HomeMy WebLinkAboutMiscellaneous - 30 GRAY STREET 4/30/2018A
!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 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:
E Passes El Conditionally Passes El Fails
El Need Further Evaluation by the Local Approving Authority
P 7 1 1 0
4 11-2-2017
l4etoet SignaturV' 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 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.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 1 of 17
Commonwealth
RECEIVED
of Massachusetts
NOV 14 2017
Title 5 Official Inspection Form
OF NORTH ANDOVER
TOWN
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments HEALTH [)EpARTmENT
30 Gray Street
Property Address
Phillip Barclay
Owner
Owner's Name
information is
required for every
North Andover MA 01845
11-2-2017
page.
City/Town State Zip Code
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.
Impoirtant: When
filling out forms
A. General Information
on the computer,
use only the tab
key to move your
1 . Inspector:
cursor - do not
Neil J. Bateson
use the return
key.
Name of Inspector
Ov
Bateson Enterprises Inc.
VQ
Company Name
111 Argilla Road
Company Address
Andover MA
01810
Cityrrown State
Zip Code
978-475-4786 SI -15
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:
E Passes El Conditionally Passes El Fails
El Need Further Evaluation by the Local Approving Authority
P 7 1 1 0
4 11-2-2017
l4etoet SignaturV' 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 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.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 1 of 17
1, Lv,
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
30 Gray Street
Property Address
Phillip Barclay
Owner's Name
North Andover
City[Town
B. Certification (cont.)
MA 01845 11-2-2017
�-t-ate -tip Code Date of Inspection
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes:
I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
D Y [I N F1 ND (Explain below):
t5ins.doc - rev. 6/16 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
30 Gray Street
Property Address
Phillip Barclay
Owner's Name
North Andover MA 01845 11-2-2017
Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
El Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
El Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if (with approval of Board of Health):
[:1 broken pipe(s) are replaced
R obstruction is removed
R distribution box is leveled or replaced
[] Y [] N E] ND (Explain below):
F1 Y El N El ND (Explain below):
F] Y F] N El ND (Explain below):
F1 The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if (with approval of the Board of Health):
El broken pipe(s) are replaced 0 Y M N F1 ND (Explain below):
El obstruction is removed F-1 Y El N n 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.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 3 of 17
A
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
30 Gray Street
Property Address
Phillip Barclay
Owner's Name
North Andover MA 01845 11-2-2017
Cityrrown '-§t-ate Zip Code Date of Inspection
B. Certification (cont.)
2. System will fall unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
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.
E] 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
El
[A
Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
El
z
Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
El
Z
Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El
Z
Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2day flow
t5ins.doc - rev. 6/16
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17
<L
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
30 Gray Street
Property Address
Phillip Barclay
Owner Owners Name
information is
required for every North Andover MA 01845 11-2-2017
page. C4rrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
E] g 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
1:1 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 QMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17
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 SAS, cesspool or privy is below high ground water elevation.
El 0
Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
El Z
Any portion of a cesspool or privy is within a Zone 1 of a public well.
El 0
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 6 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] g 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
1:1 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 QMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17
<C�X Commonwealth of Massachusetts
Title 5 Official Inspection Form
'o Subsurface Sewage Disposal System Form Not for Voluntary Assessments
30 Gray Street
Property Address
Phillip Barclay
Owner Owner's Name
information is
required for every North Andover MA 01845 11-2-2017
page. Cityfrown 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 El Pumping information was provided by the owner, occupant, or Board of Health
El Z Were any of the system components pumped out in the previous two weeks?
Z F1 Has the system received normal flows in the previous two week period?
11 Z Have large volumes of water been introduced to the system recently or as part of
this inspection?
El Z 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?
0 El Were all system components, excluding the SAS, located on site?
0 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 El
Was the facility owner (and occupants -if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
El Z
Existing information. For example, a plan at the Board of Health.
Z 11
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): N/A Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): N/A
t5ins.doc - rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17
e
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
30 Gray Street
Property Address
Phillip Barclay
Owner Owners Name
information is
required for every North Andover MA 01845 11-2-2017
page. CityfTown State Zip Code Date of Inspection
D. System Information
04 -
Description:
Number of current residents: 3'
Does residence have a garbage grinder? El Yes E No
Is laundry on a separate sewage system? (Include laundry system inspection Yes E No
information in this report.)
Laundry system inspected? D Yes [I No
Seasonaluse? El Yes E No
Water meter readings, if available (last 2 years usage (gpd)): Yes
Detail:
Sump pump? 0 Yes E No
Last date of occupancy: Current
Date
Commercial/industrial 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?
Industrial waste holding tank present?
Non -sanitary waste discharged to the Title 5 system?
Water meter readings, if available:
D Yes n No
El Yes F1 No
El Yes F No
t5ins.doc - rev. 6/16 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
1 30 Gray Street
Property Address
Phillip Barclay
Owner Owner's Name
information is
required for every North Andover MA 01845 11-2-2017
page. City/Town -§t-ate Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Type of System:
Date
Pumped 2015, owner
1500
gallons
Measured tank
Inspect tank & tees
Septic tank, distribution box, soil absorption system
Single cesspool
N Yes El No
Overflow cesspool
Privy
El Shared system (yes or no) (if yes, attach previous inspection records, if any)
El Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
El Tight tank. Attach a copy of the DEP approval.
El Other (describe):
t5ins.doc - rev. 6/16 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
30 Gray Street
Property Address
Phillip Barclay
Owner Owner's Name
information is
required for every North Andover MA 01845 11-2-2017
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Tank & d -box was replaced 2013, Leach area original, Info at B.O.H.
Were sewage odors detected when arriving at the site?
Building Sewer (locate on site plan):
Depth below grade:
Material of construction:
0 cast iron Z 40 PVC other (explain):
Distance from private water supply well or suction line:
10-12MIGIM
1.5
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
4" cast iron through wall, 3" PVC in house, no leaks visible
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
Z concrete El metal
If tank is metal, list age:
[I fiberglass
0.5
feet
El polyethylene El other (explain)
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate)
Dimensions: I O'x 5'x 4'
Sludge depth:
1 It
El Yes [] No
t5ins.doc - rev. 6/16 Title 5 Official lnspecbon Form: Subsurface Sewage Disposal System - Page 9 of 17
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
30 Gray Street
Property Address
Phillip Barclay
Owner Owners Name
information i's ry -2-2017
required for eve North Andover MA 01845 11
page. CityrFown State Zip Code Date of Inspection
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
How were dimensions determined?
321t
ill
8"
14"
Tape measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of
leakage. Outlet cover has riser cover 1" deep. Pumped septic tank.
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
El concrete El metal
Dimensions:
Scum thickness
El fiberglass El polyethylene El other (explain):
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17
<L
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
30 Gray Street
Property Address
Phillip Barclay
Owner Owner's Name
information is
required for every North Andover MA 01845 11-2-2017
page. Cityrrown §t -ate Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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
Dimensions:
Capacity:
Design Flow:
Alarm present:
Alarm level:
Date of last pumping:
El polyethylene [-I other (explain):
gallons
gallons per day
El Yes F1 No
Alarm in working order: El Yes - El No
Date
Comments (condition of alarm and float switches, etc.):
* Attach copy of current pumping contract (required). Is copy attached? El Yes El No
t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17
IEW1'7?Mt
MIMI,
NeW
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
30 Gray Street
Property Address
Phillip Barclay
Owners Name
North Andover
Cityrrown
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 0
11-2-2017
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.):
D -Box level & distribution equal, has flow levelers. No evidence of leakage. Evidence of light
carryover, pumped d -box to clean.
Pump Chamber (locate on site plan):
Pumps in working order:
EJ Yes El No*
Alarms in working order: D 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.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17
�L\l Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
30 Gray Street
party Address
Phillip Barclay
Owner Owner's Name
information is
required for every North Andover MA 01845 11-2-2017
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
n innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soil ok. Vegetation ok. No sign of ponding to surface.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth — top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow
El Yes R No
t5ins.doc - rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17
leaching pits
number:
leaching chambers
number:
El
leaching galleries
number:
leaching trenches
number, length: 3 trenches 40'
long
El
leaching fields
number, dimensions:
FJ
overflow cesspool
number:
n innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soil ok. Vegetation ok. No sign of ponding to surface.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth — top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow
El Yes R No
t5ins.doc - rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
lug 30 Gray Street
Property Address
Phillip Barclay
Owner Owners Name
information i's
required for every North Andover MA 01845 11-2-2017
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins.doc - rev. 6/16
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
30 Gray Street
Property Address
Phillip Barclay
Owner's Name
North Andover
CityrFown
D. System Information (cont.)
MA 01845
_§t -ate Zip Code
11-2-2017
Date of Inspection
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:
0 hand -sketch in the area below
El drawing attached separately
12
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t5ins.dGr - rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 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
30 Gray Street
Property Address
Phillip Barclay
Owner's Name
North Andover
City/Town
D. System Information (cont.)
Site Exam:
Z
Check Slope
Z
Surface water
0
Check cellar
Z
Shallow wells
Estimated depth to high ground water:
MA 01845 11-2-2017
State Zip Code Date of Inspection
>4
feet
Please indicate all methods used to determine the high ground water elevation:
IS-]
70-
70
Obtained from system design plans on record
If checked, date of design plan reviewed: Date
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health - explain:
n Checked with local excavators, installers - (attach documentation)
10 Accessed LISGS database - explain:
Essex County Soil Map.
You must describe how you established the high ground water elevation:
Essex County Soil Map, Sheet # 36, Canton Soil, Water > 6 'Deep
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc - rev. 6/16 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
30 Gray Street
Property Address
Phillip Barclay
Owner Owners Name
information is
required for every North Andover MA 01845 11-2-2017
page. City[Town -§t-ate Zip Code Date of Inspection
E. Report Completeness Checklist
Z 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
Z Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17
9
Commonwealth of Massachusetts
CitY/Town of
Sywm Pumping. Record
Form 4
DEP has.provided this fbrm'fo,r use -by local Boards of Health. Other forms maybe 'used, but the
information, must be substantially the tame as th
at provided here. Before using.this form, check with your
local Board of Health to determine the forrh they use The System Pumping Record must be submitted to
the local. Board of Health or other approving authority.
A. Facility Informiation.
1. System LocatlonCo/ Pjghtq2��, Left/ Righi rear of house, Left/ right side of house, Left I
Right side of building, Left Right fr6nt of buildifig, Left / Wight rear Of building, Under deck
Address ------
cwrown State Zip Code
2. System Owner
Name'
Address (if different from location)
cityrrown -
Telephone������
.B. Pumping ftecord
-7
1. Date of Pumping t 7 2. Quantity Pumped:
Date Gallons
.3. Type -Of sYstenT. El Cesspool(s) 2-9e�pficTank El Tight Tank
Other (describe):
4. Effluent Tee Filter present.? E] Ye If
,s <0 Yes, Was it cleaned? El- Yes F-1 No,
5. Condition of System:
6.. System Pumped- By:
Nell. BatesOn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati contents- were disposed:
A�LU Lowell Waste Water
Signi qfHauler( Date
t5formCdoco 06/03 System Pumping RecDrd - Page I of I
Summary Record Card generated on 10/18/2017 2:56:16 PM by Karen Hanlon
Town of North Andover
Tax Map # 210-1073-0053-0000.0
Parcel Id 18166
30 GRAY STREET
PHILIP BARCLAY
30 GRAY STREET
NORTH ANDOVER MA 01845
Page 1
Class 101 Single Family
Property Type
1 Residential
Zoning2 I Residential
Zoning3
1 Residential
Size Total 1.2 Acres
FY 2018
UB Mailing Index
Name/Address
Type Loan Number
Active/Inact.
From
Until
PHILIP BARCLAY
Owner
30 GRAY STREET
NORTH ANDOVER MA 01845
CUSHING, JOSEPH B.
Payor
Inactive
9/16/2013
30 GRAY STREET
N. ANDOVER, MA
01845
JOSEPH P CUSHING
Previous Customer
Inactive
4/17/2014
7 WALLACE STREET
METHUEN MA 01844
UB Accourit Maint.
Account No
Cycle
Occupant Name
Active/Inactive
Bldg Id. 13703.0 - 30 GRAY
STREET
Last Billing Date 8/8/2017
1090381
01 Cycle 01
Active
UB Services Maint.
Account No. 1090381
Service Code
Rate Charge
Multiplier/Users
MISCFEEADMIN FEE
0.635/8 7.82
1/
WTR WATER
01 ALL METER SIZE 57.00
/1
UB Meter Maintenance
Account No. 1090381
Serial No Status
Location Brand
Type
Size
YTD Cons
16335585 a Active
00 METE METE
w Water
0.630.63
392
Date
Reading
Code Consumption
Posted Date
Variance
7/19/2017
820
a Actual
15
8/15/2017
35%
4119/2017
805
a Actual
11
5/17/2017
12%
1/19/2017
794
a Actual
10
2/16/2017
-31%
10/19/2016
784
a Actual
14
11/16/2016
-35%
7/22/2016
770
a Actual
22
8/16/2016
144%
4/22/2016
748
a Actual
9
5/25/2016
-17%
1/22/2616
739
a Actual
11
2/19/2016
8%
10/22/2015
728
a Actual
10
11/20/2015
9%
7/24/2015
718
a Actual
9
8/14/2015
-1%
4/27/2015
709
a Actual
9
5/19/2015
-8%
1/3012015
700
a Actual
11
2/20/2015
-7%
10/24/2014
689
a Actual
11
11/14/2014
51%
7/25/2014
678
a Actual
8
8/13/2014
-100%
4/16/2014
670
f Final Bill
0
4/16/2014
-100%
1/27/2014
670
a Actual
1
2/14/2014
-4%
10/23/2013
669
a Actual
1
11/18/2013
-51%
7/23/2013
668
a Actual
2
8/15/2013
-78%
4/2412013
666
a Actual
9
5/20/2013
6%
1/25/2013
657
a Actual
9
2/13/2013
-27%
10/23/2012
648
a Actual
12
11/9/2012
-34%
7/23/2012
636
a Actual
18
8/14/2012
125%
4/23/2012
618
a Actual
8
5/9/2012
-53%
8U94
Town of North Andover
HEALTH DEPARTMENT
SS U
CHECK #: 16611 DATE:
LOCATION: 3o r. -,-u a4
H/O NAME: 6aZCxz
CONTRACTOR NAME:.A/) ze5al-) C55-(--
TyRe
of Permit or License: (Check box)
0
Animal
$
0
Body Art Establishment
$
0
Body Art Practitioner
$
0
Dumpster
$
0
Food Service - Type.
$
0
Funeral Directors
$
0
Massage Establishment
$
0
Massage Practice
$
0
Offal (Septic) Hauler
$
0
Recreational Camp
$-
0
Sun tanning
$
0
Swimming Pool
$
0
Tobacco
$
0
Trash/Solid Waste Hauler
$-
0
Well Construction
$
SEP77C Systems:
• Septic - Soil Testing $
• Septic - Design Approval $
0 Septic Disposal Works Construction (DW0 $
0 Septic Disposal Works Installers (DW1) $
0 Title 5 Inspector $
Title 5 Report $
--- :J�
11 Other (Indicate) $
He Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
30 Gray Street
Property Address
Estate of Lois
Owner's Name
North Andover
City/Town
MA 01845 6/26/2013
State Zip Code 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.
Important: A. General Information
When filling out
forms on the
computer, use 1 . Inspector:
only the tab key
to move your Neil J. Bateson
cursor - do not Name of Inspector
use the return
key. Bateson Enterprises Inc.
dl--� Company Name
olt—A 111 Argilla Road
Company Address
Andover MA 01810
Cityrrown State Zip Code
978-475-4786 S115
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 expedence 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 E] Conditionally Passes E] Fails
Needs Ffrther E�valuation by the Local Approving Authority
6/26/2013
Insp o gnature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)-within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DER The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
""This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page I of 17
Owner
information is
required for
every page.
t5ins - 3113
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
30 Gray Street
Property Address
Estate of Lois Cushing
Owner's Name
North Andover
Cityrrown
B. Certification (cont.)
MA 01845
State Zip Code
6/26/2013
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:
After permit from B.O.H., install new septic tank,outlet pipe to d -box, new d -box & plumber
connected washer machine back into main sewer pipe, inspection from B.O.H., septic system now
passes Title 5 Inspection
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.
F1 Y n N 0 ND (Explain below):
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17
7
c mon
om Wealth of Massachusetts RECEIVED
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessme
JUN 10 2013
30 Gray Street TOWN OF NORTH ANDOVER-
L..HEALTHPEPARTMENY M
Property Address
Estate Of Lois Cushing
Owner Owners Name
information i's North Andover MA 01845 5/28/2013
required for -late Zip Code Date of Inspection
every page. City/Town S
Inspection results must be submitted on this form. Inspection forms may not be altered in any /Ij
way. Please see completeness checklist at the #gad off the fonn.
Impodant: A. General Informatio
When filling out ew " �
forms on the &
computer, use 1 Inspector:
\n
only the tab key
to move your Neil J. Bateson
cursor - do not Name of Inspector
use the return
key. Bateson Enterprises Inc.
-do-mpany Name
111 Argilla Road
Company Address
Andover MA 01810
Cityrrown state Zip Code
978-475-4786 S115
Te-lephond 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:
R Passes Z Conditionally Passes El Fails
F] Needs Further Evaluation by the Local Approving Authority
5/28/2013
Inspector's ignatu Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DER The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page I of 17
1 6�,
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
30 Gray Street
Property Address
Estate Of Lois Cushing
Owners Name
North Andover MA 01845 5/28/2013
ritvrrnwn 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:
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:
Z 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.
E Y F1 N [] ND (Explain below):
C.'nrrosion holes in tank
t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
R o Subsurface Sewage Disposal System Form Not for Voluntary Assessments
30 Gray Street
Property Address
Estate Of Lois Cushing
Owner Owners Name
information i's MA 01845 5/28/2013
required for North Andover
every page. City1rown State Zip Code Date of Inspection
B. Certification (cont.)
El Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
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):
[I broken pipe(s) are replaced El Y 0 N R ND (Explain below):
El obstruction is removed [I Y Z N El ND (Explain below):
R distribution box is leveled or replaced [I Y Z N El ND (Explain below):
F] 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 F1 Y Z N Ej ND (Explain below):
obstruction is removed [:1 Y Z N [:1 ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(i)(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
t5ins - 3/13 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
30 Gray Street
Property Address
Estate Of Lois Cushing
Owners Name
North Andover MA 01845 5/28/2013
Cityrrown 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:
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-1 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:
Septic tank & d -box needs to be replaced and laundry connected to septic tank.
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
D E Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
El 0 Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El Z Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2day flow
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
30 Gray Street
Property Address
Estate Of Lois Cushing
Owner Owners Name
information is
required for North Andover MA 01845 5/28/2013
every page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
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
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.
El z
Any portion of cesspool or privy is within 100 feet of a surface water supply or
the system is within 200 feet of a tributary to a surface drinking water supply
tributary to a surface water supply.
El Z
Any portion of a cesspool or privy is within a Zone 1 of a public well.
11 z
Any portion of a cesspool or privy is within 50 feet of a private water supply
Area — IWPA) or a mapped Zone 11 of a public water supply well
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.]
El z
The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
z
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
the system is within 400 feet of a surface drinking water supply
EJ
the system is within 200 feet of a tributary to a surface drinking water supply
R
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 - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17
�L� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
30 Gray Street
Property Address
Estate Of Lois Cushing
Owner Owners Name
information i's MA 01845 5/28/2013
required for North Andover
every page. Cityrrown 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 El Pumping information was provided by the owner, occupant, or Board of Health
E Were any of the system components pumped out in the previous two weeks?
El Z Has the system received normal flows in the previous two week period?
El Z Have large volumes of water been introduced to the system recently or as part of
this inspection?
El Z Were as built plans of the system obtained and examined? (if they were not
available note as N/A)
Z Was the facility or dwelling inspected for signs of sewage back up?
Z Was the site inspected for signs of break out?
Z 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:
El 0
Existing information. For example, a plan at the Board of Health.
Z 11
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): N/A Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): N/A
t5ins - 3/13 Title 5 Official inspection Form: Subsurface Sewage Disposal System - Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form Not for Voluntary Assessments
30 Gray Street
Property Address
Estate Of Lois Cushing
Owner Owner's Name
information is MA 01845 5/28/2013
required for North Andover
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
C"
Number of current residents: 0
"9 "'-C?
Does residence have a garbage grinder? El Yes Z No
Is laundry on a separate sewage system? (Include laundry system inspection Z Yes El No
information in this report.)
Laundry system inspected? Z Yes [I No
Seasonaluse? F1 Yes Z No
Water meter readings, if available (last 2 years usage (gpd)): Yes
Detail:
Laundry discharges out side yard on ground.
Sump pump? El Yes Z No
Last date of occupancy: March 12013
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? [I Yes E] No
Industrial waste holding tank present? 0 Yes E] No
Non -sanitary waste discharged to the Title 5 system? Yes F1 No
Water meter readings, if available:
t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17
I �L\' Commonwealth of Massachusetts
Nuff-11 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Foffn - Not for Voluntary Assessments
30 Gray Street
Owner
information i's
required for
every page.
Property Address
Estate Of Lois Cush
Owners Name
North Andover
CityfTown
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
MA 01845 5/28/2013
State Zip Code Date of Inspection
General Information
Pumping Records:
Source of information: Pumped 2011
Date
Was system pumped as part of the inspection? El Yes Z No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
Septic tank, distribution box, soil absorption system
E] Single cesspool
Overflow cesspool
Privy
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
El Tight tank. Attach a copy of the DEP approval.
11 Other (describe):
t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17
Commonwealth of Massachusetts
uTitle 5 Official Inspection Form
i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
30 Gray Street
,p
Property Address
Estate Of Lois Cushing
Owner Owners Name
information i's
required for North Andover
every page. City/Town
D. System Information (cont.)
MA 01845
State Zip Code
5/28/2013
Date of Inspection
Approximate age of all components, date installed (if known) and source of information:
No info at Board of Health.
Were sewage odors detected when arriving at the site?
Building Sewer (locate on site plan):
Depth below grade:
Material of construction:
Z cast iron 0 40 PVC Fj other (explain):
Nc+nnt-a frr%m rixinfia wt3+or c" I wall nr cw-finn linae
El Yes 0 No
1.2
feet
11 rr I feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
4" Cast iron through wall 3" PVC in house, no leaks visible.
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
E concrete El metal
.2
feet
F1 fiberglass F1 polyethylene [I other (explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate)
Dimensions: 6'x 4'
Sludge depth:
1 it
El Yes El No
t5ins - 3/13 Title 5 Official inspection Form: Subsurface Sewage Disposal System - Page 9 of 17
Commonwealth of Massachusetts
ID Title 5 Official Inspection Form
Subsurface Sewage Disposal System, Form - Not for Voluntary Assessments
30 Gray Street
Owner
information i's
required for
every page.
t5ins - 3/13
Property Address
Estate Of Lois Cush
Owner's Name
North Andover
Cityrrown
D. System Information (cont.)
State Zip Code
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
5/28/2013
Date of Inspection
26"
ill
81,
20"
How were dimensions determined? Tape Measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Septic tank has corrosion holes on outlet side of tank. Both covers cracked. Tank needs to
be replaced. Liquid level below outlet, evidence of leakage.
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
F� concrete El metal
Dimensions:
Scum thickness
feet
El fiberglass EI polyethylene [j other (explain):
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
30 Gray Street
Property Address
Estate Of Lois Cushi
Owners Name
North Andover
MA 01845
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
5/28/2013
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
MateNal of construction:
El concrete El metal El fiberglass EI polyethylene El other (explain):
Dimensions:
Capacity:
Design Flow:
Alarm present:
Alarm level:
gallons
gallons per day
El Yes 0 No
Alarm in working order:
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
El Yes El No
* Attach copy of current pumping contract (required). Is copy attached? El Yes F1 No
t5ins - 3/13 Title 5 official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17
W L� 7w jl�,
IR "
Owner
information i's
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
30 Gray Street
Property Address
Estate Of Lois Cushing
Owners Name
North Andover
Cityrrown
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
5/28/2013
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.):
D -box leaking, has corrosion holes, needs to be replaced. Evidence of carryover. Evidence of
leakage, liquid level below outlets 1"
Pump Chamber (locate on site plan):
Pumps in working order:
El Yes F] No*
Alarms in working order: 0 Yes D No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17
Commonwealth of Massachusetts
Dill Title 5 Official Inspection Form
c Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
30 Gray Street
Property Address
Estate Of Lois Cushing
Owner Owner's Name
information i's
required for North Andover MA
01845 5/28/2013
every page. Cityrrown State
Zip Code Date of Inspection
D. System Information (cont.)
Type:
leaching pits
number:
leaching chambers
number:
El leaching galleries
number:
leaching trenches
number, length: 3 trenches 40'
long
El leaching fields
number, dimensions:
El overflow cesspool
number:
F� innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soil ok. Vegetaion ok. No sign of ponding to surface.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth — top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow El Yes [:] No
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4
30 Gray Street
Property Address
Estate Of Lois Cushing
Owner Owner's Name
information is
required for North Andover MA 01845
every page. City/Town State Zip Code
5/28/2013
Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 17
0
Owner
information i's
required for
every page.
t5ins - 3113
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
30 Gray Street
Property Address
Estate Of Lois Cushing
Owners Name
North Andover MA 01845 5/28/2013
Cityrrown State 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:
Z hand -sketch in the area below
F-1 drawing attached separately
CN9
':�k Z31 (0 -
b_�60K _; , 3 r I i
0
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17
9
' -C\ ' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
30 Gray Street
Property Address
Estate Of Lois Cushing
Owner Owners Name
information i's
required for North Andover MA 01845 5/28/2013
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
E Check Slope
Z Surface water
Z Check cellar
Z Shallow wells
Estimated depth to high ground water: >4
feet
Please indicate all methods used to determine the high ground water elevation:
El
F-1
EJ
Obtained from system design plans on record
If checked, date of design plan reviewed:
Date
Observed site (abutting property/observation. hole within 150 feet of SAS)
Checked with local Board of Health - explain:
7 Checked with local excavators, installers - (attach documentation)
Accessed USGS database - explain:
Essex County Soil Map
You must describe how you established the high ground water elevation:
Essex County Soil Map, Sheet # 36, Canton Soil, Water >6'
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
I IV
Owner
information i's
required for
every page.
t5ins - 3/13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
0 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
30 Gray Street
Property Address
Estate Of Lois Cush
Owners Name
North Andover
RAA ^A^-
City/Town State Zip Code
E. Report Completeness Checklist
5/28/2013
Date of Inspection
Z inspection Summary: A, B, C, D, or E checked
Z inspection Summary D (System Failure Criteria Applicable to All Systems) completed
Z System information — Estimated depth to high groundwater
Z Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17
Summary Record Card generated on 614/2013 12:02:28 PM by Maureen McAuley
Town of North Andover Test
Tax Map # 210-1073-0053-0000.0
Parcel Id 18166
30 GRAY STREET
CUSHING, JOSEPH B.
30 GRAY STREET
N.ANDOVER,MA
01845
Page 1
Class 101 Single Family Property Type 1 Residential
Zoning2 1 Residential Zoning3 I Residential
Size Total 1.2 Acres
FY 2013
UB Mallina Index
Name/Address
CUSHING, JOSEPH B.
30 GRAY STREET
N. ANDOVER, MA
01845
UB Account Maint.
Account No Cycle
Bldg Id. 13703.0 - 30 GRAY STREET
1090381 01 Cycle 01
UB Services Maint.
Account No. 1090381
Service Code
MISCFEE ADMIN FEE
WTR WATER
UB Meter Maintenance
Type Loan Number
Payor
Active/Inact. From
Occupant Name Active/Inactive
Last Billing Date 5/8/2013
Active
Rate Charge Multiplier/Users
0.635/8 7.82 1/
01 ALL METER SIZE 34.20 /1
Until
Account No. 1090381
Serial No Status
Location
Brand
Type Size
YTD Cons
16335585 a Active
00
METE METE
w Water 0.630.63
1 238
Date
Reading
Code
Consumption
Posted Date
Variance
4/24/2013
666
a Actual
9
5/20/2013
6%
1/25/2013
657
a Actual
9
2/13/2013
-27%
10/23/2012
648
a Actual
12
11/9/2012
-34%
7/23/2012
636
a Actual
18
8/14/2012
125%
4/23/2012
618
a Actual
8
5/9/2012
-53%
1/23/2012
610
a Actual
17
2/13/2012
-8%
10/24/2011
593
a Actual
19
11/14/2011
104%
7/2212011
574
a Actual
9
8/15/2011
760%
4/22/2011
565
a Actual
1
5/16/2011
-72%
1/25/2011
564
a Actual
4
2/11/2011
-75%
10/21/2010
560
a Actual
15
11/12/2010
50%
7/22/2010
545
a Actual
10
8/16/2010
100%
4/22/2010
535
a Actual
5
5/12/2010
-29%
1/21/2010
530
a Actual
7
2/12/2010
-61%
10/22/2009
523
a Actual
18
11/11/2009
5%
7/23/2009
505
a Actual
17
8/12/2009
15%
4/24/2009
488
a Actual
15
5/13/2009
28%
1/23/2009
473
a Actual
12
2/10/2009
-34%
10/22/2008
461
a Actual
18
11/12/2008
17%
7/22/2008
443
a Actual
15
8/15/2008
378%
4/23/2008
428
a Actual
3
5/19/2008
-52%
1/28/2008
425
a Actual
7
2/19/2008
-70%
10/24/2007
418
a Actual
23
11/16/2007
47%
7/20/2007
395
a Actual
15
8/15/2007
226%
4/19/2007
380
a Actual
4
5/21/2007
-40%
1/29/2007
376
a Actual
8
2/20/2007
-56%
10/25/2006
368
a Actual
17
11/16/2006
19%
7/28/2006
351
a Actual
14
8/18/2006
147%
5/2/2006
337
a Actual
6
5/16/2006
-30%
M
fl) _)l
. iFl "
.4-44
9
r 1,
ILI
It
f 4L
Ie
-It 40
'PO
SO
-oil
*10
# 'IL - '
IP 11
r)4+0-cl as
u Lio,
RECEIVED
JUL 29 ?1013
c .1 TOWN OF NORTH ANDOVER
I Q� L HEALTH DEPARTMENT
,of
(�A-j I-olv4ll-El-rf- -%41-)0 MGMEW-mori GO)e
rv�---.) l4a 0 0-7
Dx-
Jol lt�
F - q '%
North Andover Health Department
(ommunity Development Division
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: 30 Gray Street MAP: 107B LOT: 0053
INSTALLER:
DESIGNER:
PLAN DATE:
BOH APPROVAL DATE ON PLAN:
INSPECTIONS
TANK and D -Box INSPECTION: 6/28/13
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 design plan
Existing septic tank properly abandoned
Internal plumbing all to one building sewer
Topography not appreciably altered
El Building sewer in continuous grade, on
compacted firm base
Cleanouts per plan
Bottom of tank hole has 6" stone base
Ej Weep hole plugged
F-1 1500 gallon tank has been installed
H-10 loading
F-1 Monolithic tank construction
Water tightness of tank has been achieved by
visual testing
F-1 Inlet tee installed, centered under access port
.0 16 "1
El Outlet tee installed, centered under access port
(gas baffle/effluent filter)
El inch cover to within 6" of finish grade
installed over one access port
Hydraulic cement around inlet & outlet
Comments: VO as fq 6 T- a"O kL-'�j
PUMIRCHAMBEIR
F1
Bottom of tank hole has 6" stone base
E]
Weep hole plugged
[:1
1500 gallon Pump Chamber installed
n
H-10 loading
Ej
Monolithic tank construction
Inlet tee installed, centered under access port
Pump(s) installed on stable base
El
Alarm float working
El
Pump On/Off floats working
E:1
Separate on/off floats
Drain hole in pressure line
cover at final grade installed over pump
access port
El
Water tightness of tank has been achieved by
testing
El
Hydraulic cement around inlet & outlet
Comments:
CONTROL PANEL
Alarm & Pump are on separate circuits
El
Alarm sounds when float is tripped
F1
Location of control panel: basement
El
Alarm signal located inside: basement
Comments:
DISTRIBUTION -BOX
installed on stable stone base
H-20 D -Box
F-1
Inlet tee (if pumped or >0.08'/foot)
[Z
Hydraulic cement around inlet & outlets
Observed even distribution
Speed levelers provided (not required)
Comments:
P C'
o
Commonwealth of Massachusetts
RECEIVED
> City/Town of (�'l 2013
OVER
T
System Pumping Record
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
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
e Right (r�ont )f hous�e eft / Right rear of house, Left / right side of house, Left
1. System Location6 )f
-gr n o uilding, Left / Right rear of building, Under deck
0
Right side of building, Left / Righ on; i It
Address 'T .
30 6 ) k
Cityrrown
2. System Owner
Name
Address (if different from location)
Cityfrown
B. Pumping Record
1. Date of Pumping
3. Type of system:
State
Zip Code
Zip Code
�t—
Telephone Number
6
Date 2. Quantity Pumped:
Cesspool(s) ffSeptic Tank
El Other (describe):
4. Effluent Tee Filter present? Yes O -N --o
Gallons
El Tight Tank
If yes, was it cleaned? [] Yes [] No
5. Conditio
� V---1 V\,eoj —kz�x/� �A �aj >C
6. System Pumped By:
Nell Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. LocaYoaAA0ere contents were disposed:
GLLS.Ja-,-/ - Lowell Waste Water
-M�0- 4�� - - (3
Date
t5form4.doc- 06/03 System Pumping Record - Page I of 1
Commonwealth of Massachusetts
City/Town of
0 S item Pumpin
YS g- 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 tame 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 Locatio - e ight i -to-f -h o u—s e-, > tirear of house, Left/ right side of house, Left
beft Righ
Right side of bui &inag, Left Riloigaght dronEtt Auildirig, Left / Right rear of building, Under deck
Address `30 6.Cen S+ �JoC4-k&
Cil:yfrown State Zip Code
2. System Owner F?ECEIVED
04V I q
Name' ''ni 1 0
�j Z015
Address (d different ftom location) TOM OF pjopzj, ,
HEALT11 --"^1VUUVER
DEPARTMENT
Cityfrown Code
Telephone Number
B. Pumping Rpcord
1. Date of Pumping
3. Type -of systerrf.
M-ls -
Date 2. Quantity Pumped:
Cesspool(s) 'B-Sip—fic Tank
/6zlt-�:` .
Gallons
[I Tight Tank
Other (describe):
4. Effluent Tee Filter present.? Yes aiqo� If yes, was ft cleaned? El Yes El No,
5. Condition f stem:
V�
6.- System Pumped By -
Nell. Bateson
Name
Bateson Enterprises Inc -
Company
7. LoCatioD_lEhKe contents were disposed:
" S.
KE D,,) Lowell Waste Wi
F5821
Vehicle Ucense Number
— 1�57-1 Y- Is --
Date
t5form4.dor.- 06/03 System Pumping Record - Page 1 of I
f
Installer
atNo --3-0- GRAY -STREET
has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the
application for Disposal Works Construction Permit No. BHP -2013-078 Dated June 17, 2013
------------ ........
Printed On: Jun -17-2013
- -------------------- BOARD OF HEALTH
ot
Map -Block -Lot
Commonwealth of Massachusetts 107.BO053
---------------------
BOARD OF HEALTH Permit No
North Andover BHP -2013-0787
---------------------
FEE
$125.00
to ---------------------
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Todd-B-atesan ------------------ -----------------------------------------------------------------
to (Repair) an Individual Sewage Disposal System. aT) L_C4-
atNo 30GRAYSTREET
-_ - ... ------------------------------------------------------------------------ --------------------------------------------------------- ---------
as shown on the application for Disposal Works Construction Permit No. BHP -2013-078 Dated June 17, 2013
------------------------ ------------------- ------
----------------------------------------------------
BOARD OF HEALTH
-------------------
Town of North Andover
HEALTH DEPARTMENT
'33 CoNfu
CHECK#:
LOCATION:
H/O NAME
CONTRACT
6523
Type
of Permit or License: (Check box)
• Swimming Pool
0
Animal
$
0
Body Art Establishment
$
0
Body Art Practitioner
$
0
Dumpster
$
0
Food Service - Type:
$
•
Funeral Directors
$-
•
Massage Establishment
$
0
Massage Practice
$
0
Offal (Septic) Hauler
$
0
Recreational Camp
$
0 Sun tanning
$
• Swimming Pool
$
• Tobacco
$
• TrashlSolid Waste Hauler
$-
• Well Construction
$
SEPTIC Sustems:
•
Septic - Soil Testing
$
•
Septic - Design Approval
$
0
Septic Disposal Works Construction (DW0
$
)<
Septic Disposal Works Installers (DW1)
0
Title 5 Inspector
$
0
Title 5 Report
$
11
Other (Indicate)
$
U'_2
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
few
Application for Septic Disposal System 1�- /Y- 13
Construction Permit - TOWN OF TODAY'S DATE
t2� - Full Repair
'NORTH ANDOVER, NUO1845 Component
Application is hereby made for a permit to:
F] Construct a new on-site sewage disposal system*
El Repair or replace an existing on-site sewage disposal system*
R'ge�pir or replace an existing system component -What? 14A11 a- Q ey ca -1-
A. Facility Information
--?o
Address or Lot #
City/Town 0 ri 2r
2, *TYPE OF =TIC SYSTEW:
El Pump ERtravity (choose one)
***If pump system, attach copy of electrical permit to application***
B15'nnventional System (pipe and stone system)
F1 Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system.
E] Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement)
F1 Pressure Dosed (D -Box Present) S.A.S.
2. Owner Information
Name
Address (if different from above)
A)o
City/Town
3. Installer Information.
Name
/j A t--� 'It A -
Address
. A-4- J/11.4-
City/Town
4. Desig-ner Information,
Name
Address
Citvrrown
Lt j-1,
S
M/�- - <9 I
State Zip Code
61 '7 I;Y
Telephone Number
Name of Compa tyAlMsON
1 .9. - -
L A�6 tAKUILLA 65Z 11V(;.
OVER, A4A 01810
State Zip Code
q17 a -7-3
Telephone Number (Cell Phone # if possible please)
Name of Company
State Zip Code
Telephone Number (Best # to Reach)
Application for Disposal System Construction Permit - Page 1 of 2
Applicati-oh.for Septic DisposalSystem 1-13
TODAYS DATE
Wlli�N F
Construction Permit- TOWN.
IL $.250.00 � Full Repair
Ile -ORTHAND
OVER,� MA 01845 $125.00 - Component
PAGE 2 OF 2
A. Facility. Inform ation continued....
6. Type- of Building: gRrseid_e_n�tial Dwelling or [3Commercial
Be Agreement
The undersigned agrees to ensure the construction. and maintenance of the afore -described
on-site sewage disposal system in accordance with the provisions of Title 5 of the
Environmental Code, as well as the Local Subsurhice Disposal Regulations for the Town of
North Andover, and not to place the system Mi operation until a Certificate of Compliance has
been issued this Board of Health.
Na7Z Date
A, proved By: (Board of Health Representative)
Date
4p7ication D;'tp�proved for the following reasons:,
For Offfee Use Only:
I
- -Fee Att2r-bed?:
No
2-
PtOjectM-1baget ObEgadoa Form Atiach'ed?
No
3,
LU—M-A-SMS—tem.? Ifs qj At t2 cj. copyofElecgicalPerink
Y
es
No
4.
Foundadon As B Ufft? constru di n -ronly),-
yes
No
s P
2 P1.0y
(Same S SZ
2pprove
c P'0
9.
FloorPLms?(new struction onljy).
Yes—
No
A00catidnforDootal '.:Con*uctIo Permft - Page 2 of 2
n
OBLIGATIONS
'SYSTEM.-INSTA UER-PROIECT MANAGEMENT.
SEPTIC
I, r.the-propelty -at:
As the North Andovtf -licensed b'st4er for theconstructi . oil' forthe -septic s7s tern , o
For Vlans by
(Address of septic system) (Engineer)
Relativd to the.application, of Aiid dated
70rigin a e
s e
Dated 6—t.3— r3_ Vrith revisions dated
-date
-----V,oda3rs (Last revised date)
I understand the following obligations for management of -this project:
instaner I am.obligated to obtain. all permits and Board offlealth approved plans. vio—t to
i As the ork is
rfO=ingany*wotk on a site. I must have biap����d.the peftnit -on site when aam_
p
�ein �d= -
2. As the inttaller,.I.rnu'st�ca for any =d all inspections. If homeowner, contractor, project manager, or any
schedules -an inspection and the system is notready, then
other person not associated with my cornpiny
item three- shall. b e,'.applicable.
plicable in�pectioas -as
3." As -the iusta� I im-i6qui;ed to. have the necessar7 work -cQmpJetdd.p.#oi...to the AN
estinit-an ih8p c6mblefi6ft, of. the items in, acc6idgm
.1-g6deft' "' I I ' Pcdbn, withoui
od belml — - . " ': .., %, '� * 'A __ i� I r
w oct%4-wna in -v
'Mom bf B, Y, .0 1 e is a� iet6ning waU, which
ab+ emU' t6- is t4q first 1�sPedtioa*tgi.ther
must %cquest &e ifispecd6a but 406s-fiot have to be piosent.
ShAabedo ��st. Theldstalla:
.'b. Fing-Cdns'", inspection or elevotions,.Afies,'etc.
h . eol + didePt . 0, 6rthandoL7,er.go
bg ofn � from the engineer must
As-biffitof-ver. OK(ore-mail-to:
-of her+ ��&�,hstalldrcalls -for -an in eAnstinermust
betubmitied-tol)ie.Bogrd. -Healtha specti.on bw
be -a pu1#p.systdtn W�iimust be ready and able to
present for this.inspecti6n, With electrical
.;I to
causeptmp t6 -v�oxk g�id larmi''i fiinaion ii'does not
FindfGtadd —Thstall6t must request . inspection tvheh';M grading -ii corni)lete.- InstaUe
C.
hve to be onrsite.
4. As -the inst4er,*I uvd6rs . tand that only 1= pl n and I.am required
y �erfbrtn the work'(Wer than jim eexcavafio)
to coroplete ;h6instOation of the sys m iden0ed in th6. ittathed' li**, ti " for. instOation.: I fiiithe
te -�pp c� on
A h n o mv hcep�e
reason for de�ialof the. tem an _..�o gperate in. thelbwn.,ot
s-in±o Dos .. s . i e.
North And.omrr sionificant fines t2 211 -pie—rs-6h JIved �'re
5.. As the.instiller,1 un"derttand t6tJ tnuAle-o n"i " d il"' tho.0666ini cepftfi�&Rowingco
�site, urmg an nstrUction
steps: -
.1; Dctcmz&atfojithat.theproperelevidon of the erramdon has been rear -bed.
A Ifispeedon Of the sand and swj�e -to hi used.
c. Finalinspecdoir bf Board ofHealth staff or consuftwt
d Instaffadon. of"* D-Ror P�Ipgs, 8
tone, vent, pump eham er, retaiving waff and other
COMDOnents.
rd
Undersigned i1ceased Septic1noPer.
...................
TRama-iPrint)
elm
cro4yi� DOO
Town of North Andover
HEALTH DEPARTMENT
S C
CHECK
LOCATION:
H/O NAME
CONTRACT
6520
Type
of Permit or License: (Check box)
$
0
Animal
$
•
Body Art Establishment
$
•
Body Art Practitioner
$
0
Dumpster
$
0
Food Service - Type.
$
0
Funeral Directors
$
0
Massage Establishment
$
0
Massage Practice
$
0
Offal (Septic) Hauler
$
0
Recreational Camp
$
0
Sun tanning
$
11
Swimming Pool
$
0
Tobacco
$
0
Trash/Solid Waste Hauler
$-
0
Well Construction
$
SEPTIC Sustems:
•
Septic - Soil Testing
$
•
Septic - Design Approval
$
0
Septic Disposal Works Construction (DWC)
$-
0
Septic Disposal Works Installers (DW[)
$
0
�5
Title 5 Inspector
Title 5 Report
$
$
0
Other (Indicate)
$
( r2
Health Xg'ent Initials
White - Applicant Yellow - Health Pink - Treasurer
TOWN OF N, 4-a-L�- -ely
SYSTEM PUMPING RECORD
DATE: (— 5�-Op
SYSTEM OWNER & ADDRESS
DATE OF PUMPING:
SYSTEM LOCATION
(example: left front of ho
CLE i V E D
JAN 13 2005
TOWN OF NORTH ANDOVER
HEAL"4 nPPARTMENT
QUANTITY PUMPED: / GALLONS
4-'�
CESSPOOL: NO C ---Y'- ES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE :> EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTIHER (EXPLAU-4)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFEWWD To: G.L.S.D Lowell Waste
t5fbrm4.doe- 06103
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
RECEIVED
AUG 0 6 2012
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this formlor 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 LocafionCgP RightjEE6j�� / Right rear of house, Left / right side of house, Left
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
Address
go
City/Town � State
2. System Owner:
Name
Address (if different from location)
Cityrrown
State
. � 9.(� -
Telephone Number
Zip Code
Zip Code
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: 00-b
Date Gallons
3. Type of system: Cesspool(s) E�3/Septic Tank Tight Tank
El Other (describe):
4. Effluent Tee Filter present? E] Yes
5. Condition of System:
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
O�
No If yes, was it cleaned? [I Yes E3 No
Waste Water
F5821
Vehicle License Number
— -I— I — I ct4—
Date
System Pumping Record - Page I of 1
Commonwealth of Massachusetts
N. 4�" , Massachusetts
System Pumping Record
System Owner
L 'ski �1
Date of Pumping: Ito —qq
Cesspool: No Yes []
System Pumped by: 164&J'" 46a&vn&"
System Location
,3D r -'st
It -
Quantity Pumped: took ---gallons
Septic Tank: No [ I
License #
Contents transferred to: Greater Lawrence Sanitary District
Date: —inspector:
JAN 2 0 .
Yes [j—
PUBLIC HEALTH DEPARTMENT
Town of North Andover
Community Development Division
CERTIFICATE OF
COMPLIANCE
As of.- 8/1/2013
This is to certify that the iiidividual subsurface disposal system received a
SATISFACTORY INSPECTION of the:
Repair of D -Box and Tank
By: Todd Bateson
At:
30 Gray Street
Map 107B Lot 0053
North Andover, MA 01845
The Issuang of this certificate shall not be construed as a guarantee that the system will function satisfactorily.
tfsaji Sawye 511/
ubfic Health Agedt/ e"4 Py
ffo *,10
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fox 978.688.8476 Web www.townofnorthandover.com