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13ATESON ENTERPRISES ING
Septic Systems — Excavating — Water & Sewer 1 -hies
Title 5 Inspection Report
Property Address: -30 La-"'�
,,)%AOwner - 'D�% - 'iO P�C-Ios
Date Of Inspection-.
I I I Argills Rosd
Andover, Mateschutells 01810
(soe) 415-1414
My report contained herein does not consti-tilte 8
gitarantee of future usage and the functionality
of the existing septic system, sucli report issued
lierevith Is merely based upon my observations,
and I hereby disclaim any further operation of
your current septic system,
10 of 10
11 V 114
U
Nell J, Bateson
Bateson Enterprises Inc&
a
." V
William F. Weld
Governor
Argeo Paul Celluccl
U. Gmennor
Commonwealth of Massachusetts
Execdive Office of Environmental Affairs
partment of
Environmental Protectionk.,-,
Trudy Cox*
secretary
David B. Struhs
CommisWaner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Addresir'iD Address of Owner.
Date of Inspection: I –
(If different)
Name of Inspector.
Company Name, Address and Telephone Numben BATESON ENTERPRISES, INC. TEL: (508) 475-1474
&cavating - Water & Sewer Lines - Septic Systems & Pumping Se -Ice \ FAX: (508) 475-5451
CERTIFICATION STATEMENT 111 Argilla Road a Andover, Mass. 01810 \1
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 fimetion and
maintenance of on-site sewage disposal systems. The system:
P�Sses
— ConditionaXy Passes
— [Neleds urrther Evaluation By the Local Approving Authority
FAS
Inspector's Signature -
Date:
it
.0
The System Inspector shall su mit a 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 inibink 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, E, C, or D:
A) SYS PASSES:
77,11-
I have not found any information which indicates that the system violates any of the failure criteria'as defined in 310 C?4R B.303.
Any failure criteria not evaluated are indicated below.
III 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 exist�g septic tank is replaced with a ;onfortning septic tank as approved
by the Board of Health.
(revised 11/03/95) 1 X
One Winter Street 0 Boston, Massachusetts 02108 41 FAX (617) SSrar-1049 4o Telephone (617) 292-5500
40 Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (oontintled)
Property Address: o L -.a cp-" �Joc,-� " % x�'
Owner. FA �- . Da%h 4 cr,
Date of Inspection- (g , 0 _9 I,
Bi 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(*)
or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of
Health):
broken pipe(a) an 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 it removed
Cl 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 systern 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 ENVIRONME".
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 &to
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 Address: C -PA -As-\ "V'CK-
Owner.
Date of Inspection:
DI SYSTEM FAILS:
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 correct 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 pqrtion 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 50 feet of a private water supply wen.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
conform 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 16,060 gpd or greater (Largo System) and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
— 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 Zono Il of a public
water supply well)
The owner or operator of any such system shall bring the systern and facility into full 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) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Ad&�* e3o Uc�,c_aA
Owner. O -S
Date of Izwpectiow
Check if the follo have been done:
Pumpng information was requested of the owner, occupant, and Board of Health.
�e�
None of the system components have been pumped for at least two weeks and the system has been receiving normal 116w rates
d * that period. lAuV volumes of water have not been introduced into the system recently or as part of this inspection.
L., 7_2
C�As plans have been obtained and examined. Note if they al* not available with N/A.
T�hejr.cility or dwelling was inspected for signs of sewage back-up.
The system does not receive non -sanitary or industrial waste flow
_��Thesftt,"as inspected for signs of breakout.
V __�m components, excluding the Soil Absorption System, have been located on the site.
A'11
e septic tank manholes were uncovered. opened, and the interior of the septic tank w inspected for condition of baftles or
tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
41 �,,ie and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non -intrusive methods.
The 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) 4 Ir.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: '30L,0,6AAA Sk. olz- "U"
Owner. K(-. (� C (OS
Date of Inspection: s,a-qq
FLOW CONDITIONS
RESIDENTIAL.
Design flow: 4 4 - -gallons
Number of bedroo=o:-LL-
Number of current residents: 7;�L
Garbage grinder (yes or no): _V0 -
Laundry connected to system (yes or no): -Le -5
Seasonal use (yes or no): PO
Water meter readings, if available: Vi eit waAe�
Last date of occupancy: LO -VtAAA—
COMMERCIAL/INDUSTRIAL:-
Type of establishment:
Design flow:____j;&1lona/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, ifavailable:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:_
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part o( inspection: (yes or no)4es.
If yes, volume pu!nve(l- lq��Iwll
Reason for pumping: 'k �V'SQOC-A-Ao�t.:=
V -
TYPE O�,WTEM
____��Septic tahk/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yea or no) (if yes, attach previous inspection records, if any)
Other (explain)
APPR XIM.ATE AGF of all components date installed (if known) and source of information -
91 1 - AQ�AA fl- lq- 77
I aA,- \j
Sewage odors detected when arriving at the site: (yes or no) Vo
(revised 11/03/95) 5 f,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (oontinued)
Property Address:'3p Lcvp — S+
Owner. C)�""'\
Date of Inspection -
SEPTIC TANIQ
(locate on site plan) ajMe� (0 JQW -
Depth below grade:
Material of construction: _�-.ncet. _metal —FRP
Sludge depth: 15 " it
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: C
, q
Distance from top of scum to top of outlet tee or baffle: Q 0 of
Distance from bottom of scum to bottom of outlet tee or baffle:—
(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:
0
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) 6 jr
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (oontinued)
P.p.rty Addresm C) La
Owner
Date IiInspection:Rc- 0
TIGHT OR HOLDING TANK'V\O--f
(locate on site 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 on site plan)
Depth of liquid level above outlet invert: 0
Comments:
(note ifXrelad d*n*].Vlq'on is equal, evidence of soli& carryover, evideng- of leakage into or -put of 1=, etc.) C), Ra'o,
-A - %-t a CW\ (aci\\3a-A . — 1-=0 \, 6QA&CP -01- C-j�L�V " CX124 - 9 --CJ
PUMP CB"BER.JWA-Q
(locate on site plan)
'9
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 11/03/95) 7 '7�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: c) Uu_e�Ll Qov-YA AAA&L.P-�
Owner. A�-. Dctk-A,��
Date of Inspection:
'SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excavation not required, but may be approximated by not -intrusive methods)
If not determined to be present, explain:
leaching pits, number:
leaching chambers, number:
leaching galleries, number:_
leaching trenches, numberjength:
leaching fields, number, dimension L 0
overflow cesspool, number:_
r (note qonditiojI if soil, tips of hydLaulic failw level of pondinfi condition of vegetatiometc 1 0 VA
CESSPOOLS:
(locate on site plan)
Number and configuration:
Depth -top of liquid to inlet invert:
Depth of solids layer:
Depth of scam layer:
Dimensions 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: VXOAC
(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) 8 A- -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:-:� c, �a
Owner.
Date of Inspection:
S1WI`CB OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
�31 3 to
Lto'
e)4o ;,,k
D 3
DEPTH TO GROUNDWATER
Depth to groundwater: feet
method of determination or approximation: Oks
t-6 Se -
12
1)�Sq I I
(revised 11/03/95) 9 IF
LAD
0
0
CoC
.. K.
PUBLIC HEALTH DEPARTMENT
Community Development Division
March 27, 2007
Ben Osgood, Jr.
Certified Title 5 Inspector
New England Engineering Services, Inc.
1600 Osgood Street, Building 20; Suite 2-64
North Andover, MA 01845
Re: Title V Inspection at 30 Lacy Street
Dear Mr. Osgood,
This correspondence is a follow-up to our conversation held on March 26, 2007 regarding the Title V inspection
report submitted to the Health Department for the address noted above. The Inspection report was found to be
incomplete in section C, regarding the distribution box. According to the report, this important component of the
septic system was not exposed during the inspection because, "box located under the intricate cementpaver
walkway. It would be too intrusive to inspect".
Unfortunately, this is why it is important for homeowners to be very aware of the location of all their septic
components, and one reason Title V does not allow permanent structures to be constructed over system components.
Although the walkway is not pennanent, its presence has hindered the general inspection of the septic system. The
MA DEP regulation 3 10 CMR 15.302(f) requires that the distribution box be opened and inspected.
Health Department files show that the last inspection in 1997 revealed some solids buildup that needed addressing at
that time; however, there were no notations in the file regarding a paver walkway. As there were previous concerns
10 years ago, we feel it is very important that this be checked at this time.
Please complete the inspection and resubmit the report for review. Thank you for your effort in ensuring a properly
functioning subsurface disposal system.
Thank
ZIer, RE S
san Saw
ublic Health Director
Cc: Joanne Parrill, 30 Lacy Street
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fox 978.688.8476 Web www.townofnorthandover.com
L ^
l � � '��
I of 11
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:
30 Lacy Street No. Andover, MA 01845
Owner's Name:
Joanne Par -rill
Owner's Address:
30 Lacy Street No. Andover, MA 0 1845
Date of Inspection:
March 15, 2007
RECENED
MAR 2 3 2007
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Name of Inspector: (please print) Benjamin C- Osgood, Jr. Certified Title 5 Inspector
Company Name: New England Engineering Services Inc.
Mailing Address: 1600 Osgood Street Building 20 Suite 2-64, North Andover, MA 0 1845
Telephone Number: 978-686-1768
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,
accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the
proper function and maintenance of the on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section
15340 of Title 5 (3 10 CAM 15.000). The system:
Inspector's Signature:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
The system inspection 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.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does
not address how the system will perform in the future under the same or different conditions of use.
2 of It
OFFICIAL ]INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 30 Lacy Street No. Andover, MA 0 1845
Owner's Name: Joanne Parrill
Date of Inspection: March 15, 2007
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 3 10 CMR 15.303 or in 3 10 CMR
15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
k__1 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.
Answer yes, no or not determined (Y,N�ND) in the 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.
ND explain:
Observation of sewage back-up or break out or high static water level in the distribution box due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health):
Broken pipe(s) are replaced
Obstruction is removed
Distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if
(with approval of the Board of Health):
Broken pipe(s) are replaced
Obstruction is removed
ND explain:
of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 30 Lacy Street No. Andover, MA 01845
Owner's Name: Joanne Parr -ill
Date of Inspection: March 15, 2007
C. Further Evaluation is Required by the Board of Health:
1,
IVO 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:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health ( and Public Water Supplier, if any,) determines that the system is
functioning in a manner that protects the public health, safety and environment:
- The system has a septic tank and (SAS) Soil Absorption System and the (SAS) and the SAS is within 100
feet of a surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
The system has a septic tank and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private
water supply well". Method used to determine distance
* * This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and
volatile organize 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 5ppm� provided that no other failure criteria are
triggered. A copy of the analysis must be attached to this form.
3. Other:
4 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Prop" Address: 30 Lacy Street No. Andover, MA 0 1945
Owner's Name: Joanne Parrill
Date of Inspection: March 15, 2007
D. System Criteria applicable to all systems:
You must indicate "yes or No" to each of the following for all inspections:
Yes No
V Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
V, Discharge or ponding of effluent to the surface of the ground or surface waters due to an overload or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overload or clogged SAS or cesspool
too� Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2day 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 SAS, cesspool or privy is below high ground water elevation.
V Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. ( this system passes if the well water analysis, performed at a DEP certified laboratory for
coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the
presence of ammonia nitrogen and nitrogen is equal to or less than 5ppm, provided that no other failure criteria are
triggered. A copy of the analysis must be attached to this form.)
-Nk� 1)
—(Yes/No) 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.
You must indicate either "yes" or "no" to each of the following:
(The following crike
,,�ia apply to large systems in addition to the criteria above)
Yes No
The system is witfiht,�00 feet of a surfaceJAIling water supply
The system is within 200 feeit�A�butary to a surface drinking water supply
The system is located !,TlAruitrogen sens nterim Wellhead Protection Area - IWPA) or a mapped Zone 11
of a public water s_Wly well
If you answered "yes" to anylo'estion in Section E the system is considere'd-asignificant threat, or answered "yes" in Section D above
the large system has failee 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 15.3104. The system owner should contact the appropriate regional
office of the Department,
5 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 30 Lacy Street No. Andover, MA 0 1845
Owner's Name: Joanne Parrill
Date of Inspection: March 15, 2007
Check if the following have been done. You must indicate "yes" or "no" as to each of the followinz
Yes No
Pumping information was provided by the owner, occupant, or Board of Health
Were any of the system components pumped out in the previous two weeks?
Has the system received normal flows in the previous two week period ?
Have large volumes of water been introduced to the system recently or as part of an inspection ?
Were as built plans of the system obtained and examined? (If they were not available note as N/A)
V/ Was the facility or dwelling inspected for signs of sewage back- up ?
Was the site inspected for sign of break out?
Were all system components, excluding the SAS, located on site?
Were all the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the
baffles or tees, material of construction , dimensions, depth of liquid, depth of sludge and depth of scum?
Was the facility owner ( and occupants if difference from owner) provided with information on the proper
maintenance of the subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has been determined based on:
Yes No
Existing information. For example, a plan at the Board of Health.
Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable) [3l0CMRl.5.302(3)(b)]
6 of 1I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 3 0 Lacy Street No. Andover, MA 0 1845
Owner's Name: Joanne Parrill
Date of Inspection: March 15, 2007
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design) Number of bedrooms (actual)7
DESIGN flow based in 3 10 CMR 15.203 ( for example: I 10 gpd x # of bedrooms) C
Number of current residents:
Does residence have a garbage grinder (yes or no): ,VP
Is laundry on a separate sewage system (yes or no): IV'!�' [if yes separate inspection required]
Laundry system inspected ( yes or no):
Seasonal use: (yes or no): 111, �1` ,
Water meter readings, if available (last 2 years usage (gpd): it
Sump Plump (yes or no): ;,- �,.' �;A
Last date of occupancy �7
COMMERCIAVINDUSTRIAL
Type of establishment:
Design flow (based on 3 10 CMR 15.203): gpd
Basis of design flow (seats/persons/sqft, etc
Grease trap present (yes or no)�_
Industrial waste holding tank present (yes or no):
Non -sanitary waste discharged to the Title 5 system (yes or no)
Water meter readings, if available:
Last date of occupancy/use:
OTHER (
GENERAL INFORMATION
Pumping Records
Source of informatiow /+,0� Q'i- v, 'Z;
Was system pumped as part of the inspection (yes 'o'r no): Aj
If yes, volume pumped: ------ -- gallons - How was quantity pumped determined?
Reason for ournning-
TYPE OF SYSTEM
Septic tank, distribution box, soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from
system owner)
Tighttank Attached a copy of the DEP approval
Other (describe):
Approximate age of all components, date installed (if known) and source of information:
- 1 `1 7 7 i - 1�� �_ �, -7
1 "��
Were sewage odors detected wen arriving at the site (yes or no): �, 1;_ � —
7of It
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 3 0 Lacy Street No. Andover, MA 0 1845
Owner's Name: Joanne Parrill
Date of Inspection: March 15, 2007
BUH,DING SEWER (locate on site plan)
Depth below grade:
Materials of construction: cast iron 40 PVC other (explain)
Distance from private water supply well or suction line: 7�:- ::�
Comments (on condition of joints, venting, evidence of leakage, etc.):
SEPTIC TANK -._(locate on site plan)
Depth below grade- /I
Material of construction: concrete metal —fiberglass—polyethylene
— Other (explain).
If tank is metal li"-.S Is age confirmed by a Certificate of Compliance (yes or no):—(attach a copy of certificate)
Dimensions:
Sludge depth�
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:- m ee4.�, 511-114: V,
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet
invert, evidence of leakage, etc.):
GREASE TRAP:,V/ / �)- (locate on site plan)
7 —
Depth below grade
Materials of construction: concrete—metal fiberglass _polyethylene other
(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of sludge to bottom of outlet tee or baffle:
Date of last pumping:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition structural integrity, liquid levels as related to outlet
invert, evidence of leakage, etc.
8of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 3 0 Lacy Street No. Andover, MA 0 1845
Owner's Name: Joanne Parrill
Date of Inspection: March 15, 2007
TIGHT ORHOLDING TANK: A;10� (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade
Materials of construction: concrete metal fiberglass —polyethylene other
(explain
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present (yes or no):
Alarm level: Alarm in working order (yes or no):
Date of last purnping:
Comments (condition of alarm and float switches, etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 4 -
Comments ( note if box is level and distribution to outlets equal, any evidnence of solids carryover, any evidence of leakage into or
out of box, etc.)-,
I rz " Fe P F-� -I-ZF c.,,e,-?i e ii 7— iz K L-�_, 6- 2
T'r, / �J.5
PUMP CHAMBEPU 4,1/A- (locate on sire plan)
Pumps in working order (yes or no)—
Alarms in working order (yes or no)_
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.)
9 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 30 Lacy Street No. Andover, MA 01845
Owner's Name: Joanne Parrill
Date of Inspection: March 15, 2007
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan. excavation not required
If SAS not located explain why
TYPE
leaching pits number
leaching chambers, number_
leaching galleries number
leaching trenches, number in length
leaching fields, number, dimensions: 92 C, )i il.5'
overflow cesspool, number:
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)
A -0 -C -A I -C, 0 A., �- /1-1 �D ��i i A-,'
CESSPOOLS: Aj4±t (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 (yes or no):
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRIVY: I
Lb--foocate on site plan)
Material of construction:
Dimensions:
Depth of solids:
Comments (note condition of soil signs of hydraulic failure, level of ponding, condition of vegetation, etc.
10 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 3 0 Lacy Street No. Andover, MA 0 1845
Owner's Name: Joanne Parrill
Date of Inspection: March 15, 2007
1,C
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate
all wells within 100 feet. Locate where public water supply enters the building.
4- A( -j s -T iz -Fb--r
It of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Property Address:
Owner's Name:
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
PART C
SYSTEM INFORMATION (continued)
3 0 Lacy Street No. Andover, MA 0 1845
Joanne Parrill
March 15, 2007
Estimated depth to ground water 6 feet
Please indicate (check) all methods used to determine the high ground water elevation:
Obtained from system design plans on record — If checked, date of design plan reviewed:
IK Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health — explain:
Checked with local excavator, installers — (attach documentation)
Accessed USGS databasei-explain:
You must describe how you established the high ground water elevation:
4,fe-�- C H Ff? E C_ C_ �-t C (L T74,4- 71 _e
-c- 2-e 4-12-
I of It
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
Property Address:
Owner's Name:
Owner's Address:
Date of Inspection:
30 Lacy Street No
Joanne Parrill
30 Lacy Street No
March 15, 2007
PART A
CERTIFICATION
Andover, MA 0 1845
Andover, MA 0 1845
RECEIVED
APR - 3 2007
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Name of Inspector: (please print) Benjamin C. Osgood, Jr. Certified Title 5 Inspector
Company Name: New England Engineering Services Inc.
Mailing Address: 1600 Osgood Street Building 20 Suite 2-64, North Andover, MA 0 1845
Telephone Number: 978-686-1768
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,
accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the
proper function and maintenance of the on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section
15340 of Title 5 (310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature:
The system inspection 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
C,
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.
Notes and Comments
A-511
****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.
k I
2 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 30 Lacy Street No. Andover, MA 01845
Owner's Name: Joanne Parrill
Date of Inspection: March 15, 2007
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 310CMR
15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
AbL_ 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.
Answer yes, no or not determined (Y,N,ND) in the 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.
ND explain:
--Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)
or due to a brokeri, settled or uneven distribution box- System will pass inspection if (with approval of Board of Health):
Broken pipe(s) are replaced
Obstruction is removed
Distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s)- The system will pass inspection if
(with approval of the Board of Health):
ND explain:
Broken pipe(s) are replaced
Obstruction is removed
3 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 30 Lacy Street No. Andover, MA 01845
Owner's Name: Joanne Parrill
Date of Inspection: March 15, 2007
C. Further Evaluation is Required by the Board of Health:
t. r
J'v 0 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:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health ( and Public Water Supplier, if any) determines that the system is
functioning in a manner that protects the public health, safety and environment:
— The system has a septic tank and (SAS) Soil Absorption System and the (SAS) and the SAS is within 100
feet of a surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
The system has a septic tank and the SAS is within 50 feet of a private water supply well.
— The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private
water supply well". Method used to determine distance
* * This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and
volatile organize 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 5ppm, provided that no other failure criteria are
triggered. A copy of the analysis must be attached to this form.
3. Other:
4 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 30 Lacy Street No. Andover, MA 01845
Owner's Name: Joanne Parrill
Date of Inspection: March 15, 2007
D. System Criteria applicable to all systems:
You must indicate "yes or No" to each of the following for all inspections:
Yes No
V Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overload or clogged SAS or
cesspool.
V/ Static liquid level in the distribution box above outlet invert due to an overload 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
V Any Portion of the SAS, cesspool or privy is below high ground water elevation.
V Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply
I/ Any portion of a cesspool or privy is within a Zone I of a public well.
V Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 5 0 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
coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the
presence of ammonia nitrogen and nitrogen is equal to or less than 5ppm, provided that no other failure criteria are
triggered. A copy of the analysis must be attached to this form.)
A�.,)
V (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 3 10 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.
You must indicate either "yes" or "no" to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
The system is witfilh,400 feet of a surface king water supply
_dpK
The system is within 200 feeZ'0�kKbutary to a surface drinking water supply
The system is located iriernitrogen sens nterim Wellhead Protection Area - IWPA) or a mapped Zone 11
of a public water s4. y well
If you answered "yes" to any4blestion in Section E the system is considere-d-,Tsignifj cant threat, or answered "yes" in Section D above
the large system has faila" The owner or operator of any large system considered a significant threat under Section E or failed under
I
Section D shall upgrade the system in accordance with 3 10 CMR 15.304. The system owner should contact the appropriate regional
office of the Department.
5 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 30 Lacy Street No. Andover, MA 0 1845
Owner's Name: Joanne Parrill
Date of Inspection: March 15, 2007
Check if the following have been done. You must indicate "yes" or "no" as to each of the followinz
Yes No
Pumping information was provided by the owner, occupant, or Board of Health
Were any of the system components pumped out in the previous two weeks-?
Has the system received normal flows in the previous two week period ?
Have large volumes of water been introduced to the system recently or as part of an inspection ?
Were as built plans of the system obtained and examined? (If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up ?
Was the site inspected for sign of break out?
Were all system components, excluding the SAS, located on site?
Were all the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the
baffles or tees, material of construction , dimensions, depth of liquid, depth of sludge and depth of scum?
Was the facility owner ( and occupants if difference from owner) provided with information on the proper
maintenance of the subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has been determined based on:
Yes No
Existing information. For example, a plan at the Board of Health.
Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable) [3l0CMRl5.302(3)(b)]
6 of 1. 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 30 Lacy Street No. Andover, MA 01845
Owner's Name: Joanne Parrill
Date of Inspection: March 15, 2007
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design) 1i Number of bedrooms (actual 7
DESIGN flow based in 3 10 CMR 15.203 ( for example: I 10 gpd x # of bedrooms) L-, C C,
Number of current residents: 6�'
Does residence have a garbage grinder (yesor no): NO
Is laundry on a separate sewage system (yes or no): &0 [if yes separate inspection required]
Laundry system inspected ( yes or no)-.__"_�
Seasonal use: (yes or no):__N_0_-.
Water meter readings, if available (last 2 years usage (gpd)-. k4_9 F -
Sump Pump (yes or no): L.Ac_5!
Last date of occupancy_avr_�_LA
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow (based on 3 10 CMR 15.203): gpd
Basis of design flow (seats/persons/sqft, etc
Grease trap present (yes or no):
Industrial waste holding tank present (yes or no):
Non -sanitary waste discharged to the Title 5 system (yes or no).
Water meter readings., if available:
Last date of occupancy/use:
OTHER (describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of tEe inspection (yes orno): NO
If yes, volume pumped:_ -------gallons — How was quantity pumped determined?
Reason for purnpina:
TYPE 91 SYSTEM
Septic tank, distribution box, soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Innovative/Altemative technology. Attach a copy of the current operation and maintenance contract (to be obtained from
system owner)
Tight tank Attached a copy of the DEP approval
Other (
Approximate age of all components, date installed (if known) and source of information:
19 -77 PaZjL /J± — 501 Lj—
if
Were sewage odors detected wen arriving at the site (yes or no): Ali "IV
7 of 11.
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 3 0 Lacy Street No. Andover, MA 0 1845
Owner's Name: Joanne Parrill
Date of Inspection: March 15, 2007
BUIELDING SEWER (locate on site plan)
it
Depth below grade: 2
-4�
Materials of const ction: cast iron 40 PVC other (explain)
Distance from private water supply well or suction line: -2? % .
Comments (on condition of joints, venting, evidence of leakage, etc.):
_RVIE Z -P 6yo JX -J Apo e1 -HR, -y -r
SEPTIC TANK: (locate on site plan)
Depth below grade:_,
Material of constructjon:__�� concrete metal fiberRIass polyethylene
Other (explai
If tank is metal list age:—Is age confirmed by a Certificate of Compliance (yes or no) -.—(attach a copy of certificate)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: 3 L--�.
Scum thickness: .4 Z� 0
Distance fTom top of scum to top of outlet tee or baffle: L11
Distance from bottom of scum to bottom of outlet tee or baffle It
How were dimensions determined:- m eci.�r fU- 4.w * 1-1 C V,
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet
invert, evidence of leakage, etc,):
GREASE TRAP:A*Iocate on site plan)
Depth below grade
Materials of construction -,_concrete metal fiberalass —Polyethylene other
(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance ftom bottom of sludge to bottom of outlet tee or baffle:
Date of last pumping:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition structural integrity, liquid levels as related to outlet
invert, evidence of leakage, etc.
80f 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 30 Lacy Street No. Andover, MA 0 1845
Owner's Name: Joanne Parrill.
Date of Inspection: March 15, 2007
TIGHT OR HOLDING TANK: A11A (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade
Materials of construction: concrete metal fiberglass -polyethylene other
(explain)
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present (yes or no):
Alarm level: Alarm in working order (yes or no):
Date of last pumping:
Comments (condition of alarm and float switches, etc.):
DISTRIBUTION BOX: . (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments ( note if box is level and distribution to outlets equal, any evidnence of solids carryover, any evidence of leakage into or
out of box, etc.)-.
i eVX 17 C �4' - 11 - Z�_ � -_U 0 el
C;, C'7
PUMP CHAMBER: (locate on sire plan)
Pumps in working order (yes or no) -
Alarms in working order (yes or no) -
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc,):
9 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 30 Lacy Street No. Andover, MA 0 1845
Owner's Name: Joanne Parrill
Date of Lnspection: March 15, 2007
SOUL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required
If SAS not located explain why
TYPE
leaching pits number
leachiniz chambers, number
leaching galleries number
leachina trenches, number in length
Y,\ leaching fields, number, dimensions: Ly 5,
overflow cesspool, number.
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)
A-ag-)+ cL jz::� r -,j c t- (--,, -, . i4s, r 'L�, �� j1,,V,4 L�, & -A " 4 \,� i+,D 0,;--i i lk-? 7 _C
-C W�t— 3 C--> A2
CESSPOOLS: Aj4�± (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 (yes or no):
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRIVY: IJIL_� P-� (locate on site plan)
Material of construction:
Dimensions:
Depth of solids:
Comments (note condition of soil signs of hydraulic failure, level of ponding, condition of vegetation, etc.
10 of H
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SENVAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 30 Lacy Street No. Andover, MA 01845
Owner's Name: Joanne Parrill
Date of Inspection: March 15, 2007
?0
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate
all wells within 100 feet. Locate where public water supply enters the building
ZY
4- A ( � s -j 9, -F E- -T-
It of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 3 0 Lacy Street No. Andover, MA 0 1845
Owner's Name: Joanne Parrill
Date of Inspection: March 15, 2007
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate (check) all methods used to determine the high ground water elevation:
Obtained from system design plans on record — If checked, date of design plan reviewed:
Observed site (abutting property/observation holewithin 150 feet of SAS)
Checked with local Board of Health — explain:
Checked with local excavator, installers — (attach documentation)
Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
C t-( r--? F, e,-:> I -C- c- ( i�-i i G_�-tc(L 774,4 A-,! 7 -el [1
-C ge + IL c, i=-- --c. -,
NORIH ANDOVER BOARD OF H&8JTH
INSIALLATIO14 CHECK LIST
APPI�'OVT-D_N DISAPPROVED EKAVATI2A OK
Date: R -t--
Reason: 4� C/)
BiAlt Submitted
Check: Lot location,, dimensions ' of system., location in regard to
percolation tests, depth of syqtem,, i -rater table
,' �.Distance to WetXld'�eas, Stree I
,_ �&House, Drainage >_-_e�erit and S.
Water Line Location
N o PVC Pipe
�e bic Tank - Tees, Cement -Pipe to Tank -joints on both side of Tank.
6"stribution Box - No cracks in box or cover, all lines
flow equally from box.
Leach Fields
.
- Dim Ston hs .1
I ze, �10 n S ezPe6`
Capp e
/0 -lends.,
Clean double -washed stone
Z'
8._T_eac� Pits - Dimensions., Depth of Stone, Splash pad�teesj, Cement -pipe to tank -
joints on both sides of tank-, Clean double -washed stone
Garbage Disposals
Final Grading "'barricading of sub -surface system%.
*1 1
C� I
0)6 q
4
*1 U.
Reg. 2. 5
I.
Ii.
NORTH ANDOVER
SUBSURFACE DISPOSAL SYSTEM CHECK LIST
WE
0:^x kw_^at
4
General Information (10"
The submitted plan must show as a minimum:
(a)tO-the lot to be served
(bb.e location and dimensions of the system (including
reserve area)
(c)ot-design calculations
(d)otcalculations showing required leaching area
(e)prexisting and proposed contours
(f) location and log of deep observation holes -
distance to ties
(g)e4location and results of percolation tests -
distance to ties
(h)V-location of any wet areas within 1001 of the
sewage. disposal system or disclaimer
Mor -surface and subsurface drains within 1001 of
the sewage disposal system or disclaimer
(j)&Jocation of any drainage easements within
1001 of the sewage disposal system or disclaimer
(k) known sources of water supply W, of
the sewage disposal system or isclaimer
(1)6t -location of any proposed well4fos=erve tbhe lot
(m)04ocation of water lines on the property
(n) maximum ground water elevation in the area of
bqhe sewage disposal system
(o)oj�a profile of the system
no PVC is to be used in construction
(q)DI,location of benchmark
plan must be prepared by a Professional Engineer
or other professional authorized by law to prepare
such plans.
Garbage Disposers 0 4
IV. Pumps
Reg. 9.1 (a) Approval
Reg. 9.6 (b) Stand-by power
III.
Septic
Tanks
Reg.
6.1
(a)
Capacities 6IC,' 150% of flow
Reg.
6.7
(b)
Water table oz�
Reg.
6.8
(c)
(d)
Tees 0r—
Depth of teesO�
Reg.
6.9
Reg.
6.12
(e)
Access 0'1_1'
Reg.
6.18
(f)
Pumping 0&
(g)
Cleanout 6<-'
IV. Pumps
Reg. 9.1 (a) Approval
Reg. 9.6 (b) Stand-by power
V.
Reg. 10. 2
Reg. 10. 4
Distribution Boxes
(a) Slope greater than 0.08 61-
(b) Sump
4
VI. Leaching Pits
Leaching pits are preferred where the installation is
possible.
Reg. 11.2 (a), Calculations of leaching area (minimum 500 S.F.)
.Reg. 11.4 (b) Spacing
Reg. 11.10 (c) Surface drainage 2%
Reg. 11.11 W Cover material
VII.
Leaching Fields
Reg.
15.1
(a)
Greater than
20
minutes/inch
Reg.
15.1
(b)
Area (minimum
900
S.F.)
Reg.
15.4
(c)
Construction
of
field OK
Reg.
15.8
(d)
Surface drainage
2%
Ix.
Downhill Slope
(a)
Slope y/x =
(to
be shown)
(b)
Y/x X 1 50 =
(to
be shown) 04z,
SOIL PROFILE & PERCOLATION TEST DATA
Town/City .&Street 4cze.4.�
Lot No.
Loc./Subdiv. Pla
Owner
eo
Investigator '42,zaqallo Observer
I
74
Elev
SOIL PROFILES -DATE
ve 3' Elev.
0 0
F
2
3
4
5
6
9
10
Benchmark Location
Elevation Datum
Percolation Tests -Date
, / 117e
2
3
4
5
6
E-11
9
10
i —*E 1 e v .
Pit Number 2 3 4 5
Start Saturation
Soak -Mins—.
Mrt Test-�TUme
Drop of 3" -Time
Drop of 6" -Time
Mins.lst 3"Drop
Mins.2nd 3"Drop
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NORTH ANDOVER
SUBSURFACE DISPOSAL SYSTEM CHECK LIST
I. General Information
Reg. 2.5 . The submitted plan must show as a minimum:
bg-(a) the lot to be served
,4b) location and dimensions of the system (including
reserve area)
design calculationsZ----
calculations showing required leaching are�:_�
Aexisting and proposed contours
(f) r,.location and log of deep observation holes
0 distance to ties r
(g) location and results of percolation tests
distance to ties
(h location of any wet areas w*fbin_3001 of the
uu' 1 7
sewage disposal system or isclaimer
M surface and subsurface drains awi 00, of
m
the sewage disposal syste wdisc!1aimer
(j) location of any drainage ease n
100 1 of the sewage disposal system or Tisc:1;ai:m::e_r�L_-
W known sources of water supply within �2 0
' &� the -sewage disposal system or disclaimer
MaKlocation of any proposed well to serve the lot
(m)�K.location of water lines on the property
pn) maximum ground water elevation in the area of
the sewage disposal system
(o)or-a profile of the system
p) no PVC is to be used in construction
A*e�)cXlocation of benchmark
r plan must be prepared by a Professional Engineer
60eo-� other professional authorized by law to prepare
such plans.
Ii. Garbage Disposers
Ole,
III. Septic Tanks
Reg.
Reg.
6.1 (a)
6
Reg.
Reg.
6.8 - (c)
6.9 (d)
Reg.
6.12
(e)
Reg.
6.18
(g)
IV. Pumps
Capacities -
Water table
Tees
Depth of tees
Access
Pumping
Cleanout
Reg. 9.1 (a) Approval
Reg. 9.6 (b) Stand-by power
150% of flow
M
/ I =IV,
4
V. Distribution Boxes
Reg. 10.2 (a) Slope greater than 0.08
Reg. 10.4 (b) Sump
VI. Leachinq Pits
Leaching Pits are preferred where the installation is
possible.
Reg. 11.2 (a), Calculations of leaching area (minimum 500 S.F.)
Reg. 11.4 (b) Spacing
Reg. 11.10 (c) Surface drainage 2%
Reg. 11.11 (d) Cover material
VII. Leaching_Ejelds
Reg. 15.1 OV -4a) Greater than 20 minutes/inch
Reg. 15.1 Ob) Area (minimum 900 S.F.)
Reg. 15.4 (c) Construction of field
Reg. 15.8 d) SWface d ain- e 2%
44�
Ix. DownhilL_�j �oe
(a) Slope y/x = (to be shown)
(b) Y/x X 150 = (to be shown) 01/e—
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