HomeMy WebLinkAboutMiscellaneous - 29 CROSSBOW LANE 4/30/2018 (2)0
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DEP has
prov ded this form for use by lopal Boards of Health. The System Pumping Record mu,
be submitted to the local Board of Health or other approving authority,
�apfllty Information
Immrtant:
Men filling out
forM3 on the
computer, u&e
only the tab key
to move your
cursor-.do.not
use the return
key.....
2.
SystOwner
�.M�c
, n V--, Y-)<
/L�0--
state
lip Qode
t. Add ress (it altie rent from location)
CityIT7w-n State Zip Code
Telephone Number
V P.umpIng Record
I Date of Pumping 2. Quantity Pumped:
gions
Type of system:_ Cesspool(s) [;o15eptIc Tank Tight Tank
Other (describe):
4, Effluent Tee FI I Iter present? Yes No If �e's','Vvas it cleaned? Yes No
5. Condition of System:
TIMPump d
U
Ipj
Vehicle Ucense Num )er
Company
7. Locatlopwhere contents were'disposed: c,
Zrgna 0 uler
http:/Ayww,rhass.gov/d.epA,v6ter/app
ro.valsA.5forms.;hUriffinspect
t5form4.doc, 06/03
SAtem Pumping Record - Page 1 ot 1
(" ir"
Commonwealth of Massachusetts
City/Town of North Andover
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CIVIR 15.351.
J'%ji- 0 7 2014
TOWN OF NORTH ANDOVER
HEALTH D
A. —�--.EPARTMENT
A. Facility Information
Important: When
filling out forms
1. System Location:
on the computer,
use only the tab
key to move your
Address
cursor - do not
North Andover
use the return
Ma
01886
key. City/Town State Zip Code
2. System Owner:
n i<i n - s
Name
Address (if different from location)
Cityrrown
State Zip Code
SCV L/ I I-rf(6
Telephone Number
B. Pumping Record
1. Date of Pumping 6h 2. Quantity Pumped: /T-60
Date Gallons
3. Type of system: Ej Cesspool(s) Septic Tank E] Tight Tank El Grease Trap
El Other (describe):
4. Effluent Tee Filter present? El Yesp�No If yes, was it cleaned? El Yes El No
, 5. Condition of System:
16. System Pumped By:
NaXe Vehicle License �umber
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewqas Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
auler 4C ------- Date
I Ss' ?nature Of Receiving Facility Date
t5form4.doc- 03/06', System Pumping Record - Page I of 1
6850
W
Town of North Andover
HEALTH DEPARTMENT
CHECK #: DATE:
LOCATION: A P�o
H/O NAME:
CONTRACTOR N
TYRe
of Permit or License: (Check box)
0
Animal
$
0
Body Art Establishment
$
0
Body Art Practitioner
$
0
Dumpster
$
0
Food Service - Type.--
$
0
Funeral Directors
$
0
Massage Establishment
$
0
Massage Practice
$
11
Offal (Septic) Hauler
$
0
Recreational Camp
$
0
Sun tanning
$
0
Swimming Pool
$
0
Tobacco
$
0
TrashlSolid Waste Hauler
$-
0
Well Construction
$
SEPTIC Systems:
0 Septic - Soil Testing $
0 Septic - Design Approval $
0 Septic Disposal Works Construction (DWQ $
0 Septic Disposal Works Installers (DWI) $
0 Title 5 Inspector $
"y Title 5 Report $.
13 Other (Indicate) $
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer I
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
29 Crossbow I n All/
rfOPerrY A00reSS
Owner Jane Jenkins
information is 5Wners �Nsme
required for every No Andover MA 01845
page. CRY, I own ------- 6,26-2014
State Zip Code Liate ofinsPectlon
'Inspection results must be Submitted on this form. Inspection forms may not be altered In any
way, Please See completeness checklist at the and of the fornn. 'i
Important, When
filling out form�
on the comouter,
use only the tab
key to movo your
cursor - do not
�.se the return
key,
uenerai information
1, Inspeotor:
S
CompenyAddjj5-3-------
Bradford
978-372-7471
fe__Iep�ona -Num�er
5. certification
RECEIVED
JUL' 0 3 2014 ,
TOM OF NORTH ANDOVER
- "EA TH DEPARTMENT
Me - 01835
State Yl P—C _Qd
6113386
Ti c—e n—s s_N u m b a —r
I Certify that I have personally inspected the sewage disposal system at this address
informa and that the
reported below is true, accurate and complete as of the time of the Inspection. The Inspection
was Performed based on my training and experience In the Proper function and -maintenance of on's Ite
sewage disposal Systems, I am a DEP approved system inspector Pursuant to $
Title 5 (310 CMR 00tion 15.340 of
15-000). The system:
Passes Conditionally Passes Ej Falls
Needs Fwrther�valuatlon b the Loc
I I - I �y al Approving Authority
n6' atoreftnature 6-26-2014
T r
SYStOm Inspector shall submit a copy of this inspection report t the Approving Authority (5o
Q , ard
oiHealth or DEP) within 30 days of completing this inspection, If the system is a shared s
has a design flow of 10,000 gpd or greater, the inspector and the system owner sha' yetem or
report to the appropriate regional office of the DER - 11 submit the
The original should be sent to the system owner
and copies sent to the buyer, If applicable, and the approving authority,
****This report only describes conditions at the time of inspection and under the conditio - no of use
at that time. This Inspection does not address how the system will perform In the future und
the same or different conditions of use. or
Wins - 3113
Title a oftidal lnepgctiom parm� Subsurfe(� 86W
_RQq PIPPOA I Sys( M ppoe 1 of I?
',Clx Commonwealth of Massachusetts
9 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
29 Crossbow Ln
Property Address
Jane Jenkins
Owner Owner's Name
information is
required for every
page, I
B. Certification(co-n—t.)
MA 01845 6-2e-2014
$tate Zip Code Pate of inspection
Inspection Summary: Check A,B,C,D or E / alWays complete all of Section D
A) System posses:
1 have not found any Information which indicates that any of the failure
10C criteria described
in 3. MR 16,303 or in 310 CMR 15,304 exist, Any failure criteria no 0 . ed are
indicated below. , t valuat
Comments:
Lrecommendq removal of cy
8) System Conditionally Passes:
One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or -
the Board of Health, will pass, repair, as approved by
Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not
determined," please explain,
The septic tank Is. metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration'or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available,
El Y 0 N 0 ND (Explain below):
Wn,6 o 3/13 T10o 6 Offloial ins oolar, pprn: 4y�§Wrf#jC,9 p
Commonwealth of Massachusetts
Title 5 Official.inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
29 Crossbow Ln
Property Address
Jane Jenkins
owner Owner's Name
information"Is
required for every No Andover MA 01845 6-20-2014
page. CityfTown state Zip Code Date of Insp ction
B, Qertification (cont.)
PUMP Chamber pumps/alarms not operational. System will pasQ, with Board of Health approval if
pumps/alarms are repaired,
B) System Conditionally Passes (cont.);
0 Observation of sewage backup or break out or high static water level in the distribution box due
to broken or o0strwcted pipe(s) or due to a broken, settled r uneven dis
p I ass inspectio I n if , (with approval of Board of Health): 0 tribution box, System will
broken pipe(s) are replaced Y [] N ND (Explain below):
obstruction is removed El Y El N Ej NQ (Explain below):
El distribution box is leveled or replaced 0 Y 0 N []. ND (Explain below):
The system required pumping more then 4 times a year due to broken or obstructed Pipe($), The
system Will pass inspection if -(With approval of the Board of Health):
broken pipe(s) are replaced Y N [] ND (Explain below);
C1 obstruction is removed, r-1 Y Cj N [I ND (Explain belowr)!
C) Further Evaluation Is Required by the Board of, Health:
Conditions exist which require further evaluation by the Board of Health in order to determine If
the system is failing to protect public health, safety or the environment.
I - System will pass unless Board of Health. determines in accordance with 310 CIVIR
116.303(l)(b) that the system Is not functioning in a manner which will protect public health,
safety and the environment
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within .50 feet of a bordering vegetated wetland or a salt marsh
Title 5 Official inspection Form: Subsurfece Sam a Dioppea! $ystarn � Poge 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
29 Crossbow Ln
Property Address
Jane Jenkins
Owner Owner's Name
information Is
required f6r every No Andover MA 01845 6-26-2014
plage. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fall unless the Board of Health (and Public Water Supplier, If any)
determines that the system Is functioning In a
manner that protect1l; the public health,
safety and environment:
E3 The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply, '
[I The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
The system has a septic tank and SAS and the SAS is within 60 feet of a private water
supply well,
The system has a septic tank and SAS and the SAS is less then 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
t§ins - 3113
This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen Is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form,
1 3. Other:
D) System Failure Criteria Applicable to All Systems:
You mus.11: Indicate "Yes" or "No" to each of the following for all inspections -
Yes No
Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface water$
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 orcesspool
Liquid depth in cesspool is less than 6" below Invert or available volume is less
then% day flow
Tlilo 6 Offloial Inspoction Form: Subsurfage $swags Disposal Systo Page 4 o! 17
-S�— Commonwealth of Massachusetts
0MROMEMMI
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
29 Crossbow Ln
Property Address
Jane Jenkins
,)wner Owner's Name
nformation is
equired for every No Andover MA 01845 6-26-2014
age. City/To I wn I State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
Required pumping more than 4 times in the last year.NOTdue to clogged or
obstructed pipe(s). Number of times pumped:
Any portion of the $AS, cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis (This
system passes If the well water analysis, performed at a DEP certified
laboratory, . for fecal collform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen Is equ r al to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd,
The system 11 Lis. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the'system falls, The
system owner should contact the Board of Health to determin . e what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpq.
For large systems, you must indicate either "yes" or "no"
questions in Section D, to each of the following, in addition to the
I 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
I the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area - IWPA) or a mapped Zone 11 of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed unders-ection D shall . upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
Wn4 - 3113
Title 5 Official Inspection Form: Sutgurface $awagq Dloposal $ystaM ? Page 5 of 17
I
p
For large systems, you must indicate either "yes" or "no"
questions in Section D, to each of the following, in addition to the
I 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
I the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area - IWPA) or a mapped Zone 11 of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed unders-ection D shall . upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
Wn4 - 3113
Title 5 Official Inspection Form: Sutgurface $awagq Dloposal $ystaM ? Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Ln
Jane Jenkins
Owner Owner's Name
information Is
required foi every No Andov2r MA 01845 6-26-2014
page'r . Cityrr.own State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or Unotp
as to each of the following:
Yes No
R D
Pumping information was provided by the owner, occupant, or Board of Health
Were any of the system components pumped out in the previous two wpeks?
Has the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of
this inspection?
Were as built plans of the system obtained and examined? (if they were not
available note as NIA)
Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
Were all system components, excluding the SAS, located on site?
Z
Were the septic tank manholes uncovered, opened, and the interior of the tank
Inspected for the condition of the baffles or tees, material of Construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
Was the facility owner (and, occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The sixe and location of the Sol[ Absorption System (SAS) on the site has
been determined based on:
Z E]
Existing information. For example, a plan at the Board of Health.
Determined in the field (if any of the failure criteria related to Part C Is at issue
approximation of distance is unacceptable) (310 CMR 15.302(5)]
D. System information
Residential Flow Conditions:
Number of bedrooms (design)- 4 Number of bedrooms (actual); 4
DESIGN flow based on 310 CMR 15,203 (for example: 110 gpd x # of bedrooms): 600 pgd
Wins - 3M Title 5 Officlol Inspection Form: Subsurface Saw -age Uiqposel System - Ps a 6 of 17
P,,-\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
50 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
29 Crossbow Ln
Property Address
Jane Jenkins
Owner Owners Name
information is
required for every NoAndover MA 01845 6-26-2014
page. City(Town State Zip Code Date of Inspection
D. System Information
Description:
t5ins - 3113
Number of current residents:
Does residence have a garbage grinder?
Is laundry on a separate sewage system? (Include laundry system inspection
information in this report.)
Laundry system, inspected?
Seasonaluse?
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
2
Sump pump?
Yes
Lost date of occupancy:
No
Yes
Commerciallindustrial Flow Conditions:
No
El
Yes
Design flow (based on 310 CMR 15-203):
No
El
Yes
(0
No
Sump pump?
Yes No
Lost date of occupancy:
.0owpi ' ed
Dote
Commerciallindustrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15-203):
Gallons per day (gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present?
E Yes
Industrial waste holding tank present?
Yes No
Non -sanitary waste discharged to the Title 5 system?
Yes No
Water meter readings, if avaiijable�
Title 6 Official inspection Form: Subsmrface Se"g@ pispopi SystaM - P990 7 of 17
.&�, Commonwealth of Massachusetts
Title 5 Official Inspection Form
0 Subsurface Sewage Disposal System Form Not for Voluntary Assessments
29 Crossbow Ln
Property Address
Jane Jenkins
Owner Owners Name
information Is
reqvired for every No Andover MA 01845 .6-26-2014
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occwpancy/use!
Other (describe below);
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection?
If yes, volume ppmped:
I How was quantity pumped determined?
Reason for pumping:
Date
Stewart's Septic
1500.9al
gallons
Site guage on truck
Inspect tank
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) and a'copy of latest
inspection of the I/A system by system operator under contract
Tight tank. Attach a copy of the DEP approval.
Other (describe):
15ins - W13 Title 5 Official Inspection Form: Subsurface Sawage Dioposal System - Page 0 of 17
Commonwealth of Massachusetts
Ewa Id
i itle 5 Official Inspection Form
Subsurface Sewage Disposal System Form . Not for Voluntary Assessments
29 Crossbow Ln
Property Address
Jane Jenkins
Owner Owners Name
information Is
required for every No Andover MA 01845 6-26-2014
page. City[Town State Zip Code Date of Ins's io -------------
Oct n
D. System InformatiOn (cont.)
t5ins - $/13
Approximate age of all components, date installed (if known) and source of information:
30 years
Were sewage odors detected when arriving at the site? Yes No
Oullding Sewer (locate on site plan):
Depth below grade: 22"
feet
Material of construction,
cast iron 0 40 PVC El other (explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.) -
T
Septic Tank (locate on site plan)�
Depth below grade:
Material of construction:
(9 concrete El. metal fiberglass
11 It
fept
EJ polyethylene other (explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Yes No
Dimensions -
Sludge depth:
Title 5 Official Inspection Form: Subsurface Sewage Disposal System pa a 9 of 17
commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
29 Crossbow Ln
Property Address
Jane Jenkins
Owner
Owner's Name
information is
required for every No Andover MA 01845 6-26-2014
page. City/Town State Zip Code Date of Inspect on
D. System Information (cont)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle 301!
Scum thickness 0
Distance from top of scum to top of outlet tee or baffle 611
Distance from bottom of scum to bottom of outlet tee or baffle 1511 -----------
How were dimensions determined? Tage measure, sluge judge
Comments (on pumping recommendations, inlet and outlet tee or bqffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc,):
Both baffle$ in place liguid level good no leakage
Grease Trap (locate on site plan)l
Depth below grade:
feet
Material of construction:
F� concrete metal fiberglass polyethylene E
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: Date
t5ins - 3/13 Tifle 5 Official Inspedon Form: Subsurface $awago Disposal SystaM - page 10 of 17
�L\ Commonwealth of Massachusetts
"I"itle 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
29 Crossbow Ln
Property Address
Jane Jenkins
Owner Owner' s Name
information is
required for every No Andover MA 01845
--------- 5-26-2014
page. Cftyfrown State Zip Code Date of Fns—pe—ciion--�
D. System information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):'
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade',
Material of construction:
concrete metal El fiberglass polyethylene other (explain):
Dimensions:
Capacity:
,y
gallons
Design Flow:
gallons per day
Alarm present: Yes rl No
Alarm level:
Alarm in working order: Yes No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.),
Attach copy of current pumping contract (required), Is copy attached? Y e s No
*n§ - ail a
Title 5 Official InSpection Form: Subsurfacp SpWap plepo�el 8y8tom . pggp 1,1 pfl, 7
-Q-\ � Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Die
posal System Form - Not for Voluntary Assessments
29 Crossbow Ln
Property Address
Jane Jenkins
Owner Owners �i�ne
information is
required for every No Andover MA 01845 6-26-2014
page. City/'r wn State
Zip Code Date_�f Finspecii�on
D. System Information (cont.)
Distribution Box (if present mus be opened) (locate on site plan):
Depth Of liquid level above outlet invert 0
Comments (note If box is level and distribution to outlets equal, any evidence of solids corryover, any
evidence pf leakage Into pr out pf b etc*
ox.
Uquid levels good . no solids carry over, no leakagie
PPMP Chamber (locate or site plany
Pump6 in working or -der; Yes N P
Alarms In working order-, Yes No-,
Comments (note condition of pump phamber, condition of pumps anO appurtenances etc,
If Pumps or alarmo are not in working order, system is -on
_ a P . ditlQnal pass,
W11 Absorption System (SA$'.) (locate on site plan, excavation not required):
If SAS not located, explain why:
t§ipa i MS T100 5 MIMI IrISP0019n Fprfn; Sqb*Wf.f;ga S
pwg99 pi p §pj By to,11
S of 17
CommonWealth Of Massachusetts
i le 5 Official Inspection Form
t
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
29 Crossbow I n
Properry ACCIreSS
Jane Ipnleinc
Owner OwnersName
Information 14
required for every No Andover
page. I City/Town
D. Syste
m Information'(cont.)
Type:
0
leaching pits
0
leaching chambers
0
leaching galleries
C3
leaphing trenches
leaching fields
overflow cesspool
innovative/alternative system
MA 01845
State Zip Code
number:
number:
number:
6-26-2014
Date of inspection
number, length:
number, dimensions: 1-20x 45
number.,
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of pondin
vegetation, etc,): g, damp soil, condition of
No hydraulic failure, no Pondina . no darnn Qrtile
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan)o
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
I
t5ins - 3/13
yes No
TO 5 Oftal Inspedon Form: Swbsurface Sewage p1spO341 py6tam t Page 13 of 17
t—� , Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
29 Crossbow Ln
Property Address
Ow Jane Jenkins
. or 5�ne?s-Niriie
information is
reqwired for every No Andover MA 01845 6-26-2014
page. Cityfrown state Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of pon.ding, condition of vegetation,
etc,).,
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.);
TRI9 5 Official Ins,pootion Form: SubsurfaGe 89Wagg owqqu! pygle a of
pm , p, ge J4 , 1�e
COMMOnwealth of Massechuseft
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
29 Crossbow lane
Jane Jenkins
Owner 0 -ir!' N - --' ' ' ' — - -.1. .
information is .wn. 6 aft
requirej for. overy No Andovor MA 6L2,6/204
P090i state Zip Code Date of inSpeCtion -r
E). system Inficirm 1 (0960
ReWh Of Sowago DIPpo5al Systow� Provido a, view of the sewage disposal system, ine
-lwdinq tio� to
at leat twQ pormanent. retronce loRdm@rK§ or Oenphrnairks
Loqate all w@lls within 100 fft, Locate
1410A � @14 0 TWO 5 001*90 ISP.P.Oirm No: $Av".4" §W4@'Qq PIRP9141 §YWPfq P IRse?, 1� of 37
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
29 Crossbow
Fr-opertyAddress
Ln
Owner
information is
required for every No Andover
MA 01845
.Page. City1rown 6-26-2014
State 71n rneja U81e OT Inspection
D., System Information (Cont.)
Site Exam:
Check Slope
S-urfape water
Check cellar
Shallow wells
Estimated depth to high ground water: 42" & 36"
feet
Please indicate alliethods used to determine the high ground water elevation:
Obtained from system design plans on record
If checked, date of design plan reviewed: May 23, 1983
Date
Observed site (abutting property/observation hole within 150 feet o
f SAS)
Checked with local Board of Health - explain:
Pulled files
Checked with local excavators, installers - (attach documentation)
Accessed USGS database - explain:
You must describe how you, established the high ground water elevation;
Water@ elevation 106.0 bottom Of bed @ elevation 110-04'waterseperation to bottomof bed.
PLans bv Thomas E Ninvp AAR
I
Before filing this inspection Report, please so Report Complete
e nose Checklist on next page.
l6ins - 3/is
Title 5 01ficial Inspodon Form: SubsUrl009 Sawage Dispoeal Syst.em - Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form , Not for Voluntary Assessments
29 Crossbow Ln
Prnniar+v apm
Jane Jenkins
Owner Owner's Name
information is
reqPired for every No Andover
Prage. City/ I own MA 01845 6-26-2014
E. Report Comple state Zip Code Udle OTinSpection
teness Checklist
Inspection Summary- A, B, C, D, or E checked
Inspection Sum
. Mary D (System Failure Criteria Applicable to All Systems) completed
System Information — Estimated depth to high groundwater
Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
Wns � 3/13
TIVS 5 Offle1@1 Inspechon Form: SuOsUrfg0a s$Wage 010posa, Sy#tom _ page 17 of 17
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000SM4089BOW 40 44180MUOWWOO
1 61
Commonwealth of Massachusetts
IN ". M. City/Town of No Andover
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. Th Record must be submitted to
the local Board of Health or other approvi -rAq'0aKLV
ng authority wit in 14j4ffiftlLbt��ump ng date in
accordance with 310 CMR 15.351. ,VWump
A. Facility Informatio
n
ImportAnt: When,
TOWN OF NORTH ANDOVER
filling out forms
System Location:
'HEALTH DEPARTMENT
on the computer,
uoe only the NO
29 Crossbow lane
key to move your
AddreM
cursor - Oo not
No andover
MA
use the return
key,
State
2. System Owner:
Jane Jenkins
Name
Address (if different from looetion)
Pity/Town
-�iat Zip Code
I -fe I a p h 6 n -iN u rn b tir
B. Pumping Record
6-26-2014 1500
11. Qate of Pumping Date 2. Quantity Pumped: Gallons
Type of system: D Cesspool(s) Septic Tank ED Tight Tank Grease Trap
Other (describe):
1
4.� Muent Tee Filter present? Ej Yes [3 No
5.' Condition of System:
19
If yes, was it cleaned? 0 Yes 0 No
7, Locatiom where contents were disposed:
I(Jbhf% 1"UPKWSOA
-MIW
Date
1
* Z 1 0.. 0
t61b.rM4,0oC- 03/06 System Pumping Record a Pa
go I of I
-SACK,F-DC-rE- RIM
k -8A S /A/
F CATC
ELEV.=112.53'
XO
/08
�AL
ol, 8
�.iq
Je.-
.14
10
LF-AC14
14%
LZACWFIEL17
Fw
Sam )'10TE
N
D\NE Ll-lr4611� 1/0
ty
C0Q.--TzocT ION, ek�
#zul-r I -Nei Lcm�'-
ip
EASEA4E:&/7 0,100
ITO
Ald A EAD-1--Yd
16�c& -
HAlb OA ZYA.Ie
//-.I R - S.?
10-T * -3
/3 41 R
lie
"
S2
1 1, 0/10,
rlff(pt-
A
7.
IVA
%T0VN4)F'N04THANDoVBR
Sys
IkM PUWINO RECORD'
'DATE
-'Q 4 zin v W'Ntx & ADDRESS
IT
C ro 85 0 a 1) o /xj
0 - OM90 vel� )12qr,
SYSTEM L(�C—ATJON
DATE OF P
QUANTITY'PUWIID
CESSPOOL No ys IC TANK No
NATURE OF SE�VICE,,�,Rq:
YES-�
7W ENMROENCY
OBSERVATIONS:
GOOD �CONDIUON` -17r Tr r
FULL -TO COVER
Ro. BAFFLES IN LACE
OTS
LEACHFIELD RMACY,
BXCBSSM SOLIDS FLOODED
SOL�) CARRyOVE' OTFM
k-�— R ENPLAIN
SYSTEM PUNgb BY
. . . . . . . ...
COMNfENTS,
----------
7ENTS TRANSFERRED To,
T -N OF NORTH ANDOVER
OW
SYSTEM PUMPING R-ECORD
-�O STEM OWNER & ADDRESS
Jon a-)
g a
NO, QAdap lvqa
SYSTEM LOCATION
(example: left from of houst)
el I
u -\TE, OF PUMPING: 911q142— QUANTITY PUMPED 0 i� L L 0
P 0 0 L: N 0 Lo,'�Y E S SEPTIC TANK: NO YES
",.ATURE OF SERVICE: ROUTINE __IZF-M ERG ENCY
V.�� T 10 N S:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
,) P U M 1) E D B Y:
C U � I.'y1 FN T S:
—k��FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
01�HER (EXPLAIN)
( TI Z A N S F E I Z I � E D TO:
4--
0
0)
CL)
r)
4-j
C)
ID I C-InHr. I / HI Ivu v Er,
A1,6(4h Alvwve-r 2.a4- STBIZART I s Sl�mc TIM sl��Cz
47 RMLiROAD S-rRM
; ih A BWFORD, Mh 01835
978-372-7471
r) Lic,
MONM OF
-ALL$
Mao��y REPORT FOR TCWN OF
DATE
ADDRESS
GALWNS
I/ A.
V/
L b�eo+
L,
'yo
e,3 e Cr
V/. L. LO
71 (�C?r
4?"
fif
15?6
v �5 �-/
r- HUr- U-1
Board of Health -
North An4gyar M&BB.
"V
M
V,W
BEM.0 SISTEK
INSTALLATION CHECK LIM
Reammst -,D r- 1,
tit.,
.,�le Distance Tot
a. WetIands
'Z 1. ri._ - 4 -
0 0
c. Well
--"""'2. Water Line Location
3- No PVC Pipe
Septic Tank
a. -Tees .-Length & To Clean -Out Cover.
b. Cement Pipe to Tank.- on Both Sides of Tank
Distribution Box
a. Covers & Box - No Cracks
b. All Lines Flowing Equal Amounts
c. No Back Flow
Leach Field or Trench
a. Dimensions
b. Stone Depth
a Capped 'Ends
d: Cle
.an Double washed Stone
7. Leach Pits
a.' Dimen 8
b St ;
0 _4A.
Sto Dep uh
ce ash Pads
ees
d. oes
e. Csmmt Pipe to Pit - Both Sides
f. Clean Double Washed Stone
8. No Garbage Disposal
9. -Final. Grading Inspection
10. Barricading Covered System
13, As Built Submitted
a. Lot Location
b. Dimensions of Sy"
c. Location with Regard -to Perc Test
d. Elevations
e 0* Water Table
LOT _2!5 Cf-ADSS ,j
xCAvATI �61_[ML
-1. / —
It) (te,
Board of Health
I
.1crth '#n&ver2Y1&sis
SUBsURFACE DIEPOSAL DFMGN CHECK LIST
LOT
APPROVED DATE DISAPPROVED DATE
Provided: Reasons:
_U I &
Title --v FAIL CK
Reg 2.5 The submitted plan must show as & Minimml
-area
�a) the lot to be served jdimensions lot #.,abutteris
N ocation and log deep observation Mes-distance to ties
location and results pemolation tests -distance to ti8s
design calculations & calculations showing required leaching area
location and dimensions of system -including reserve area
existing and proposed contours JODI of ser;�-,age disposal system or
7(g) location any wet areas within
—L-Awk
7W
v7j�d)
disclaimer -check wetlands mapping disposal
surface and subsurface drains within 1DO' of sewage
system or disclaimer
(i) location any drainage easements within ID01 of se -.age disposal
system or disclair�er-Planning Board files
kno= sources of water supply within 2001 of sevage disposal
uystem or disclaimer -om leacl�ing �acili.
�k� location of =y -proposed well to _aer7ej0t-_2.Q0 1 fr 1tv
-_7 location of -wster lines on property -101 from leaching facilit,
M) location of benchmark
r
W drivevays
4ill(p) garbage disposals
pyrjo PVC to be used in construction
jq) profile of system- elevations of basement,, plumb., pipe,, septic tanki
distribution box inlets and outletsj, distribution field piping and
6�0'
fter elevations stem
r7Aram ground iater elevation in area serwage disposal sy
' ma er or other
s) plan mast be prepared by a Professional Eagine
professional authorized by law to prepare such. plans
Reg 6 Septic Tanks-
(��p
cities -15o,% of flow., water table., tees, depth of tees.,
�Yaccess., punping
cleanout
101 from cellar imll or inground suimming pool
(d) 251 from subsurface drains
Reg 10.2 (/ Distribution Boxes
(a) -slope greater than 0.08
Reg 10.4 1 ;.(b) surp
COwc-
(4)stko�'3 vo vc\
cp
Subsurface Desi
FAIL
Reg 11. 2
n-4
11.10
11.11
teg 15.1
15.4
15.8
3.7
teg 14.1
14.3
14.4
14.6
14.7
IL,ao
0
.eg 9.1
9.6
Check Liat
I (K I
2
Leaching Pits
Leaching pits are p ed where the installation is possible
a) calculations eaching area-ydnimzim 500 eq ft,
.b) :spacing
I
.0 mwface, e 2%
1 - " 1%
,d) cover terial
e)) 21 x4O spla�sh pad
e Z
at elbow
g) no bends in pipe from d -box to pipe
Leaching fields
no greater than 20 minutes/inch
area-minimuz 900 aq ft
construction of field
surface drainage 2 %
e) 202 from cellar va.0 o
.�ground swimo3dng pool
Leaching '
a) calculaEr
b) spacing -4
0 dimension
d) cons
e) szn;��
'eaching area -min 500 sq ft
6 ft with reserve between
f) ainage 2%
Aounhill Slone
a) slop;�--yWr�to —be sho —wm)
b) y/x X 150 = (to be shown)
a)Z7al
b) 8 7d_by power
TO:
FROM:
NORTH ANDOVER, MASS -19 2?3
BOARD OF HEALTH
DESIGN ENGINEER
Re: Soil Absorption Sewage
System Inspection
This is to certify that I have inspected the construction of the said disposal system at
T 2 ORE S's Z 0 W North Andover, Mass.
SITE LOCATION
The grades and construction are as specified in Qm� plans and specifications dated
MAy -23 1 a 'q R /V "C Vr "q S-5, a C 5,
CoAll"i
CO
/>
Pro A-Wne'er/R-ek.*�ditaria-n
BOARD OF HEALTH
DESIGN APPROVAL
Lot # 75 STREET C12,0-_,S.,5CVj
Proposed Construction lb09-1-k "-ov5e
Septic -Tank
Permit #
vJ/ 1,Av-- v�,,o6P_ ow
%%Qs of= I.Vb � , Approx Building Size
Garage Z Under Attached None
Min elevation of top of slab -&ONE- I C>j. o
Min elevation of top of foundation %0.s
Heiaht of foundation wall Ts
Footing in fill— yes no
Further Comments
0
7 VFW 0
�4zt:��5 V;W-v�
DER Os prcMd
ad 01iform for use by local Boari Is
*-Ub�nl4e-d t' of RESSUBDOM" Dumping Record
o thq.lo.cal'Soard of Health or other approying aut
hority,
lit ft��tlon .
y..1 n fO
TOWN OF NORTH ANDOVER
f&Q out
systeiTi HEALTH DEPARTMENT
on)y W'ks Y Addre3s Qz
to Moye youl
do Pot
rown
tvfr
U34
ZIP
1,j 63temowner,*
Nam$ -,q:;,
9.,
Addr M locauQn)
ront frQ
state
.�Pc
Tolep no N lber
-6rd
U
to�
..... ..... ..
At
08
w!QfPUm*q. 2,'Quaintl� Pumped:
01(s) Septic.Tank
Tlqht Tank
...... J. Other
EM
'Yes. No'
If yes. was it o'leaned? CD Yes.4j;, No
--C 6d!Von
vehide can
66i. M
�,v v.
'I!- TA" Lo
� Ma 6Qn. Wh6re'Pon ton t3'Were'd1opos ed:
1A
(NA.
of
Date
Plw, er/apprQv�ls/t�f��ms,'h�n#lnspect
OUQ3
SYCOM PUMPInq Rocort - PjQe I
4
5
6
7
8
9
10
Benchmark
Elevation
4
SOIL PROFILE & PERCOLATION
TEST DATA
North Andover,
Mass. Street No
ele, s sa a, e_�
lot No
5
Loc/Subdiv.
6
Pland
Owner
Investigator
%778- :51?_1o03
Observer
!!�t L,63
7
Start 'Test -T, e
7
;11ae>
8
SOIL PROFILE DATES
Drop of Y -Time
l_'Elev
2.Elev
3.Elev
4.Elev
Drop of 61' -Time
67/Z /93
0.
0 r. p
0 77 11� 2-
0
Mins.2nd 3" Drop
b
Percolation
Ties t Test
pils
2
2
2
3
3
3
4
5
6
7
8
9
10
Benchmark
Elevation
4
4
4
5
5
6
6
7
Start 'Test -T, e
7
8
8
9
10
DATES
9
10
—Location
Datum
PERCO;.ATION TESTS
// A /., / _57A 1A,3 5-1,_183
4
5
6
7
8
9
10
-Z -
Pit Number
2 3
4
Start Saturation
Soak-Mlinutes
Start 'Test -T, e
Drop of Y -Time
Drop of 61' -Time
M6ns.lst 31' drop
Mins.2nd 3" Drop
Percolation
f( NO
Vol
),4
RECEIVED
TOWN, DEC 0 6 2005
U -A I't TOWN OF NORTH ANDOVER
SYSTT�N" POMPINQ RJ-100KI
HEALTH DEPARTMENT
7T, I I ��vm �o
�vpuc l*cjjA tj.
HA rVg� C)y 3UAVIC
Q . 14 . I
VLL 11) VQ
UAY7
KOM.:
1sXQU$ry3
MMEXPLAI)q
r
a�o
;r