/day
Gre ira
ase resent: (Yes or no)—
Indus rial Was
je Holding Tank present: (yes or no)_
Non -s ry
�anj;a yva�;g Ois har ed to the Title 5 system: (yes or no)
Water meter reaoinp, if available:
Last Oate o i oCcurpancy:
OTHER: (,Describe)
Last date pfoccupancy:-
GENERAL INFORMATION
PUMPING RECORDS and source of information. -
90 0WVV�
System umped as pan of inspection: (yes or no)4
T P " .
.If yes, Volume pumped: ISOC-) 11
Reason for pumping:
TYPE OtWTFM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Pr'
Shared system (yes or no) (if yes, attach previous inspection records, if any)
VA Technology etc. Copy of up to date contract?
other
APPRPXI"TE AGE of all, components, date installed (if known) and source of information: Qc's�-" o
I
CVA
Sew -No
odors detected when arriving at the site: (yes or no)
(rplyipod 04/;�/07) V&FO 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
PrOpVrtyA4-dr9ss;Ql'JQ SUOTAQC-
Ownw:
Date of. lropcolon'
BUILDIK SEWR:L.,o�
(Locate an site plan)
it
Depth below grode; 114
material of construct
, _ . jon-. _Los <�rn
other xplaia it
2-1,k) �-:3 (Ne— 'I V\ ��S-e
Distance frO7 prlyfle water supply well or suction line'
Diamelor
Comwnts: ition joints, venting, �viclence of leakage, etc.)
SEPTIC TANK;
(locate On site plan)
Depth beloW grade:
Material of constryc�lo—n d., �Oncrete _metal _Fiberglass _Polyethylene —other(explain)
if tank is metal, list age Is age confirmed by Certificate of Compliance — (Yes./No)
Mnimsions:
Sludge depth: n
Disi#nce from to, oisludge to bottom of outlet tee or baffle:':�k I
Scum thi*pss: Nc 21
Distance frqm top of Kurn 10 top Of Outlet tee or baffle- It
Distance from bottom of scum to bo�p of out et t battle.
How dimensions were determined: C-9 !�e
ff
Comments:
(recommendation for pumping, condit' outlet Ieej or
'.. S��
integrjty, evidence qklea�age, etc.),
GREASE TRAP'�OW'P—
(locate on site plan)
of I
Depth below grade* tal _Fiberglass Polyethylene 9ther(explain)
Material of construction:
Dimensions:
scum thickness:
DistMca from top of scum to lop of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:—
Date of last pumping:
_6
to
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.)
Pago 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property A40reS$:L
owner: Sv mv,&� tE�� Kb "XA4-
Daltv'pf Insp0ion:
C-3,
)
TIGH,T OR tjQLDING TANK-YC"le (Tank Must be pumped prior to, or at time, of inspection)
(locate on site plan,)
De below grade:
Material of construction: concrete _metal Fiberglass _Polyethylene other(explain)
Dimensiop's:
Capacity: gallons
Design flow: p1lons/day
Alarm level: Alarm in working order Yes; No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
t
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet inven: 0
Comments:
j Lit e to or t 01
(note if Kyel grid distrib ion is equal, evidence of Aolids carryover, evidence of I* U f box etc.)
V) C-\Q.AAC CCkAT-V-An,-TT PC)
92t?\ cxj) -771
I N42 0 A C' 4��-3 \CPN C-0 S2'%- -
P . UMP C"AMBEON�&Q --CAkzW \t�VJ-4AA,�,
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms in working order (Yes or No)
Comrpents;
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(roviped 04/;S/97)
Page 7 of 10
A
SUBSVRFACE SEWAGE PISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INfORMATION (continued)
PropeirtY Addrfts:
Owner. am e�
Pate of Inwction: io
SOIL WORPTION SYSTEM (SAS):
(locate on y _�not required, but may be approximated by non -intrusive methods)
#ite plan, it possible; exca ation
if not de!orrninqd to be present, explain:
Type:.
leaching pits, number:
!Pa.chipg chambers, pumber:_
leaching galleries, number
45
leachin i' , ches, numberTen,
g rgn
le
aching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note -.,iti n of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
_-1-_)(\cA -1 kA(A 2,47"
CESSPOOP; _Y\0V1k_
(locate on site plan)
Number and configuration:
DepthApp of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
pirponsio s of cesspool:
n
'I of. construction:
Inclicatio
n of groundwater:
inflow (cesspool must be pumped as pan of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(locate on site plan)
materials of construction: Dimensions:
Depth
� I of solids:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Addre
Owner,
Date Inspection:
SKE76
j OF SEWAGE DISPOSAL SYSTEM:
1nclu e ti s to at le asl two perr a benchmark$
manent references landm, rks or
1p;:atg all we
lls within 100' (Loca e where public water supply comes into house)
kr-\-C-
114'1 D'(
CDC.D"
(r4pvipod 04/25/P7) Pa9f 9 of 10
110(t
C
$PPSPRFACE SEW GE PISPP SYSTEM INSPECTION FORM
-SA
PART C
SYSTEM lNFPRMA C
TION gntinued)
PrOpOiAddrpss:
Wrier*
P*� 'qj Im pe-Cliop:
10 —9 P-
-D ;p G ater Feet
PPO _rounow,
Ple* d I th met pOs used to Opter ine High Groundwater Elevation:
ined from Design Plans on record
9 se a
0.,,�,#tion of Site (Abutting property, obsery tion hole, basement sump etc.)
Determine it fronp, local conditions
w ca of health
_!!h lo—I Board
Che -
FEMA
Cheq- pumping records
CheF� local excavators, installers
Use�.USGS Data
Dpjcribi 'in your owp words how you established the High Groundwater Elevation. (Must be completed)
es,4
I
�kkgo 20 of 20
A
� en 0(�- -� �
Neil J. Bateson
Bateson Enterprises, Inc.
Page 11 of 11
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 CMR 15.351. 1 — — - — I - I- �
A. Facility Information
Important: When
filling out forms
1 . System Location:
on the computer,
use only the tab
272 SUMMER STREET
key to move your
Address
cursor - do not
NORTH ANDOVER
use the return
City/Town
key.
2. System Owner:
DIANE SPENCER
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Component:
10/31/13
Date
El Cesspool(s)
El Other (describe):
MA
State
State
Telephone Number
NOV 19 2013
TOWN Ul- NUK I M ANIJUVER
HEALTH DEPARTAA9zfrr
01845
Zip Code
Zip Code
2. QuantityPumped: 1500
Gallons
Z Septic Tank El Tight Tank [] Grease Trap
4. Effluent Tee Filter present? 0 Yes El No
5. Observed condition of component pumped:
GOOD CONDITION
6. System Pumped By:
JAMES H CURRIER 11
Name
XSEPTIC & DRAIN
Signature -of Hauler
If yes, was it cleaned? El Yes E] No
H79 406
Vehicle License Number
10/31/13
Date
Signature of Receiving Facility (or attach facility receipt) - I Date
t5form4.doc- 11/12 System Pumping Record - Page 1 of 1
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
VC]
Commonwealth of Massachusetts
City/Town of NO. 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 r m -geheek-,,
local Board of Health to determine the form they use. The System Puml Lrd A R e.�sub
the local Board of Health or other approving authority. i
A. Facility Information
1. System Location:
272 SUMMER ST.
Address
NO.ANDOVER
Cityrrown
2. System Owner:
Name
DIANA SPENCER
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
10/28/11
Date
3. Type of system: E] Cesspool(s)
E] other (describe):
4. Effluent Tee Filter present? El Yes EV /No
5. Condition of System:
6. System Pumped By:
James H. Currier
Name
J's Septic & Drain
Company
7. Location where contents were disposed:
GLSD
Signaturepffiau ee
A N
POAR
MA
State
State
Telephone Number
01845
Zip Code
Zip Code
Quantity Pumped: 1500
Gallons
�'Septic Tank E] Tight Tank
It yes, was it cleaned? n Yes F1 No
H79 406
Vehicle License Number
10/28/11
Date
t5form4.cloc- 06/03 System Pumping Record - Page 1 of 1
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Cwte1S71-,4NS46N i! I � 11,11:11ii!
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114 XENOZ4 .4 VE., A�4kl&,el-lll
L,
Board of Haalth -
North AnO.O_V__8_r_.3,M"8*
OVED DATE
8EPTIC SISTEH
INSTAMATICK CHECK M ST LGT`f_�
14 u
T% A AU1
7--5
LTICN OIE FAIL
Septic Tank
..,.?ees r. -Length & To Clean Oat Covers
b. lement Pipe t6 Tank On Both Sides of Tank
5t.
DiEtribution Box
a. Covers & Box - No Cracks
b. All Lines Flowing,Equal Amunts
c. No Back Flow
6.-
Leach Field or Trench
a. Dimensions
b. Stone Depth
a *, Capped Ends'
d. Clem Double'Washed Stone
7.
Leach Pits
a. Dimensi6ns
b. Stone Depth
c. Splash Pads
d.. Teed
e. Cenent Pipe to Pit Both Sides
f .1 clean Double Washed Stone
No Garbage Disposal
Yji3al Grading Inspection
10.
Bar'ri eading Covered S�7stem
3.1.
As Built Snbimitted
a. Lot Location
b.- Dimmsions of System
c. Location with Regard -to Pere Te.
d. Elevations
Water Table
% Health
.,hdover,MaBs
SUBSURFACE DISPOSAL DESIGN CHECK LIST
APPROVED DATE
Providedr-r 74
,Title V I FAIL I OK
Reg 20-5 '-
Reg 6
Reg 10. 2
Reg 10.4
The
a)
b
c
dj
e)
f)
9)
E
r)
a)
DISAPPROVED DATE
Reasonsi.
06
I (AUDOIV�i .
LOT #
submitted plan must show as a minimum:
the lot to be served-area,9dimensions lot #,,abutters
location and log deep observation Mes-distance to ties
location and results percolation testa -distance to ties
design calculations & calculations showing required leaching area
location and dimensions of system -including reserve area
existing and proposed contours
location any wet areas within 1001 of sewage disposal system or
disclaimer -check wetlands mapping
surface and subsurface drains within 1001 of sewage disposal
system or disclaimer
location any drainMe easements within 1WI of sewage disposal
system or disclaimer -Planning Board files
known sources of water supply within 2000 of sewage disposal
system or disclaimer
location of any. proposed well to serve I )t-1001 from leaching facility!
location of water lines on property -3.01 �rom leaching facility
location of benchmark
driveways
garbage disposals
no PVC to be used in construction
profile of system- el evationB of basement,, nlumb,, pipe., septic tank,,
distribution box inlets and outlets., distribution field piping and
fther elevations
maximam ground -water elevation in area sewage disposal system
plan mast be prepared by a Professional Engineer or other
professional authorized by law to prepare such plans
Septic Tanks
a) capacities -150% of flow., water table., tees,, depth of tees.,
acceess pupping
b) cleanout
c) 101 from cellar wall or inground s -Arming pool
d) 251 from subsurface drains
stribution Boxes
a) slope gre—a-Mer-It"RE 0.08
b) sunp
06
Reg 10. 2 1 Distribution Boxes
(a) slope greater U_= 0.08
Reg 10.4 1 :jM MUP
Boar
Sort.i., nadover,.Mass,
SUBSURFACE DISPOSU DMGN CHWK LIST Tuv&5
LOT # 7
API�OM DISAPPROM DATE
Provided* Reasons:
101-ObA TOIM:�
w5vDa6p 6F aQ� 11v 6elu -relu >-ivax
Title V
FAIL
09
Reg 2.5
,,s,,a)
The submitted plan must 'show as a minimum:,
the lot. to.b6 Bdrved-area, diiae�I�ions' lot #,abutters
2
; b location and.log de I pp obsprvl�tion hoi66-1 distance to ties
c location and remats �,Oerc6lation, tests -distance to ties
d design calculi tions & calculations showing required leaching area
location and dimensions of system -including reserve area
existing and proposed contours of .. sewage disposal system or'
(g) location any vet. areas wLthin. 1001
7:,
71e)
c,,(f)
z,-
disclaimer -check wetlands mapping,
(h) surface and subsurface drains within 1001 of sewage disposal
system or disclaimer
location any drainage easements within 1001 of,sewage disposal
4'fi)
system or disclaime' r -Planning Board files
'known sources of water supply within 2001 of sewage, disposal
Z-0)
system'or.disclaimer.
I oposed'vel.1 to serve lot -1001, from leaching facility
(k) location of any pr
location of water lines on. property -101 from leaching facility
il.(l)
location of,benchmark
,-(m)
(a) driveways
(o) garbage disposals
no PVC to be -used in construction
q) P, file of tem-elevationB of basement.. plumb' pipe., septic tank.,
ro , By's I
distribution box inlets and outlets, distribution field piping and
T,
&,Ir)
other elevations
maximum ground water elevation in area sewage disposal system
plan mast be prepared by a Professional Engineer or other
professional authorized by law to prepare such- plans
Reg 6
&--'(a)
Septic Tanks
capacities -15u or flow, water tablep teesp depth of tees.,
access.. pumping
(b) cleanout
10, from cellar wall or inground. swimming pool
Mc)
251 from subsurface drains
'--Ad)
Reg 10. 2 1 Distribution Boxes
(a) slope greater U_= 0.08
Reg 10.4 1 :jM MUP
North Andover, Mass. Street No Lot No
u
LOC/Subdiv.--'— Pland Owner
Tnvestigator Observer—
SOIL PROFILE DATES
1-'Elev 2.Elev El ev-- 4.Elev
0 0 0 0
Ti-ps to Tesl
Pits
�2 2 2 2
7
4 4
8
0!
Berchmark
Elevation
7
8
9
10
4 -
Start Satu-ration
-114 I—PRI;
5
6
7
9
ca 'Ll i r) n
Dat,,Lm
PF_RCOT I-IIT0jq
5
6
7
8
10
Fit
2
4 -
Start Satu-ration
nu'L-Ies
jcq�op of 3" -Td -me
Drop of 6"-Tjjrje
I,' �, .1-st 3" drop
T". -j s. 2nd E�ro
el r co 1 a on
ip
WILLIAM F. WELD
Govemo:
ARGEO PAUL CELLUCCI
Lt. Govemor
9. u. 4 �
COMMONNN.rEALTH OF MASSAC14USETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
5'5,V
ONE WINTER STREET. BOSTON. NIA 02108 617-292- dN OF NORTH A' `iL
BOARD OF HEALTh
TROY COXI
ISecretary
__DAVID�'B. STRUHS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION4.01M Commissiom
PART A
CERTIFICATION
Property Address: c) Address of Owner:
Date of Inspection: (if different)
Name of Inspector. -
I am a D approved system in ursuant to Section 15.340 of Title 5 (310 CMR. 15.000)
cj�� spector p
Company Name:
Mailing Address:
Telephone Number: qV-J;S -�j L-1 t7 -4;— 1-1 Q 6 C,2
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete'as of the time of inspection. The inspection was performed based on my training And experience in the proper function and
0naintenance of on-site sewage disposal systems. The system:
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
F il 4
t
TVA
Inspector's Signature: r r I Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of torniplitting this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the gystem owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system Owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates' any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below
A -!Wt V-61
COMMENTS: D-
BI 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.
Indicate yes, no, or not determined CY, N, or ND). Describe basis of determination in all Instances. If *not deteemlAed4i explain wh� not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a certificati of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the ihioodibn; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltrationj & tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced With A Conformirig.teoit tank
as approved by the Board of Health.
(revised 04/25/97) Page I 0i 10
DEP on the World Wide VVOb: hft:/Mww.rn9;inet.state.Ma.uS1deP
0 Printed on Recyded Paper
TOWN OF NORTH ANDOVER
BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
DATE OF COMPLIANCE:
This is to certify that
the individual subsurface disposal system
constructed ( ) or repaired ( X
D -BOX ONLY
by North Andover Licensed Installer
Todd Bateson
at
272 Summer Street, North Andover, MA 0 1845
has been installed in accordance with the provisions of Title V of the State Sanitary Code
and with the North Andover Board of Health regulations as described in the Design
Approval Site System Permit # dated .
The Issuance of this certificate shall not be construed as a guarantee that the system will
function satisfactorily.
Board of Health Inspector
PLC
APPLICATION FOR DISPOSAL WORKS CON STRUCTION PERMIT ED
DATE: CURRENT INSTALLER'S LICENSE#
LOCATION:
LICENSEDINSX_
SIGNATURE: TELEPHONE#
CHECK ONE(
REPAIR:
NEW CONSTRUCTION:
IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT.
-'b &D�
Administrative Use Only
$75.00 Fee Attached? Yes No
Foundation As -Built? Yes No
Floor Plans? Yes No
Approval Date-
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Conuno!iwealth of Massachusetts
P. , Massachusetts
Svstem P
System Owner
4-j O-XAj-
Ole PC 11pulping:
C'Psspool: No Yes H
15 ---
System Location
r�,7 Z, &IA.1,V�104 ':�+
Quantity Pumped: �62-0— gallons
Septic Tank: No LI Yes f;�
VdNeq, License
System I umped by:
Coolents1ransrerrredlo: Gteater Lawrence sanitary Olstrict
Date: Inspector:
12
TOWN OF- /kj'
SYSTEM PUMPING RECORD
6 *7-0 3
DATE: .
SYSTEM OWNER4 ADDRESS
SYSTEM LOCATION
�j .
(example: left front of ho*)
DATE OF PUMPING: 3--o 3 QUAMITY PUMPED:
JUL - 3 2003
/ GALLONS
CESSPOOL: NO S SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER,
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFEIMED TO. &