HomeMy WebLinkAboutMiscellaneous - 28 JERAD PLACE 4/30/2018Ati
N
I
W #
Lot & Street R;9 J IC rc-4 Map/Parcel
CONSTRUCTION APPROVAL
Has plan review fee been paid: PYES NO
Plan Approval: Date: J Approved by:
Designer: Plan Date: LZ ZO
Conditions:
Water Suppir. Town Well
Well Permit: Driller:
Well Tests: Chemical �Dapproved
Bacteria I Date Ap-p-roved
Bacteria 11 Date Approved
Plumbing Sign -Off: Wiring
Sign -off:
Comments:
Form "U" Approval: Approval to Issue: YES NO
Date Issued By:
Conditions:
Final Approval:
All Permits Paid?
YES
NO
Well Construction Approval?
YES
NO
Septic System Construction Approval?
YES
NO
Certification?
YES
NO
Other?
YES
NO
Any Variance Needed?
NO or
C6 6'
FINAL BOARD OF HEALTH APPROVAL:
DATE:
APPROVED BY:
L -I
SEPTIC SYSTEM INSTALLATION
CONDITIONS:
Is the installer licensed?
Type of Construction:
E NO
(---�YN �EW
New Construction:
Certified Plot Plan Review
YES
Floor Plan Review
YES NO
Conditions of Approval from Form U YES NO
Issuance of DWC permit:
NO
4B
DWC Permit Paid?
DWC Permit #
NO
Installer: 75po
Begin Inspection:
NO
Excavation Inspection:
Needed:
Passed:
By:
Construction Inspection:
Needed:
As Built Plan Satisfactory:
YES:
Approval of Backfill:
Date: 71i�
By: 'IX
Final Grading Approval:
Date:
By:
Final Construction Approval: Date:
By:
Certificate of Compliance: Approval: Date:
PARCEL # STREET
QONSTRUCTION -APPROVAL
HAS PLAN REVIEW FEE BEEN PAID?� NO
PLAN APPROVAL: DATE APP. BY.
DESIGNER: PLAN DA]'E
' WATER SUPPLY:(::TWELL
'
� WELL I DRILLER
-----'--_-'_-- _ '
WELL TESTS: CHEMICAL DAlE APPROVED________
B I DAlE (1P)RUVED
`
, . BACTERIAII DATE APPROVEU__.... ........ _...
__
COMMENTS: .
FORM U APPROVALx
APPROVAL TU ISSUE
'
NO
DATE ISSUED -BY
CONDITIONS:
FINAL APPROVAL:
ALL PERMITS PAID
WELL CONSTRUCTION APPROVAL
YES
NO
SEPTIC SYSTEM CONSTRUCTION
APPROVAL YES
NO
OTHER
YES
NO
ANY VARIANCE NEEDED
YES
NO
FINAL BOARD OF HEALTH APPROVAL:
DATE:/�_��48Y:_
IS THE INSTALLER LICENSED? NO
'
TYPE OF CONSTRUCTION: ' - - REPAIR
NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW NO
CONDITIONS OF APPROVAL YES NO
(FROM FORM U)
ISSUANCE OF DWC PERMIT' NO
DWC PERMIT NO. INSTALLER�
.
BEGIN INSpECTION�:
----'
EXCAVATION INSPECTION: NEEDED:
PASS B�
AS BUILT PLAN SATISFACTORY:
APPROVAL TO BACKFILL: DATE: y
'
. FINAL GRADING APPROVAL: D
FINAL CONSTRUCTION APPROVAL: DATE:
c
Owner
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Commonwealth of Massachusetts
Title 5 Official Inspection Form ��'j 24)
Subsurface Sewage Disposal System Fonn - Not for Voluntary Assessments
28 Jerad Place
Property Address
Stephen Sadowski
Owner's Name
North Andover
City/Town
MA 01845
State Zip Code
Inspection results must be submitted on this form. Inspection forms
way. Please see completeness checklist at the end of the form.
A. General Information
1. Inspector:
Neil J. Bateson
Name of Inspector
Bateson Enterprises Inc.
Company Name
111 Argilla Road
Company Address
Andover
City/Town
978-475-4786
Telephone Number
B. Certification
MA
State
S115
License Number
8/12/2014
Date of Inspection
iay-not be altered.in.ar
AUG 2 2 2014
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
01810
Zip Code
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 0 Fails
edp Further Eva' n by the Local Approving Authority
8/12/2014
Ins4ecWe+gnature V 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 I of 17
MIR!
Owner
information is
required for
every page.
Commonwealth of Massachusetts,
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
28 Jerad Place
Property Address
Stephen Sadowski
Owners Name
North Andover
Cityrrown
B. Certification (cont.)
RAA n iqAr%
8/12/2014
State Zip Code 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:
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.
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.
0 Y F1 N 0 ND (Explain below):
t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
28 Jerad Place
Property Address
Stephen Sadowski
Owner Owners Name
information is
required for North Andover MA 01845 8/12/2014
every page. CityfTown State Zip Code Date of Inspection
B. Certification (cont.)
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):
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 E] Y E] N E] ND (Explain below):
El obstruction is removed El Y El N 0 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:
Ej 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
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 3 of 17
broken pipe(s) are replaced
DY
R N
F-1
ND (Explain below):
obstruction is removed
El Y
[:1 N
F1
ND (Explain below):
distribution box is leveled or replaced
F1 Y
F] N
F1
ND (Explain below):
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 E] Y E] N E] ND (Explain below):
El obstruction is removed El Y El N 0 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:
Ej 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
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
28 Jerad Place
Property Address
Stephen Sadowski
Owner Owners Name
information is
required for North Andover MA 01845 8/12/2014
every page. City[Town 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:
E] 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.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
El The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes
No
El
E
Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
El
E
Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
El
M
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 Yz day flow
t5ins - 3/13
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
28 Jerad Place
the system is within 400 feet of a surface drinking water supply
Property Address
E]
Stephen Sadowski
Owner Owner's Name
information is
required for North Andover
MA 01845 8/12/2014
every page. City/Town
State Zip Code Date of Inspection
B. Certification (cont.)
Yes
No
Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
El
0 Any portion of the SAS, cesspool or privy is below high ground water elevation.
El
E Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
E]
E Any portion of a cesspool or privy is within a Zone 1 of a public well.
El
E Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
El
E Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
El 0 The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
1:1 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 16,000 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
E]
El
the system is within 400 feet of a surface drinking water supply
El
E]
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 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins - 3113 Title 5 Offirial 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
28 Jerad Place
Property Address
Stephen Sadowski
Owner Owner's Name
information is
required for North Andover MA 01845
every page. Cityrrown State Zip Code
C. Checklist
8/12/2014
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
El E
Were any of the system components pumped out in the previous two weeks?
0 El
Has the system received normal flows in the previous two week period?
0 E
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)
z 1:1
Was the facility or dwelling inspected for signs of sewage back up?
• El
Was the site inspected for signs of break out?
• El
Were all system components, excluding the SAS, located on site?
• 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?
z 1:1
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:
• El
Existing information. For example, a plan at the Board of Health.
• El
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 - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17
Commonwealth of Massachusetts
.14 Title 5 Offic ' ial Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
28 Jerad Place
Owner
information is
required for
every page.
Property Address
Stephen Sadowski
Owners Name
North Andover
City/Town
D. System Information
Description:
Number of current residents:
MA 01845
State Zip Code
8/12/2014
Date of Inspection
Does residence have a garbage grinder?
0 Yes
[_1
No
Is laundry on a separate sewage system? (include laundry system inspection
El Yes
N
No
information in this report.)
Yes
E]
No
Laundry system inspected?
0 Yes
No
Seasonaluse?
Yes
No
Water meter readings, if available (last 2 years usage (gpd)):
Yes
Detail:
Sump pump?
El Yes
N
No
Last date of occupancy:
Current
Date
Commerciallindustrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present?
Industrial waste holding tank present?
Non -sanitary waste discharged to the Title 5 system?
Water meter readings, if available:
Gallons per day (gpd)
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17
Yes
No
Yes
No
D
Yes
E]
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
28 Jerad Place
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
Pumped 2013, owner
1500
gallons
Measured tank
Inspect tank & tees
Type of System:
0 Septic tank, distribution box, soil absorption system
El Single cesspool
F-1 Overflow cesspool
n Privy
8/12/2014
Date of Inspection
E Yes [:1 No
11 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
F Tight tank. Attach a copy of the DEP approval.
El Other (describe):
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17
Property Address
Stephen Sadowski
Owner
Owners Name
information is
required for
North Andover MA 01845
every page.
City/Town State Zip Code
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
Pumped 2013, owner
1500
gallons
Measured tank
Inspect tank & tees
Type of System:
0 Septic tank, distribution box, soil absorption system
El Single cesspool
F-1 Overflow cesspool
n Privy
8/12/2014
Date of Inspection
E Yes [:1 No
11 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
F Tight tank. Attach a copy of the DEP approval.
El Other (describe):
t5ins - 3/13 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
28 Jerad Place
Property Address
Stephen Sadowski
Owner Owners Name
information is
required for North Andover
every page. Cityrrown
D. System Information (cont.)
MA 01845
State Zip Code
8/12/2014
Date of Inspection
Approximate age of all components, date installed (if known) and source of information:
13 years old, 12/20/2001, as built plan
Were sewage odors detected when arriving at the site? El Yes E No
Building Sewer (locate on site plan):
Depth below grade: 1.8
feet
Material of construction:
El cast iron Z 40 PVC El other (explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
4" PVC through wall, 3" PVC in house, no leaks visible.
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
Z concrete El metal
feet
El fiberglass El polyethylene [] other (explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate)
Dimensions: 10'x 5'x 4'
Sludge depth: 4"
El Yes R No
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17
Owner
information is
required for
every page.
t5ins - 3/13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
6 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
28 Jerad Place
Property Address
Stephen Sadowski
Owner's Name
North Andover
Cityrrown
D. System Information (cont.)
State
01845 8/12/2014
Zip Code Date of Inspection
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle 29"
Scum thickness 4"
Distance from top of scum to top of outlet tee or baffle 8-1
Distance from bottom of scum to bottom of outlet tee or baffle ill,
How were dimensions determined? Tape 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.):
Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
El concrete El metal
Dimensions:
Scum thickness
feet
El fiberglass 0 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: Date
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 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
28 Jerad Place
Property Address
Stephen Sadowski
Owners Name
North Andover
MA 01845
Cityfrown 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.):
8/12/2014
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
El concrete El metal El fiberglass El polyethylene F1 other (explain):
Dimensions:
Capacity: gallons
ngnei n Mnime
gallons per day
Alarm present: El Yes 0 No
Alarm level: Alarm in working order: El Yes El No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
* Attach copy of current pumping contract (required). Is copy attached? El Yes [:1 No
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17
<C'�N Commonwealth of Massachusetts
A Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
28 Jerad Place
Property Address
Stephen Sadowski
Owner Owners Name
information is
required for North Andover MA 01845 8/12/2014
every page. City1rown 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 0
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.):
D -box level & distribution equal. No evidence of leakage. Evidence of carryover, pumped d -box
to clean
Pump Chamber (locate on site plan):
Pumps in working order: El Yes F-1 No*
Alarms in working order: 0 Yes F� No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17
Commonwealth of Massachusetts
9. TTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
28 Jerad Place
Owner
information is
required for
every page.
Property Address
Stephen Sadowski
Owner's Name
North Andover
City[Town
D. System Information (cont.)
Type:
State
01845 8/12/2014
Zip Code Date of Inspection
number:
number:
number:
number, length:
number, dimensions: 1 field 20'x 50'
number:
E] 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.):
Soil ok. Vegetation ok. No sign of ponding to surface.
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 EI Yes [:] No
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17
leaching pits
leaching chambers
El
leaching galleries
El
leaching trenches
ED
leaching fields
E]
overflow cesspool
State
01845 8/12/2014
Zip Code Date of Inspection
number:
number:
number:
number, length:
number, dimensions: 1 field 20'x 50'
number:
E] 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.):
Soil ok. Vegetation ok. No sign of ponding to surface.
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 EI Yes [:] No
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17
Owner
information i's
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
28 Jerad Place
Property Address
Stephen Sadowski
Owner's Name
North Andover
MA 01845 8/12/2014
Cityfrown 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 - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
28 Jerad Place
Property Address
Stephen Sadowski
Owner Owners Name
information is
required for North Andover MA 01845
every page. Cityrrown State Zip Code
8/12/2014
Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the s ewage 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
A-
LW It.'
ts 1$71 1
32�'5
A
X
D.-aor-
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17
9
Commonwealth of Massachusetts
uTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
28 Jerad Place
,p
Owner
information is
required for
every page.
t5ins - 3/13
t-roperry Aaaress
Stephen Sadowski
Owner's Name
North Andover
City/Town
D. System Information (cont.)
Site Exam:
Z
Check Slope
Z
Surface water
Z
Check cellar
Z
Shallow wells
MA 01845 8/12/2014
State Zip Code Date of Inspection
Estimated depth to high ground water: 4
feet
Please indicate all methods used to determine the high ground water elevation:
Obtained from system design plans on record
If checked, date of design plan reviewed: 10/2/2001
Date
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health - explain:
Design plan
El Checked with local excavators, installers - (attach documentation)
El Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
As per design plan test pit data
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17
. <LN<
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
28 Jerad Place
Property Address
Stephen Sadowski
Owner's Name
North Andover MA 01845 8/12/2014
Cityrrown State Zip Code Date of Inspection
Owner
information is
required for
every page.
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
.. ................
Town of North Andover
Tax Map # 210-106.A-0009-0000.0
Parcel Id 17158
28 JERAD PLACE
SADOWSKI, STEPHEN & KELLY
28 JERAD PL
NORTH ANDOVER, MA
01845
Class 101 Single
Family
Property Type
1 Residential
Zoning2 1 Residential
Zoning3
1 Residential
Size Total 1 Acres
FY 2015
IJI3 Mailinq Index
Name/Address
Type Loan Number
Active/Inact. From
Until
SADOWSKI, STEPHEN & KELLY
Payor
28 JERAD PL
NORTH ANDOVER, MA
01845
UB Account Maint.
Account No
Cycle
Occupant Name
Active/inactive
Bldg Id. 17660.0 - 28 JERAD PLACE
Last Billing Date 7/8/2014
3170330
03 Cycle 03
Active
UB Services Maint.
Account No. 3170330
Service Code
Rate Charge
Multiplier/Users
MISCFEEADMIN FEE
0.635/8 7.82
1/
WTR WATER
01 ALL METER SIZE 49.40
/1
UB Meter Maintenance
Account No. 3170330
Serial No Status
Location Brand
Type Size
YTD Cons
35341146 a Active
ERT HH LEFT b Badger
w Water 0.630.63
1037
Date
Reading
Code Consumption
Posted Date
Variance
6/11/2014
966
a Actual
13
7/16/2014
157%
3/11/2014
953
a Actual
5
4/11/2014
-38%
12/10/2013
948
a Actual
8
1/17/2014
-78%
9/11/2013
940
a Actual
36
10/15/2013
71%
6/12/2013
904
a Actual
21
7/24/2013
-21%
3/13/2013
883
a Actual
27
4/22/2013
14%
12/11/2012
856
a Actual
23
1/9/2013
-78%
9/13/2012
833
a Actual
110
10/15/2012
243%
6/12/2012
723
a Actual
31
7/16/2012
7%
3/14/2012
692
a Actual
30
4/14/2012
9%
12/12/2011
662
a Actual
27
1/17/2012
-50%
9/12/2011
635
a Actual
58
10/13/2011
118%
6/7/2011
577
a Actual
25
7/20/2011
22%
3/8/2011
552
a Actual
20
4/13/2011
-61%
12/9/2010
532
a Actual
52
1/12/2011
-78%
9/10/2010
480
a Actual
250
10/15/2010
316%
6/7/2010
230
a Actual
57
7/15/2010
203%
3/9/2010
173
a Actual
19
4/14/2010
-6%
12/8/2009
154
a Actual
20
1/12/2010
-14%
9/9/2009
134
a Actual
24
10/15/2009
-63%
6/8/2009
110
a Actual
61
7/20/2009
288%
3/13/2009
49
a Actual
17
4/29/2009
-2%
12/9/2008
32
a Actual
14
1/20/2009
-64%
9/24/2008
18
a Actual
18
10/10/2008
-100%
8/20/2008
0
n New Meter
0
10/10/2008
-100%
8/20/2008
3469
r Replacement
89
10/10/2008
251%
6/5/2008
3380
m Manual estimate
30
7/16/2008
45%
3/7/2008
3350
m Manual estimate
20
4/11/2008
11%
12/11/2007
3330
m Manual estimate
20
1/22/2008
-84%
Town of North Andover
Office of the Health Department
Community Development and Services Division
27 Charles Street
North Andover, Massachusetts 01845
Sandra Starr
Public Health Director
TOWN OF NORTH ANDOVER
BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
DATE OF COMPLIANCE
01/03/02
This is to certify that
the individual s ubsurface disposal system
constructed 0 or repaired (K)
M
John Soucy
at
28 Jared Place Road
Telephone (978) 688-9540
Fax (978) 688-9542
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.
The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily.
# V"/, 0e,
B11'an J. LaGrasse
Board of Health Inspector
BOARD OF APPEALS 688-9541 BLTILDING688-9545 CONSERVATION 688-9530 BEALTH688-9W PLANNING 688-9535
0 F W -C
M
I T O'TvV'N* 0 F N 0 RT H ANDOVER SEWAGE', DISPOSALS)"STEA4
1-'\-,STALLA-rION CERTIFICATION
'The und-ershmed here:C;y cet-,Ifv that the Sewa2e DISP05al SYSte-71 COnSt.7,1CUCd'.
by_ ae
located at 26 Mct a E-� D ;)'I- A C- C
was installed in C'Onfc.,mance with the North AnC'ove,r Board of Hecith a--'prove� plan..
System Design dated with, an acc-roved design
flow of gallons per day The materials,use-a; were In conforrriar:.,-�- �.%--Irh those
specined oh the app�ro�71-e- plan; the sysiem was instafled in accor&T.cc -%,.Iei[h Che previsions
of 31 10 CNM 15.000, Title 5 and local ret.-ilatioris, and the final 2rading agre-es
su6stantially -,',-Ith the approved plan. Ail work is accurate' Y represented �)r ihe As -built
which has been submitted to the Board c-1- Health.
P,ed inspection dat-� it
Engineer RI-prits,�n:ative
Final
.nspect:cn te- Ot
Lristal'er: L.0 Date�
RICHARD
CesiLrn Enizincer: 4 C. I Date�
TANGARD
I
AS -BUILT CHECKLIST
toT-NtwBE-it, STREET NAM[E
ASSESSORS MAP & P ARCEL NUMBER
ORIG INAL STAA4P & SIGNATURE
INTERVIOUS AREAS - DRIVEWAYS, ETC.
NORTH ARROW
LOCATION & ELEVATIONS OF BENCHMARK USED
w,xw
LOT LINES & LOCATION OF DWELLINGS
LOCATIONS & DIMENSIONS OF SYSTEM,
INCLUDING RESERVE
TIES TO LOT LINES & DWELLING, WELLS
a. FROM SEPTIC TANK
b. FROM LEACH AREA
LOCATIONS OF DEEP HOLES & PERC
TESTS
ELEVATIONS OF DISPOSAL SYSTEM
TOP OF FDN ELEVATION
LOCATIONS OF WELLS, DRAINS, WATERCOURSES
WITHIN 150'OF SYSTEM
LOCATION OF WATER, GAS, ELECTRIC LINES, CABLE
DISTANCES FROM CORNERS OF HOUSE TO CENTER OF
TANK & D -BOX
ORIG INAL STAA4P & SIGNATURE
INTERVIOUS AREAS - DRIVEWAYS, ETC.
NORTH ARROW
LOCATION & ELEVATIONS OF BENCHMARK USED
w,xw
Town of North Andover, Massachusetts Form No. 3
BOARD OF HEALTH
Of 14ORTH
16 . "Y -mo
0
DISPOSAL WORKS CONSTRUCTION PERMIT
CHUS
Applicant
Site Local
Permission is hereby granted to Construct ( ) or Repair (4)-Xn---I—ndividual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No
CHAIRMAN, BOARD OF HEALTH
D. W.C. No.
Fee
BOARD OF HEALTH
NORTH ANDOVER.) MA 01845
978-688-9540
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE: Lo–�13-01
LOCATION: 9 -8 -
LICENSED INSTALA:
CURRENT INSTALLER'S LICENSE9
C
SIGNATURE:– 1,,1-lrllk //4(rLn - TELEPIONE# 'q-7&- . 61
CHECK ONE: r
REPAIR:_ 1-j- NEW CONSTRUCTION:
IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT.
Administrative Use Only
C 7
$160-00 Fee Attached? Yesv---,,, No
Foundation As -Built? Yes No
Floor Plans? 4L.Yes=�— No
Approval I zlkJ
OCT 2 3 ?001
Date: 10A4
INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction of the septic system for the
property at rL*_P_� /J. relative to the application
t— 0 f
of �04-(C' "gkpated !I —1 —7 —V for plans by A.) eA__J and
r I/
dated q— 17-41 ( with revisions dated.. —0/
I understand the following obligations for management of this project:
1. As the installer I am obligated to call for any and all inspections. If homeowner, contractor,
project manger, or any other person not associated with my company schedules an inspection
and the system is not ready then item two shall be applicable.
2. As the installer I am required to have the necessary work completed prior to the applicable
inspections as indicated below. I understand that requesting an inspection, without
completion of the items in accordance with Tile 5 and the Board of Health Regulations may
result in a $50.00 fine being levied against my company.
a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done
first. Installer must request the inspection but does not have to be present.
b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As -built or
verbal OK from engineer must be submitted to Board of Health, after which installer calls for
inspection time. Installer must be present for this inspection. With pump system all electrical
work must be ready and able to cause pump to work and alarm to function.
c) Final Grade — Installer must request inspection when all grading is complete. Does not have to be
on site.
3. As the installer I understand that persons or companies not associated with my company may
not perform the work required by my company to complete the installation of the system
identified in the attached application for installation. I further understand that work by others
unlicensed to install septic systems in North Andover can constitute reasons for denial of the
system, and/or revocation or suspension of my license in the Town of North Andover plus
significant fines to all persons involved.
4. As the Installer I understand that I must be on site during the performance of the following
construction steps:
a) Determination that the proper elevation of the excavation has been reached..
b) Inspection of the sand and stone to be used.
c) Final inspection by Board of Health staff.
d) Installation of tank, D -box, pipes, stone, vent, pump chamber, retaining wall and other
components.
5. As the installer I understand that I am solely responsible for the installation of the system as
per the approved plans. No instructions by the homeowner, general contractor, or any other
persons shall absolve me of this obligation.
Undersigp'64 Licensed SenYic Installer
orks Constriction PerKiit #
Date: 10 3-01
R
OCT 2 3 2001
NEW ENGLAND ENGINEERING
INC
SERVICES
TOWN OF NORI H ANUUvri
BOARD OF HEALTH
Cr-) F 2 1 2om
September 21, 2001
Sandra Starr, Administrator
North Andover Health Department
Town Hall Annex
27 Charles Street
North Andover, MA 0 1845
Re: 28 Jared Place Road, North Andover, Septic system design
Dear Sandra:
Enclosed are the following documents relative to the above referenced property.
1. 5 sets of septic system design plans, 2 with original stamps.
2. Soil evaluator sheets.
3. Application form.
4. Check to cover the fee.
The owner of this property is in a hurry to have the system installed so to expedite the
review process I have enclosed extra copies of everything and an envelope with postage
to send the information to john Nunan.
If you have any questions regarding the information submitted please do not hesitate to
contact this office.
Sincerely,
/EIT
Benjar C. OJ2r,
President
60 BEECHWOOD DRIVE -NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 -FAX (978) 685-1099
SEPTIC PLAN SUBMITTAL FORM
LOCATION: J-&iZE-,p ?L fte, -
NEW PLANS: <:SD $160.00/Plan,_
REVISED PLANS: YES
$ 60.00/Plan
SITE EVALUATION FORMS INCLUDED: NO
DATE:_..j) a I 1 0 1
DESIGN ENGINEER: 1v
DATE TO CONSULTANT:
When the submission is all in place, route to the Health Secretary.
NOONAN & Mc DOWELL, INC.
25 Bridge Street, Suite 6, Billerica, MA 01821-1023
Voice (978) 667-9736 Fax (978) 671-9565
Email: nm(a-)netway.com
Date: October 2, 2001
Town of North Andover
Office of the Health Department
Community Development and Services Division
27 Charles Street
North Andover, MA 0 1845
RE: Subsurface Sewage Disposal System
Plan Review, 1770/042a
28 Jerad Place Rd
Assessors Map 106A, Lot 9
Dear Members of the Board,
i 7-C
Q
waft",
Please be advised that Noonan & McDowell, Inc. has reviewed the plan dated 10/2/00, by New
England Engineering Services, Inc. It is our opinion that the proposed design will meet the
requirements of Title 5 and the North Andover Board of Health "By -Laws" if the following is
addressed
1) Please revise year of plan.
2) The profile identifies distance from septic tank to D -Box as 20 ft. Revise distance and
slope.
3) The profile shows a continuous slope of 2%. The plan view shows a different grading.
Please revise.
Respectfully,
7
�Z
ohn 1. Noonan., P.L.S.-P.E.
&office/fonns/1770016
Land Surveyors Civil Engineers Environmental Planners
NOONAN & Mc DOWELL, INC.
25 Bridge Street, Suite 6, Billerica, MA 01821-1023
Voice (978) 667-9736 Fax (978) 671-9565
Email: nm@netway.com
Date /a4�_
Town of North Andover
Office of the Health Department
Community Development and Services Division
27 Charles Street
North Andover, MA 0 1845
RE: Subsurface Sewage Disposal System
Plan Review, 1-770/ 574-7-14
- -z_,15- --, �5&lw
Assessors Map 10 i� , Lot
Dear Members of the Board,
Please -be advised that Noonan & McDowell, Inc. has reviewed the plan dated Ye:! -e 7- L7
by IeL-c— /
It is our opinion that the proposed design will meet the requirements of Title 5 andfhe North
Andover Board of Health "By -Laws" if the following is addressed:
;r er-,rz- 7Y e-- 4=-v,
p / 57
_V
4:7, Z_ 109t " 6�� 4!S7-
. 00� e_4?
& �-- 7— ;,-o0o'
Respectfully,
John L. Noonan, P.L.S.-P.E.
G:office/forms/tonarev
.1411- 5 lxlk7 4_4�,914 /-->
Land Surveyors Civil Engineers Environmental Planners
NEW ENGLAND ENGINEERING SERVICES
INC
October 5, 2001
Sandra Starr, Administrator
North Andover Health Department
Town Hall Annex
27 Charles Street
North Andover, MA 0 1845
Re: 28 Jerad Place Road, North Andover, Septic system design
Dear Sandra:
Enclosed are revised plans for the above referenced property. The following changes
have been made.
)1. The year of the plan has been revised.
2. The distance to the distribution box from the tank and the pipe slope has been
corrected.
The profile has been corrected.
Also enclosed is a check to cover the review fee.
If you have any questions regarding the information submitted, please do not hesitate to
contact this office.
Sincerely,
'6' C �az I
Benjamin C. Osgood, ., EIT
President
R-vt1i,i O'� 4-r-,7-4 ANQ0VFR/
'71
Off - t, ?001
60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099
SEPTIC PLAN SUBMITTAL FORM
LOCATION: 2 E� Te (-C4 C), p le- C e- (LS
NEW PLANS: YES $160.00/Plan
REVISED PLANS: (:YES) $ 60.00/Plan
SITE EVALUATION FORMS INCLUDED: YES
DATE: 10
— ldril
DESIGN ENGINEER: A)el Ij
a
DATE TO CONSULTANT:
When the submission is all in place, route to the Health Secretary.
5 2001
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Town of North Andover
�J' Office of the Health Department
C6-nmunity Development and Services Division
27 Charles Street
North Andover, Massachusetts 01845
Sandra Starr
Health Director
October 10, 2001
Glen Schermerhorn
28 Jerad Place
North Andover, MA 0 1845
Dear Mr. Schermerhom:
Telephone (978) 688-9540
Fax (978) 688-9542
This is to notify you that the revised plans dated 10/02/01 for 28 Jarad Place have been
approved. This allows for the waiver of North Andover distance to wetlands from 100
feet to 86 feet. With this variance, the plans are approved.
If you have any questions, please do not hesitate to call the Board of Health Office at
978-688-9540.
Sincerely,
Brian Lagrasse
Health Inspector
BL/aem.
cc: Houde
File
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 NURSE 688-9543 PLANNING 688-9535
BOARD OF HEALTH
NORTH ANDOVER, MASS. 01845
APPLICATION FOR SOIL TESTS
TC aN 0 - , i
TF -L.'688:!'9540
r
AUG 19 2001
DATE:
LOCATION Or SOIL TESTS: d,9
Assessor's map & parcel number: lc>(, pt
OWNER: TEL.NO.:
ADDRESS: 9E. 3-A a jl-� r) "D
ENGINEER:A) �.C&-,�TEL.NO.: q76-G23A-i7&9 i
CERTIFIED SOIL EVALUATOR: kr-�,cao C "7-r-Lvjj- Dno,.03-A�
Intended use of land: residential subdivision, single family home, commercial
Repair testing Undeveloped lot testing
N. A. Conservation Commission Approval:
THE FOLLOWING MUST, BE INCLUDED WITH THIS FORM:
1 Proof of land ownersh,lp (Tax bill, deed, or letter from owner permitting
tests)
2. Plot plan
3. Fee of $275.00 per lot for new construction. This covers the minimum two deep holes
and two percolation tests required for each disposal area. Fee of $75.00 p & lot for
repairs or upgrades.
GENERAL INFORMATION
1 . Only Certified Soil Evaluators may perform deep hole inspections.;,
2. Only Mass. Registered 8anitarians and Professional Engineers can design . septic
plans.
3. At least two deep holes and two percolation tests are required for each septic system
disposal area. . f
4. Repairs require at least two deep holes and at least one percolation test, at the
discretion of the BOH representative.
5. Full payment will be required for all additional tests within two weeks of testing.
6. Within 45 days of testing, a scaled plan (no smaller than 1"-100') shall be submitted to
the Board of Health showing the location of all tests (including aborted tests).
7. Within 60 days of testing soil evaluation forms shall be submitted.
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FORM I I -SOIL EVALUATOR FORM
Page 2 or 3
-7
Location Address or Lot Ao. 2 6 J-4ti,4sV FL -A c_c- /,c1c;o
/V 4 IV 49OV465,
On-site Review
Deep Hole Number Date:_2/_1_-,Z0 Time: IL " "32 Weather e -4L e;*-= 70
Location (identify on site plan)
Land Use C\1 Slope L Surface Stones
V6getation e v?, 009 3 9
Landform
Position on landscape (sketch on the back)
It
Distances from: EL
Open Water Body ;;p /00/
�et Drainage way :2 feet
Possible Wet Area feet Property Line _.!_LZLfeet
JYJ
Drinki ng Water Well 'f0sV feet "Other
'30
DEEP OBSERVATION HOLE LOG* 7W
Depth from SoAl Hori4zo SoilTexaure Soilcolor soil Other
Surface (inches) 4USDA) tmunsell) Mottling IlStructme. Stones. Boulders. Consiste.4. %
I I I I Graven
Parent Material (geologic)
CaPdRoSedrock >
Depth to Groundwater Standing Water in the Hole: 'ev 0 Aj hr- Weepino (forn Pit Face:
Estimated Seasonal High Ground Water: 79"
F
DEP APPROVED FORM - t2M7JVS
-i ve, v
Cz"
jr - v e- pvwr
SL
93
AY
Parent Material (geologic)
CaPdRoSedrock >
Depth to Groundwater Standing Water in the Hole: 'ev 0 Aj hr- Weepino (forn Pit Face:
Estimated Seasonal High Ground Water: 79"
F
DEP APPROVED FORM - t2M7JVS
-i ve, v
Cz"
Location Address or Lot Ao.
FORM 11 - SOIL EVALUATOR FORM
Page 2 or 3
. On-site Review -
Deep Hole Number Date: IhO./ Time: —Weather CL40tM
Location (identify on site plan)
Land Use 60" A-) Slope M Surface Stones
V4igetation 6 fSA 11
Landform
Position on landscape (sketch on the back)
Distances from:
Open Water 80-dy >A9 feet Drainage way feet
Possible Wet Area :� 10 0 feet Property Line feet
Drinking Water Well feet "Other
4— ov 0 ov DEEP OBSERVATION HLOLE LOG*
Depth from
Surface (inches)
Soil Horizon
Soil Texture
JUSDA)
Soil Color
(Munsell)
SON
Mottling
Other
(Structure. Stones. Boulders. Consistency. %
Graven
od�
A 7—
7,
'T
9
7
OF.2 FK l5F-n111QF;n
LT &;V&QV
MrWW I
ftrent Material lgeologic) DepthtoR /47)
Depth to Groundwaler: Standing Water in the Hole: e0VOMo�&_"_ Weeping from ft Face:
Estirnated Seasonal H4h r-ound Water: -7 X 4
DEF APPROVEn F1DRM - lZie7195
FORM 11 - SOIL EVALUATOR FORNI
Page I of 3
No.
Date:
Commonwealth of Massachusetts
Massachusetts
Soil Suitabilijy- Assessment Lo . On-site Sewage Disposal
Date:
Performed By: ....... --
WitnessedBy: . . . ........ .. ... ... ... ... ..... .. ................... ........... ..
Add—s m 04t6�`� O.-,xr'i Nx�.
Aftess. Ad
z /1/141
Tdephom 1 2:�� :� K� . I;p
Ala.
Jew construction El Repair FYI
Off -ice Review
Published Soil Survey Available: No El Yes
Year Published /�/ ............... Publication Scale/-/�� Soil Map Uni c -
Drainage Class 17.4 ............. Soil Limitations ........ ..
Surficial G ' eologic Report Available: No I Yes
Year Published Publication Scale
Geologic Material (Map Unit) ........ ............ ................................... ......... I ......
La-ndform ............................................................................. ... ........... I ...... ................ ................
Flood Insurance Rate Map:
Above 500 year flood boundary No E]Yes
Within 500 year flood boundary No E]Yes El
Within 100 year flood boundary No E]Yes
Wetland Area:
National Wetland Inventory Map (map unit) ........ ....... .. ... . .... .. ..... ... .
Wetlands Conservancy Program Map (map unit) ...... ...... I ............
Current Water Resource Conditions (USGS): Month ... ...
Range :Above Normal E]Normal ZBelcw Normal El
Other References Reviewed:
hiDEP APPROVED FORM - 12107/95
FORM 11 - SOIL EVALUATOR FOI�N,j
Page 2 V 3
Location Address or Lot No. /��-
On-site Review
Deep Hole Number D a t e: Weather
Location (identify on site plan) ....... ... ...... . . ..........
Land Use Slope Surface Stones V, F7_7,,�
Vegetation
Landform
Position on landscape,(sketch on the b a c k)
Distances from:
Open Water Body feet Drainage way./_1525 feet
Possible Wet Area feet Property Line .... . feet
Drinking Water feet Other . ...... ...
DEEP OBSERVATION'HOLE LOG*
Depth from
.Surface (Inches)
Soil Horizon
Soil Texture
(USDA)
Soil Color
(Mun5ell)
Soil
Mottling
Other
(Structure. Stones, Boulders, Consistency, %
Gravel)
-5
�//o —5 ��4
MINIMUM
OF 2 BOLES REMIREU
Al EVERY
PROPOSED DI.qP().(;Al APPA
Parent Material (geologic)
Depth to Groundwater Standing Water In the Hole:
Eslirnated Seasonal High Ground Water:
DEP APPROYED FO"l - 12107/9S
71�4_ e- DepthtoBodrcck:
Weeping from Pit Face:
FORM 11 - SOIL EVALUATOR FORM
Page 2 of 3
Location Address or Lot No. -"20 /2--, R -)l
On-site —Review
Deep Hole Number Date:- T1 m a: W a a t h a
Location (Ida If n site plan)
D-� y 0 ... ...... . ....
Land 'Use /4P!5V7�/- Slope M Surface Stones
Vegetation
Landform
Position on landscape,(sketch on the back)
Distances from:
Open Water Body feet Drainage way feet
Possible Wet Area feat Property Line feet
Drinking Water Well,�"/:�� feet Other . . .. .. ............. .... 1,
DEEP OBSERVATION'HOLE LOG*
Depth from
,Surface (Inches)
Soil Horizon
Sol[ Texture
(USDA)
Soil Color
(Munsell)
Soil
Mottling
Other
(Structure, Stones, Boulders, Consistency, %
Gravel)
A-
/4 RI
ale,
MINIMUM
OF 2 HULLb
LQUIKEU EVFRY
popush,D Dl.1;p().qAI �mrTi
Parent Material (geologic) 4e�,w 0�ve�- DepthtoSedrock:
Depth to Groundwater: Standing Water in the Hole: Weeping from Pit Face:
Eslimated Seasonal High Ground Water:
DEP "PROVED F0101 - 12107195
Local ion Address or Lot No.
FORM 11 - SOIL EVALUATOR FORNI
Page 2 of 3
Deep Hole Number Date:— Time. Weathe
Location (identify on site plan) . .......
Land Use slope m Surface Stones
Vegetation
Landform
Position on lands cape,,(s ketch on the back) .. ... .... .
Distances from:
Open Water Body/-�� (5> feet Drainage way. feet
Possible Wet Area feet Property Line feet
Drinking Water Well< ':�� feet Other
DEEP OBSERVATION'HOLE LOG'
Depth from
,Surface (inches)
Soil Horizon
Soil Texture
(USDA)
Soil Color
(Munsell)
Soil
Monling
Othei
(Structure, Stones, Boulders, Consistency, %
Gravel)
V
A//0
�14
�-v
ld--7�
MINIMUM
OF 2 HOLES REMIKIEL)
Al EVEHYT�8
17,11=0SA[
A
-R -FA
Parent Malarial (geologic) e-1 DepthtoBedrock:
Depth to Grovnowaier,* Standing Water in the Hole: Weeping from Pit Face:
Eslimated Seasonal High Ground Water:
DEP APPROVED FOM - 12/07/95
I
LocaLlon Address or Lot No.
FORM 11 - SOIL EVALUATOR FORN.1
Page 2 of 3
'te Revie
Deep Hole Number D a t e:.
-:;2� W a a t h a
Location fl��tlfy on site plan) , '5a� -'r
L a n d U s a Slope M S u r f a c e S t o n a
Vegetation
Landform
Position on landscape,(sketch on the back)
Distances from:
Open Water Body/36�"� feet Drainage way. feet
Possible Wet Area feet Property Line feet
Drinking Water Well feet Other
DEEP OBSERVATION'HOLE LOG"
Depth from
.Surface (inches)
Soil Horizon
Soil Texlure
(USDA)
Soil Color
(Munsell)
�011
Mortling
Other
(Structure, Stones, Boulders, Consistency, 0/a
Gravel)
YIZ
?Vle
_'y
1�mv 4
W7,
;ko
MINIMUM
OF 2 HOLES RE60IR
D A] EVERY
PROPOS --D DfqPo.qA[ APPA
Parent Material (geologic)
Depth to Grovndwalor Standing Water In the Hole:
Eslimated Seasonal High Ground Water: ;;v
E
DEP APPROVED FO"I - 12/07/95
DepthtoBodrock:
Weeping from Pit Face: —
FORM 11 - SOIL EVALUATOR FOR_N1
Page 3 of 3
Location. Address or Lot No. -��
Determination for Seasonal High Water Table
Method Used:
F� Depth observed standing in observation hole... I nches
Depth weeping from side of observation hole....., inches
Depth to soil mottles ....... < ... inches
D Ground water adju.stment ................... f e e t
Index Well Number ............ Reading Date .................. Index well level .
Adjustment factor .................. Adjusted ground water level
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in 'all areas
observed throughout the area proposed for the soil absorption system?
If not, what is the depth of naturally occurring pervious material?
Certification
I certify that on (date) I have passed the soil evaluator examination
approved by the Department of Environmental Protection and that the above analysis
was performed by me consistent with the required training, expertise and experience
described in 310 CMR 15.017.
Sign aturek44-lel<r"�A/ �ate
WDEP A.PPROVED FORM - 12/07195
F M 12,
OR PERCOLATIO.NTEST
+ -Z-
Location Address or Lot No. 7Z t? 114M CV P�'- 4 e7
COMMONWEALTH OF MASSACHUSETTS
A' - A"001/4:"� Massachusetts
Percolation Test*
'9
0)
Date: Time%
-----------
Observation Hole #
Depth of Perc
r2: 'r &0 7 -
Start Pre-soak
576
End Pre-soak
Time at 12"
+ 0
/ 3
Time at 9"
Time at 6"
5
Time (9"- ")
Rate Min./Inch
Minimum of I percolation test must be performed in
reserve area. both the primary area AND
Site Passed
Site Failed
... ................... . .................. ................... . ... .... ............................... . ........................
Performed By: 19) e_0tvbcw--t,, 0 roe 0 075
Witnessed By:
Comments:...._
"MOVM FORM - UWjs
NEW ENGLAND ENGINEERING SERVICES
INC
July 27, 1999
North Andover Board of Health
Town Hall Annex
27 Charles Street
North Andover, MA 01845
RE: TITLE V REPORT: 28 Jared Place Road, North Andover
Enclosed is -a copy of the Title V report for the above referenced property. The system passe our
inspection.
If there are any questions please call me at my office, 686-1768.
Sincerely
I r
12 -
BefnjaWn C s �/),E. 1. T.
President
T, -r) -r' --rP
' -;H1EALrH
JUL "'2
33 WALKER ROAD - SUITE 23 - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099
ARGEO PAUL CELLUCCI
Gove or
COMMONWEALTH OIF MASSACHU,SETTS
EXECUTIVE OFFICEOF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENviRoNMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500
TRUDY COXE
Secretary
DAVID B. STRUHS
Conunissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Propefty Addiress: db �/K40 1��If' /0 N- ~'IF� N. f.Ownef /)/,d - lad- 1JiF Olt ". fe
Date of Inspection: '71V,71�f Address of Owner: 7d7e��,p
Name of Inspectoor: (Please Print) —Benj amin Q. Osgood, Jr
I am a DEP approved system inspector pursuant to Section 15.340 of Tide 5 (310 CMR 15.000)
CompmyNarne: New England Engineering Services Inc.
MaAngAddress: 33 Walker Rd-, Suit -P 219 North Andover, MA 01845
TelephoneNumber: 978-686-1768
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
maintenance of on-site sewage disposal systems. The system:
ZP.sses
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Darte:
The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)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
sball submit.the report to the appropriate regional office of the Department of,,Environmental Protection. The original should,be sent to-vw
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
revised 9/2/98
Page I of I I
e. J* 11i,nied n R�cyded P,;-
a
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
'ILI
Property Address: VV Al"If A01
Owner: -SUL.% r,— 6r0t..,L-1-W-#e—
Date of Inq%pecti*n-
q(
INSPECTION SUMMARY: Check A, B, C. or D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CIVIR 16.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair. as approved by the Board of Health, will pass.
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, 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 exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
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
distribution box is levelled or replaced
The system required purnping-moye than iourlimes a yeardue to broken orobstructed pipe(s). The Tysturn will
insoction if (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
revised 9/2/98 Page 2 of I I
!SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
N.Wty Addr..: A) fMZCD PGAC-f— A) ph\JbAlf-9-
Ovirw:-�Su'-(E- CPLLL-r�
Dat6 of kmpection q rj
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 the
public health, safety and the environment.
SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 (1)(b) THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICKYALLPIRCITECT THE PUBLIC HEALTH AND SAFETY. AND THE ENVJRONMEPLT-
Cesspool or privy is within 50 feetof 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 tS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALT4-1 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply wall.
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
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. Method used to determine distance (approximation not valid).
3) OTHER
0
revised 9/2/98
Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continitied)
Property Address: 4% '5AJZ-F-0 POC*�- (Z'10-) Aj' (+kyDLVF4e_
Owner: UUI_t�_ CTVtA1T)iEtIL
Date of kispection: rj
D. SYSTEM FAILS:
You must indicate either "Yes" or "No- to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CIVIR 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 �ewage iryto 4acilirrar-jTstarn component- due qo arn overloaded iomWgged 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 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
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.
E. LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a 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-*t4xAarV-4o A &urf&o"4nkin.9 -water -*upply
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) I I
The owner or operator of any such system �hall upgrade the system in accordance with 310 CIVIR 15.304(2). Please consult tjie local regional
office of the Department for further in.forgiation.
revised 9/2/98 Page 4 of I I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Addre": 'V. 'WLVVj'W
Owner: Jwoi (�ha'r)C4
Ciete of Inspec6on:
� 91 A 191
Check if the following have been done: You must indicate either "Yes- or "No- as to each of the following:
Ye No
Tt:� Pumping information was provided by the owner, occupant, or Board of Health.
None of the sy'stem�cornlmmu%nu.hama�n pusnpadLfor�xKjaast two we&ks an&the'irystarn has boo =eceiuia wm"Kal Aow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
tZ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non -sanitary or industrial waste flow.
The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the 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 the Soil Absorption System orr the site has been determined based on:
Existing information. For example, Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
11 5.302(3)(b)]
The facility owner (and.acr-upants.if differew from_owner).wazP_,prauidad.with information.Dn the proper rna6nf-n,QCe_of
SubSurface Disposal Systems.
revised 9/2/98 p2ge 5 of I I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: Q1Z Wo PLW eb.) Aj. 41-k"-fz
Owner:
Date of knpecti4m:
RESIDENTIAL:
Design flow:_g. p. d. /bedroom.
Number of bedrooms (design): Number of bedrooms (actual):
Total DESIGN flow & 0,9
Number of current residents:
Garbage grinder (yes or no):
Laundry (separate system) (yes or no): JVP ; If yes, separate inspection required
Laundry system inspected (yes or no)
Seasonal use (yes or no):_J�D
Water meter readings, if available (last two year's usage (gpd): Tvwt-4
Sump Pump (yes or no): N 0
Last date of occupancy: to re F4
COMMERCIALRNDUSTRIAL:
Type of establishment:
Design flow: qpd I Based on 15.203)
Basis of design flow -
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:_
GENERAL INFORMATION
PUMPING RECORDS and sou rce of information:
'S E- 9 C1
System pumped as part of inspection: (yes or no)_
If yes, volume pumped: _gallons
Reason for pumping:
TYP!,��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)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank — Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed4if known) -and source of4Moffnation: (�j C1
Sewage odors detected when -arriving at the site: (yes or no) jA4 V
revised 9/2/98 Nge 6 or i i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
P,op" Add,..: -4
Ownef:-Sk�L-lij5- CWUL-TIF4Z
Darte of lnsp-6-�:
1 9 XJ) 199
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction: — cast iron /40 PVC other (explain)
Distance from private water supply well or suction line
Diameter Lf "
Comments: (condition of joints, venting, evidence of leakage, -etc.)
�.Aj I tA Fj, ftse-;m rc mT
SEPTIC TANK:—
(locate on site plan)
Depth below grade:
Material of construction: —concrete —metal —Fiberglass _Polyethylene _other(explain)
If tank is Fnetal. list age _ is.age.contwme(i by UertlTlcaxe Or tompuance _ J T C511vul
Dimensions: WA -4
Sludge depth:
Distance from top of sludge to bottom of outlet tee or traffle:—C?
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 dimensions were determined: MEAcL)CE STICV-
Comments:
(recommendation for pumping, condition of inlet and outlet tees or -baffles, depth of liquid level in relation to outlet invert. structurol4ntogrity,
evidence of leakage. etc.) ;efr 17WrneU A-757�VLL 0,4= 7V W / (0 0 "
elf ISH C A=E-$.= OLENUU(4- rcjl.(Pl 7,f
OF -k . e-iu�P-Z _'�. . - T -A -^k k<- ( fU 06
GREASETRAP.PL
(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:
(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.) I I
revised,9/2/98 Page 7 of I I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMAT10N (continued)
Property Addirww: /V. A4jbOve-g-
Owner: -5 k C. -
Date of Inspection:
I t7p--� I
TIGHT OR HOLDING TANK -_NJ (Tank must be pumped prior -to, or 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
Alarm level: Alarm in working order: Yes _ No_
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches. etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
F>0 -jL I Nk CTV0'D " tjl> t T1 0 t-3 .
PUMP CHAMBER -.__W
(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.)
0
revised 9/2/,98
p2ge 8 of I I
SUaSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (cofftinued)
Prop" Address: �D�b t'�JbOVE -fe
0- C-T0L>'T*-'e-
Date of Inspection: 1 -&'7 )
r7
SOIL AEtSORPTION SYSTEM (SAS):_
(locate on site plan,. if possible: excavation not required, location may be approximated by ngn-intrusive methods)
If not located, explain:
Type:
leaching pits. number:
leaching chambers, number:_
leaching galleries, number: -
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number: -
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding. damp soil, condition of vegetation, etc.)
o f�- -�-j S TS VL -i L-00 $C�- &)0iZ-n-V1-'r-- NO P012bt'-J!�r
0 4 -)*f- En I;: k- -Pm 4,+-)
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)
Comments:
(note condition of soil, signs of hydraulic failure, level of VoMing, zondition of-vege-tation, etc.)
PRIVY: �&4
(locate on site plan)
Materjals of construc.tion: Dimensions:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation; etc.)
I I
revised 9/2/98 Page 9 of I I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C,
SYSTEM INFORMATION (continued)
Property Addre":
Owner: 5 LkL%rr GMU k—Ttez
Date of IrLspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where- blic water supply comes into 7hif
pl�,
I
601
revised 9/2/98 P2gC 10 Of I I
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECT]ION FORM
PART C
SYSTEM INFORMATION lcontinued)
Property Address: JAW fW #4'j N. 4rj 0 01*9-
Ownw:*_5�.&�O;_'_ CT-DQ�-C-V2_
Daft of inspection:
fl )l C)
NRCS Report name SoiL_ S')?-JQ-4 of- 0-tA
Soil Type C 4^t TOM
Typical depth to groundwater 0
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate -Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater 40 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
IK
Obtained from Design Plans on record
Observed.Site (Abutting property, observation hole. basemeat Wrnp etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators, installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
e- t'L D I CxN'-T1V- ".� UdA-re, z Cr(u"�-T'f-12 P4A Al
fl� R L a "-.) S %� R- F"q-c F -
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
TOWN OF MORTH ANDOVE
BOARD OF HEALTH
L'S 2 4 2001
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 28 Jerad Place –
– North Andover�-
Owner's Name: – Glen Schermerchorn–
Owner's Address: 28 Jerad Place-
-North Andover, Ma. 01845
Date of Inspection: 8/17/2001
Name of Inspector: – Neu J. Bateson–
Company Name: –Bateson Enterprises Inc._
Mailing Address: –111 Argilla Road-
-Andover, Ma. 01810_
Telephone Number: _( 978 ) 475-4786_
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 fimction and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5 (310 CNM 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
X— Fat
Inspector's Signature: r _U , &)�Z�Date: 8/17/2001
1 v \
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
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
%d
Page 2 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 28 Jerad Place —
– North Andover_
Owner: Schermerchorn
Date of &-s–pection: 8/17/2001
Inspection Summary: Check AMCD or E / ALWAYS complete all of Section D
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 3 10 CMR
15.303 or in 3 10 CNM 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the "Conditional Pass" section need to be replaced or
repaired. The 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 determined7' 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):
ND explain:
broken pipe(s) are replaced
obstruction is removed
Page 3 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 28 Jerad Place -
North Andovers-
Owner: Schermerchorn
Date of linspection: 8/1-7/2001
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 wettand 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 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 28 Jerad Place –
– North Andover_
Owner: -Schermerchorn
Date of Inspection: 8/17/2001
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or "no?'to each of the following for all inspections:
Yes No
–Yes– — Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
— –No– Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
— –No– Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
–Yes– — Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2day flow
–No– Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
–No– Any portion of the SAS, cesspool or privy is below high ground water elevation.
–No— Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
– No Any portion of a cesspool or privy is within a Zone I of a public well.
–No-- Any portion of a cesspool or privy is within 50 feet of a private water supply well.
–No– 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__ (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as
described in 3 10 CMR 15.303, therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design How of 10,000 gpd to 15,000
gpd.
You must indicate either "yes" or "no" to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
— — the system is within 400 feet 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.
Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 28 Jerad Place –
– North Andover_
Owner: Schermerchorn
Date of &-spection: –8/17/FO01–
Check if the following have been done. You must indicate "yes7 or "no?' as to each of the following:
Yes No
–Yes– — Pumping information was provided by the owner, occupant� or Board of Health
— –No– Were any of the system components pumped out in the previous two weeks ?
–Yes– — Has the system received normal flows in the previous two week period ?
–No– Have large volumes of water been introduced to the system recently or as part of this inspection ?
–Yes– — Were as built plans of the system obtained and examined? (If they were not available note as N/A)
–Yes– — Was the facility or dwelling inspected for signs of sewage back up ?
–Yes– — Was the site inspected for signs of break out ?
–Yes– — Were all system components, excluding the SAS, located on site ?
–Yes – — 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 ?
–Yes– — 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:
Yes no
–Yes– — Existing information. For example, a plan at the Board of Health.
No Determined in the field (if any of the failure criteria related to Part C is at issue approximation of
di_stan�e is–unacceptable) [3 10 CMR 15.302(3)(b)]
Page 6 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 28 Jerad Place —
– North Andoverm—
Owner: – Schermerchorn–
Date of Inspection: 8/17/2001
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): – 4 — Number of bedrooms (actual): 4
DESIGN flow based on 3 10 CMR 15.203 (for example: I 10 gpd x # of �–ediooms): 600
Number of current residents:
Does residence have a garbage grinder (yes or no): Yes–
Is laundry on a separate sewage system (yes or no): –No�- [if yes separate inspection required]
Laundry system inspected (yes or no):
Seasonal use: (yes or no): –No–
Water meter readings: June 00 to June 01 = 58,200 Ft3 x 7.5 = 436,500 Gals. /365 Days = 1196 Gals./Day
Sump pump (yes or no): -N0= --
Last date of occupancy- Surrent_
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow (based on 3 10 CMR 15.203): jwd
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: –Pumped two years ago, owner–
Was system pumped as part of the inspection (yes or no): –No–
If yes, volume pumped: ..... gallons -- How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
_X_ 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
�b&ined from system owner)
— Tighttank Attach a copy of the DEP approval
— Other (describe):
Approximate age of all components, date installed (if known) and source of information: –7 years old. 6/10/1994.
As built plan._
Were sewage odors detected when arriving at the site (yes or no): –No–
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: 28 Jerad Place
North AndovW
Owner: — Schermerchorn—
Date of Inspection: 8117/2001
BUELDING SEWER (locate on site plan) X
Depth below grade: _18"
Materials of construction: —cast iron —X-40 PVC other (explain):
Distance from private water supply well or suction li�e.
Comments (on condition ofjoints, venting, evidence of leakage, etc.): —4" PVC thru wall & to septic tank. 3"
PVC in house. No leaks.
SEPTIC TANK: —X —locate on site plan)
Depth below grade: —6"—
Material of construction: —X—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)
Dimensions: 101 x 51 x 41
Sludge depth- ' 3"
Distance from top of sludge to bottom of outlet tee or baffle: —24"
Scum thickness: 3"
Distance from top of scurn to top of outlet tee or baffle: —8"—
Distance from bottom of scum to bottom of outlet tee or baffle: —18"
How were dimensions determined: —Subtract scum & sludge depth to tee length.
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.)-. —Inlet & outlet tee ok. Depth of liquid at outlet invert. No
evidence of leakage. Evidence of higher level in septic tank, soil around tank cover soiled black._
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.):
Page 8 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: - 28 Jerad Place -
-North Andover -
Owner: Schermerchorn
Date of &specdon: 8/17/-2001
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.):
DISTRIBUTION BOX- -X— (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: —0—
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box, etc.): -D-box level & distribution equal. No evidence of leakage. Evidence of
carryover. Evidence of higher level in d -box, soil around d -box soiled black.
PUN[P CHAMBER- (locate on site plan)
Pumps in working order Cyes or no):
Alarms in working order (yes or no):
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Page 9 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 28 Jerad Place -
North AndoveK-
Owner: - SchermerZborn-
Date of Inspection: 8/17/2001
SOIL ABSORPTION SYSTEM (SAS): —X— (locate on site plan, excavation not required)
If SAS not located explain why:
Type
leaching pits, number:
--k-leaching chambers, number: -3-
leaching galleries, number:
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:
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.): - Soil oL Vegetation ok. No sign of ponding to surface. Sign of hydraulic failure of chambers, camera
inside of chambers thru outlet pipes in d -box. Chambers # 1& 2, water up in invert of pipe into chambers.
Chamber # 3 water 10" from invert.
CESSPOOLS: _ (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth - top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow (yes or no):
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.):
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: 28 Jerad Place —
— North AndoveFa—
Owner: — Schermerchorn—
Date of Inspection: 8/17/2001
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
Page 11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 28 Jerad Place –
North Andover
Owner: – Schermerchorn–
Date of Inspection: 8/17/2001
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water —4— feet
Please indicate (check) all methods used to determine the high ground water elevation:
— X_ Obtained from system design plans on record - If checked, date of design plan reviewed: 7/7/1989
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: –As per design plan. _
Tel: (978) 475-4786
Fax: (978) 475-5451
BATESON ENTE"MSES, INC.
Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service
111 Argilla Road Andover, Mass. 0 1810
Title 5 Inspection Report
Property Address: 28 Jerad Place, North Andover
Owner: Schermerchorn
Date of Inspection: 8/17/2001
My report contained herein does not constitute a guarantee of future usage and the functionality of the existing
septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further
operation of your current septic system.
Neil . Bateson
Bateson Enterprises, Inc.
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