HomeMy WebLinkAboutMiscellaneous - 283 CAMPBELL ROAD 4/30/2018;o
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VQ
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. OthE
RECEIVED
Auc 0 4 2014
FINORTH ANDOVER
HEA TH DEPARTMENT
r forms mav be used, bu7
Information must be substantially thesame 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 31Q CMR 15.351,
A. Facility Information
1. System Location:
283 Campbell Rd
._j�ddres�
No Andover MA
City/Town State Zip Code
2. System Owner:
Tschitahat
Name
Address (if different from location)
City/Town State Zip Cole
Telephone Number
B. Pumping Record
1 - Date of Pumping 2. Quantity Pumped: [�P AO
Date Gallons
3. Type of system: Cesspool(s) U� Septic Tank El Tight Tank [I Grease Trap
El Other (describe):
4. Effluent Tee Filter present? [] Yes [j No
5. Condition of System:
6. System Pumped By:
Name
Stewart's Septic Service
Company
If yes, was it cleaned? E] Yes [I No
Vehicle License Number
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler
Signature of Receiving Facility
Date
Date
t5form4.doc, 03/06 System Pumping Record - Page 1 of I
or
FILE COMMENTS
Name: Dave Hope
Comments:
Date: 121912004
Spoke to Dave Hope on December 9, 2004 requesting a new drawing of the
Septic System relating to the house.
He said he will come down.
Michele E. Grant
12116104
Dave dropped off a drawing, however I'm still not clear on theftont verses the
backofthehouse. I have put another phone call into him.
2. System Owner
Name
Address (it dtfferent hm location)
CltyfTown state Zip Code
Telephone Number
B. P ump Ing Record
I///ho-
1 Date of Pumping Date 2. Quantity Pumped: Gallons
3 Type of -system: 0 CesspoolN )d Septic Tank Tight Tank
Other (describe):
4. Effluent Tee Filter present? C1 Yes C3 No If yes, was it cleaned? [] Yes [] No
5. Condition of System.
6. Syltem Pumped By:
C ry) 14(:�
mp
7. —Locaawhere contents were c
htm#4nspect
Vehicle Uoense Number
Date
t5formCdoop 06M System Pumping Record - Page I of 1
'Ith' Massachusetts
9m., o.nWed
OW n of NORM ANDOVER,
MASSACHU
CEI ED
"System Pumpiq Record..
Fonn 4
DEC 16 2010
DEP has provided this forTn for use by local Boards of Health. The Sys V0 mus
=8d?FA%90VER
be submitted to the local Board of Health or other approving authority. HEALT EPARTMENT
X Facility Information
Importknt
�Wm " out I . System Location,
forms on Uw f rploe,
Computer, use
Only ft W key Address
to move your Pnelo\a-
m
oirsor - do not Cftyffown
state
ZJp Code
use the roWm
2. System Owner
Name
Address (it dtfferent hm location)
CltyfTown state Zip Code
Telephone Number
B. P ump Ing Record
I///ho-
1 Date of Pumping Date 2. Quantity Pumped: Gallons
3 Type of -system: 0 CesspoolN )d Septic Tank Tight Tank
Other (describe):
4. Effluent Tee Filter present? C1 Yes C3 No If yes, was it cleaned? [] Yes [] No
5. Condition of System.
6. Syltem Pumped By:
C ry) 14(:�
mp
7. —Locaawhere contents were c
htm#4nspect
Vehicle Uoense Number
Date
t5formCdoop 06M System Pumping Record - Page I of 1
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Page 10 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 7-03 6 A124 P Mrit, 12 D
)Joarff� A-,,J,)0z'x
Owner. T-(— Tsalllzt-tAez�(
Date of Inspection: :;) , I a%kz7'Zq 15)0,3
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal systm including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells widiin 100 feet. Locate where public water supply enters the building.
1-% / . I A-Oota-
3
NEW ENGLAND ENGINEERING SERVICES
lk INC
rp - 5 2003
March 5, 2003
North Andover Board of Health
Town Hall Amex
27 Charles Street
North Andover, MA 0 1845
RE: TITLE V REPORT: 283 Campbell Road, North Andover, MA
Dear Sirs:
Enclosed is a copy of the Title V report for the above referenced property. The system PASSED
our inspection.
The owner of the home would like to fmish his basement. His house as it exists today has four
bedrooms and a total of eight rooms. The addition of a room in the basement will bring the total
room count to nine rooms, which under Title 5 has a 4 bedroom loading requirement. Since the
house already has 4 bedrooms the proposed new room would not require the enlargement of the
existing system.
If there are any questions please call me at my office, 686-1768.
Sincerely
Benja - C. Osgo,4 Jr.
60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099
COMMONWEALTH OF MASSACHUSETTS
ExECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 293 C-Ami?0CCL Pi.
Qoa-I-H A-IJ90002, /K/1
Owner's Name: -rlm 7-6Cty/P-Hffjtj-
Owner's Address: -,z F3 ?,
1009--nt
Date of Inspection: — -;'I , 1 0
Name of Inspector: (please print) - 6 -e-, m,,, C (D -S cr-t. 0-0 0-a-
CompanyName: NGLk�, EQ&-Ln-*,� Ev&wceti-lev
MaKingAddress: &c2 j�,C-e-cwwc)op--J)pAt)C-
J-�(LTW All"ooea, ,ott
Telephone Number.
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection. 1he 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 CMR 15.000� The system
Conditionally Passes
Needs Furdier Evaluation by the Local Approving Authority
Fails
Inspector's Signature: 0.2 Date: 3j-3LO-3
Z If I �
The system inspector shall submit a copy of this insperction report to the Appr i Authority (Board of Health or
"Ing
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.
Page 2 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: �Z 9 3, 6aojp,5,r-L-L- (Zv
fSO a,-11-1 _AM)V1c,,)U,
Owner: 1-3mc 141 (L
Date of Inspection: 311 IL,3
Inspection Summary: Check ABCD or E / ALWAYS complete all of Section D
A. System Passes:
-,"-I have not found any information which indicates that any of the failure criteria described in 3 10 CMR
15.303 or in 3 10 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the "Conditional Pass" section need to be replaced or
repa The system, upon completion of the replacement or repair, as approved by the Board of Health, will pas
I
Answer yXesor not determined (YNND) in the for the following.statements. If "not det ed7- please
�l 7Ke
explain.
The septic tank itvetal and over 20 years old* or the septic tank �whether me��P-65r- not) is structurally
unsound, exhibits substanti;ajik�filtration or exfiltration or tank failure is imminent. em will pass inspection if the
existing tank is replaced wi a -wnpl en C
ying septic tank as approved by the a Health.
f
4
1! 9 and if a
*A metal septic tank will pass inspe on if it is structurally sound, not and if a Certificate of Compliance
W
indicating that the tank is less than 20 s old is available.
ND explain:
Observation Of Sewage backup or break out or �O static water level in the distribution box due to broken or
obstructed pipe(s) or due to a broken, settled 7��� digtrij7�ion box. System will pass inspection if (with
approval of Board of Health):
bj?!;��,pipe(s) are replaced
obstruction is removed
distribution box is leveled or
ND explain:
The sy4od required pumping more than 4 times a year due to broken or obgtiq4cted pipe(s). The system will
pass inspe5i& if (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: Z63 c-p.,%4prze,.� at,
0. o wn-( &,iPooF(L �
Owner: r-1 M i iz h A rcr
Date of Inspection: aj I I o -t;,
C- Further Evaluation is Required by the Board of Health:
Conditions exist which require finther evaluation by the Board of Health in order to determine if the system
is fail�ng to protect public health, safety or the environment.
1. S��em.will pass unless Board of Health determines in accordance with 310 CMR IS390)(b) that the
syste" not functioning in a manner which will protect public health, safoty and the,4nvironment:
Cessp�or pr!vy is within 50 fed of a surface water
i___l ,
I orTnvy is within 50 feet of a bordering vegetated wetland or a
2. System win fail unless the Boardb�Health (and public
system is functioning in a manner that pv�qtects the public I
— The system has a septic tank and soil A
surface water supply or tributary to a surface
Supplier, if any) determines that the
safety and environment:
(SAS) and the SAS is within 100 feet of a
— The system has a septic tank and SASAdd theS\kS is within a Zone I of a public water supply.
— The system has a septic tank
— The system has a septic
private water supply well!Y
and the SAS 1syvithin 50 feet of a private water supply well.
and SAS and the SAS is less,�an 100 feet but 50 feet or more from a
iod used to determine distance \
"This tem p if the well water analysis, performed at a DEP c��ified laboratory, for coliform
bacterig =aunid v atile (organic compounds indicates that the well is free fir"Alpollution from that facility and
the presen of ammonia nitrogen and nitrate nitrogen is eq
ualtoorless an,,�ppm, provided that no other
lf
failure cr teria are triggered. A copy of the analysis must be attached to this fonn,
3. Other:
Page 4 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: ZOa c-Aw?
IFL.L. JZP.
tj,> glj� A- tj p ou c 4 -
Owner: VIAL L&C HZHj+t2-T
Date of Inspection: - 1 o-,>
D. System Failure Criteria applicable to all systems:
You must indicate 'W or "noP to each of the following for all inspections:
Yes No
v- Backup of sewage into fiLcility or system component due to overloaded or clogged SAS or cesspool
__Z Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
--!!f 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 1/2day flow
-y�. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped
__v/ Any portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
v 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 cotiform. 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.]
NO. (Yes/No) The system fails. I have determined thatone or more of the above fidlure criteria exist as
described in 3 10 CMR 15.303, therefore the system fiLils. The system owner should contact the Board of
Health to determine what will be necessary to correct the fiLijure.
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
You mus-tt%kcate either "yes" or "no?' to each of the following:
(The following a" apply to large systems in addition to the criteria above)
yes no.
the system is within 4" of a surface drhhhil�dng wat ply
c
the system is within 200 feet of a tri a surface drinking water supply
the system is located in a .
Zone 11 of a pub ritrogen sensitive ar�l� Wellhead Protection Area - lVvTA) or a mapped
4c-wlater supply well
If you havS-V8'We-red "Yes" to any question in Section E the system is 'c'63midered a significant threat or answered
"yae' -�n-Section D above the large system has failed. The owner or operator -4 -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: Z83 9-,p
Qoa:� Atopoilit
Owner: 'n AA, 're P T
Date of Inspection:
Check if the following have been done. You must indicate'W or "no" as to each of the following:
Yes No
-I'- — Pumping information was provided by the owner, occupant or Board of Health
— _j!�- Were any of the system components pumped out in the previous two weeks ?
— Has the system received normal flows in the previous two week period ?
v'- Have large volumes of water been introduced to the system recently or as part of this inspection ?
V" Were as built plans of the system obtained and examined? (If they were not available note as N/A)
Was the ficility or dwelling inspected for signs of sewage back up ?
Was the site inspected for signs of break out ?
Z Were all system components, excluding the SAS, located on site ?
Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition
of !J-aiffles 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
�iiinl�ena-nce 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
I -' Existing information. For example, a plan at the Board of Health.
_Z— Determined in the field (if any of the failure criteria related to Part Cis at issue approximation of distance
is unacceptable) [3 10 CMR 15.302(3)(b)]
Page 6 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: Z83 CAM�JFLL JZV
0 ID ft -1 A,.j youOa
Owner: -n AA TS C- 14 1 R k Of Vt1_
Date of Inspection: 31 o �,
FLOW CONDITIONS
RESEDENTIAL
Number of bedrooms (design): Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): —
Number of current residents: 4f
Does residence have a garbage grinder (yes or no): Ye7s
Is laundry on a separate sewage system (yes or no): A10 [if yes separate inspection required]
Laundry system inspected (yes or no): —
Seasonal use: Cyes or no): A10
Water meter readings, if available Oast 2 years usage (gpd)): A/ C/o 6-, -4
Sump pump (yes or no): NO
Last date of occupancy, c,;Iz N -r
COMMERCIAIANDUSTRIAL
Type of establishment:
Design flow (based on 3 10 CMR 15.203):
Basis of design flow (seats/persons/sqftetc.):
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:
L,ast date of occupancy/use:
OTHER (describe):
GENERAL INFORMATION
Pumping Records
Source of information: 0C ea'j to
Was system pumped as part of the inspection (yes or no): _Wa
If yes, volume pumped: ____gallons — How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank, distribution box, soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be
obtained from system owner)
Tighttank Attach a copy of the DEP approval
Other (describe):
Approximate age of all components. date installed (if known) and source of information:
W Q'+45 P '�F� n',,AA02-
Were sewage odors detected when arriving at the site (yes or no): _A[ 0
Page 7 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 283 ea,41paeL4 6ZD
NO(L-11.1 AMPov
Ovvrner: TIAA T5C-*K)(ZR)tzT
Date of Inspection: 3111-3
BUILDING SEWER (locate on site plan)
Depth below grade: 3'
Materials of construction: _Zcast iron 40 PVC —other (explain):
Distance from private water supply well or suction fine: /V_A-
Comments (on condition ofjoints, venting, evidence of leakage, etc
il F E- /-�') 1j, s- 6z) c' '- I jo
SEPTIC TANK: _ (locate on site plan)
Depth below grade: 3
Material of construction: _L/ concrete metal
____9ther(exp,
If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): (attach a copy of
certificate)
Dimensions:
Sludge depth: 5
Distance from top of sludge to bottom of outlet tee or baffle: ;27
Scum thickness- 4 1 "
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: /,-3
How were dimensions determined: zu CAsulze
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
I -&l /� 1,,.j &v'p r> e --e> X, j> J T) o I\j
GREASE TRAP:/V I-
.L(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: 2E33 jZD
Owner:
Date of Inspection:
TIGHT or HOLDING TANK: ALL (tank must be pumped at time of inspectionXIocate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass
Dimensions:
Capacity. ______pllons
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. _ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert
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.):
9 1 J K co N b 15- R 1,P)LI -1-7 o yj E Qo px_. 1yo OF
C A (Z- (2-y ou C- (2- 6-C 66-1,
C 9- fkC 14,[ b, (Z i C 0 M &/V j)- A c cA7r
PUMP CHAMER: N4 (locate on site plan)
Pumps in working order (yes or no):
Alarms in working order (yes or no):
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Page 9 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: Z 83 C-014A4PaELJ- P -r)
No (LTW Alv 0 o,,6-4 A
Owner: -Fj,1A. J3,-j-fjjZj?tf1ZT
Date of Inspection: -3 1 .1 03.
SOIL ABSORMON SYSTEM (SAS): _ (locate on site plan, excavation not required)
If SAS not located explain why:
Type
leaching pits, number:
leaching chambers, number:
leaching galleries, number:
leaching trenches, number, length: Z LEA -el-( -j a.6 AJ COE5 j- OA -,6 -
leaching fields, number, dimensions:
overflow cesspool, number:
innovativetalternative system Typetname of technology:
Comments (note condition of soiL signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
A2 IV 94 AJ Cr 1) A
CESSPOOLS: 104 (cesspool must be pumped as part of mspectionXiocate 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: A!& (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Page 10 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 7-03 e 14M 0 IZD
Owner: T-(— Ts c t-� //Z t4t4lf
Date of Inspection: :;), to -3
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: —'703 "mP5r-t�L- ab
,00ttTR AAJ P co
Owner: S6 (-ele-HAl"T
'5
Date of Inspection: 03
SITE EXAM
Slope
Surfitce water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate (check) all methods used to determine the high ground water elevation:
Obtained from system design plans on record - If checked, date of design plan reviewed:
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health -explain:
Checked with local excavators, installers- (attach documentation)
Accessed USGS databaso-explain:
You most describe how you established the high ground water elevation:
Q,"1 -',C -j5- 44AP5 /.,V P1 C,0 IF WR?y-A >(,-o' -,V .6
FC -5 A-, ME-& 'j,:, -
114 4 " ne m a,4 0 13 08w-
FORM U -LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
*****************************APPLICANT FILLS OUT THIS SECTION*******;;;;;
APPLICANT /"//M -)'-S CH ) k tttkT PHONE LI -T5 5
LOCATION: Assessor's Map Number.
PARCEL
SUBDIVISION LOT (S)
STREET CAMP &eV- t'FST. NUM B ER 28.3
USE
I RECOMMENDATIONS OF TOWN AGENTS:
CONSERVATION ADMINISTRATOR DATE APPROVED
DATE REJECTED
COMMENTS
TOWN PLANNER
COMMENTS
FOOD INSPECTOR -HEALTH
SEPTIC INSPECTOR -HEALTH
M "q
CO
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE- REJECTED—
J D &,z I–
PUBLIC WORKS - SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECT
Revised 9\97 jm
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to
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lk
NEW ENGLAND ENGINEERING SERVICES
INC
H AN 0%
6 T
H,::/'.
Vi
April 15, 2003
North Andover Board of Health
Town Hall Amex
27 Charles Street
North Andover, MA 0 1845
RE: TITLE V REPORT: 283 Campbell Road, North Andover, MA
Dear Sirs:
Enclosed is a copy of the Revised Title V report for the above referenced property. The system
PASSED our inspection. As part o the revised inspection the D -Box cover was replAced and the
If there are any questions please call me at my office, 686-1768.
Sincerely
b,.-, 6 0. ijr.
Benjamin C. Os
60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099
COMMONWEALTH OF MASSACHUSETTS -
ExEcuTivE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
0�
Rev'& jD 0
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
PropertyAddress: Z6-3 JZ-*")
a-ri-f h10 DnoC- e- -41t Iq
Owner's Name: '-ri c i1i
,Owner's Address: zq�� C-fqv�pf�Fa, 0-9
VoaxW
Date of kspection: c -z
41 t;d -o 3
Name of Inspector: (please print) Ben -i amin C. Osgood, � Jr.
CompanyName:New England Engineering Services Inc.
MailingAddress:60 Beechwood Drive,
ljorth Andover. MA 01845
Telephone Number:. 978-686-1768
CERTIFICATION STATEMENT
I cer* 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 CMR 15.000� 1he system:
'Apasses
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: (- I) , -� Date:
Ille system inspector shall submit a copy of this ir�ipectiion 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 fiLspector and the system owner shall submit the report to die appropriate regional office of the
DEP. The original should be sent to die system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments
T) - Cx�CJQ _D, 6-0-# fi&C_ '0 IS pp_5
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Page 2 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
PropertyAddress: 6artpj5,r-,L, (4v
Date of Inspection:
c, 7, 4' q /0 -4
Inspection Summarr. Chock A;BCD or E complete all of Section D
A. System Passes:
I have. not fou nd a ny information wh ich indicates that any o f the fit ilu r e criteria described in 3 10 CM R
15.303 or in 3 10 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One Or more system components as described in the "Conditional Passr section need to be replaced or
i The system, upon completion of the replacement or repair, as approved by the Board of Healdi, will
11
""h� -
,,Ainswer m or not determined (YNND) in the for the following statements. If "not dder�ecr please
explain.
The septic tank kvk". and over 20 years old* or the septic tank (whether In not) is structurally
-bits subs tiaiiq�ltration or exfiltration or tank failure is imminent. em will pass inspection if the
unsouad, exhi
,existing tank is replaced with a 00%plying septic tank as approved by the Boarof Health.
*A metal septic tank will paw ins�on if it is structurally sound, not and if a Certificate of Compliance
indicating " the tank is less ffian 20 Y�w old is available.
ND explain
Observation of sewage backup or A out or static water level in the distribution box due to broken or
obstructed pipe(s) or due to a broken, setilted or bwL System will pass inspection if (with
approval of Board of Health):
s) are replaced
zope�
AN&Uction is removed
Ir
in
e7
v
la
' b
ID *c
ed ' box"
;ys� th
n
en ibution
ep
distribution box is leveled or repl%ai
ND ex:plain:
The
_ ;�'. r es Year u. to ..Or
if required pumping more &an 4 times a year due to broken or cted pipe(s).'Ihe system will
(, �� f
"0=pass if (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: Z 8.� C-AA1VP&E&4- al,
Owner: Vi A rC —t
Date of Ins
C- Further Evaluation is Required by the Board of Health:
Conditions o"which require finher evaluation by the Bmd of Health in order to determine if the system
to protec
is to Protect public heald4 safety or the environment.
e wiR pass unless Board of Health determines in accordance with 310 CbM 15-M3(40) that the
m:m
syste ' not functioning in a manner which win protect public health, safety and thonvironnient-
%syste I
— C;esspoNor privy is within 50 fed of a surface water
— cesspool is Within 50 feet of a bordering vegetated wetland or a arsh
i v'&* '0 f et
e of a b, e w, /tlmd
or I ar'
H lh
�W
2. System Will fau:dlnnlm the Board Realth(andftblic Supprier,,iff &Zny) determines that the
:ss P
\r
tects n
system is functioning in a ma=nner thaot the public th, safety and environment:
— The system has a septic tank and soil em (SAS) and the SAS is wid-in 100 *feet of a
.surface water supply or tributary to a surace Ply.
The system has a septic tank and SAS the is within a Zone I of a public water supply.
1he system has a septic tank AS and 1he SAS widiin 50 feet of a private water supply well.
ic
1he systeni has a septic and SAS and the SAS is 1 100 feet but 50 feet or more from a
Private water Supply We Method used to determine distance
Z"This system if the Well water analysis, Performed at a DEP ified laboratory, for coliforka
=an v e organic compounds indicates that the well is free pollution from 1hat facility and
the presen of ammonia ndrogen and nitrate nitrogen is equal to or less ppm, provided that no other
failure
Wxre are triggered. A copy of the analysis must be attached to fl -As
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: zo?, c-Aw6lFt-L- 0.
ftT
6
Owner: VIA& r&Cq1fzH1Va-T
Date of inspection:
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or "noP to each of the following for jH_inspections:
Ye4 No
-.%/- Badcup of sewage into fiLdlity or system component due to overloaded or clogged SAS or cesspool
--Z Discharge or ponding of effluent to the =&ce of the ground or =-face 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
-Y!� Liquid depth in cesspool is less than 6" below invert or available volume is less than % day flow
Required Pumping more than 4 times in the last year MOT due to clogged or obstructed pipe(s). Number
of times pumped
Any portion of the SAS, cesspool or privy is below high ground water elevation.
Any Portion Of cesspool of privy is within 100 feet of a nafice water supply or tributary to a surface
water supply.
_zL Any Portion of a cesspool or privy is within 4 Zone I of a public welL
-!:�- Any portion of a cm5P001 or privy is within 50 feet of a private water supply welL
v Any Portion Of a cesspool Or Privy is less than 100 fed but greater than 50 fed from a private water
supply well with no acceptable water quality analysis. Mils system passes if the well water analysis,
Performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the weH is free fi-om 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 fallum criteria
are triwred. A copy of the analysis must be jttached to this fornq
-NQ (YMNO) Ile system f& I have determined that one or more of the above fitilure criteria exist as
described in 3 10 CMR 15.303, therefore the system Ms. The system. owner should contact the Board of
Health to determine what will be necessary to correct the failure.
K Large Systems:
To be considered a 11arge system the system must serve a facility with a design flow of 10,000 gpd to 15,000
ff d.
ou
ou M
cate either'W or "noP to each of the following:
�ga� eithe
I
(The following - ia apply to large systems in addition to the criteria above)
yes no
the system is within 4 dr
00 of a surface drinUng wat ply
et of tri ce
the sYstem is within 200 feet of a * a surface -&Inking water supply
the system is I ted ,en sensitive ar�l� Wellhead Protection Area - IWPA) or a mapped
a
a
y v
Zone Il of a puolcc�=ate�r A�su42i-, well
p
If you havS-Www6red "Yee to any question in Section E the system is�:o �deared a significant threat or answered
'W-kSection D above the large system has failed. The owner or operator o large system considered a
r 0
significant threat under Section E or failed under Section D shafl 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: P-83 c-A,,jpgqj_ 99
Wt:rR
Ovmer.
Date of 4
Check if the Lolloyting have been done You must indicate W or "nor as to each of the following
Yes No
.,I- — Pumping information was provided by the owner, 0=4XIntor Board of Health
Were any of the system components pumped out in the previous two weeks?
Has the system received normal flows in the previous two week period ?
Have large volumes of water been introduced to the system recently or as part of this inspection ?
Were as buth plans of the system obtained and examined? (If they were not available. note as N/A)
—v**'- _ Was he 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 ?
— Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition
of the baffles or tees, material of construcdon, dimensions, depth of liVK depth of sludge and depth of scum ?
Was the facdO owner (and occupants if different from owner) provided with Information on the proper
maintenance of subsur&ce sewage disposal systems ?
The size and location of the Soil Absorption System (SAS) on the site has been ddermined based on:
Yes no
I -Z Existing information. For example, aplan attheBoard of Health.
Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [3 10 CMR 15.302(3)(b)]
Page 6 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 7, 8-11 C -A -1715f LL AP
14 0 RR4 Atj rouC
Owner: -nAA 754W I R R 1+4-T
Date of Inspection: -
RESWENTIAL 'FLOWCONDMONS
Number of bedrooms (design): Y Number of bedrooms (acW*.
DESIGN flow based on 310 CMk 15203 (for example: 110 gpd x #of bedrooms):
Number of current residents: Lf
Does residence have a garbage grind (yesorno):` __ /VO — PCM&().C--o 19-5
Is laundry on a separate sewage system (yes or no):' MQ [if yes separate inspection required]
LaurAy system ins� (yes or no):
Seasonal use: (ves or no): AtO
Water meter readings, if available Oast.2 years usage (gpd)): I/ C/O 6 --
sump pump (yes or no): No ��Te m
1,ast date of occupancy-
COMMERCULIINDUSTRUL
Type of establishment:
Design flow (based on 3 10 CMR. 15103� gpd
Basis of design flow (seats/persons/sq%etc.)-
Grease trap present Cm or no): _
Industrial waste holding tank present Cyw or no):
Non-sanhary waste discharged to the Title 5 system (yes or no):
Water meter reading&, if available:
Last date of occupancy/use:
OTHER (descrjbe):
PumpingRecords GENERAL RO)ORMATION
Source of information: oc—, P, Zoo, ?6� a.,JtjCP-
Was system pumped as part of the inspection (je--s or ii�): __Wo
If yes, volume pumped: How was quantity pumped detertnined?
Reason for pumping:
TYPE OF SYSTEM
-�6 Septic tank, distnibution. box, sod absorption system
— Single cesspool
Ov�rflow cesspool
— Privy
SWed system (yes or no) (if yes, attach previous inspection records, if any)
111110vatIVO(Alterliative technology Attach a copy of the current operation and maintenance contract (to be
obtained from system owner)
Tight tank Attach a copy of the DEP approval
— Other (describe):
Approximate age of all components, liate installed (if known) and source of information:
Were sewage odors detected when arriving at the site (yes or no): -ht 0
Page 7 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (conti=4
.]Property Address. 283 ecL,,1ppeL,,- gv
NO 91W A" vov e4 -
Owner: T(AA T-5Cq)tz"fz—,
Date of Inspection: Z
BUILDING SEWER (locate on site plan)
Depth below grade. 3
Miterlals of construction: Zc-ast tron 40 PVC __Aer (explain):
Distance fi-om private water supply well or mchon line: /VA -
Comments (on cmdition. of joints, venting, evidence of I-eakage. etc.)-
SEMC TANIL- _ (locate on she plan)
Depth below grade: 3
Matcrial of construction: Zconcrete metal fiberglass ..polyethylcae
Iftank is metal list age-. _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of
certificate)
Dimensions: _ 250- - &-ALWAI-S
Sludge depth: Sid
Distance from top of sludge to bottom of outlet tee or baffle: —n
Scum thickness, 4 1 "
Distance from top of scum to top of outlet tee or baffle: A"
'Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined. ^ rtsvp-e
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet inver� evidence of leakage, etc.):
I 4J K 1A) &t�p D A, i> -n o ,j -
GREASF TRAP:N &-oocate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass
(explain): --__polyeffiylene
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 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (confinued)
Prop"Address: Z03 ea,"?gE,,L_ OD
0 �� 9M-1 AALQ_Cj a
Owner: -rk/6.- 1_5cH[0Lj&+d:;_
Date of Inspection:
11GHT Or HOLDING TANK., &L (tank must be pumped at time of inspection)(locate, on site plan)
Depth below grade:
MaterW of construction: concrete metal ---fiberglass ----polyethylene ___o&er(exp1aia):
Dimensions:
Capacity: —lions
Design Flow-.
Alarm present (yes or no):
Alarm level: - . - - Alarm in working order Cyes or no):
We of last pumping: —
Comments (condition of alarm and float switches, etc):
DMMUTION BOX: (if present must be openWIocate on site pbn)
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.):
-f;ox i C', ri r:. (-E OF
oi-tr> S G I AJ C) R
covE R C 9- Nc KE b, FRIZI- 0/=
PUMP CHAMBM- NA (locate on site plan)
Pumps in working order (yres or no):
Alarms in working order (yes or no):
Comments (10te condition Of Pump chamber, condition of pumps and apprtenances, CW.):
Page 9 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: Z83 C-t4MPaEu- Vu)
-NOOW
Owner. T-tAk 1-S 1-*A-1?t1Ft4
Date of Inspection: , �L
—.31 "10 -a A . / 11to
SOIL ABSORPTION SYSTIX (SAS): — (locate on site plan, excavation not required)
If SAS not located explain why -
Type
leaching pits, number:
leaching chambers, number:
leaching galleries, number.
leaching tretiches, number, lenA: Z Ta&AJC(.(i3 XID' J-0 A.1
leaching fields, number, dimensions:
Ovallow cesspool,. number:
innovative/alternative system Type/name of technoloU.
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, conditionof vegetation,
etc.):
-A A; 6- C) I C-
CESSPOOIS: de�j (cesspool must be pumped as part of inspectionXiocate on she 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: &
d- (locate on site plan)
Materials of constiuction:
Dimensions:
Depth of solids:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Page 10 of I I
OFFICIAL INSPECTION FORM 'NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 7-03 R -D
"0944 A-AiDo.�—ox
Owner: 7—(AA� Ts C t-1 /A 1.4447
Date of Inspection: A), 14 15)o,3
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
beachmarks. 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: e—jqmp5rtt_ Qb
Owner.
Date of Inspection:
SrIE EXAM
Slope
SurfiLcewater
Check cellar
Shallow wells .1
Estimated depth to ground water 0 feet
Please indicate (check) all methods used to determine the high ground water elevation:
Obtained from system design plans on record - If checked, date of design plan reviewed:
Observed site (abutting property/obs�on hole within ISO fed of SAS)
Checked with local Board of Health-explam:
Checked with local excavators, mstaflers- (attach documentafton)
Accessed USGS database -explain:
You must describe how you established the high grotind water elevation:
U!;& 5 C - j! r, 440f!5 ._,. W > &.0, -A
pe -5
�1 A
Ii—y s 7Y
Town of North Andover
Office of the Health Department
Community Development and Services Division
William J. Scott, Division Director
27 Charles Street
North Andover, Massachusetts 01845
Sandra Starr
Health Director
North Andover, MA 01845
Re: Application for
Telephone (978) 688-9540
Fax (978) 688-9542
Dear: 7_5GI711,6�q i�F
.10cat has b6en reviewed by the Health Department. The
Your application for r e ri5) �)a � �JqR
application was denied on qIA6 , 20Q% for the following reasons:
I - Fr"" Missing information
2. 0 Passing Title 5 inspection of septic system required
3. 0 Location of structure not acceptable
To address the problem(s):
If# I is checked, please supply:
Floor plan of existing and proposed addition
b. Certified plot plan showing house, septic system and proposed project in scale
If #2 is checked:
a. Have the septic system inspected by a certified Title 5 inspector to determine the size of the system
and whether it is operating properly: OR
b. Tie-in to municipal sewer
If #3 is checked:
a. Relocate the project
Please feel free to call the Health Office at 978-688-9540 with any questions you may have.
Sincerely,
"40
Revi—e,�er
Cc: Building Department
File
BOARD OFAPPEALS 688-9541 BUILDFINIG 688-9545 CONSERVATION 688-9530 NTURSE 688-9543 PLANTINMO 688-9535
PHONE: 978-688-9540
FAX: 978-688-9542
Lit";
-M
TO, From:
Fam
Pages:
Phorm Date:
Re.- CC:
Urgent 0,#or Review 0 Please Comment 0 Please Reply 0 Please Recycle
Comments:
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
27 CHARLES STREET .
NORTH ANDOVER, MASSACHUSETTS 01845
Sandra Starr
Public Health Director
Tim Tschirhart
283 Campbell Road
North Andover, MA 0 1845
Re: Title 5 inspection of Septic System
Dear Mr. Tschirhart:
Telephone (978) 688-9540
FAX (978) 688-9542
The North Andover Health Department has received and reviewed the inspection report that
resulted from the inspection of your septic system on March 1, 2003. The DEP-approved system
inspector has determined that your system was not deemed to be "...failing to protect or
threatening public health and safety or the environment..." as defined in Title 5 of the State
Sanitary Code. However, after review of the inspection report, the Health Department has
determined that prior to the issuance of an occupancy permit for your proposed basement
remodeling project you must:
X Retain the services of a licensed plumber to obtain a plumbing perinit t
X remove your garbage disposal; 9� /o e (tlo ) ou
re-route your laundry drain pipe to yo septic syst�l .
Retain the services of a North Andover licensed septic system installer to obtain a
disposal works construction permit and:
repair or replace your cracked septic tank;
replace the defective cover on the distribution box; QoNe- qi�03
repair or replace damaged piping;
and have the work inspected and approved by the Health Department.
Please have all work performed within 90 days of receipt of this notice. Should you have any
questions, please call the office at 978-688-9540.
Sincerely,
Sandra Starr, R.S., C.H.O.
Health Director
Cc: File
Bldg. Dept.
H& ---
CONSTRUCTION
*-Restoration
Additions
Renovations
Kitchens
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48003
03/20/2003 13:08 FAX 978 952 2001
VISTA CONTROLS MA
@001
To: Pain @ the Board of Health Fax: 978-688-9542
From: Timothy J. Tschirhart Date: 3/20003
Re: Building Permit/Title 5 Pages: 13
CC:
12 Ument D For RWeW 0 Please Comment El plew Reply 0 Please RecyrJe
Z
P W
of the Title 5 hispection compleled, on our property at 283 C=4&U Rd. in North
—16 " 2003. 1 was concemed did you did not have a copy despite Ben Osgood telling
dropped off the. docunient with the Bowd of Health.
it� Ms. Sandra Stan. has requested me tc) submit to the Board of Health a floor plan of
provide her with mformation to suppoft our peand application to iniprove, an existing
uld
our basement You spoke to iny contactor and me inforining us did my contract0i co
directly provide that infixmation in his own drawing. The infonnation in this drawing is fully
supported by the Town ofNorth Andovees current propedy tax records - in addition, you informed
both my contrwtor and me dig no additional information was request%L
Please make it known dot the sole purpose of this irnprovwient is to provide an open space for MY
children to play and store their toYs.
Please contact me directly ifthere are new requireirtents that the Town and the Board of Health need
me to address.
Sin=ely,
n y J. Tsct
n j. Tschirhart
978-975-7785 (Home)
978-952-2031 (Work)
978-314-9985 (Cell)
03/20/2003 13:08 FAX 978 952 2001 VISTA CONTROLS MA 10002
NEW ENGLAND ENGINEERING SERVICES
INC
March 3, 2003
Tim Tschirbart
283 Campbell Road
North Andover, MA 0 1845
-RE: Title 5 inspection
283 Campbell Road, North Andover
Enclosed is a copy of the Title 5 Report for the above referenced property. The system PASSED
our inspection.
As per the requkements of my license a copy of this Mort has been sent to the Board of Heal&
If them are any questions do not hesitate to call.
Sinm*,
Benjamin C. OsSoD L, Certified title 5 inspector
60 SEECKWOOD DRIVE - NORTH ANDOVER, MA 0`1645 - (978) GWI768 - (88B) 359-7646 - FAX (978) 685-1099
03/20/2003 13:08 FAX 978 952 2001 VISTA CONTROLS MA 10003
COMMONWEALTH OF MASSACHUSEWS
ExEcuTriE OFFICE OF ENVIRONMENTAL AFFAiRs
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
'OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
PropertyAddrem: ZL?3 CAAA P 8,6iL 9,10
voani hAivoociz �qll
Ownees Name: TIAA T!5r-iY1j2H#W1-
OWneesAddrem Zaa gj>
- WOUK
Date of Inspection: -;I -I a
KUM of hqwdor* (Please print) &-' -1-04A4%W C 0-5CM410 ap--
CompanyNawn- NIEw JF0&Liit,2 E&&Wc-cxtv&
b�2ETW AAj �, outM, ^Att
Telepbone No '77Q -696-/764a
CERTIFICATION STATEMENT
I Oct* dud I have personally inspected the sawage, disposal system a this aftess and that the information reported
below is hue, accurate and complete as of1he time of dw inspection. Ue kispugm was peformed based an my
training and experience in the proper fimetion and maintenance of on site wwage, disposal systems. I am a DEP
approved system inVector purvant to Section 15340 of 116c 5 (310 CMR 15.000� 1he system:
Conditiotially Pam
Needs Further Evaluafim by the Local Approving Authority
Fails
Inspector's Signature: _L2
Date: 4"o
Ike system inspector shall submit a copy of this mspeition report to the Appmvmg Amftrity (Dowd of Heatth or
DEP) within 30 days of cempleting ibis irispection. if the system is a shared system or has a design flow of 10,000
gpd or greater, the irmq3ector and the system owner shall stAxnit 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
au&orily.
Notes and Comments
****nb report only describ" conotim at the time of inspection and under fte emotions of use at that
time. This inspection does " "dress bow the qskm wiff perform in the fiature under the saim or dillerent
conditions of us&
03/20/2003 13:09 FAX 978 952 2001 VISTA CONTROLS MA IA004
Page 2 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Addre= 2 8 -�; ea M p, Oc- L� - Rv
"0 jM4 AY2CjU_ -144'
Owur. 1-1 M r-4"- k I 1z W Orr ar
Date of Inspection: 311103
Inspection Summary: Check AACD or E / ALWAYS complete all of Section D
A. System Passes:
-,0"Ih2VV not lbundiny infimnation vAhich indicates the any of the failure criteria descrilW in 310 CMR
15.103 or in 3 10 CMR 15.304 exisL Any fikilure criteria not evaluated are indicated below.
Comments:
IL System Cosiditiomlly Passm.
One or more ristem, components as described in die"Conditional Passr section need to be replaced or
The system, qpKe completion of the rephcement or repair, as approved by the Board of Health, will Pa. S
"epai* " systm
Ans7wer yMes, or nd determined (YNND) in the for the following statements. If -not please
Plea!
Mlain. -- �r�
—1heseptictrAkik, and over 20 years o1d* or die septic tank (whedw meho not) is structurally
unound, cAiNts subs— tration or offiltration or tmk failme is immineaLSIstem will pass inspection if 1he
ecisting tank is replaced with a lying septic tsnl� as aWoved by the Boar#4 HeaftL
Ma
*AmeWqqpfictmkvnHp&ssi if it is structurally soundL and if a Certificate of Compliance
indicating 11W the tank is less d= �5 old is available,
ND explain:
Observation of sewage backup or kuk out or static water level in the distribution box due to broken or
obstracted pipe(s) or due to a broken, or bmL System vA pass inspection if (with
approval of Board of HcaM�
pipe(s) am replaced
on is removed
-distritiution box is leveled or
ND explain:
The 'ed dom 4 himes a year due to broken or
raw, PIR11109 Man
aSs if fwith approvalof the Board of Heaft
—ir
broken pipe(s) we replaced
obstrucfim is removed
ND explain:
pipe(s)- 7110 "oem will -
03/20/2003 13:09 FAX 978 952 2001 VISTA CONTROLS VA Q005
Page3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 963 eaAAESE&4- a_
0.oaTw &-proUL
Owner. nm TCejjUzjiA1rr
Date of Inspection:
C- Further Evaluation is Requind by the Board of Health:
Conditions wdst which requim hudw evaluafian. by the Board of Health in order to deterinifte if the system
ishikng to pvtod public heallti, safi* or the envionment
1. Skspem wfll pm unless Board of Redth, determines in accordance with 310 CMR 1&390)(b) that the
systv-&* not functioning in a manner whkh wffl protect public beal* safely and thonvuvasseut:
Cesspo 50 feet of a mrfitce water
Xor privy is within
Cesspool is within 50 fict of a bordering vegetated wedand or a
t welland or
W
2. System wM fail unless the Board Realth(andPa0fte SuppNer, If say) deterodues that the
en=system is fawdosing in a manner that the public safty and envirownent:
— The syshm has a septic tank and soil (SAS) and the SAS is within 100 fed of a
surfitm water supply or tralutary to a strfitce ly.
— no system has a septic tank and SAS the is willik a Zone I of a public wata supply-
- 1he system has a septic tank AS and the SAS within 50 fed of a private water supply well.
a
ha
s
s
a
a
c
tan�
tan�
and SA
A
S
S an
d
d
is
SAS
11c system has a septic and SAS and the SAS'is less 100 fed but 50 fed or more from a
n
o u
d W �d
ffiel labc
sy !a Z
private water supply well . Method used to determine distance
* water 1po
"This system if the well waW analy* performed at a DEP ffied laboratory, for oolfttp
is system die
e - a
bactworima and organic compounds indicates that the well is fi= pollution kom. *d &wq and
coni
a In less pr
-tr n1
the of ammonia nitrogen and nitaft nitrog is equal to or less ppm, pmvided that no othcr
t e wu� to a
tri = �
failure Xre triggered. A copy of the analysis nim be affached to this
3. Other
03/20/2003 13:09 FAX 978 952 2001 VISTA CONTROLS MA Q006
Page 4 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTMCATION (continued)
Property Addresr. Z8z cA&6,c" 0.
Owner. T-IdA, rr� C - vt i rZ if *11-T
Date of bspectim Si k I D;t
D. System Failure Criteria applicable to all systems: -
You must indicate "yes7 or "ad'to each of the following for IU inspections:
Yes No
_V' Badwp of sewage, into bcinW or system component due to overlmled or clogged SM or cesspool
-z Diadharp or ponding of effluent to the surfim of the Smund or surface vraters due to an overloadect or
-clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
�V Liquid depth in cesspool is less than 6" below invert or available volume is less thari Y2 day flow
_je Required pumping more don 4 times in The LW year WXdue, to clogged or obstructed pipe(s). Number
of times pumped
_j/ Any portion of the SAS, cesspool or privy is below high ground water dmb*L
__K Any portion of cesspool or privy is within 100 feet of a surface water supply or trilbutary 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 priyaw water suppliwell.
v Any portion ofa cesspool or privy is Iess, than 100 fed but greaw than 50 fixkfrom a private wate:
supply well with no acceptable water quality analysis. Fna system passes U the well water assiysis,
performed at a DEP cerdfied laboratory, for colfform bacteria and volatile organic compounds
indicates dkat the well is free from pollution from that facility and the prmace of ammonla
nitrogen and nitrate Mtrogen is equal to or less than 5 ppon, provided that ae other fallure Criteria
are triggered. A Copy ofthe analysis must be attached to dds; form.)
(Yes/No) 11e system && I have, dommined that one or mom of the above failure criteria exW as
described in 310 CMR 15", therefore the system ffils. The system owner should contact theBoard of
Health to determiat who will be necessary to cmTect the failure.
F- lArge System:
TO be Considered a large qs(em the system mut serve a facility with a design ftow of 10,WO gpd to 15.M
You mudlakptc efter'W or "noP to each of the following:
(111C f1o110WiVg-diWU_ apply to large systems m addition to the crite& above)
yes no
the system is withilk ofa surfice driWking
drdkin wal
a wfitce drmkmg water supply
the.system, is withmin t2OO. fed of a
dic system is located in 0*
4XWO-sm. sensitive a crim Wellhead Protection Area - IWPA) or a mapped'
r4 tw
Zone Il :of a �pubi well
er supply.
Ifym hanpm*ed 'W to any question in Section E the system is 'dered a sigaificant threat, cc answered
em
'W-irSection D above the large system has Wed. The =ovmrr or y large systan considered a
significant threat under Section E or fitiled under Section D shall the system in accordance with 3 10 CMR
15.304. 1he system owner should contact the appropriate regional office of the Departmcnt.
03/20/2003 13:09 FAX 978 952 2001 VISTA CONTROLS MA
Page 5 of 11
[A 007
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
PropertyAddress: Z" cftme&R4�
oofia
Owner: BOA 'MCUIRDW-6
Date of Inspection: — -jj i I o,,, -
Check if the following have bow done You must indicate W or "no?* as to each of the fblkm&g: - -
Yes No
Pumping information was provided by the owner, oomVant, or Board of HW&
Were any of the system components pumped out in te previous two weelm
Z�— Has &c system received normal flows in the previous two we& period ?
-'*- Have large volumes of water been introduced to the system recetitly or as part of ft mspafion 7
o/ Were as built plans of the system obtained and examined? (If they were not available note as N/A)
Was the ficility or dwelling itispected 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 7
_k�— _ Were die septic tank manholes mcovered, opened, and the interior of The tank inspected for the condkion
of the baffles or tfts� material ofecinstruction, dimensions, depth of fiquid, depth of sludge and depth of scum ?
to" Was the fiwi* owner (and occupants if different from owner) provided with mformation on the, proper
;i�G�mce of subsurfitce sewage dislwsal *Uems ?
The alze md location of the Soil Absorption Sy3tem (SAS) an the site has been determined based om
Yes no
- -,' Existing information. For example, a plan at 1he Board of Health.
-Z_ Determined in the fiM(if any of the failure criteria related to Part Cis at issue vroximation of distance
is macceptable) [3 10 CMR 15-IW)(b))
03/20/2003 13:10 FAX 978 952 2001 VISTA CONTROLS MA 10008
Page 6 of 11
OFFICIAL INSPEC71ON FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
PrWrly Address: Z al C. A -715f Ll� A17
b?0&j A1j_Dou0P- - - -
Owner. 'rIA4 :�kcwlj3tedA-T
I)ate of inspecdon: 0 3,
F1OW CONDITIONS
REMENTUL
Number of bedrooms (design): Number of bedrooms (actual)
DESIGN flow based on 310 CMR 15203 (for example: 110 gpdx# of bedrooms):
Number of currient residents: ki
Does residence, have a garbage grinder -(yes ornd):,yr5 —
Is laundry on a separate sewage system (yes or no),.,8LO rifyes separate inwWon required]
L=ndry sy*cm inspcded (yes or no): —
Seasonal use. (yes or no): "0
Water meter readbigs, if available (last 2 years usage (gpd)). '/�10
sump pump (yes at no): A-10
Lad date of owq=W. _L_?�T-
COMMERCUL/INDUSTRUL
Type of establishment:
Design flow (based on 3 10 CMR 15203� gpd
Basis of design Raw (seaWpers"sq%etc;,):
Grew trap, Vesent (yes or no): _
Industriall waste hdding tank prment Ly= Or D*�
Non -sanitary waste discharged tolhe litle 5 syst= (yes or no):
Water meter readings, if available:
Last " of occupancyAnc.-
tnwk (descnU):
0 GENERAL 11NFORMATION
P=pIng Rem*
Sourceofinibrmatim on: 3, Z001 ?itz tWAAre-
Was system pumpW as part ofithe inspection (yes or no): _No
If yes, volume pumped- ___pllons — How was qmdty pumpeid datermined7
Reason, for pumping:
TYPE OF SYSTEM
Septic ta* distribution box, sod absorption
singe owpod
overflow cesspool
privy
Sharvd system (yes or no) (if yes, aduh prMous inspeiefion records� if any)
Innovative/Afternative technology. Atta& a copy of the cmTent operation and maintenance contract (to be
;i;6� fimm system owner)
Ili& tank _ Attach a copy of the DEP approval
Other (describe):
Approximate age of all cornponents. elate installed (if known) and source of information:
I CA45 pEA
Wem snmge odors detected when arriving at the site (yes or n0. go
03/20/2003 13:10 FAX 978 952 2001 VISTA CONTROLS MA 10009
Page 7 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSU"ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (contirmed)
Property Address: Z,83 ofearmF&C-4- 9-10
Wcalk
Owner:
Date of Inspection-
BUnDING SLVER 60cate on she plan)
als of condmcdoo; ad iron '40 PVC __Aar (explain):
Distance fi-om-privatewater sifflywell or suctionline /VA- -
Comm" (an omdition ofjoints, venting, evidence of leakage, etcl
A A � , r.
SEMC TANK: — (locate on site plan)
Depth below grade: 3 -,
Ma*W of c�nstruciicoZconcrete mew _fiberglass --polYfedeene
Ntank is metal Ud Mr. Is ap confirmed by a Cmfificate of Compliance (yes or no): (aftch a COPY Of
certificate)
Dimensions: )5
9-
Shxlgedepdi:
Distance ftlil top OfSludge to bottom of outlet tee or baffle: 27"
scum tidmc= x I
Distance fivm top of scum to top of outlet toe or beftle: a
Distance from bottom of man to bottom of outlet tee or baffle: -L&:L
How weredimensionsdetarinined- ^Fhjva�e sne-14.
Comments (an pumping recommendations, inlet and outlet tee or baffle coridifton, structural integrity, liquid levels
as relaW to outlet invert, evidence of leak&M etc.):
A 1/v cm�! D ra u P -n o mi
GREASY, TRAP. -N
Bocate on site PUB)
Depth below grade -
Material of construction: concrete Metal __fiberglass
_jvbethylene —other
Dimensions:
SCUM thickness.
Distance fim top of scum to top of outlet tee or baffle: A
Distance fiom, bottom of scum to botto.m of outlet tee or baffle:
Date of last pumping..
comments (on pivnpm*g voommcndzflons� inlet and oudet tee or baffle conditica, suuctural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
03/20/2003 13:10 FAX 978 952 2001 VISTA CONTROLS NA 10010
Page 8 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
. PART C
SYSTEM INFORMATION (continued)
PropertyAddrm: 2$3 C001JO&L AD
0-1-1 f- P 0,; f
,A
Owmr; -r%A-- zmclaI4
Date of ELqwfiou: _31jQ)_
17GHT or HOLDING TANK.- &L (tank must be pumped at tune of inspectio0XIocate an 9" Plam)
Depth below grade:
Material of Construction: concrete meW —fiberglass _.__polyvthylene__o&er(exPWn):
Dimensions:
Capacitr- gallons
Desip Flow. __gelloWday
Alarm present (yes or no):
Alum level: Alum in wo*kg order (yes or no):
Date of last pumping:.
Comments (condition of abrut and float switches, etc.):
DWRIBUTION BOM _ (if present must be openeMocate on site plan)
Dep& of liquid level above outlet invert 0
Comments (note if box is level and dbb*Won to outlets equal, any evidenot of solids carryover, anY evidence Of
leakage into or out of W4 etc.):
&2S i tJ. e> Y, to N m. N10A. b I Sri R &U T7 o Aj EQaflL__ _J20 LLPE"e-E OF
$0 L -k 0 c A 99-YooG P_ ok t_EPKh&E tAj oA
ro.jE 0, a AC ME b. Ricom&vb x e qi_ A c I -K c^j-�
MWCHAXXM-A/4 (locateonshephn.)
Pumps in working order Cm or no):
Alarms in working order (yes or no):
Comments (note condition ofpump, 6amber. condition of pumps and ppurtenancm em):
03/20/2003 13:10 FAX 978 952 2001 VISTA CONTROLS NA [A011
Page 9 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
PropertyAddrew. Z83 CAMPM"- aO
IVoaTW Alvgo�,CA
Owner. -rf.,,4 -13 (-&AWAT
Date of Inspection: -3 J./o � —
SOIL ABSORMON SYSITM (SA�: _ (locate on site plan, excavation not required)
if SAS not located explain Y*3r
am
leadft pits, amber: _
leaching chambers, number:
leaching galleriM number
leaching trenchM umber, hngth: Z Le!!��T�,Ucgj> 6-
104ft fields� number, dimensions:
overflow cesspool, number:
innovativefaltanative system Typethame of tecimloff-
Comments (note condition of soil, signs ofhydraulic fidure, level of ponding, damp soil, condition of vegetation,
etc.):
CFM4)OLS.-.&d (cesspool must be pumped as part of inspectionXIocate on site plan)
Number and oonfiguration:
Depth - top offiquid to inlet invat:
Depth of solids lqw:
Depth of scm lryw.
Dimensions ofeesspool:
Materials of construction:
Indication. of groundwater inflow (yes or no):
Comments (note condition of soil, sips of hydraulic failure, level of ponding, condition of vegetation, etc.�
PRIVY: AY -L Pocate on site Plan)
Materials of consftuctiow.
Dimensions:
D*h of solids:
.Comments (n6te oondition of s4 signs of hydraulic failure, level of ponding, condition of vagetationetc):
03/20/2003 13:10 FAX 978 952 2001 VISTA CONTROLS MA
Page 10 of I I
(0012
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continu4
Property Address: Z k 3 eAmil &&:L- p -D
pj 0 IMH - A.AJ 1) a -, ;�'L
Owner. 7-1 nCm'1Aj-t.4oC,-
Doti of Inspection: AI. iv 3
SICETCH OF SEWAGE DISPOSAL SYSTEM -
Provide a sk" of the sawage disposal rystm including ties to at least two pumanent reference tandmarks or
benchmmks. 14cme all wells within 100 ED& Loocatewhere public water mWy enters die building.
03/20/2003 13:11 FAX 978 952 2001 VISTA CONTROLS MA 10013
Page 11 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Addrem ---,e
, —:z,
A.;Q&& v v Cfig-k
Owner: I t.44 C 1-ug-HA47.
Date of inspection: I o _3
SrM EXAM
Slope
Surface water
Check cellar
shallow wells
Edbuted depffi to ground water fed
Please indicate (check) all me&ods used to detenum the bigh ground waW elevation:
Obtained, filom rystm design plans on record - if Checked, date of design plan reviewc&-
ObsmvW site (abutting properWobservabon hole wdhin 130 fed of SAS)
Checked with local BoW of Health-expkm
Checked with local v=vatms, UISlallels- *ich �&cumenWion)
se Accessed USGS databaso-explain:
You Must describe how YOU eftblished the NO Wound water elevation:
>L-0, -Ac"w" CA6--,v.6
0 20 Ago*' A26f !1.->
U >
cl)
(D
(D
Ul)
V)
0
(D
::3
I
C)
0
in
(D
M
r-tl
(D
0
-h
-n
h
0
0
>
(D
I
W
V)
I
0
0 0)
0 tv
314M
U >
cl)
(D
(D
Ul)
V)
0
(D
::3
I
C)
0
in
(D
M
r-tl
(D
0
-h
-n
h
U
TOWN OF NORTH ANDOVER
SYSTEM KWING RECORD
DATE OUO]3'
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
--Fs Ch 1'rh ar7'
,21(3,5 aivphe)l Rd.
afn overl.ma.
f,
DATE OF PUMPING //--2-o3 -QUANTITY PUMPED �-5-00
CESSPOOL NO YES SEPTIC TANK NO YES
NATURE OF SERVICE: ROUTINE 4,-�RGENCY
OBSERVATIONS:
GOOD CONDITION "L TO COVER
BEAVY GREASE BAFFLES IN LACE
ROOTS LEACHFIELD RLNBACK
EXCESSIVE SOLIDS FLOODED
SOLID CARRYOVER OTBER EXPLAIN
SYSTEM PUMPED BY
J
COMMENTS:
CONTENTS TRANSFERRED TO
TOWN OF NORTH ANDOVER
SYSTEM PUMTING RECORD
I
DATE:
SYSTEM OWNER & ADDRESS
SYSTEM LOCATION -
(example: left front of house)
Ad t -� �/
DATE OF PUMPING: --/67 QUANTITY PUMPED 1,32V GALLONS
CESSPOOL: NO ZYES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE _ZEMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS EACHFIELD RUNBACK
EXCESSIVE SOLIDS :Lf'ILOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY: ,qnOoVe,(- fg4h(,
COMMENTS:
CONTENTS TRANSFERRED TO: S:) S-+
IWILLIAm F WELD
Govcrno:
COM
Mo\\VEALTH OF MASSACH'USETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON. MA 02109 617-292-5560
TRUDY COXE
Sectcur%
ARGEO PAUL CELLUCCI DAVID B. STRUHS
LA. Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Corrtmiuioncr
PART A
CERTIFICATION
C ricr:
,V,., p�e
Properly Address: Address of Ow
Date of Inspection: la (if different)
Name of Inspector: BENJAMIN C. OSGOOD JR.
I arn a DEP approved system inspector pursuant to S-ection 15-340 of Title S (310 CMR 15-0001
Company Name: NEW ENGLAND ENGINEERING SERVICES_,_ INC.
Mailing Address: 33 WALKER ROAD, NO TH ANDOVER, M -A 01845
Telephone Number: 508-686-1768
CERTIFICATION STATEAENT I
I certify that I have personally inspected the sewage disposal system at this address and that the in(ofmation 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 funcuon and
maintenance oi on-site sewage disposal systems The system:
_41Passes
onclitionaltv Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Date:
IF oy of this i peci
The Svstern inspector shall submit a copy of this i pection 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 &A or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Envifortmental Protection. The original should be sent to the system owner
and copies sent to the byyer. if applicable. and the approving authority
INSPECTION SUMMARY: Check A, B, C, or D:
A] SYSTEM PASSES:
have not iound any information which indicates that the system viol . ztes any o(the failure C."te.ia 2s d2fineAd in 310 CMR 15-3 03.
Any failure criteria not evaluated are indicated below.
COMMENTS:
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 o(the replacement or repair. as approved by the Board of He2lth, will pass.
if -not determined', expt2in why not.
Indicate yes. no. or not determined (Y. N. or ND). Describe basis o(cletermination in all instances.
The ieptic tank is metal. unless the owner or operaw has provided the s em, ins r wit c 0( C rtificate of
yst Pc06 h a OPY 2 e
Compliance (attached) indicating that the tank was installed within twenty (201 yrars prior to the date of the ingx-aion; 01
the septic tank. whether or not metal. is cracked. structurally unsound, shows substanti2l infiltration or Cxr1ltr2ti0n. or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming s4nxic tank
as approved by the Board of Health.
I
., ._A ., , /4471 P-0- I 'r to
.......... ..... ... .......
SUBSURFACE SEWAGE DISPOSAC SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection: & (f 6 c- f-e-',cL-
� '? I'l P,
61 SYSTEM CONDITIONALLY PASSES (continu�dj
Sewage backup or breakout of high static water level observed i,n the distribution box is due to broken or obstructed
pipe(s) of due toa broken. settled or uneven distribution box. The system will pass inspection if'(with approval of the
Board of Health,. Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obs(ructed pipe(s). The system will pass
inspeFion if (with approval of the Board of Health):
broken pipe(s) are (eplacec�
obstruction is removed
C) FURTHER EVALUATI I ON IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which reauke further evaluation by the Board of Health in order to determine if the system.is failing to protect the
public health. safety and the environmem
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILLFROTECT THE PUBLIC HEALTH AND SAFM AND THE ENVIRON ENT:
— Cesspool or pri%v is within 50 feet of a surface water
— Cesspool of 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 APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT: I
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tribut4ty 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 SUPPIV well.
The system has a septic tank and soil absorption system and the SAS is within So feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but So 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 ol'ammonia nitrogen and nitrate nitrogen is equal to of
less than 5 ppm. Method used to determine distance ... (approximation not valid).
3) OTHER
(V -via -d 04/2S/91) rag. 3 *( 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 2 (3 3 CCLWI-yWk (ZcQ-4C AJ -
Owner: " C 0 clm� C�.—
Date of Inspection: C18
D) SYSTEM FAILS:
You must indicate either -Yes- or -No- as to each o(the (ollowing:
I have determined that the system violates one or more of the fd1lowing failure criteria as defined in 3 10 CMR 15.303. The b2Sis
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 dogged SAS or
cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cessp ool.
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 ttAnes pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Anv portion of
a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Anv portion of a cesspool or privy is within a Zone I of a public well.
An% ponion of a cesspool or privy is within 50 feet of a private water supply well
Anv pOrlion 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. anach copv of well water analysis for
coltiorm bactfria. volatile organic compounds, ammonia nitrogen and nitrate nitropen.
El LARGE SYSTEM FAILS: I
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 (a6lity with a design flow of 10,000 go 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 2rea (Interim Wellhead Protection Area - IVV?AJ or a mapped Zone If of a
public water supply well)
The owner or operator o(any such system shall bring the system and facility into full compliance with the groundwater treatment prog4m
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revimad 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART 8
CHECKLIST
Property Address: 283 c,.m fkh 0-- Aj - 44 Q Q e(Z-
Owner: Co
Date of Inspection:
Check if the following have been done: You must indicate either -Yes- or -No- as to each -of the following:
Yes No
Pumping information was provided by the owner. occupant. or Board of Health.
None of the' system components have been pumped (or at least two weeks and the system haS been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as pan of this inspection
Al'iq As built plans have been obtained and examined. Note if they are not avai(ab.e with N/A.
The iacilitv or dwelling was inspected for signs o i sewage back-up.
The system does not receive non -sanitary or industrial waste flow.
4Z_ The site was inspected for signs of breakout.
I/- All system components. excluding the Soil Absorption System. have been located on the site.
The septic tank =nho19 were uncovered. opened. and the interior of the septic tank was inipected 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 ownea were provided with information on the proper rnaintenance of
Subt-Surface Disposal System.
Existing information. Ex.iPlan at B.O.H.
Determined in the field (if any of the failure criteria (elated to Part C is 21 issue. approximation of distance is
unacceptable) (I 5.302(3)(b)l I
(revisod 04i25/971 PAVO 4 of 10
Property Address:
Owner:
Date of Inspection:
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION -FORM
PART C
SYSTEM INFORMATION
R& AJ-
jo rse Y -e 3 C<_
t-1 tq .0
FLOW CONDITIONS
RESIDENTIAL:
Design flow: p.dJbedroom for S.A.S
Number of bedrooms: q
Number of current residents: Z
Garbage g,-r.der (yes or not:
tA
-:7
Laundry conneaed to system �es or no):
Seasonal use (yes or no): AoA
Water meter readings. if available (last two (2) year usage (gpd): 1:77 6, f" D�
Sump Pump (yes or nol:lVo
Last date of occupancy:_i�_-_._elt
COMM ERCIAL/I ND USTRIAL:
Type of establishment:
Design flow:—____pllons/dav
Grease trap present: (yes or no)
Industrial Waste Holding Tank present: ives of no)
Non -sanitary waste discharged to the Tiae 5 sys1ern- tyes or nol_
Water meter readings. if available
Last date of o�cupancv:
OTHER: (Describe)
Last date ofoccupancy.
GENERAL INFORMATION
PUMPING RECORDS and source of information
,5" -
System pum`__� as pan of inspection: (yes or nol-AIC9
If yes, volume pumped: allo�s
Reason for pumping.
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if Yes. attach previous inspection records, if any)
VA Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: 1.2 e
Sewage odors detected when arriving at the site: (yes or no) /14)
(revised 04/2S/971 page S of 10
Property Address: 283
Owner: CTO
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'fc"nf4eft acA
CC> r r- 4�0-
Depth below grade:
material o(construc(ion: Zcast iron — 40 PVC — other (explain)
Distance from private water supply well of suction lerj -ALd—
Dianweter
Comments
,�(conclition of loinjs, venting. eviden,9 of leakage. etc.)
% I - I
SEPTIC TANK:—
(locate on site plant
Depth below grade:
material of construction: V-1c"Oncrete metal Fibetglas� Po(vethylene _other(explain)
If tank is metal. list age is age confirmed by Cenificate oi Compliance _ (Tes/N01
Dimensions: 1-5-vo &-.t //0 '1 S
Sludge depth-. ( " " I
Distance from top of sludge to bottom of outlet tee or baiflp-: Z!Y
Scum thickness: /, I
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bonom of outlet tee or baffle:
How dimensions were determined: nje�a-r,,rre- 4rle K
Comments:
(recommendation for pumping. condition of inlet and outlet tees of baffles, depth of liquid level in relation to outlet invert, stru ural
integrity. evidence of I kage, etc.) G-4Dop C0 C\, -A ec�� �c -C
c)
e:WN-
GREASE TRAP:Al-#+-
(locate on site,plan)
Depth below grade:
Material o(construction: —Concrete —metal _Fiberglass _Polyethyiene _otherlexplain)
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 of baffle:
Date of last pumping:
Comm,ents: rt, structural
(recomm,end2tion for pumping, condition of inlet and outlet t"s of baffles. depth of liquid level in relation to outlet inve
integrity, evidence of leakage. etc.)
(r iv -d 04/2$/271 rag. 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Properly Address: G'Vv'r�,J( /J
Owner: J-0 4e V�- (20'c -
Date of Inspection:
TIGHT OR HOLDING TANK: A/A CT;ink 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:
Capaclr\ - gallons
Design i!ow g?llon-Jda%
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 planj
Depth of liquid level above outlet inven:
Comments:
(note ii level and distribution is equal evidence o(solids carryo+e(.
19 ,x it') -- r5.,5 �p -
PUMP CHAMBERAJ#
(locate on site plan)
of leakage into or out of etc.)
" e- 9 C e' -L t U. e V.X.
Pumps in working order: (Yes or Not
Alarms in working order (Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revisad 04/25/971 rag. 7 of 10
I
...... .....
SUBSURFAtE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: WU Qk, ii - tqj o z) k/z
Owner: C, CL_
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):—
(locate on site plan. if possible; excavation not required. but may be approximated by non -intrusive methods)
If not determined to be present. explain:
Type:
leaching pits. number:
leaching chambers. number:
leaching galleries. number:
leaching trenches. number,lenglh: tt-9 6t �e-5,
leaching fields' * I 'umber. dimensions: L
overflow cesspool. number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil. signs of hydraulic failure. level of pond,*Z conditiorav of vegetation,. etc.),
f
0 's
C�
jqi4ei gL :s-. ,ec
CESSPOOLS: 61t+
(locate on site plan)
Number and configuration
'Depth -top of liquid to inlet invert:
Dr-pth.of solids layer:
Depth of scum layer:
Dimensions of cesspOO!:
tv,�aterials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil. signs o(hydraulic failure. level of ponding, condition of vegetation. etc.)
PRIVY:
(locate on site plan)
materWs of construction:
Depth o(solids:
Comments:
(riote condition of soil. Signs Of h%1di2UIiC failure. level of ponding, cGnildition o(vegeLation. etc.)
(r-visod 04/25/27) P.9. a of 10
Dimensions:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: Ca -
Owner: ccae^
Date of Inspection.
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
I
-- - - - - - ---------------------------- -
I
1--> v?, (Q Z-�-
(r-�iffsd 04/25/97) paq. 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Properiv Address: o j ce
Owner:
Date of InspeCtion:
Depth to Groundwater Feet
Please indicate all the me(hods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abutting property. observation hole. basement sump etc.)
Determine it irom local conditions
Check %v!th !oca!"Buard oi health
Chec� FEMA Maps
Check pumping records
Check local excavators, installers
_ZUse USGS Data
Describe in vour own words how you established the High Groundwater Elevation.' (Must be completed)
(r—la.d 04/25/17) P.q. 10 of 20
APPLICATION FOR SEWAGE DISPOSAL INSTALLATION
HEALTH DEPARTMENT - NORTH ANDOVER, MASS.
I hereby make application for a permit for a sewage disposal installation at
Lot-# 3. Campbell Rd. 0 1 will install this system in ac-
cordance with all the laws of the Commonwealth of Massachusetts and regulations of
the Board of Health of the Town of North Andover.
Further, I will construct the house sewer of bell and spigot pipe, the minimum
diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre-
ceding the septic tank, where the grade shall not exceed 2%. 1 will install a con-
crete septic tank of 1000 gal, in size. A manhole (s) permitting easy cleaning
will be provided with removable cover (s) of iron or concrete within 12 inches of
the ground surface. I will provide subsurface disposal field with 4 inch perforated
or open jointed pipe and laid in a series of.trenches, the bottom of which will pro-
vide a minimum of 200 —lineal (2gqM) feet of effective absorption area.
The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging
in size from 3/4 to 1-112 inches (dia.) and the pipes will be surrounded by similar
material to a height of 2 inches above the crown of the pipe, The joints of these
pipes will be protected from clogging and before filling the trench, 2 inches of
gravel or stone 1/81, to 1/41, (dia.) will be placed over the course gravel or stone.
The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single
tile line will exceed 100 feet in length and in any case, two lines of tile will be
installed. A minimum of 6 feet will be maintained between the center lines of the
disposal field trenches and the average depth of trench shall not exceed 36 inches.
No part of the installation will be less than 100 feet from any private water supply,
25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line.
I further aZree not to cover any portion of this installation until approved by the '
inspection officer, as provided below, and to incorporate any additional requirements
That may be attached to the permit. Plot Plans must be submitted with application.
Well t be in front of lot -100 ft. from field.
DATE ��� - e4_' 119 & I/
I hereby issue the above permit for
Andover, Massachusetts.
DATE
46
Signature of Applicant
the Board of Health of the Town of North
(�&gnature of Health Agent
I have inspected the uncovered system indicated above and find everything done
as describ d.
DATE 2,7
:: U
Signature �i Inspecting Ufficer
Percolation Test 4 min. Soil: Sandy -clay
Cwu-bage Grinder No
(ftre A
DONAHOE,
John
Lot # 3
Caikpbell Rd,
APPLICATION FOR SEWAGE DISPOSAL INSTALLATION
HEALTH DEPARTMENT - NORTH ANDOVER, MASS.
I hereby make application for a permit for a sewage disposal installation at
Lot-# 3. Campbell Rd. 0 1 will install this system in ac-
cordance with all the laws of the Commonwealth of Massachusetts and regulations of
the Board of Health of the Town of North Andover.
Further, I will construct the house sewer of bell and spigot pipe, the minimum
diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre-
ceding the septic tank, where the grade shall not exceed 2%. 1 will install a con-
crete septic tank of 1000 gal, in size. A manhole (s) permitting easy cleaning
will be provided with removable cover (s) of iron or concrete within 12 inches of
the ground surface. I will provide subsurface disposal field with 4 inch perforated
or open jointed pipe and laid in a series of.trenches, the bottom of which will pro-
vide a minimum of 200 —lineal (2gqM) feet of effective absorption area.
The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging
in size from 3/4 to 1-112 inches (dia.) and the pipes will be surrounded by similar
material to a height of 2 inches above the crown of the pipe, The joints of these
pipes will be protected from clogging and before filling the trench, 2 inches of
gravel or stone 1/81, to 1/41, (dia.) will be placed over the course gravel or stone.
The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single
tile line will exceed 100 feet in length and in any case, two lines of tile will be
installed. A minimum of 6 feet will be maintained between the center lines of the
disposal field trenches and the average depth of trench shall not exceed 36 inches.
No part of the installation will be less than 100 feet from any private water supply,
25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line.
I further aZree not to cover any portion of this installation until approved by the '
inspection officer, as provided below, and to incorporate any additional requirements
That may be attached to the permit. Plot Plans must be submitted with application.
Well t be in front of lot -100 ft. from field.
DATE ��� - e4_' 119 & I/
I hereby issue the above permit for
Andover, Massachusetts.
DATE
46
Signature of Applicant
the Board of Health of the Town of North
(�&gnature of Health Agent
I have inspected the uncovered system indicated above and find everything done
as describ d.
DATE 2,7
:: U
Signature �i Inspecting Ufficer
Percolation Test 4 min. Soil: Sandy -clay
Cwu-bage Grinder No
BOARD OF HEALTH
TOWN OF NORTH ANDOVER, MA
- I
tj '6'
g-nr
06
J,
rAd
3ce -f,
1. NAME kio D—au.&kg::gz: DATE zolez
2. ADDRESS. LOT NO. TEL. �il 7q2,1
3. NO. OF BEDROOMS_ DEN YES NO X
4. GARBAGE GRINDER YES NO-L_
5. SHOW DIMENSIONS OF HOUSE
6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES
7. SHOW DIMENSIONS OF LOT
8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL
9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM
10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC.
11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE
NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY.
BOARD OF HEALTH OF NORTH ANDOVER, MASSACHUSETTS
SEWAGE DISPOSAL
DATE October 24, 1964
NAME OF APPLICANT John Donohoe
LOCATION Lot #3, Campbell Road
Address of 18t no.
BUILDING: Dwellin x Other
SYSTEM: New x
Repair
GENERAL DESCRIPTION OF LAND high
SUBSOIL: Clay Gravel Sand Y Clay
PERCOLATION TEST 4 minutes per inch.
MINIMUM INSTALLATION RECOMMENDATIONS
CONCRETE SEPTIC TANK lv00O gallon capacity.
LEACH FIELD 200 lineal feet of drain pipe.
0L "-- L1\111 -
William J. Dr�scoll, Engine-(�-r
Board of Health
'of
.,..,_,0Mh1onWe sachusefts.
..a. t
IRK qq
'ANDOVER,MAS
SAC U !�S
IT
YS
u* C "e Nov 13 Z006
y�. en P mping.Re 0.d
Form 4':
R
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FP rl -TMENT
-TMENT
TOWN 0 [)F
TH D
DEP. has provided this form for use by local Boards of Health. Thes2 g ecordi must
be submitted to the local Board of Health or other approving authority.
-"Pumping Record
C Date- of Pumping I 151t 2. Quantity Pumped
Date
3. Type of syst em: Cessp eptic Tank
001(s)
/Z lb
Other (describe):
.4. Effluent Tee Filter prqsent? [I Yes/E13��No' If yes, was it cleaned? E] Yes M Nc
5. Condition of System.
rc til� 0/(
y em Pumped B
Name Vehicle Ucense Number
ma"rd 97a -
Company
7.. Location where contents were disposed:
I)Aad d, a3a--
64nature of Wouler Date
http:/twww.mass.g�/dep/water/�pprova.Is/t5forms.htm#inspect
t5forryA.doc-.06103 System Pumping Record - Page I of 1
Gallons
Tight Tank
Ai Facility Information
tj�n'
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fom�s on the
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Cityfrown
State Zip Code
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2.' System Owner:
Name
Address (if different from location)
City/Town
State Zip C e
&?-79
Telephone Number
-"Pumping Record
C Date- of Pumping I 151t 2. Quantity Pumped
Date
3. Type of syst em: Cessp eptic Tank
001(s)
/Z lb
Other (describe):
.4. Effluent Tee Filter prqsent? [I Yes/E13��No' If yes, was it cleaned? E] Yes M Nc
5. Condition of System.
rc til� 0/(
y em Pumped B
Name Vehicle Ucense Number
ma"rd 97a -
Company
7.. Location where contents were disposed:
I)Aad d, a3a--
64nature of Wouler Date
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<L\ Commonwealth of Massachusetts
City/Town of No.Andover
System Pumping Record
Form 4
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
VQ
IL 0
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. Befc let% ith your
local Board of Health to determine the form they use. The System Purr ping MM"44=�t...5subr iitted to
the local Board of Health or other approving authority within 14 days fn im the pumping date in
accordance with 310 CMR 15.351. U Z-011
A. Facility Information
1. System Location:
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Address
I .
Signature of ReceivinyFicility
No.Andover
Ma
01845
City/Town
State
Zip Code
2. System Owner:
1
fz
Name I
Address (if different from location)
City/Town
State
Zip Code
Telephone Number
B. Pumping Record
10-12-11
1 . Date of Pumping Date
2. Quantity Pumped:
Gallons
3. Type of system: El Cesspool(s)
�Septic Tank El Tight Tank
F1 Grease Trap
M Other (describe):
4. Effluent Tee Filter present? El Yes F1
No If yes, was it cleaned?
[:] Yes E] No
5. Condition of System: 0 n
6. tern Pumped By:
\'Nam Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler
Date
Signature of ReceivinyFicility
Date
t5form4.doc- 03/06 System Pumping Record - Page 1 of 1
Important: When
filling out forms
on the computer,
use only the tab
Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
TC'V."q 07 NCRTH AA
j—,.HEALT,'-j
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CIVIR 15.351.
A. Facility Information
System Location:
key to move your
Address
cursor - do not
North Andover
use the return
key.
City/Town
01-� 2. System Owner
Name
Address (if different from location)
CityfTown
C a M PhA
CCL rn bd I
Ma
State
State
Telephone Number
01845
Zip Code
Zip Code
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: 450()
Date Gallons
3. Type of system: Ej Cesspool(s) .2"Septic Tank El Tight Tank El Grease Trap
El Other (describe):
4. Effluent Tee Filter present? n Yes
.1eN o
5. Condition of System:
6. System Pumped By:
VN a m�
Stewart's Septic Service
Company
7. Location where contents were disposed
If yes, was it cleaned? n Yes [I No
Vehicle License Number
8 rt's Pre-treatmeM44a4,-20-Sa-U ill Bradford, Ma 01835
&
Signature au e Date
Signature of 14-e�eiving Facility Date
t5form4.doc- 03/06 System Pumping Record - Page I of 1