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BEGIN INSPECTION
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Commonwealth of Massachusetts
Title 5 Official Inspection Form�`
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
290 Barker street
Property Address
Patrick Linbquist
Owner's Name
North Andover
City[Town
Ma 01886
State Zip Code
Y
October 7,2015
Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. General Information
1 Inspector:
NOV 2 3
John
2015
DiVincenzo
Name of Inspector
TOWN OF NORTH ANDOVER
Stewarts Septic Serive
HEALTH DEPARTMENT
Company Name
58 South Kimball street
Company Address
Bradford
MA
01835
City[Town
State
Zip Code
978-372-7471
S113386
Telephone Number
License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
Z Passes El Conditionally Passes F� Fails
Needs Further Evaluation by the Local Approving Authority
Date
In 1,"ture'
T�e system inspector shall submit a copy of this inspection report to the Approving Authority (Board
o Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 1 of 17
Owner
information is
required for every
page.
Commonwealth of Massachusetts
t e 5 Official Inspection Form
si
Sub urface Sewage Disposal System Form - Not for Voluntary Assessments
290 Barker street
Property Address
Patrick Linbquist
Owner's Name
North Andover
Cityrrown
B. Certification (cont.)
Ma 01886 October 7,2015
State Zip Code Date of Inspection
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes:
ER I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
n Y F1 N El ND (Explain below):
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17
a
Owner
information is
required for every
page.
Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
W
MLM
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
290 Barker street
Property Address
Patrick Linbqui
Owner's Name
North Andover
City/Town
Ma 01886
State Zip Code
October 7,2015
Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. General Information
r- C-2- I V va- D
Inspector: NOV 2 3 2015
John DiVincenzo
E)WN �IQOTH A NlnoVFR
Name of Inspector HEALTI-I'DEPARTMENT
Stewarts Septic Serive
Company Name
58 South Kimball street
Company Address
Bradford
City/Town
978-372-7471
Telephone Number
B. Certification
MA
State
S113386
License Number
01835
Zip Code
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
F-1 Passes 0 Conditionally Passes F� Fails
El Needs Further Evaluation by the Local Approving Authority
g - — It/-7/15-
Inspeiror's Signature Date
Tht- system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DER The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 1 of 17
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
290 Barker street
Property Address
Patrick Linbquist
Owner's Name
North Andover Ma 01886 October 7,2015
CityrTown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes:
El I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
El Y F1 N El ND (Explain below):
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
290 Barker street
Property Address
Patrick Linl��
Owner's Name
North Andover
CityfTown
B. Certification (cont.)
Ma 01886
State Zip Code
October 7,2015
Date of Inspection
El Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
El Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if (with approval of Board of Health):
El broken pipe(s) are replaced
El obstruction is removed
El Y 0 N El ND (Explain below):
El Y [I N El ND (Explain below):
0 distribution box is leveled or replaced Z Y El N F] ND (Explain below):
Dist box leakinci around outlet inverts.
F-1 The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if (with approval of the Board of Health):
broken pipe(s) are replaced El Y F1 N [I ND (Explain below):
obstruction is removed 0 Y El N 0 ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
El Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(l)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
El Cesspool or privy is within 50 feet of a surface water
El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 3 of 17
<�\ Commonwealth of Massachusetts
q..- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
290 Barker street
Property Address
Patrick Linbquist
Owner Owner's Name
information i's North Andover Ma 01886 October 7,2015
required for every
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
D The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
El The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
El The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
El The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes
No
E]
z
Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
El
0
Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El
M
Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2day flow
t5ins - 3/13
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17
The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
E-] M The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CM R 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the
questions in Section D.
Yes No
El El the system is within 400 feet of a surface drinking water supply
El El the system is within 200 feet of a tributary to a surface drinking water supply
FJ El the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area — IWPA) or a mapped Zone 11 of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CIVIR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17
Commonwealth of Massachusetts
Title 5
Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
290 Barker street
Property Address
Patrick Linbquist
Owner
information i's
Owner's Name
required for every
North Andover
Ma 01886 October 7,2015
page.
City/Town
State Zip Code Date of Inspection
B. Certification (cont.)
Yes
No
Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
El
0 Any portion of the SAS, cesspool or privy is below high ground water elevation.
0
E Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
El
0 Any portion of a cesspool or privy is within a Zone 1 of a public well.
El
E Any portion of a cesspool or privy is within 50 feet of a private water supply well.
El
E Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
E-] M The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CM R 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the
questions in Section D.
Yes No
El El the system is within 400 feet of a surface drinking water supply
El El the system is within 200 feet of a tributary to a surface drinking water supply
FJ El the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area — IWPA) or a mapped Zone 11 of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CIVIR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
290 Barker street
Property Address
Patrick Linbquist
Owner Owner's Name
information i's North Andover Ma 01886 October 7,2015
required for every
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate.' yes" or "no" as to each of the following:
Yes No
Z El Pumping information was provided by the owner, occupant, or Board of Health
El N Were any of the system components pumped out in the previous two weeks?
10 0 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?
0 El Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
Z El Was the facility or dwelling inspected for signs of sewage back up?
Z El Was the site inspected for signs of break out?
N El Were all system components, excluding the SAS, located on site?
Z El
Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
Z 1:1
Was the facility owner (and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
Z El
Existing information. For example, a plan at the Board of Health.
Z El
Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440
t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
290 Barker street
Property Address
Yes
[]
No
El
Patrick Linbquist
El
No
El
Yes
Owner Owner's Name
No
information is
required for every North Andover Ma 01886
October 7,2015
page. Cityfrown State Zip Code
Date of Inspection
D. System Information
Description:
Number of current residents:
4
Does residence have a garbage grinder?
M
Yes
El
No
Is laundry on a separate sewage system? (Include laundry system inspection
Yes
M
No
information in this report.)
Laundry system inspected?
Yes
El
No
Seasonaluse?
El
Yes
M
No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump?
Last date of occupancy:
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present?
Industrial waste holding tank present?
Non -sanitary waste discharged to the Title 5 system?
Water meter readings, if available:
Gallons per day (gpd)
El Yes 0 No
Occupied
Date
El
Yes
[]
No
El
Yes
El
No
El
Yes
El
No
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17
<C\ Commonwealth of Massachusetts
J; Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
290 Barker street
Property Address
Patrick Linbquist
Owner Owner's Name
information i's
required for every North Andover Ma 01886
page. Cityrrown State Zip Code
D. System Information (cont.)
Last date of occupancy/use: Date
Other (describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
gallons
Type of System:
0 Septic tank, distribution box, soil absorption system
El Single cesspool
El Overflow cesspool
El Privy
October 7,2015
Date of Inspection
LE111110111051110.
El 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
E] Tight tank. Attach a copy of the DEP approval.
El Other (describe):
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
290 Barker streei
Property Address
Patrick Linbquist
Owner Owner's Name
information is
required for every North Andover Ma 01886 October 7,2015
page. CityfTown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site?
Building Sewer (locate on site plan):
Depth below grade:
Material of construction:
Z cast iron [140 PVC other (explain):
Distance from private Wntimir --" I %mall r%r c"Mir%n linz*
X]1111�04�
26-1
feet
111` 7 feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
Z concrete El metal
1211
feet
El fiberglass [:1 polyethylene El other (explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate)
Dimensions:
Sludge depth:
0 Yes El No
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
290 Barker street
Property Address
Patrick Linbquist
Owner Owner's Name
information i's
required for every North Andover Ma 01886
page. City/Town State Zip Code
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
30"
6"
1711
October 7,2015
Date of Inspection
How were dimensions determined? Tape measure & sludge judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Both baffles good no leakage. liquid level good no leakage.
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
0 concrete El metal
Dimensions:
Scum thickness
feet
El fiberglass [:1 polyethylene F� other (explain):
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
t5ins - 3/13
Date
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
290 Barker street
Property Address
Patrick Linbquist
Owner Owner's Name
information is
required for every North Andover Ma 01886
page. CityfTown State Zip Code
October 7,2015
Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
El concrete El metal El fiberglass El polyethylene El other (explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: El Yes F No
Alarm level: Alarm in working order: Yes N o
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
* Attach copy of current pumping contract (required). Is copy attached? El Yes El No
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17
:)wner
nformation is
,equired for every
:)age.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
290 Barker street
Property Address
Patrick Linbqu
Owner's Name
North Andover
City/Town
D. System Information (cont.)
Un
OWLU
01886 October 7,2015
Zip Code Date of Inspection
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
I
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Box needs replacing leakage around outlet inverts cracked on both sides
Pump Chamber (locate on site plan):
Pumps in working order:
El
Yes
El
No*
Alarms in working order:
El
Yes
El
No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17
(z
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
290 Barker street
Property Address
Patrick Linbquist
Owner Owner's Name
information is
required for every North Andover
Ma
01886 October 7,2015
page. City[Town
State
Zip Code Date of Inspection
D. System Information (cont.)
Type:
E]
leaching pits
number:
11
leaching chambers
number:
El
leaching galleries
number:
leaching trenches
number, length:
leaching fields
number, dimensions: 1-18'X60'
E]
overflow cesspool
number:
11
innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
No hydraulic failure ng ponding no damp soils.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth — top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow
t5ins - 3/13
El Yes 0 No
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Pacle 13 of 17
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
290 Barker street
Property Address
Patrick Linbquist
Owner's Name
North Andover
CityrTown
D. System Information (cont.)
Ma 01886 October 7,2015
State Zip Code Date of Inspection
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 17
Big
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
290 Barker street
Property Address
Patrick Linbquist
Owner Owner's Name
information is
required for every North Andover Ma 01886
page. Cityrrown State Zip Code
October 7,2015
Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
hand -sketch in the area below
drawing attached separately
t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17
gt,\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
290 Barker street
Property Address
Patrick Linbquist
Owner Owner's Name
information i's
required for every North Andover Ma 01886 October 7,2015
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
Z Check Slope
0 Surface water
0 Check cellar
El Shallow wells
Estimated rJonth tr) hi h rn"nrI %Ainfizrm
4'
U U feet
Please indicate all methods used to determine the high ground water elevation:
R-55
I
Obtained from system design plans on record
If chorkinri rinfiz rif Amci n Inn rovizimizHe
5/25/94
I U v Date
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health - explain:
Pulled files
0 Checked with local excavators, installers - (attach documentation)
El Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
Bottom of systems @ elevation 97.33 water at elevation 94.0 system above water table.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17
k
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
290 Barker street
Property Address
Patrick Linbquist
Owner Owner's Name
information is
required for every North Andover Ma 01886
page. City/Town State Zip Code
E. Report Completeness Checklist
October 7,2015
Date of Inspection
JZ Inspection Summary: A, B, C, D, or E checked
Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
System Information — Estimated depth to high groundwater
Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17
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SUBSURFACE DISPOSAL SYSTEM
LOCATED IN
Oov'Ti'i
AS REPARED MR go 57,
l::.Iu 1 -1-1 1--V L- k5 t�- 1-4 �2V �j
DATE: Puy -2c2 , le -1,944
SCALE: I I,- +o'
rt -4
MERRIMACK ENGINEERING SERVICES, INC.
PROFESSIONAL ENGINEERS 0 LAND SURVEYORS 0 PLANNERS
66 PARK STREET ANDOVER, MASSACHUSETTS 01110 Or TEL (617) 475-3555. 373-5721
I
PUBLIC HEALTH DEPARTMENT
Town of North Andover
Community Development Division
CERTIFICATE OF
COMPLIANCE
As of.- 10/28/15
This is to certify that the individual subsurface disposal system received a
SATISFACTORY INSPECTION of the:
Repair of D -Box
By: John DiVincenzo
At:
290 Barker Street
Map 061.0 Lot 0029
N, r
0, th Andover, MA 01845
of this 6 rtific sh(all not be construed as a* guarantee that the system will function satisfactorily.
00
Michele Grant
Public Health Agent
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fox 978.688.8476 Web www.townofnorthandover.com
North Andover Health Department
(ommunity and Economic Development Division
QNSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: 290 Barker St. MAP: 061.0 LOT: 0029
INSTALLER: John DiVincenzo
DESIGNER:
PLAN DATE:
BOH APPROVAL DATE ON PLAN:
INSPECTIONS
D -Box INSPECTION: ID 'c�� 1 0
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
Comments:
SEPTIC TANK
Contractor reports any changes to des�ign plan
�xisting septic tank properly abandonedj
internal plumbing all to one building sewer
Topography not appreciably altered
Building sewer in continuous grade, on
compacted firm base
F-1 Cleanouts per plan
F-1 Bottom of tank hole has 6" stone base
Weep hole plugged
1500 gallon tank has been installed
H-10 loading
Monolithic tank construction
Water tightness of tank has been achieved by
visual testing
Inlet tee installed, centered under access port
H-20 D -Box
Inlet tee (if pumped or >0.08'/foot)
Hydraulic cement around inlet & outlets
Observed even distribution
Speed levelers provided (not required)
Schedule 40 PVC Pipe
a 4�'Q-
Comments:
0,6
V� 0 P � N \�) �L
,VAL d� u4n 1- 4 "'-1 � 0- 'd 3��
El
Outlet tee installed, centered under access port
(gas baffle/effluent filter)
inch cover to within 6" of finish grade
installed over one access port
F-1
Hydraulic cement around inlet & outlet
Comments:
PUMP CHAMBER
El
Bottom of tank hole has 6" stone base
El
Weep hole plugged
F1
1500 gallon Pump Chamber installed
H-10 loading
Monolithic tank construction
Inlet tee installed, centered under access port
F1
Pump(s) installed on stable base
R
Alarm float working
F1
Pump On/Off floats working
Separate on/off floats
Drain hole in pressure line
El
cover at final grade installed over pump
access port
F1
Water tightness of tank has been achieved by
testing
Hydraulic cement around inlet & outlet
Comments:
CONTROLIPANIEL
F1
Alarm & Pump are on separate circuits
Alarm sounds when float is tripped
Location of control panel: basement
F1
Alarm signal located inside: basement
Comments:
DISTRIBUTION -BOX
Installed on stable stone base st'L-�
H-20 D -Box
Inlet tee (if pumped or >0.08'/foot)
Hydraulic cement around inlet & outlets
Observed even distribution
Speed levelers provided (not required)
Schedule 40 PVC Pipe
a 4�'Q-
Comments:
0,6
V� 0 P � N \�) �L
,VAL d� u4n 1- 4 "'-1 � 0- 'd 3��
Commonwealth of Massachusetts Map -Block -Lot
061.00029
-----------------------
BOARD OF HEALTH Permit No
North Andover - BHP -2015-08 - 81 ----
--------------- --
-----------------------
P.I. FEE
F.I. $125.00
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted -John-DiVincenzo
to (Repair) an Individual Sewage Disposal System.
atNo - 2-9-0- BARKER -STREET
as shown on the application for Disposal Works Construction Permit No. BBP-2015-088 Dated October 09, 2015
---------- --------
Issued On: Oct -09-2015
---------------------------------
Commonwealth of Massachusetts
-BOARD 0 HEALTH
North An ver
Tj
E RR IFI E MPLI
T
TO CER Y That th dividua Sewage isposal Sys
by .__Joft DiVi
OF HEALTH
(Repair)
Map -Block -Lot
061.00029
-----------------------
at No -M�K \j
`99 �j ------------------------
Iled i acc dance with the provisions of TITLE 5 of the State
has been. ista nvirolh e tal Code as described in the
spos Dated October 09, 2015
application for Di os orks Construction Permit No. -BB-P-2-01-5---088--
Printed On: Oct -09-2015
- ------------------------------------------------- BOARD OF HEALTH
Commonwealth of Massachusetts Map -Block -Lot
061.00029
BOARD OF HEALTH -----------------------
Permit No
North Andover BHP -2015-0881
-----------------------
FEE
$125.00
-----------------------
DISPOSAL WORKS CONSTRUCTION PERMIT
Pdrmission is hereby granted John-DiVincenzo ------------------------------------------------------------------------------------
to (Repair) an Individual Sewage Disposal System.
at No 290 BARKER STREET
----------------------------------------------------------------------------------------------------------------------------------------------------------
as shown on the application for Disposal Works Construction Permit No. BBP-2015-088,D ed OctoberO9,2015
--------------
-------------- I ---------------
----------- -- ---------------
Issued On: Oct -09-2015
- ------------------------------------------------------------------------------ BOARD OF HEALTH
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
VQ
Application for Septic Disposal System
0 il RU4 ill i
Application is hereby made for a permit to:
El Construct a new on-site sewage disposal system*
El Repair or replace an existing on-site sewage disposal system*
Ve"p'air or replace an existing system component — What? A
A. Facil
n
0;/ flo Zely
Aaress or Lot #
A PIZ dejy_t
City/Town
i /
TODAY'S DATE
$ 250.00 — Full Repair
$125.00 - Component
2.- *TYPE OF SEUIC SYSTEM*:
> E]Pump -M Gravity (choose one)
***If pump system, attach copy of electrical permit to application***
> Conventional System (pipe and stone system)
> Infiltrator or Biodiff user (Gravel -Less) (Attach a copy of your certification to install this type of system.)
> Pressure Distribution S.A.S. (No D -Box)
> El Pressure Dosed (D -Box Present) S.A.S.
> E] Does the system require an effluent filter? Yes No w"_
17!
If yes, does plan specify make and model of flitter? YES = (no further info. nee5ed)
NO = (installer must specify brand of filter before DWC issuance) OCT G 9 Z015
What is the Make? Wbat is the Model?
2. Owner In
C K Z I/-.,
- 0V 6/ly
Address (if diffe�ent from
12� il�L
State
ToWji CF NORTH AtICOVER
HEALTH DEPART',vIENT
Zip Code
Email address Telephone Number
3. Installer, Information
:To__I�') / 4 r :� �<
Name Name df Company
Addr;�,
az :?�:3
City/Town State M?_
017-90(l)
Telephone - Number (Cell Phone # if possible please)
4. Pesi-piner Information
Name Name of Company
Address
City/Town State Zip Code
Telephone Number (Best # to Reach)
Application for Disposal System Construction Permit - Page 1 of 2
h
V WA'J
"Is GILA
PAGE 2 OF 2
A. Facility Information continued....
5. Type of Building,: DResidential Dwelling or E]Commercial
B. Agreement
TODAY'S DATE
$ 250.00 - Full Repair
$125.00 - Component
The undersigned agrees to ensure the construction and maintenance of the afore -described
o, 't
n'si elsewage disposal system in accordance with the provisions of Title 5 of the
Env' e Co9ve) as well as the Local Subsurface Disposal Regulations for the Town of
N or ir 0
t A d ri I Ond that until a final Certificate of Compliance has been issued by
is 01
th rd 7Hea=stalled system is not approved.
Date
Representative
I )
— 0
Date
Application Disapproved for the following reasons:
For Office Use Only:
_V/
1. FeeAttached? Yes No
Ye
2. Project Manager Ohligation Form Attacbed? YesV No
3. Pump Svs P If so, Attach copy ofElectrical Pennit Yes No
Applicant received copy of
"Electrical Inspection Notes for Septic Systems" Yes No
HandoutP
4. Reviewed approval letter, aflpaperworkreceived? Yes No
Mis *
.5. Foundation As-BuiltP (new construction only):
(Same scale as approvedplan) ,
Yes No
6. Floor Plans? (new construction only): Yes No
Application for Disposal System Construction Permit - Page 2 of 2
SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
e) 6,1 r I ker- 51—
(Address of septic system)
Relative to the applicationof
(Installer's name)
Dated /Iozey LJK:
f �4oday's date)
For plans by
And dated
With revisions dated
I understand the following obligations for management of this project:
(Engineer)
(Original date)
(Last revised date)
1. As the installer, I am obligated to obtain all permits and Board of Health approved plans p1lior to
performing any work on a site. I must have the approved 121ans and the perajit on site when any work is
being done.
2. As the installer, I must call for any and all inspections. If homeowner, contractor, project manager, or any
other person not associated with my company schedules an inspection and the system is not ready, then
item three shall be applicable.
3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as
indicated below. I understand that requesting an inspection, without completion of the items in accordance
with Title 5 and the Board of Health lieg�Lations mgj result in a $50.00 fine being levied aanst me and/or
my compay.
a. Bottom of Bed — Generally, this is the first (1'� inspection unless there is a retaining wall, wl-�ich
should be done first. The installer must request the inspection but does not have to be present.
b. Final Construction Inspection — Engineer must first do their inspection for elevations, ties, etc.
As -built of verbal OK (or e-mail to: healthdel2t@to-,vnofnorthandover.co from the engineer must
be submi*tted to the Board of Health, after which installer calls for an inspection time. Installer must
be present for this inspection. With a pump system, all electrical work must be ready and able to
cause pump to work and alarm to function.
c. Final Grade — Installer must request inspection when all grading is complete. Installer does not
have to be on-site.
4. As the installer, I understand that only I may perform the work (otber than simple excavation) and I am required
to complete the installation of the system identified in the attached application for installation. I further
understand that work done by others unlicensed to install septic systems in North Andover can constitute
reasons for denial of the system and/or revocation or suspension of m): license to operate in the Town of
North Andover, sig!1ificant fines to all persons involved are also possible.
5. As the installer, I understand that I must be on-site during the performance of the following construction
s teP s:
a. Determination that theproper elevation of the excavation has been reached.
b. Inspection of the sand and stone to be xsed.
c. Final inspection by Board of Health staff or consaltant.
d. Installation of task, D-Boxpipes, stone, vent, pmmp chamber, retaining wall and other
Components.
6. As the installer, I understand that I am solel-y responsible for the installation of the system as er the
-P
approved plans. No instructions by the homeowner. ggeneral contractor, or any other persons shall absolve
.me of this obligation.
Undersigned Licensed Septic Installer: (Today'f Dat�)
17
— ;Q) 0 L V I V) 'i \ cz—A-1
ame —
Ceommonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
290 Barker St
I --V-Y ---
ATy Lindq)�Lst
Owner Owner's Name
information i's
required for North Andover
every page. City/Town
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
41f,
Y1
Ma 01845
St-ate —Zip Code
5/23/2011
Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. General Information
1. Inspector:
John DiVincenzo
Name of Inspector
Stewart Septic Service
Company Na�e
58 South Kimball
Company Address
Bradford
City/Town
978-372-7471
Felephone Number
B. Certification
LE
State
S113386
License Number
01830
Zip Code
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
0 Passes F Conditionally Passes F-1 Fails
eds Furftr 7Evalua ion by the Local Approving Authority
/ '. t , __
5/23/2011
,or's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DER The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system wilLp-erform in the future under
the same or different conditions of use.
15ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 1 of 17
Owner
information is
required for
every page,
'Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
290 Barker St
F I UPC[ LY MUUIC55
!�my nd vist
Owner's Name
North Andover
Gityl-rown
B. Certification (cont.)
Ma 01845
State Zip Code
5/23/2011
Date of Inspection
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes:
Z I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
13) System Conditionally Passes:
El one or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
n Y 0 N El ND (Explain below):
15ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17
<L
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
290 Barker St
B. Certification (cont.)
B) System Conditionally Passes (cont.):
5/23/2011
Date of Inspection
El Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if (with approval of Board of Health):
El broken pipe(s) are replaced
0 obstruction is removed
EJ Y El N 0 ND (Explain below):
F-1 Y n N El ND (Explain below):
0 distribution box is leveled or replaced El Y E-1 N 0 ND (Explain below):
El The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if (with approval of the Board of Health):
F-1 broken pipe(s) are replaced El Y 0 N El ND (Explain below):
obstruction is removed El Y El N F-1 ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
El Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(l)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
El Cesspool or privy is within 50 feet of a surface water
[I Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 3 of 17
r1uperty moaress
AMy Lindqvist
Owner
Owner's Name
information is
required for
North Andover Ma 01845
every page,
C ityrrown State Zip Code
B. Certification (cont.)
B) System Conditionally Passes (cont.):
5/23/2011
Date of Inspection
El Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if (with approval of Board of Health):
El broken pipe(s) are replaced
0 obstruction is removed
EJ Y El N 0 ND (Explain below):
F-1 Y n N El ND (Explain below):
0 distribution box is leveled or replaced El Y E-1 N 0 ND (Explain below):
El The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if (with approval of the Board of Health):
F-1 broken pipe(s) are replaced El Y 0 N El ND (Explain below):
obstruction is removed El Y El N F-1 ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
El Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(l)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
El Cesspool or privy is within 50 feet of a surface water
[I Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 3 of 17
Owner
information is
required for
every page.
'Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
290 Barker St
r- 1 Uyvi ty MUU I Ubs
Amy_�i�ndqvist
Owner's Name
North Andover
Cityrrown
b. Gertification (cont.)
Ma 01845
State Zip Code
5/23/2011
Date of Inspection
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
El The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
El The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
El The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
F� The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes
No
E]
z
Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
El
0
Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El
0
Liquid depth in cesspool is less than 6" below invert or available volume is less
than % day flow
t5ins - 11 /10
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the
questions in Section D.
Yes No
El El the system is within 400 feet of a surface drinking water supply
El El the system is within 200 feet of a tributary to a surface drinking water supply
El El the system is located in a nitrogen sensitive area (interim Wellhead Protection
Area — IWPA) or a mapped Zone 11 of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins - 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17
Commonwealth of Massachusetts
Title 5
Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
290 Barker St
Property Address
Amy Lind vist
Owner
information is
Owner's Name
required for
North Andover
Ma 01845 5/23/2011
every page.
City[Town
State Zip Code Date of Inspection
B. Certification (cont.)
Yes
No
El
Z Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped: .
El
Z Any portion of the SAS, cesspool or privy is below high ground water elevation.
E]
0 Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
El
E Any portion of a cesspool or privy is within a Zone 1 of a public well.
El
Z Any portion of a cesspool or privy is within 50 feet of a private water supply well.
El
Z Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
1:1
z The system is a cesspool serving a facility with a design flow of 2000gpd-
1 0,000gpd.
1:1
z The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the
questions in Section D.
Yes No
El El the system is within 400 feet of a surface drinking water supply
El El the system is within 200 feet of a tributary to a surface drinking water supply
El El the system is located in a nitrogen sensitive area (interim Wellhead Protection
Area — IWPA) or a mapped Zone 11 of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins - 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17
I
'Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
290 Barker St
Property Address
Amy Lt4)�ist
)wner Owner's Name
nformation is
equired for North Andover Ma 01845 5/23/2011
very page. City/Town -
State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
0 11
Pumping information was provided by the owner, occupant, or Board of Health
El
Were any of the system components pumped out in the previous two weeks?
0
Has the system received normal flows in the previous two week period?
F
Have large volumes of water been introduced to the system recently or as part of
this inspection?
N F-]
Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
El
Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
Were all system components, excluding the SAS, located on site?
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,
r
dimensions, depth of liquid, depth of sludge and depth of scum?
Was the facility owner (and occupants if different from owner) provided with
e
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
Existing information. For example, a plan at the Board of Health.
Yes No
0 11
Pumping information was provided by the owner, occupant, or Board of Health
El
Were any of the system components pumped out in the previous two weeks?
0
Has the system received normal flows in the previous two week period?
F
Have large volumes of water been introduced to the system recently or as part of
this inspection?
N F-]
Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
El
Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
Were all system components, excluding the SAS, located on site?
Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
Was the facility owner (and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
Existing information. For example, a plan at the Board of 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 CIVIR 15.203 (for example: 110 gpd x # of bedrooms): 440
t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17
'Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
290 Barker St
5/23/2011
Date of Inspection
Number of current residents: 5
Does residence have a garbage grinder?
Property Ad�_res_s
Yes
Amy Lindqvist
LLcAl__
Owner
Owner's Name —
information is
Yes
required for
-North Andover Ma 01845
every page.
City/Town State Zip Code
Yes
D. System Information
No
Description:
5/23/2011
Date of Inspection
Number of current residents: 5
Does residence have a garbage grinder?
0
Yes
0
No
Is laundry on a separate sewage system? [if yes separate inspection required]
El
Yes
Z
No
Laundry system inspected?
El
Yes
N
No
Seasonaluse?
El
Yes
0
No
Water meter readings, if available (last 2 years usage (gpd)):
74
GPD
Detail:
Water meter readinqs
Sump pump?
El
Yes
0
No
Last date of occupancy:
Occu p±ed
Date
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?
El
Yes
R
No
Industrial waste holding tank present?
El
Yes
El
No
Non -sanitary waste discharged to the Title 5 system?
El
Yes
R
No
Water meter readings, if available:
15ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17
'Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
290 Barker St
Last date of occupancy/use:
Other (describe below):
Pumping Records:
Source of information:
01845 5/23/2011
Zip Code Date of Inspection
Date
General Information
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Andover Se
1500
gallons
§�Ite guage on truck
inspect tank
��M �
Type of System:
N Septic tank, distribution box, soil absorption system
El Single cesspool
E] Overflow cesspool
El Privy
E] 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):
t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17
Property Address
��-Mj
Owner
Owner's Name
information is
required for
North Andover Ma
every page.
City/Town State
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
Pumping Records:
Source of information:
01845 5/23/2011
Zip Code Date of Inspection
Date
General Information
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Andover Se
1500
gallons
§�Ite guage on truck
inspect tank
��M �
Type of System:
N Septic tank, distribution box, soil absorption system
El Single cesspool
E] Overflow cesspool
El Privy
E] 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):
t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17
Commonwealth of Massachusetts
z
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
290 Barker St
Owner
information is
required for
every page.
. —1-1 1-1—
Amy. Lindqvist
Owner's Name
orth Andover
Uty/Town
D. System Information (cont.)
Ma 01845
State Zip Code
5/23/2011
Date of Inspection
Approximate age of all components, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site?
Building Sewer (locate on site plan):
Depth below grade:
Material of construction:
X cast iron El 40 PVC El other (explain):
Distance from private water supply well or suction line:
23"
feet
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
H concrete El metal
1011
feet
El fiberglass El polyethylene El other (explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate)
Dimensions. -
Sludge depth:
EJ Yes D No
t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17
Owner
information is
required for
every page.
t5ins - 11 /10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
290 Barker St
rlupu-rty mooress
Amy_j�ingqv�ist
Owner's Name
North Andover
City/Town
U. System Information (cont.)
Septic Tank (cont.)
Ma
State
01845 5/23/2011
Zip Code Date of Inspection
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
26"
2"
7"
14"
How were dimensions determined? Slu e 'ud e, ta e measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Inlet and outlet baffles are in good condition, no structual damage, no lea qg�_
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
El concrete El metal
Dimensions:
Scum thickness
El fiberglass
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:
feet
El polyethylene El other (explain):
Date
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17
Commonwealth of Massachusetts
E— ---
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
290 Barker St
Owner
information is
required for
every page.
Property Address
Aqjy Lindqvist
Owner's Name
North Andover
City/Town
Ma 01845
State Zip Code
5/23/2011
Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
Li concrete LJ metal L -j fiberglass El polyethylene El other (explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: El Yes El N 0
Alarm level: Alarm in working order: El Yes Ej N o
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
* Attach copy of current pumping contract (required). Is copy attached? El Yes D No
t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17
W -
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
290 Barker St
AMy Lindqvist
Owner's Name
North Andover
Gity/Town
D. System Information (cont.)
Ma 01845
State Zip Code
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
I
5/23/2011
Date of Inspection
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.):
Replaced cover, no solids carryover, no leakage, D -box level qood
Pump Chamber (locate on site plan):
Pumps in working order: [I Yes F� No
Alarms in working order: 0 Yes F] No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
290 Barker St
r-rapeny Aaaress
Am
j Lindq ist
Owner's Name
North Andover
U. System Information (cont.)
Ma 01845
State Zip Code
5/23/2011
Date of Inspection
Type:
El
leaching pits
number:
11
leaching chambers
number
E]
leaching galleries
number:
El
leaching trenches
number, length:
0
leaching fields
number, dimensions:
El
overflow cesspool
number:
El
innovative/alternative system
1-18 X 60
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
No n.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth — top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow D Yes M No
t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
290 Barker St
MUPUILY MUUFeSS
Amy Lindqvist
Owner's Name
North Andover
Cityf'rown
U. System Information (cont.)
Ma 01845
State Zip Code
5/23/2011
Date of Inspection
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
290 Barker St
Property Address
AMy Lindqvist
Owner's Name
North Andover
City/Town
Ma
State
01845 5/23/2011
Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
El hand -sketch in the area below
Z drawing attached separately
15ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17
%�N - Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
0 290 Barker St
Site Exam:
E Check Slope
El Surface water
E Check cellar
El Shallow wells
01845 5/23/2011
Zip Code Date of inspection
Estimated depth to high ground water: 41
feet
Please indicate all methods used to determine the high ground water elevation:
a
I
Obtained from system design plans on record
If checked, date of design Dian reviewed:
6-24-1994
Date
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health - explain:
Went threw file
El Checked with local excavators, installers - (attach documentation)
El Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
Checked plans on file at the No. Andover B.O.H
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17
VIU[JUILY MUWIC55
Am Lindqvist
YA-1
Owner
Owner's Name
information is
required for
orth Andover Ma
every page.
City/Town State
D. System Information (cont.)
Site Exam:
E Check Slope
El Surface water
E Check cellar
El Shallow wells
01845 5/23/2011
Zip Code Date of inspection
Estimated depth to high ground water: 41
feet
Please indicate all methods used to determine the high ground water elevation:
a
I
Obtained from system design plans on record
If checked, date of design Dian reviewed:
6-24-1994
Date
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health - explain:
Went threw file
El Checked with local excavators, installers - (attach documentation)
El Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
Checked plans on file at the No. Andover B.O.H
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
290 Barker St
r-[Upeuy mouress
AtIly Lindqvist
Owner Owner's Name
information is
required for North Andover Ma 01845 5/23/2011
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
0 inspection Summary: A, B, C, D, or E checked
Z Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
0 System Information — Estimated depth to high groundwater
0 Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17
SEWEAR MAIN6S'
WATER MAINS
STORM DRAINAGE
ROADS
EouIPMENT RENTAL
ENGINEERING
i. r
Ramey Contractors - Engineers, Inc.
33 OAK KNOLL ROAD
METHUEN. MASSACHUSETTS
60'
-TE-LEPHONE
683-6791
0 CTa
9-1,3 0
OPFICIAL
COMMONWEALTH OF MASSACHUSETTS
ExECUTIVE OFFICE OF ENVIRONMENTAL AyFAlp
S
DEPARTMENT OF ENVIRONMENTAL PR O*TECTIO
rz�,E C rk---! I. .. ",
DEC 1 a 2004
TOWN OF NC �-)OVER
TITLE 5 HEALTH 11
'I' FORM — NdT FOR VOLUNTARY ASSESSMENTS
ACE SEWAGE DISPOSAL SYSTEM FORM
PARTA
CERTIFICATION
Property Address: 212��
Owner9s Name:
Owner's Addres7s.:
Date of bspection:
Name of inspector: (please print)
Company Name:
Mailing Address:
r
Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and
below is true, accurate and complete as of the ti t e o
tha th inf rma
on my
P unction and maintenance of on site sewage di Posal systems. I am a DEP
tMilling and experience in the Proper f me of the inspection- The tion reported
inspection was Performed based
2Pproved system inspector S
ursuant to Section 15340 of Title 5 (310 C74R 15.000). The system:
-,—/Passes
— Conditionally Passes
— Needs Further Evaluation by the Local Approving Authority
Fails
-7'
Inspector's Signaturq
Date:
The system inspector shall submit a COPY of this inspection report to
the Approving Authority (board of Health or
DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the
DER The original should be sent to the system owner and copies sent,to t e buyer, if applicable, and the approving
authority. h
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.
Title 5 Inspection Form 6/15/20oo page I
Page 2 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: ?
IC........................ . ..
Owner: 0 k--S-Y
Date of Inspection:
Inspection Summary: Check A,.B,C,D or E /AL.WAyS complete all of Section D
A. System Passes:
-Z, have not found any information which indicates that any of the failure criteria des cribed in 3 10 CMR
15.303 or in 3 10 CMR 15.304 exist Any failure criteria not evaluated are indicated below.
Comments: A
B. System Conditionally Passes:
One or more system components as described in the "Conditional Pass" section need to be replaced or
repaired- The sYstenk upon completion of the replacement or repair, as approved by the Board of Health, will pass.
Answer Yes, no or not detennined (YN,ND) in the
explain. for the following statements. If "not determined� please
The septic tank is metal and over 20 years old* or the septic tank (whe met or not) is structuraIly
iltration or tank failure is imminent. System w
unsound, exhibits substantial infiltration or exf ther al
existing tank is replaced with a complying septic tank as approved by the Board of Health. ill Pass inspection if the
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
— Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
— broken pipe(s) are replaced
— obstruction is removed
— distribution box is leveled or replaced
ND explain:
— The system required Pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
Pass inspection if (with approval of the Board of Health):
— broken pipe(s) are replaced
— obstruction is removed
ND explain:
T;"l' 'q ["O��t;^n P^� r%n ;/,)nnn
Page 3 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
C. Further Evaluation is Required by the Board of Health:
- Conditions exist which require flulher evaluation by the Board of Health
is failing to protect public health, safety or the environment. in order to determine if the system
System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b) that the
System is not functioning in a manner which will protect public health, safety and the environment:
— Cesspool or privy is within 50 feet of a surface water
— Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the
system is functioning in a manner that protects the public health, safety and environment:
— The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone I of a public water supp . ly.
Ile system has a septic tank and SAS and the SAS is within 50 feet of a private water supply weH.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well**. Method used to determine distance
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 PPM Provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this forlm
A113. Other:
'r;#1. 'Z r-� 411
! % Page 4 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: ?2 jo - /' 5 �r
AJ- 7 Y
Owner: S
Date of Inspection:
. -7 —CILI
D- System Failure Criteria applicable to all systems:
You must indicate "yes" or "no" to each of the following for all inspections:
Yes 1%ackup of sewage into facility or system cOmPonent due to overloaded Or clogged SAS or cesspool
Dischuge Or POnding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above Outlet invert due to an overloaded or clogged SAS or
cesspool
Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow
Required pumping more dian 4 times in the last year MOT due to clog ed or obstru Number
of times pumped _. 9 cted pipe(s).
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 wen.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
led laboratory, for conform bacteria and volatile organic compounds
performed at a DEP certif H a a, s
supply well with no acceptable water quality analysis. [This system passes if the we w ter an ysi ,
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 P*Pm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.)
(Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 da 15.303, therefore the system fails. Ile system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
' E. Large Systems:
To be considered a large system the system must serve a facility with a design flow Of 10,000 gpd to 15,000
gpd.
You must indicate either "yes" or "no" to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped
Zone 11 of a public water supply well
If you have answered "yes" to any question in Section E the system is consid
14 ered a significant threat� or answered
yes" in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 3 10 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
17— 4/iz/,)nAA 4
Page 5 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner:
Date of nspection:
Check if the
Yes No
V/-
- -Z
have been done. You must indicate ",
or I.noll as to each of the
Pumping information was provided by the owner, occupant� or Board of Health 41�11014111e5� 001W—
re any of the sy . stem 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 built plans of the system obtained and examined? (If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up ?
Was the site inspected for signs of break out ?
Were all systern co one— 1 .4
u ing e SAS, located on site ?
Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition
of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ?
r vi
Was the facility owner (and Occupants if different f Om Owner) pro ded with information on the roper
maintenance of subsurface sewage disposal systems ? P
Ile size and location of the SOB Absorption System (SAS) on the site has been determined based on:
Yes no
Existing information. For example, a plan at the Board of Health.
Determined in the field (if any of the failure criteria related to Part C is at i sue approx on of ce
is unacceptable) [3 10 CMR 15.302(3)(b)] s imati distan
Page 6 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner: - le -s ,Oco I I
Date of Inspection: j,7
:: v
RESIDENTIAL �OW CONDITIONS
Number of bedrooms (design): 4' Number of bedrooms (actual):
DESIGN flow based on 3 15 CMI -15.203 (for example: 110 gpd x # of bedrooms):
Number Of current residents:
Does residence have a garbage grinder (yes or . no):
Is laundry on a Separate sewage system (yes or no):AL4�._ (if yes separate inspection required)
Laundry system inspected (yes or no)o
Seasonal use: (yes or no): ,j 0 t �
Water meter readings, if available (last 2 Years usage (gpd)): ZL
Sump Pump (yes or no): 4,v
Last date of Occupancy- -7�s-enil�
COMMERCIAL/MUSTRIAL
Type of establishment:
Design flow (based on310 UF1 �.2?3)--�� _gpd
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:
Last date Of Occupancy/use:
OTHER (describe):
Puniping Records GENERAL INFORMATION
Source of information:
Was system pumped as part of Zins*ction fy�e �®rna�l--,U,,, �'7�
If yes, volume pumped: allons — How was quantity Pumped determined?
Reason for pumping: -----------
TYIP�E OF SYSTEM
--L/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/Altemative technology. Attach a copy of the current operation and main nan
obtained firoin system owner) te ce contract (to be
— Tight tank _ Attach a copy of the DEP approval
Other (describe):
Approximate age Of all components, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site (yes or no): —z,16)
T;t'" r�- 4/1;/,,nAA
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: fo /3" - —
Owner: Y-S�
Date of Inispection:
/ /,^GHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan
Depth below grade:
Material of construction: —concrete --metal _fiberglass ---Polyethylene —other(explain):
D isions:
Capacity: llons;
Design Flow: gallons/day
Alarm presentTy—es or �no)- —
Alarm level: Alarm in working order (yes or no):
Date of last pumpmg:
Comments (condition �fi —alarm and float switches, etc.):
DISTRIBUTION BOX: V<
(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments (note if box is level and distri
leakage into or out of box, rc.): bution to outlets equal, any evidence of solids carryover, any evidence of
I . A , - I
/(/�PUMP CHAMBER: (locate on site plan)
Pumps in worldng order (yes or no):
Alarms in working order (yes or no):
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
'r;*'. ' T'c--t;A- JZ- A/I'C/)AAA
Page 7 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
SYSTEM IN PART C
Property Address: i FORMATION (continued)
134 e r S T
v-er nr-
Owner:
Date of I
nsPection: -7 U
13UILDING SEWER (locate on site plan)
Depth below grade:
Materials of construction:
—Cast iron V" 40 PVC -- other (explain):
Distance from Private water supply well—
Comments (on condition ofjoints, ven Or suction line:
tingg evidenc
e of leaka e, etc.):
SEP77C TANK 'Zoocate on site plan) Z55-11 --------
Depth below grade:
Material. of construction.
—Other(explajn),,111,, . -4-econcrete —metal _fiberglass __Polyethylene
If tank is metal Lis ....................... ..... .....
t age: l�� ........... .......................
age ccq,j .. te f
certificate) 61med by
Dimensions: 'np ance (yes or no (attach a copy of
Sludge depth:
Distance from �Oftom of �Outlet �tee or baffle:
V 11
Scum thickness,
Distance fro
rorn bottom of Scum to bottom 0 e or baffle:
Distance f m top O'Scurn to top Of outlet te
f outlet tee or baffle -
How were dimensions determined:
CorannienIs ((on PunVing recommend! - �s, �H
at'Ons, inW91et and �Ou6let t 0 affle condition, structural integrity,
as related to outlet invert, evidence of leakage, tc.): liquid levels
11VWGREASE TRAP:
—(locate on site plan)
Depth below grade:
Material of construcZ—n-
(explain): —concrete —metal _fiberglass
Dimensions: --Polyethylene _Other
Scum thickne7s7---
Distance from to----�
Di I stance P of scurn to top Of outlet tee or baffle:
Date of lafrom bottom Of Scum to bottom Of outlet tee o
st Punipmg: i1affle.
Comments (o ----
n Pumping recommendations, inlet and outlet tee or baffle condition, structural
as related to outlet invert, evidence of leakage, etc.): Integrity, liquid levels
� 'r;tf- ; r-' 41 iz"')nnn
Page 9 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SU13SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: f- r
ff 60rAft
±ttz --�
Owner: C
41"�-
Date of Inspection: 'L --
SOIL ABSORPTION SYSTEM (SAS): zoocate on site plan, exC2V2tion not required)
If SAS not located explain why:
Type
leaching pits, number
— leaching chambers, number
— leaching galleries, number.-
- leaching trenches, number, length:
leaching fields, number, dimensions:
Overflow cesspool, number:
innovativetalternative system TyPe/name of technology:
Comments (note condition of soil, signs of hydraulic failure, le I Of Pondina. dam qnil
etc.):
Depth - top of li --
quid to ini , ert:
Depth of solids layer. - ---------------
Depth of scum layer
Dimensions of cesspool:
Materials of construction -:---------
Indication of groundwa infl -
ter kyes or no):
Cotriments (note condition Of soil, signs of hydraulic failure, level of Ponding, condition of vegetation, etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments (note —con—ditio—nof �soij, signs of hydraul ic failure, level of ponding, condition of vegetation, etc.):
------------
E
13
Page 10 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE D1SPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 2-1 Q g, C- <--,.I
r
Owner A
-C,�,Jp � ka 1-4,,
Date of Inspection: --- /z -2
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 ebters the building.
14.4 koalS-11,3
A, 1- 0 0 �
6Y -5- /
7
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Page 11 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL
SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property jAduddress: f7j
Owner: .4 YY
Date of Inspection:
SrrE EXAM
Slope -3-1 ve
-j-/
Surface water
A,>
Check cellar
Shallow wells
Estimated depth to ground water &Z feet
Please indicate (check) all methods used to determine the high ground water elevation:
—ZObtained from system design plans on record - If checked,
—,ZObserved site (abutting property/observation hole wi date of design Plan reviewed:
thin 150 feet of SAS)
— Checked with local Board Of Health -explain:
— Checked with local excavators, installers- (at1—ach—d—oct=—e—nta—tion—)--
- Accessed USGS database -explain:
-b
YOU must descni how You established the high ground water elevation:
- - - - - - - - - -
'r;tl. 'z �-- 4/i;/')nnn I I
SEWER MAINS
WATER MAINS
STORm DRAINAGE
ROADS Ramey Contractors - Engineers, Inc.
EquIPMENT RENTAL
ENGINEERING 33 OAK KNOLL ROAD
METHUEN, MASSACHUSETTS
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al
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0 CrO Ta 17 k in 18, CA
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SEWER MAINS TELEPHONE
WATER MAINS 683-6791
STORm DRAINAGE
ROADS Ramey Contractors - Engineers, Inc.
EoulPIVIENT RENTAL
ENGINEERING 33 OAK KNOLL ROAD
METHUEN, MASSACHUSETTS
V
A,5&11�
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1
In V,
1,560
MIS
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SEPTIC SYSTEM INSPECTION FORM
ADDRESS 2-�o o--,- kc",— 3 1�-
DATE INSPECTED I fe"
PROPERLY FUNCTIONING? Y N ?
WEATHER CONDITIONS Dr
COMMENTS:
DYE TEST PERFORMED? Y N
DATE?
SKETCH:
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FORM U - IDT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
/APPLICANT:
Phone
L40CATION: Assessor's Map Number Parcel
Subdivision
/Street
Lot (s)
9C St -1 4�
St. Number _),) L
************************Official Use only************************
RECOMMENDATIONS OF TOWN AGENTS:
Cons ation Administrator
Date Approved
Date Relected b
Town Planner Date Approved
Date Rejected
Comments
z F od Inspector -Health -
�JA
SeptJ;.c inspec-k-or-health
Comments
Public Works ewer/wa+ 4- 4
,*driveway permit
/Fire Department
Date Approved
Date Rejected
Date Approved
Date Rejected
Received by Building Inspector Date
M �g
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Form No.3
Town of North Andover, Massachusetts
BOARD OF HEALTH
&ORTH
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DISPOSAL WORKS CONSTRUCTION PERMIT
$SACK S
Applicant NAME ADDRESS
Site Location
Repair an Individual Soil Absorption
Permission is hereby granted to Construct or
Sewage Disposal System as shown on the Design Approval S.S. No.
C 2HA -IR 4M, A�A aR
D.W.C. No.
Fee —LL—
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