HomeMy WebLinkAboutMiscellaneous - 291 WINTER STREET 4/30/2018Commonwealth of Massachusetts
= City/Town of
System Pumping- Record
Form 4
DEP has provided this form for use-, by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. Information
1. System Location: Left/ Right front of house, Left Mg@rEar of ou , Left./ right side of house, Left/
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
Address
Citylrown state Zip Code
2. System Owner.
Name
Address (if different from location)
w
City/Town 1�1�
B. PumpingRecord
1. Date of Pumping
3. Type of system: ❑
4.
State ] Zip Code
Telephone Number
Data
Cesspools)
❑ Other (describe):
Effluent Tee Filter present? ❑ Yes No
;uan Pumped
ptic Tank
Gallons
❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No:
5. Condition oK71c),j
tem:
�����(/�
6. System Pumped By.
7.
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
company
contents were disposed:
t5fbrm4.doa 06103 System Pumping Record • Page 1 of 1
Town of North Andover o t NORTH
OFFICE OF 3? �` ' �a�° L
COMMUNITY DEVELOPMENT AND SERVICES p
27 Charles Street : �o
North Andover, Massachusetts 01845 �9ssA�Hus�t�y
WILLIAM J. SCOTT
Director
(978) 688-9531 Fax (978) 688-9542
March 24, 2000
Mr. & Mrs. Michael Morgan
291 Winter Street
No. Andover, MA 01845
Re: Sewer Tie-in
Dear Mr. & Mrs. Morgan:
The Health Department has been supplied with a list of all residences, currently on septic,
which have access to the municipal sewer system As previously published at a Public
Hearing on March 17, 1994, the Board of Health has adopted regulations concerning the
required sewer tie-in. The following timetable concerning your property status was
adopted:
4.1 All establishments that currently do not have municipal sewer available
to them must connect to the sewer as soon as it becomes available, with a
maximum time limit of sig months.
The purpose of these regulations is to safeguard North Andover's drinking water, surface
waters, groundwater and surrounding environment. Sanitary sewer is believed to be the
most effective form of wastewater treatment. A copy of the entire regulation can be
obtained at our office.
Your property is in violation of this Board of Health regulation. Please contact the Health
Department regarding this matter immediately. If we do not hear from you by May 10,
2000 your name will be placed on the regularly scheduled Board of Health meeting agenda
and placed on public notice. The meeting will be held on May 25, 2000 for discussion of
legal action including court hearings.
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
s,
Sewer Tie -In 291 Winter Street Page 2
Any questions concerning this regulation should be directed to the Board of Health at
(978) 688-9540. Additional inquiries regarding the physical tie-in and permitting process
should be directed to the Department of Public Works at (978) 685-0950. Please be
advised this Board intends to persevere in this regulation.
Yours truly,
Gayton Osgood, -C'�a
C'4 .,.
J
Francis P. MacMillan, M.D., Member
00,
ohn S. Rizza, D.M.D., MeiWer
SF/smc
Form No. 4
Town of North Andover, Massachusetts
BOARD OF HEALTH
December 23199_
CERTIFICATE OF COMPLIANCE
This is to certify that
the Individual Soil Absorption Sewage Disposal System constructed ( ) or repaired (g)
by Ken Rea
Distribution Box Only
INSTALLER _._�
at 291 Winter St -rept,
SITE LOCATION
has been installed in accordance with Board of Health Regulations as described in the Design
Approval Site System Permit No. N/A dated
19
The issuance of this certificate shall not be construed as a guarantee that the system will
function satisfactorily.
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE: j ( ? CURRENT INSTALLER'S LICENSE# l �
LOCATION: V(fitc-, C`
LICENSED INSTALLER
SIGNATURE: IC31--7�`�S _
CHECK ONE -
REPAIR:
-
REPAIR: )) � NEW CONSTRUCTION:
o
=ma C
IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. -
$75.00 Fee Attached?
Foundation As -Built?
Administrative Use Only
Yes__LZ No
Yes -_`'/_1:14 No
Floor Plans? Yeses No
Approval �� Date: : / �^�
William F. Weld
t3OWMW
ArSeo Paul Celiucci .
LL Gwernor
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: qt�1
Date of Inspection:
N
Trudy Cote
Secretary
David S. Struhs
Cornnftsioner
Address of Owner.
(If different)
ame of Inspector. j- f C3
Company Name, Ad and a ephone Number. j�RIL 1y✓�L,G` Oi00-IS'
RY�crc�, -►
CERTIFICATION STATEMENT r
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
_ Passes
Conditionally Passes
_ Needs Further Evaluation By the Focal Approving Authority
_ . Fails
Inspector's Signature: r Date: 1 f /� /9 �7
The System Inspectors mit a copy of this inspection report to the Approving Authority /within thirty (30) days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the.system owner shall submit the
report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D:
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes
inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not)
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration,.or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a Fonforming septic tank as approved
by the Board of Health.
(revised 11/03/95)
One Winter Street a Boston, Massachusetts 02108 a FAX (617) 556-1049 a Telephone (617) 292.5500
0 Printed on Recycled Paper
le
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
cqep /CERTIFICATION (continued)/j/)
Property Address: �t (t W � E'i�� /V6. A✓�er,
Owner. MCGM—sdr
Date of Insp�
BJ SYSTEM CONDITIONALLY PASSES (continued)
(� Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution bar. The system will pass inspection if (with approval of the Board of
Health):
broken pipe(s) are replaced
obstruction is removed
_ distribution box is levelled or replaced
The system required pumping more than four 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
C1 FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A
MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.
3) OTHER
(revised 11/03/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property d
Owner: 2tx j& rY1 C C r'—Q�p�
Date of Inspection:
Dj SYSTEM FAIIB:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for
this determination is identified below. The Board of Health should be contacted to determine what will be necessary to oorrect the
failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 60 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public
health and safety and the environment because one of more of the following conditions exist:
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 II of a public
water supply well)
The owner or operator of any such system shall bring the system and facility into Rill compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.•
(revised 11/03/95)
is
1T
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Addrem
p� r
Owner.
Date Inspsoii` n:
Check if the following have been done:
-/ Pumping information was requested of the owner, occupant, and Board of Health.
JNone of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
N1 Z As built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non -sanitary or industrial waste flow
The site was inspected for signs of breakout.
V All system components, excluding thasoil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
ZThs size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non -intrusive methods.
ZThe facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub -
Surface Disposal System.
(revised 11/03/95)
Property Address:
Owner. 's
Date of Inspection:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
CYk:Gc�ra�
I�I15l9�..
RESIDENTIAL:
Design clow:gallons
Number of bedrooms:,
Number of current residents:
Garbage grinder (yes or no):_)o
Laundry connected to system (yes or no):-rS
Seasonal use (yes or no):_
Water meter readings, if available:
Last date of occupancy: 1 �Ol) . 1 199 }
. Avkd�, ma.
FLOW CONDITIONS
S.
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow:_gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non -sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER (Describe)
Inst date of occupancy:T_
GENERAL INFORMATION
PUMPING
System pumped as part of inspection: (yes or no)lLb
If yes, volume pumped: eallons
Reason for pumping:
TYPE OF SYSTEM
OC Septic tanWdistribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Other (explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information: OCUJ�
Sewage odors detected when arriving at the site: (yes or no) ,"J
(revised 11/03/95)
'r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Ad V I Lj(Y C rm'
DOwner. of inspection: i c G
SEPTIC TANK_
(locate on site plan)
Depth below grade:
Material of construction: jtconcrete _metal _FRP —other(explain)
Dimensions
Sludge depth.- If y
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thiclmess:
Distance from top of scum to top of outlet tee or baffle:,
Distance from bottom of scum to bottom of outlet tee or baffle: �a
Comments:
(recommendation for pumping,
dition of ' t tlet tees or es, depth of li level in relation to outlet inverts structural integrity,
evidence of leakagg, etc.) coMyl e,..� � 1 h ���t�e l c.r vA chniw,
GREASE TRAP:_
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP —other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
(revised 11/03/95)
sseu
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFMUTIOIN (oontfnu )
Property Al+. ag NO
Date of I on ' / `C � �L7
TIGHT OR HOLDING TANK
(locate on ate plan) —
Depth below grade:
Material of construction concrete —metal —FRP—other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX—
(locate
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note` if level and "n4ion is equal, evidence of
PUMP CHAMBER_
(locate on site plan)
Pumps in working order:(yes or no)
of leakage into or out of box, etc.) v j�Z�lf� 6_�_
�rtSC�'
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 11/03/95)
LE
n
ti
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMA'IION (oontin�)
Owner. ih n'(C 14/�0(�
Date of Inspection:
SOIL ABSORPTION SISIL (SAS):_
(locate on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number•_
leaching chambers, number:
—
leaching galleries, number:
leaching trenches, number,length: ��rrott 'COk � o �Ok'J
leaching fields, number, dimensions:
overflow cesspool, number:
(no condition ofdoil signs of hydrauliure, level of ponding, ccondition of vegetation etc.) Ala
CESSPOOLS: _
(locate on site plan)
Number and configuration:
Depth -top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer-
Dimensions
ayerDimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of 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.)
(revised 11/03/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (oontinued)
Pro1erty Ad 991 (b i v xer-t-Tew j, j . "&uQr, C _ a ceK—
Owner. ti '" 1 rnG V
Date of Inipeo on:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all .yells within 100'
7
DEPTH TO GROUNDWATER
Depth to groundwater., -'a et Gmarr-method ^ / �1
5 i Cipy�lxb n/� P��a iat�-- — �f-> >r �� C) l P��Qi�, �L p77'1l O tl� % °�1c^ Mx
(revised 11/03/95) 9
7
9 "
36/ Is
C
g'
DEPTH TO GROUNDWATER
Depth to groundwater., -'a et Gmarr-method ^ / �1
5 i Cipy�lxb n/� P��a iat�-- — �f-> >r �� C) l P��Qi�, �L p77'1l O tl� % °�1c^ Mx
(revised 11/03/95) 9
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DANIEL A. GIARD
130A Appleton Street
NORTH ANDOVER, MA 01845 DATE
Phone 686-7653
C�
-_....._................_..._....._ __ _ _ _ _.._.............. ...... . ___........................ _.._... _...... ...... ....... ....... __ _ _............. _ _ ....... ....... ..........
TERMS: _ (;
PLEASE DETACH AND RETURN WITH YOUR REMITTANCE $ /
DATE ( INVOICE NUMBER / DESCRIPTION I CHARGES I CREDITS I BALANCE
BALANCE FORWARD 0
" PAY LAST AMOUNT
DANIEL A. GIARD
IN THIS COLUMN
PPODUCT!W2 a ac.Gr::_-VESaG!e%t To Or-PNCNE TOLL FP-E!-3Yt22i,UG
SEPTIC SYSTEM INSPECTION FORM
ADDRESS 2 C9 ( Wia4er
DATE INSPECTED 1 6
PROPERLY FUNCTIONING? b N
WEATHER CONDITIONS
COMMENTS:
WAi"ER aVALi T Y TES I Eb ? JZEsULTS�
DYE TEST PERFORMED? Y N
DATE?
SKETCH:
WATERSHED RESIDENTS QUESTIONNAIRE
1. Name
2. Street Address •�) C%� C!t<
3. How many members are in your household?
4.
What type of sewage disposal system do you have?
❑ cesspool
& septic tank and leaching area
❑ connection to municipal sewer
❑ other (describe)
❑ do not know
5. Are the plans (drawings) for your sewage disposal system on file with the Board of Health?
❑ yes ❑ no 'K do not know
6. How old is your sewage disposal system? ❑ 0-5 years 6-10 years ❑ 11-20 years
❑ over 20 years ❑ do not know
7. Has your sewage disposal system been rebuilt or repaired?
❑ yes M no ❑ do not know
If yes, approximately how long ago?
years. What was done?
8. How frequently is your sewage disposal system pumped out? X annually
❑ every 2-4 years ❑ every 5-10 years-.% ❑ over 10 years ❑ never
9. Have you had any problems with your sewage disposal system? ❑ yes V no
If yes, what problems?
-❑ repeated pump -outs needed
❑ system clogs, backs up, or drains slowly
❑ odors
❑ sewage surfaces through ground
10. How many of each appliance are connected to your sewage disposal system?
washing machine dishwasher garbage disposal
dehumidifier drain sump pump toilet CP-
roof/pavement drains shower/bathtub -5 _
11. Please state the brand and type (liquid or powder) of detergent you use for:
dishwasher
clotheswasher �-1-
12. Does your property have a lawn? 10 yes ❑ no
If yes, approximately what size?
❑ less than 1/4 acre ❑ 1/4 acre ❑ 1/z acre ❑ 3/4 acre acre
❑ more than 1 acre (Specify) acres
13.
How often do -you fertilize your lawn?
No. of applications per year
Season(s) of the year
14. Please state the brand and type (liquidranula of lawn fertilizer you use:
❑ Check here if your lawn is maintained by a professional landscape contractor.
III SIH E.11
1 k�C_
I\
QUESTIONNAIRE
1. Isar iJ '� `:`1`',`,_�
���`t✓s�t
L�``�
=;G � i�
t� ! t�,�
�t�t; �---
E
2. Streci'. Address
,
3. Hoff- rnarty members are in your household?
4. N.Vh�;: type vi sewage disposal system do you have?
❑ ce sspo:rl
,0 : cp.i4 tank and leaching area
❑ ccnneertian to municipal sewer
❑ mher (describe)
❑ e o rtut know
5. Are he plans (drawings) for your sewage disposal system on file with the Board of Health?
❑ ves ❑ no $9 do not know
6. HoE.- cold is your sewage disposal system? ❑ 0-5 years 2 6-10 years ❑ 11-20 years
❑ over 20 years ❑ do not know
7. Has your sewage disposal system been rebuilt or repaired?
❑ yes: _1 no ❑ do not know
1f yes, approximately how long ago? years. What was done?
L . ioN frequently is your sewage disposal system pumped out? L annually
❑ every 2-4 years ❑ every 5-10 years ❑ over 10 years ❑ never
9. 1 ave you had any problems with your sewage disposal system?❑ yes Vno
1' yet, v:..at problems?
❑ reheated pump -outs needed
❑ system clogs, backs up, or drains slowly
❑ odors
❑ see. a.ge surfaces through ground
10. log mzny of each appliance are connected to your sewage disposal system?
washing mz chive I dishwasher garbage disposal /
deh:ii:iaifier drain sump pump toilet ;
roofirpavement drains shower/bathtub �'-
11. Piea_ac stale the brand and type (liquid or powder) of detergent you use for:>.!
clot' ^ss;'as:�ef.
12. Lo, your property have a lawn?
1f Y. a)7roximately what size?
❑ !_ss than 1/4 acre ❑ '/4 acre
❑ more than 1 acre (Specify)
13.
Hove, often do you fertilize your, lawn?
No. of arplicrtions per year �—
Sea- <Irl(s) of t`,he year
�(] yes ❑ no
❑ 1/2acre ❑ 3/4 acre 1 acre
acres
14. Please state the brand and type (liquid �gr� anulara'of lawn fertilizer you use:
ClEc•c:l; here if your layvn is maintained by a professional landscape contractor.