HomeMy WebLinkAboutMiscellaneous - 30 OXBOW CIRCLE 4/30/2018 (2)N)
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CONSTRUCTION APPROVAL
Has plan review fee been paid: YES NO Permit#
2is:)
Plan Approval: Date:
Z�Ia7_ Approved by:
Designer: Plan Date:
Conditions: /_/�,),95 -Q1 C-,9_-SeMCUr.S 7-6Z&
�Rel.OAC 7-0 COAJ57;eUC-7 -/00-
Water Supply: ( �To w Dn Well
Well Permit:
Driller:
Well Tests: Chemical
i5it–e-Approved
Bacteria I
Date Approved
Bacteria 11
Date Approved
Plumbing Sign-Offi.
Wiring Sign -Off:
Comments:
Form "U" Approval: Approval to Issue: S
NO
Date Issued
By:
Conditions:
Final Approval:
All Permits Paid?
YES
NO
Well Construction Approval?
YES
NO
Septic System Construction Approval? YES
NO
Certification?
YES
NO
Other
YES
NO
Any Variance Needed?
Y,qe 16IZ14 7
NO Qo " 7--0 we_ -7-,
FINAL BOARD OF HEALTH APPROVAL:
DATE:
APPROVED BY:
k/yc
I
SEPTIC SYSTEM MSTALLATION
Is the installer licensed?
Type of Construction:
NO
New Construction: Certified Plot Plan Review
YES
REPAIR
Floor Plan Review
YES
NO
NO
Conditions of Approval from Form U
YES
NO
Issuance of DWC permit:
DWC Permit Paid?
YES
NO
DWC Permit Installer:
NO
12
Begin Inspection:
YES
NO
Excavation Inspection:
Needed:— �5)C-Vc- /9/j?k, �Z�- "h Foe S�Wb
Passed:
Construction Inspection:
Needed:
Satisfactory -
Approval of Backfill: Date:
ME
Final Grading Approval: Date- B y'-:
Final Construction Approval- Date: By:
Certificate of Compliance: Approval: Date:-
PUBLIC HEALTH DEPARTMENT
Town of North Andover
Community Development Division
CERTIFICATE OF
COMPLIANCE
As of-. 5/17/16
This is to certify that the individual subsurface disposal system received a
SATISFACTORY INSPECTION of the:
Repair of D -Box
By: John DiVincenzo
At:
30 Oxbow Circle
Map 107.B Lot'0146
North Andover, MA 01845
The Issu ce of this e ificate shall not be construed as a guarantee that the system will function satisfactorily.
c
1 c
r
Bri J. aGrasse
Public Health Director
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fox 978.688.8476 Web www.townof north an dover.com
North Andover Health Department
(ommunity and Economic Development Division
QNSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: 30 Oxbow Circle MAP: 107.B LOT: 0146
INSTALLER: John DiVincenzo
DESIGNER:
PLAN DATE:
BOH APPROVAL DATE ON PLAN:
INSPECTIONS
D -Box INSPECTION:
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS E-5 /"' Contractor reports any changes to design plan
EIA/'�-,Existing septic tank properly abandoned.
Internal plumbing all to one building sewer
Topography not appreciably altered
Comments:
=1 200aff-11 IN, r.11
Building sewer in continuous grade, on
compacted firm base
El
Cleanouts per plan
Bottom of tank hole has 6" stone base
Weep hole plugged
E]
1500 gallon tank has been installed
H-10 loading
Monolithic tank construction
E]
Water tightness of tank has been achieved by
visual testing
El
Inlet tee installed, centered under access port
F-1 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:
PUMP CHAMBER
F] Bottom of tank hole has 6" stone base
E] Weep hole plugged
1500 gallon Pump Chamber installed
H-10 loading
Monolithic tank construction
Inlet tee installed, centered under access port
E] Pump(s) installed on stable base
n Alarm float working
Pump On/Off floats working
Separate on/off floats
Drain hole in pressure line
cover at final grade installed over pump
access port
Water tightness of tank has been achieved by
testing
Hydraulic cement around inlet & outlet
Comments:
CONTROLPANEL
F1 Alarm & Pump are on separate circuits
Alarm sounds when float is tripped
Location of control panel: basement
Alarm signal located inside: basement
Comments:
DISTRIBUTION -BOX
installed on stable stone base
H-20 D -Box
Inlet tee (if pumped or >0.08'/foot)
Pr Hydraulic cement around inlet & outlets
Observed even distribution
Speed levelers provided (not required)
Schedule 40 PVC Pipe
Comments:
6 L/ f- '-j Rew r I tuoU. . (s eeuv-, W"
For Commonwealth of Massachusetts Map -Block -Lot
107.BO146
-----------------------
BOARD OF HEALTH Permit No
North Andover - B - HP -2016-01 - 51 ----
- ------------- --
PA. FEE
F.I. $175.00
-----------------------
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted John DiVincenzo
---- - --------------- ------------------------------------- ------------------------------
to (Repair) an Individual Sewage Disposal System.
atNo 1 --3-0- -OXBOW- CIRCLE ---------- b6x ---------------------------------------------------------------------------------------
as shown on the application for Dispqsal Works Construction Permit No. 13HP-20-1-67-0).5---, Dated,,_ May 11, 2016 --------
-----------------------------------------------------------------
Issued On: May -1 1-2016 BOARD OF HEALTH
- -- - - --------------- -------------------- ---------------
Application for Septic Disposal System
A.
.L
Construction Permit — TOWN OF
NORTH ANDOVER, MA 01845
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
01_�
V%=A
la,f
Application is hereby made for a permit to:
El Construct a new on-site sewage disposal system*
611111�
TODAY'S DATE
$350.00 - Full Repair
$175.00 - Component
E] Repair or replace an existing on-site sewage disposal systeb* f2 �
15T5/Repair or replace an existing system component– What?
A. Facility Information
lo 0 )�.g
Address or Lot #
,�& 04&2A_e_V_ RECEIVED
City/Town
2.- *TYPE OF SEPT4C SYSTEM*: MAY 112016
> E] Pump E91travity (choose one)
***If pumLsy-4em, attach copy of electrical permit to application— TOWN OF NORTH ANDOVER
> LSMonventional System (pipe and stone system) HEALTH DEPARTMENT
> El Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system.)
> [:] Pressure Distribution S.A.S. (No D -Box)
> E] Pressure Dosed (D -Box Present) S.A.S.
> [:1 Does the system require an effluent filter? Yes No
If yes, does plan specify make and model of filter? YES = (no further info. needed)
NO = (installer must specify brand of filter before DWC issuance)
What is the Make? What is the Model?
2. Owner Information
V a M I OL t-1
Name
Address (if different trorn agove)
/w —
City/Town
State Zip Code
Email address
Telephone Number
3. Installer Information
Z'o ko L i V ij C r
9'e-jr r I C
Name
,:5-7 so P T�
Name of Company
Addres,p
City/Town
State Zip Code
— ' e - 9*0 -7 - 'T-) .3
/ 71
Telephone Number (Cell Phone # if possible please)
4. Designer Information
Name
Name of Company
Address
City/Town
State Zip Code
Telephone Number (Best # to Reach)
Application for Disposal System Construction Permit - Page 1 of 2
Applic tion for Septic Disposal System TODAY'S DATE
Construction Permit — TOWN OF
$350.00 - Full Repair
NORTH ANDOVER, NUO1845 $175.00 - Component
PAGE 2 OF 2
A. Facility Information continued....
5. Type of uildina: �Residential Dwelling or nCommercial
B. 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
EnvironmetItal Code, as well as the Local Subsurface Disposal Regulations for the Town of
No 441& until a final Certificate of Compliance has been issued by
th is not approved.
KXe Date
Applidation. Ap roved B . oa. e resentative)
ka a o(
NaMe Date
Application Disapproved for the following reasons:
For Office Use Only:
1. FeeAttachedP
Yes
No
2. Project Manager Obligation Fonn AttacbedP
Yes
No
3. Pump SVs P If so, A ttach copy of Electrical Pennit Yes No
Applicant received copv of
"Electrical Inspection Notes for Septic SVs tems Yes No
Handout?
4. Reviewed approval letter, allpaperwork received? Yes No
.5. Foundation As-BuiltP (new construction only): Yes No
(Sanle scale as approvedplan)
6. Floor Plans? (new construction only): Yes No
Application for Disposal System Construction Permit - Page 2 of 2
SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
(Address of septic system)
Relative to the application of V"Iricc,-'(w
(Installer's name)
Dated 5_11111�
I (foday's date)
For plans by
And dated
With revisions dated
I understand the following obligations for management of this project:
(Engineer)
(Original date)
(Last revised date)
1 . As the installer, I am obligated to obtain an permits and Board of Health approved plans P,
nor to
performing any work on a site. I must have the a1212roved plans and the 12ermit on site when anv work is
being done.
2. As the installer, I must call for any and all inspections. If homeowner, contractor, project manager, or any
other person not associated with my company schedules an inspection and the system is not ready, then
item three shall be applicable.
3. As the *installer, I am required to have the necessary work completed prior to the applicable 'inspections as
indicated below. I understand that requesting an inspection, without completion of the items in accordance
with Tide 5 and the Board of Health keVulations may result in a $50.00 fine being levied agaLmst me and/o
M co=a11y.
a. Bottom of Bed - Generally, this is the first (1') inspection unless there is a retaining wall, which
should be done first. The installer must request the inspection but does not have to be Present.
b. Final Construction Inspection - Engineer must first do their 'inspection for elevations, des, etc.
As -built of verbal OK (or e-mail to: healthdel2tQtownofnorthand6ver.co from the engineer must
be submitted to the Board of Health, after which installer calls for an 'inspection time. Installer must
be present for this inspection. With a pump system, all electrical work must be ready and able to
cause pump to work and alarm to function.
c. Final Grade - Installer must request 'inspection when all grading is complete. Installer does not
have to be on-site.
4. As the installer, I understand that only I may perform the work (otber Than simple excavation) and I am required
to complete the installation of the system identified 'in the attached application for installation. I further
understand that work done bv others unlicensed to install sentic systems in North Andover can constitute
reasons for denial of the system and/or revocation or susl2ension of my license to ol2erate in the Town of
North Andover, significant fines to all persons involved are also possible. 1
5. As the installer, I understand that I must be on-site during the performance of the following construction
steps:
a. Determination that the proper elevation of the excavation has been reached
b. Inspection of the sand and stone to be used
c. Final inspection by Board ofHealth staff or consultant.
d Installation of tank, D -Box, pipes, stone, vent, pump chamber, retaining wall and other
components.
6. As the installer, I understand that I am solely responsible for the i stallation of the system as 12er the
a1212roved plans. No instructions by the homeowner. general contractor, or any other 12ersons shall ab!
me of this obligation.
I
Undersigned Licensed Septic Installer: (Today' Date)
ame —
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 Oxbow circle
Property Address
Damian
Owner's Name
North Andover
City/Town
RECEIVED
MAY 16 2016
TOWN OF NORTH ANDOVER
IjE,lli,_LT DEPARTMENT
A, q
Ma 01886 May 10,2016
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: When
A. General Information
filling out forms
on the computer,
use only the tab
1 Inspector:
key to move your
cursor - do not
John DiVincenzo
use the return
key.
Name of Inspector
Stewarts Septic Serive
Company Name
58 South Kimball street
Company Address
-Bradford
City/Town
978-372-7471
Telephone Number
B. Certification
MA
State
S113386
License Number
01835
Zip Code
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
El Passes 0 Conditionally Passes F] Fails
Ej Nodg7urfipr�valdlation by/the Local Approving Authority
re Date
The system inspector s�all subr
,aft a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within"�ys of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DER The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
30 Oxbow circle
Property Address
Damian
Owner Owner's Name
information i's
required for every North Andover Ma 01886 May 10,2016
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes:
El I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
13) System Conditionally Passes:
one or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
El Y r-1 N F] ND (Explain below):
t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17
AIR, 7-2- z
L
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 Oxbow circle
Property Address
Damian
Owner's Name
North Andover Ma 01886 May 10,2016
Cityrrown 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):
El
F-1
0
broken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
El Y
El Y
0 Y
El N
El N
El N
El
0
r-1
ND (Explain below):
ND (Explain below):
ND (Explain below):
El The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if (with approval of the Board of Health):
R broken pipe(s) are replaced El Y El N Ej ND (Explain below):
F1 obstruction is removed Ej Y El N El ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
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:
El Cesspool or privy is within 50 feet of a surface water
Ej 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
4*&IR S 5
EMFFc�AQ=A m@n\$a#A=—,aan@-O^fJ8eyFr-su"- +-LL-T-a-z§2/Q@tdA
All iism z
L W
Lei
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 Oxbow circle
Property Address
Damian
Owners Name
North Andover Ma 01886 May 10,2016
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
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.
0 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
Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
El
N
Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El
0
Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2day flow
t5ins - 3/13
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17
E] 0 The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
0 z The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the
questions in Section D.
Yes No
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
E] 1:1 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
Commonwealth of Massachusetts
Title 5
Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
30 Oxbow circle
Property Address
Damian
Owner
Owner's Name
information is
required for every
North Andover
Ma 01886 May 10,2016
page.
City/Town
State Zip Code Date of Inspection
B. Certification (cont.)
Yes
No
El
E 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
X Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
El
N Any portion of a cesspool or privy is within a Zone 1 of a public well.
El
E Any portion of a cesspool or privy is within 50 feet of a private water supply well.
El
E Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
E] 0 The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
0 z The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the
questions in Section D.
Yes No
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
E] 1:1 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
I I
-C\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
30 Oxbow circle
Property Address
Damian
Owner Owner's Name
information i's
required for every North Andover Ma 01886 May 10,2016
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
Z El
Pumping information was provided by the owner, occupant, or Board of Health
E] 0
Were any of the system components pumped out in the previous two weeks?
N El
Has the system received normal flows in the previous two week period?
Z
Have large volumes of water been introduced to the system recently or as part of
this inspection?
Z El
Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
N El
Was the facility or dwelling inspected for signs of sewage back up?
Z 1:1
Was the site inspected for signs of break out?
Z E]
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?
Was the facility owner (and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
Existing information. For example, a plan at the Board of Health.
Z
Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440
t5ins - W13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17
IJOHV<<$QK- rr5f
Y,8; L'q�bbVOSb66NJ-?.J +-11OXti dW
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
30 Oxbow circle
Ma 01886 May 10,2016
�tate _Zip Code Date of Inspection
D. System Information
Property Address
Damian
Owner
Owner's Name
information is
required for every
North Andover
page.
City/Town
Ma 01886 May 10,2016
�tate _Zip Code Date of Inspection
D. System Information
Description:
Number of current residents:
4
Does residence have a garbage grinder?
El
Yes
0
No
Is laundry on a separate sewage system? (Include laundry system inspection
EJ
Yes
Z
No
information in this report.)
Laundry system inspected?
El
Yes
El
No
Seasonaluse?
El
Yes
Z
No
J971
CiPD
Water meter readings, if available (last 2 years usage (gpd)):
Detail-, , :��. "k
�j
Sump pump*?
El
Yes
Z
No
Last date of occupancy:
Occupied
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? F] Yes 0 No
Industrial waste holding tank present? El Yes E] No
Non -sanitary waste discharged to the Title 5 system? El Yes [_1 No
Water meter readings, if available:
t5ins - 3/13 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
30 Oxbow circle
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
Pumping Records:
Source of information:
Ma 01886 May 10,2016
State Zip Code Date of Inspection
General Information
Stewarts
Date
Was system pumped as part of the inspection?
If yes, volume pumped: 1500
gallons
How was quantity pumped determined? Site guage on truck
Reason for pumping: inspect tank
Type of System:
0 Septic tank, distribution box, soil absorption system
El Single cesspool
Z Yes El No
El Overflow cesspool
El Privy
El Shared system (yes or no) (if yes, attach previous inspection records, if any)
El Innovative/Alternative technoloay. Attach a CODV of the current oneration 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 - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17
Property Address
Damian
Owner
Owner's Name
information i's
required for every
North Andover
page.
Cityrrown
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
Pumping Records:
Source of information:
Ma 01886 May 10,2016
State Zip Code Date of Inspection
General Information
Stewarts
Date
Was system pumped as part of the inspection?
If yes, volume pumped: 1500
gallons
How was quantity pumped determined? Site guage on truck
Reason for pumping: inspect tank
Type of System:
0 Septic tank, distribution box, soil absorption system
El Single cesspool
Z Yes El No
El Overflow cesspool
El Privy
El Shared system (yes or no) (if yes, attach previous inspection records, if any)
El Innovative/Alternative technoloay. Attach a CODV of the current oneration 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 - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
30 Oxbow circle
Property Address
Damian
Owner Owner's Name
information is
required for every North Andover Ma 01886 May 10,2016
page. City/Town State Zip Code Date of Inspection
D. Syste Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
15 Years
Were sewage odors detected when arriving at the site?
Building Sewer (locate on site plan):
Depth below grade: 20"
feet
Material of construction:
0 cast iron N 40 PVC El other (explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
0 concrete F-1 metal
25
feet
El Yes Z No
El fiberglass El polyethylene El other (explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate)
Dimensions:
Sludge depth:
El Yes El No
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
30 Oxbow circle
Property Address
Damian
Owner Owner's Name
information i's
required for every North Andover
page. City/Town
D. System Information (cont.)
Septic Tank (cont.)
Ma 01886 May 10,2016
State Zip Code Date of Inspection
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
30"
0
6"
14"
How were dimensions determined? Tape Measure & Sludge judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Both tees good liquid leve good no leakage.
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
R concrete 0 metal
Dimensions:
Scum thickness
feet
El fiberglass M 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 - 3/13
Date
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
30 Oxbow circle
Property Address
Damian
Owner Owner's Name
information i's
required for every North Andover
page. City/Town
State Zip Code
May 10,2016
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 F-1 polyethylene El other (explain):
Dimensions:
Capacity:
Design Flow:
gallons
gallons per day
Alarm present: El Yes [—] N o
Alarm level: Alarm in working order: EJ Yes El No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
* Attach copy of current pumping contract (required). Is copy attached? El Yes Ej N o
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17
,\MMIMI,
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mjj�l
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
30 Oxbow circle
D. System Information (cont.)
RA,
01886 May 10,2016
Zip Code Date of Inspection
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Equal dist solids carryover pumped with tank.Box coroaded around outlket inverts. Box needs
Pump Chamber (locate on site plan):
Pumps in working order: El Yes F1 No*
Alarms in working order: El Yes F1 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
Property Address
Damian
Owner
Owner's Name
information i's
required for every
North Andover
page.
City/Town
D. System Information (cont.)
RA,
01886 May 10,2016
Zip Code Date of Inspection
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Equal dist solids carryover pumped with tank.Box coroaded around outlket inverts. Box needs
Pump Chamber (locate on site plan):
Pumps in working order: El Yes F1 No*
Alarms in working order: El Yes F1 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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
30 Oxbow circle
F'roperty Aadress
Damian
Owner Owner's Name
information is
required for every North Andover
page. City/Town
D. System Information (cont.)
Type
Ma 01886 May 10,2016
State Zip Code Date of Inspection
El leaching pits
number:
El leaching chambers
number:
El leaching galleries
number:
0 leaching trenches
number, length: 2-2'X3'X60'
El leaching fields
number, dimensions:
El overflow cesspool
number:
El innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic
failure, level of ponding, damp soil, condition of
vegetation, etc.):
no hydraulic failure no ponding no damp soils.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth — top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow Yes No
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17
r
hS�rs
-C\� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
30 Oxbow circle
Property Address
Damian
Owner Owner's Name
information is
required for every North Andover Ma 01886 May 10,2016
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 - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 17
MMEN,,
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Owner
information i's
req u i red fo r eve ry
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
30 Oxbow circle
Property Address
Damian
Owner's Name
North Andover Ma 01886 May 10,2016
City/Town 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:
El hand -sketch in the area below
Z drawing attached separately
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
30 Oxbow circle
Property Address
Damian
Owner Owner's Name
information i's
required for every North Andover Ma 01886
page. Cityrrown State Zip Code
D. System Information (cont.)
Site Exam:
0
Check Slope
0
Surface water
0
Check cellar
0
Shallow wells
Estimated denth to hi h rn"nri %Ainfizr*
36"
May 10,2016
Date of Inspection
feet
Please indicate all methods used to determine the high ground water elevation:
100
I
I
Obtained from system design plans on record
If checked date of rJAQi n Inn rz%/i,=%At,=rj
6/24/97
I IU 1`11 Date
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health - explain:
pulled file
Checked with local excavators, installers - (attach documentation)
Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
Design plans on file water at elevation 153.50 bottom of trenches 157.50 4' above water table.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
30 Oxbow circle
Property Address
Damian
Owner Owner's Name
information is
required for every North Andover Ma 01886
page. City/Town State Zip Code
E. Report Completeness Checklist
May 10,2016
Date of Inspection
Inspection Summary: A, B, C, D, or E checked
inspection Summary D (System Failure Criteria Applicable to All Systems) completed
System Information — Estimated depth to high groundwater
Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17
FIK
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COMMONWEALTH OF MASSACHUSETTS
EXECUTWE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENvIRONMENTAL PROTECI
F-R-ECEIVED
DEC 0 2 2005
�NN aTH AN�DOVER�
0"
3 TM N- T
TITLE 5 LfHEAOLTH D�EPAR E
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 30 Oxbow Circle
— North Andover—
Owner's Name: — Robert MacInnis—
Owner's Address: 30 Oxbow Circle —
— North Andover, Ma 01845
Date of Inspection: 11/23/2005
Name of Inspector: — Neil J. Bateson—
Company Name: —Bateson Enterprises Inc.—
Mailing Address: —111 Argilla Road —
— Andover, Ma. 01810
Telephone Number: _( 978 ) 4754786
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 firnction 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:
Passes
Conditionally Passes
"a Evaluation by the Local Approving Authority
Inspector's Signature: Date: 11/23/2005
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
DEP. 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.
Page 2 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 30 Oxbow Circle —
— North Andover—
Owner: MacInnis
Date of inspection: —11/23/2005
Inspection Summary: Check ABCD or E / ALWAYS complete all of Section D
A. System Passes:
X 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:
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 (YNND) 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 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:
Page 3 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: — 30 Oxbow Circle -
- North Andover -
Owner: MacInnis
Date of linspection: -11/23/2005_
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 CNM 15.303(l)(b) that the
system is not functioning in a manner which will protect public health, safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the
system is functioning in a manner that protects the public health, safety and environment:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a
;i-v7&ce 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 SAS 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
Fnvate water supply well". Method used to determine distance _
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Page 4 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 30 Oxbow Circle -
- North Andover -
Owner: MacInnis
Date of inspection:- 11/23/2005
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or "no" to each of the following for all inspections:
-No - Backup of sewage into facility or §3 Lstern component due to overloaded or - cl2ggo SAS or cesspool
_No�_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
-No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
- No Liquid depth in cesspool is less than 6" below invert or available volume is 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
- No Any portion of the SAS, cesspool or privy is below high ground water elevation.
-No- Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
-No- Any portion of a cesspool or privy is within a Zone I of a public well.
-No- Any portion of a cesspool or privy is within 50 feet of a private water supply well.
-No- 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 five from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
_NoL (Yes/No) The system fail& 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 "ye:e' or "no" to each of the following:
('Ibe following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped
Zone 11 of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered
"yee' in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 3 10 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
Page5 of1l
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 30 Oxbow Circle
North Andover
Owner: MacInnis
Date of Inspection: 11/23/2005
Check if the following have been done. You must indicate "yes" or "no,' as to each of the following:
Yes No
—Yes— — Pumping information was provided by the owner, occupant, or Board of Health
—No— Were any of the system components pumped out in the previous two weeks ?
—Yes— — Has the system received normal flows in the previous two week period ?
—No— Have large volumes of water been introduced to the system recently or as part of this inspection ?
—Yes— — Were as built plans of the system obtained and examined?
—Yes— — Was the facility or dwelling inspected for signs of sewage back up ?
—Yes— — Was the site inspected for signs of break out ?
—Yes— — Were all system components, excluding the SAS, located on site ?
—Yes — Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the
conditio� —of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of
scum ?
—Yes— — 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:
Yes no
—Yes— — Existing information.
Yes Determined in the field (if any of the failure criteria related to Part C is at issue approximation of
aistan—ce is unacceptable) [3 10 CMR 15.302(3)(b)]
Page 6 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 30 Oxbow Circle —
— North Andover—
Owner: MacInnis
Date of Inspection: —11/23/2005
FLOW CONDMONS
RESIDENTIAL
Number of bedrooms (design): —4— Number of bedrooms (actual): —4—
DESIGN flow based on 3 10 CMR 15.203 440
Number of current residents:
Does residence have a garbage grinder (yes or no): —No—
Is laundry on a separate sewage system (yes or no): —No—
Laundry system inspected (yes or no):
Seasonal use: (yes or no): —No—
Water meter reading: _Yes_
Sump pump (yes or no): —NoL
Last date of occupancy: —Current—
COACKERCIALANDUSTRIAL
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 INFORMATTON
Pumping Records
Source of information: —Pumped last year, owner
Was system pumped as partof the mispection (yes or no): —Yes—
If yes, volume pumped: _1500— gallons -- How was quantity pumped determined? —Measured tank—
Reason for pumping: —Inspect tank & tees—
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
�btained from system owner)
Tight tank _ Attach a copy of the DEP approval
Other (describe): _
Approximate age of all components, date installed (if known) and source of information: —7 years old, 6/17/1998,
as built plan_
Were sewage odors detected when arriving at the site (yes or no): —NoL
Page 7 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 30 Oxbow Circle —
North Andover
Owner: Maclunis
Date of &spection:— 11/23/2005
BUMBING SEWER — X — (locate on site plan)
Depth below grade: _13"
Materials of construction: —X— cast iron —X 40 PVC other
Distance from private water supply well or suction fine:
Comments (on condition ofjoints, venting, evidence of leakage, etc.) —4" Cast Iron thru walt. 3" PVC in house,
no leaks visible
SEPTIC TANKS: —X
Depth below grade: _1" _
Material of construction: —X— concrete — metal —fiberglass __polyethylene
____9ther(explain)
If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): (attach a copy of
certificate)
Dimensions: — 10'x5'x4'—
Sludge depth: — 3"—
Distance from top of sludge to bottom of outlet tee or baffle: —24"—
Scum thickness: —2"—
Distance from top of scum to top of outlet tee or baffle: —8"—
Distance from bottom of scum to bottom of outlet tee or baffle: —19"—
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. _ Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of
liquid at outlet invert. No evidence of leakage_
GREASE TRAP: _0ocate on site plan)
Depth below grade: _
Material 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 scum 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.):
Page 8 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 30 Oxbow Circle -
North Andover -
Owner: MacInnis
Date of Inspection: 11/23/2005
TIGHT or HOLDING TANK: _ (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass ___polyethylene other(explain):
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 BOXES:
Depth of liquid level above outlet invert: -0-
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. No evidence of leakage. Evidence of
carryover, pumped d -box to clean -
PUW CHANMER: (locate on site plan)
Pump in working order (yes or no): _
Alarm in working order (yes or no): _
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Page 9 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 30 Oxbow Circle —
North Andover
Owner: —Maclunis—
Date of Inspection: 11/23/2005
SOIL ABSORPTION SYSTEM (SAS): _X_ (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, length: —2 trenches 601 long_
leaching field, number, dimensions:
overflow cesspool, number:
innovativelalternative system Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.): —Soil oL Vegetation oL No sign of ponding to surface —
CESSPOOLS:
Number and configuration: _ _
Depth — top of liquid to inlet invert:
Depth of sludge 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: _ (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.):
Page 10 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 30 Oxbow Circle —
— North Andover—
Owner: MacInnis
Date of &spection.— 11/23/2005_
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.
Page I I of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 30 Oxbow Circle
— North Andover—
Owner: Maclunis
Date of &specdon:— 11/23/2005
SUE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water — 61
Please indicate (check) all methods used to determine the high ground water elevation:
_X_ Obtained from system design plans on record - If checked, date of design plan reviewed: 5/5/1998
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health -explain: _
Checked with local excavators, installers- (attach documentation)
Accessed USGS databage-explain:
You must describe how you established the high ground water elevation: —As per design plan
ME
11
j Telnet 10.1.71.55
U/S ACCOUNT HISTORY 2100040-MACINNIS, ROBERT & EIMMETER #1: 2100040
ft CYCLE SERVICE PRIOR CURRENT -USE WATER SEUER FEES TOTAL
1 2000-12 08/02/1999 341 490 149 406,77 0,00 0.00 406.7
2 2000-22 11/30/1999 490 586 96 262.08 8'00 0.00 863-0
2 2000-22 03/06/2000 586 602 16 43.68 0,00 8.00 43.6�
4 2000-42 05/16,2000 602 616 13 35.49 0'00 0,00 35'4
5 2001-12 08/07/2000 615 708 93 353.09 0,08 11.00 264'8
6 2001-22 11/08/2000 708 749 41 111,93 0.00 I1'00 182'9
7 2001-32 02,14/2001 Y49 768 19 51'87 0,00 11.00 62'8
8 2001-42 05/16/2001 768 818 S0 136.50 0.00 11.00 147'S
9 2002-22 11/27,2001 984 1109 125 455.16 0.00 S.65 460'7
10 2002-32 03/12,2002 1109 1138 29 77,23 0.00 5,36 82,7
11 2002-42 06/1S/2002 1138 1154 16 39'62 0.00 5'B 45,0
12 2002-12A 10/11/2001 984 904 0 0'00 8.00 S.B 5'6
13 2002-7P 08/13/2001 818 984 166 453.10 0.00 36.00 408.1
14 2003-12 08/01/2002 1154 1203 120 461,80 0'00 S,97 467,7
1S 2003-22 11/06/2003 1283 1435 133 535.00 0'00 [,97 S40,9
16 2003-32 02/0S/2003 1436 1461 26 70'40 0.00 5'99 76.3
17 2003-42 WS/02/2003 1461 1482 21 61.40 0.00 S,97 57,3
18 2004-12 08/11/2003 1482 1589 107 349,60 0'00 7.42 357.0
REU|GB CHOICE # or <ENTER> MORE HISTORY:
�
�
leg
GOVERN, - 10, 1, 71.4 R... Tehiet 10.1.71.55
2:52 PM
Fdday, Nov 18, 2005 02:53 PM
Class
Size Total
IFY
Summary Record Card generated on 11/18/2005 2:42:02 PM by Lisa Warren
Town of North Andover
Tax Map # 210-1073-0146-0000.0
30 OXBOW CIRCLE
MACINNIS, ROBERT & KIMBERLY
30 OXBOW CIRCLE
NORTH ANDOVER, MA
01845
101 Single Family Property Type
0.65 Acres
2006
UB Mailing Index
Name/Address Type
MACINNIS, ROBERT & KIMBERLY Payor
30 OXBOW CIRCLE
NORTH ANDOVER, MA
01845
LIB Account Maint.
Account No Cycle
Bldg Id. 14098.0 - 30 OXBOW CIRCLE
2100040 02 Cycle 02
Bldg Id. 13337.0 - 30 OXBOW CIRCLE
2100041 02 Cycle 02
UB Services Maint.
Loan Number Active/Inact. From
Occupant Name Active/inactive
Last Billing Date 8/31/2005
Active
Last Billing Date 8/31/2005
Active
Service Code Rate
MISCFEE ADMIN FEE 0.63 5/8
WTR WATER 01 ALL METER SIZE
UB Meter Maintenance
Multiplier/Users
Serial No Status
1/
Location
43993604 a Active
Brand
R ENC F.RT.
Date Reading
Code
11/8/2005
2160
a Actual
Trouble Code:03
134
9/12/2005
8/10/2005
2061
a Actual
Trouble Code:03
76
12/17/2004
5/5/2005
1927
a Actual
2/14/2005
1903
a Actual
Trouble Code:03
11/6/2003
11/18/2004
1886
a Actual
Trouble Code:03
8/10/2004
1810
a Actual
Trouble Code:03
5/14/2004
1721
a Actual
2/17/2004
1697
a Actual
11/6/2003
1669
n New Meter
Charge
Multiplier/Users
7.82
1/
669.48
/1
Brand
Type
?
w Water
Consumption
Posted Date
. 99
134
9/12/2005
24
6/8/2005
17
3/15/2005
76
12/17/2004
89
9/20/2004
24
6/14/2004
28
4/16/2004
0
11/6/2003
Size
0.630.63
Page 1
1 Residential
Until
YTD Cons
0
Variance
-20%
360%
55%
-75%
-25%
267%
1 %
0%
0%
Tel: (978) 475-4786
Fax: (978) 475-5451
BATESON ENTE"FJSES, INC.
Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service
111 Argilla Road Andover, Mass. 0 18 10
Title 5 Inspection Report
Property Address: 30 Oxbow Circle, North Andover
Owner: MacInnis
Date of Inspection: 11/23/2005
My report contained herein does not constitute a guarantee of future usage and the functionality of the existing
septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any ftuther
operation of your current septic system.
Neil J. Bat on
Bateson Enterprises, Inc.
P.o. 0 -
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
"Q-PVPT1n1%T MUM – NnT Vn12vni.1TNTARV AV%QFR%.9MFNTq
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 30 Oxbow Circle –
– North Andover–
Owner's Name: -Larry Thuet
Owner's Address: 30 Oxbow Circle
–North Andover, Ma. 01845
Date of Inspection: 6/08/2001
Name of Inspector: –Ned J. Bateson–
Company Name: –Bateson Enterprises Inc.–
Mailing Address: –111 Argilla Road
– Andover, Ma. Win—
Telephone Number: _( 978 ) 475-4786_
V�) or—
r -
0 2001
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 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
'IS 60JT—�� Date: 6/08/2001
Inspector's Signature:
The system inspector shall submit a copy oPthis 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.
Page 2 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 30 Oxbow Circle
—North Andover
Owner: Thuet
Date of Inspection: 6/08/2001
Inspection Summary: Check AB,C,D or E / ALWAY complete all of Section D
A. System Passes:
- X I have not found any information which indicates that any of the failure criteria described in 3 10 CMR
T5.3-03 or in 3 10 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.
Answer yes, no or not determined (YNND) 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 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:
I
Page 3 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 30 Oxbow Circle —
—North Andover—
Owner: Tbuet,
Date of Inspection: 6/0812001
C. Vurther Evaluation is Required by the Board of Health:
Conditions exist which require ftirther 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 soil absorption system (SAS) and the SAS is within 100 feet of a
'�_u_rface 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 SAS 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 coliforin
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppin, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Page 4 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 30 Oxbow Circle
—North Andover
Owner: Thuet
Date of Inspection: 6/08/2001
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or "no?'to each of the following for all inspections:
Yes No
—No— Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
—No— Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
—No— Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
—No— Liquid depth in cesspool is less than 6" below invert or available volume is less than V2day flow
—No— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
—No— Any portion of the SAS, cesspool or privy is below high ground water elevation.
—No— Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
—No— Any portion of a cesspool or privy is within a Zone I of a public well.
—No— Any portion of a cesspool or privy is within 50 feet of a private water supply well.
—No— 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 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.]
(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 within 400 feet of a surface drinking water supply
— — the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped
Zone 11 of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat� or answered
"yes" in Section D above the large system has faded. 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.
Page 5 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 30 Oxbow Circle —
— North Andover—
Owner: Thuet
Date of Inspection: 6/08/2001
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
—Yes— — Pumping information was provided by the owner, occupant, or Board of Health
— —No— Were any of the system components pumped out in the previous two weeks ?
—Yes— — Has the system received normal flows in the previous two week period ?
— —No— Have large volumes of water been introduced to the system recently or as part of this inspection ?
—Yes— — Were as built plans of the system obtained and examined? (If they were not available note as N/A)
—Yes— — Was the facility or dwelling inspected for signs of sewage back up ?
—Yes— — Was the site inspected for signs of break out ?
—Yes— — Were all system components, excluding the SAS, located on site ?
—Yes— — 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 ?
—Yes— — 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:
Yes no
—Yes— — Existing information. For example, a plan at the Board of Health.
No Determined in the field (if any of the failure criteria related to Part C is at issue approximation of
Yisian�e is—unacceptable) [3 10 CMR 15.302(3)(b)]
I
Page 6 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 30 Oxbow Circle -
-North Andover -
Owner: Thuet
Date of Inspection: 6/08/2001
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 3 10 Q& 1-5.203 (for example: I 10 gpd x 4 of ;-ed�-o—orns): 440
Number of current residents:
Does residence have a garbage grinder (yes or no): -No-
Is laundry on a separate sewage system (yes or no): -No- [if yes separate inspection required]
Laundry system inspected (yes or no):
Seasonal use: (yes or no): - No -
Water meter readings�_May 00 to May 01 = 21,600 Ft� x 7.5 = 162,000 Gals. / 365 Days = 444 Gals. Day
Sump pump (yes or no): -No- Has sprinkler system
Last date of occupancy: —Current
COMMERCIALAINDUSTRIAL
Type of establishment:
Design flow (based on 3 10 CMR 15.203): gp d -
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: -Pumped May last year, owner -
Was system pumped as part of the inspection (yes or no): -Yes-
If yes, volume pumped: _1500_gallons -- How was quantity pumped determined? -Measured tank
Reason for pumping: —Inspect tank & tees
TYPE OF SYSTEM
J�_ 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
;-b�ined from system owner)
— Tight tank _ Attach a copy of the DEP approval
— Other (describe):
Approximate age of all components, date installed (if known) and source of information: -3 years old. 6/17/1998.
As built plan_
Were sewage odors detected when arriving at the site (yes or no): -NO -
Page 7 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 30 Oxbow Circle —
- North Andover—
Owner: Thuet
Date of Inspection: 6/08/2001
BUILDING SEWER (locate on site plan) X
Depth below grade: _13"
Materials of construction: -X—cast iron -X-40 PVC — other (explain):
Distance from private water supply well or suction line:
Comments (on condition ofjoints, venting, evidence of leakage, etc.): -4" Cast iron thru wall to septic tank. 3"
PVC in house. No leaks.
SEPTIC TANK: -X -locate on site plan)
Depth below grade: _1" -k-concrete metal fiberglass polyethylene
Material of construction:
___pther(explain)
If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): (attach a copy of
certificate)
Dimensions: - 101 x 51 x 41
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or baffle: —26"
Scum thickness: I"
Distance from top of scum to top of outlet tee or baffle: —8"—
Distance from bottom of scum to bottom of outlet tee or baffle: —20"
How were dimensions determined: -Subtract scum & sludge depth to tee length,_
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.): -Pumped septic tank. Inlet & outlet tees ok. Depth of liquid
at outlet invert. No evidence of leakage. _
GREASE TRAP: _(locate on site plan)
Depth below grade: _
Material of construction: —concrete —metal —fiberglass . polyethylene —other
(explain):
Dimensions:
Scum thickness:
Distance from top of scwn to top of outlet tee or baffle:
Distance from bottom of scum 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.):
Page 8 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: - 30 Oxbow Circle -
-North Andover -
Owner: Thuet
Date of Inspection: 6/08t2001
TIGHT or HOLDING TANK: _ (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: _
Material of construction: —concrete —metal —fiberglass ____polyethylene other(explain):
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: -X- (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: —0—
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box, etc.): - D -box levl & distribution equal. No evidence of leakage. Evidence of slight
carryover, pumped d -box to clean. _
PUW CHAMBER: (locate on site 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.):
Nge 9 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 30 Oxbow Circle —
—North Andover—
Owner: Thuet
Date of Insp;ction: 6/08/2001
SOIL ABSORPTION SYSTEM (SAS): _X_ (locate on site plan, excavation not required)
If SAS not located explain why:
Type
leaching pits, number:
leaching chambers, number:
leaching galleries, number:
— X_ leaching trenches, number, length- — 2 trenches 60 ' long_
leaching fields, number, dimensions:
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.): —Soil oL Vegetation oL 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 (yes or no):
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.):
Page 10 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 30 Oxbow Circle —
— North Andover—
Owner: Thuet
Date of Insp�ction: 6/08/2001
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.
Driveway
House B
Water Me)er 1
Tank
Nll��n 2
• to 1 = 131211
• to 2 = 13'
• to 3 = 14'5"
• to D -Box = 25'
B to 1 = 32'6"
B to 2 = 361
B to 3 = 39'7"
B to D -Box = 4911"
3
D -Box
F60'
�age 11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 30 Oxbow Circle —
North Andover
Owner: Thuet
Date of Inspection: 6/08/2001
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water —6— feet
Please indicate (check) all methods used to determine the high ground water elevation:
— X— Obtained from system design plans on record - If checked, date of design plan reviewed: –May 5, 1998
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health -explain:
Checked with local excavators, installers- (attach documentation)
Accessed USGS database -explain:
You must describe how you established the high ground water elevation: _As per design plan _
Tel: (978) 475-4786
Fax: (978) 475-5451
BATESON ENTE"MSES, INC.
Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service
I I I Argilla. Road Andover, Mass. 01810
Title 5 Inspection Report
Property Address: 30 Oxbow Circle, North Andover
Owner: Thuet
Date of Inspection: 6/8/2001
My report contained herein does not constitute a guarantee of future usage and the functionality of the existing
septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further
operation of your current septic system.
Neil J. 8Bat son
Bateson Enterprises, Inc.
MERRIMACK ENGINEERING SERVICES, INC,
PROFESSIONAL ENGINEERS 0 LAND SURVEYORS 0 PLANNERS
66 PARK STREET * ANDOVER, MASSACHUSETTS 01810 * TEL. (508) 475-3555, 373-5721 * FAX (508) 475-1448
September 25, 1997
0 ;1V1171T
Town of North Andover
Board of Health
Town Hall
30 School Street
North Andover, MA 01845
RE: Lot 26 Oxbow Circle - Woodland Estates
A.C. Builders, Inc.
Dear Board Members:
Due to dimensional constraints and wetland locations on the subject lot, we find it necessary
to request a variance to the "Town of North Andover Minimum Requirements for the
Subsurface Disposal of Sanitary Sewage" Regulation 5.02 so that a leaching facility may be
90' from a wetland in lieu of 100' as required.
Please schedule this item for action at the next available meeting of the Board of Health and
feel free to call me if you have any questions or comments.
Very truly yours,
MERRIMACK ENGINEERING SERVICES
Les Godin
Project Manager
cd
�1/
11Z
FOP14 U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant
fills
out
this section*****************
APPLICANT: A. - 6, 6 U I Id t
Y, 5 1
A C,
Phone 185_83eo
LOCATION: Assessor's Map Number
Subdivision W00J land E5�Jt--�,
street &,�QXJ50&j C;Yck,
Parcel
Lot (s) cl� &
St. Number
************************Official Use Only************************
RECOMMENDATIONS OF TOWN AGENTS:
Conservation Administrator
Comments
Town Planner
Comments
Food Inspecto_rrHealth
.1_s6g�_fc 6enspiector`-::46�lth
Comments
-Public Works -.sewer/water connections
- driveway permit
Fire Department
Date Approved
Date Rejected
Date Approved
Date Rejected
Date Approved
Date Rejected
Date Approved
Date Rejected
Received by Building Inspector. Date
Town of North Andover
OITICE OF
COMMUNITY DEVELOPMENT AND SERVICES
WILLIAM J. SCOTT
Director
October 7, 1997
Aurele Cormier
AC Buiilders
33 Walker Road
North Andover, MA 01845
RE: Woodland Estates
Dear Aurele:
30 School Street
North Andover, Massachusetts 01845
0
This letter is to inform you that the proposed septic plans for Lots 21 and
26 Oxbow Circle have been approved. However, before the Board of Health can
sign off on the Form U for Lot 26 Oxbow Circle, evidence of the recording of the
proposed lot line change must be filed with the department.
If you have any questions, please do not hesitate to call the Board of
Health office at the number below.
Sincerely,
Sandra Sta , R.S.
Health Administrator
cc: Wm. Scott, Dir. CD&S
Merrimack Engineering
Kathleen Colwell, Town Planner
File
.,C_qNS.ERVAT10.N 4132-9530, BEALTH 688-9540 PLANNING 688-9535
t
0 iL t Ck,
FORM 11 - SO11L EVALUATOR FORN1
Page 1
Date
..q -
No . .......... . .. .. .. .. Commonwealth of MassaChusetts .. . ... 7 ..... ...
WaF-TVI AwwveZ, Massachusetts
Lmfion Address or 0--', N.- - A.C. Bu i&DEP-5. I IQC--
I—dr 26, OY,130L.) Ckge—Lr— Address. and -33 WALV-ef& Q0AD
Telephorr # IQ0(Z-rj-4 k1,4Dovere, MA.
New Construction V Repair R
Office Review
Published Soil Survey Available: No El Yes
Year Published A.W.. Publication Scale (.� ...
Drainage Class ... 5 ........ Soil Limitations -5f�Yf�F . ..................
Surficial Geologic Report Available: No El Yes
Year Published . .. . ..... Publication Scale ..................
Geologic Material (Map Unit) .. . ........................................ - ....................
................................................................................. .........................
Landform . . . ... .... ... .. . 77�
Soil M Unit J�p
,Cte_ OL; iff 4 V -Th o-1
......................................... -- / ... t-(04-LI—S
Flood Insurance Rate Map: +1 7—S -001e) oo to B 01
Above 500 year flood boundary
Within 500 year flood boundary
N o 1-1
Yes
N o Ef
Yes F�
Within 100 year flood boundary No Y6 Yes LJ
Wetland Area:
National Wetland Inventory Map (map unit) .............. C. ).. W 9 311!� ......... D. aA-. r... t P ........ ......
Wetlands Conservancy Program Map (map unit) ................. . ..........................................................................
Current Water Resource Conditions (USGS): Month
Range Above Normal F� Normal D""" Below Normal D
A�so"r-D
Other References Reviewed: —V - � - 6; - e,- - MAPc>
-4)
FORM 11 - SOIL EVALUATOR FORM
Page 2
On-site Review
Deep Hole Number .1.j..Z Date: 6.411 T7 Time:..P:�.M— Weather
Location(identify on site plan) .... ........................................................................................................................................
Land Use S!.46 ..... Slope M �57 ....... Surface Stones �!A.w .. Y ............................................... ..........
Vegetation...... CLAW.0D . .......... ................................ .............................................. ........ .................................................................................................
Landform....... WJA . ............................................... I ............... .......... ............................................ I ............................................................... ......................
Position on landscape (sketch on the back) .... PLA.�-A ....... ........................................ ..............................................................
Distances from:
Open Water Body .... feet Drainage way...."Z.�Z.t. feet
Possible Wet Area ...IPP.T feet Property Line .... 1.0 ... T�-. feet
Drinking Water Well 1047t feet Other ....... .. . .....................
DEEP OBSERVATION HOLE LOG
Depth from Surface
Soil Horizon
Soil Texture
Soil Color
Soil Mottling
Other
(Inches)
(USDA)
(Munsell)
(Structure, Stones, Boulders,
Consistency, % Gravel)
0"—
6tihO. S.L.
wiaLil(,
664-
CC S-1 6
t 4 A rS I FF -i A ?WS
"A lrAN( TA).A jD
IZ - \-( (43
+
A ppg�b
of.- all
6RAV. 9 - L,
jv.- JZ0"
6 RA V,
F(Z(.q8't'e—
LoAmy rA)j-o
7. 9-1 a s -/g
e -
Parent Material (geologic) .... 6."C.i.A.L . .............................. .................... .. Depth to Bedrock: ..WA .... .........
Depth to Groundwater: Standing Water in the Hole: MA ....... Weeping from Pit Face: 44.1A...
Estimated Seasonal High Ground Water:
FORM 11 - SOIL EVALUATOR FORM
Page 3
Determination for Seasonal Ht ater Table
:gh W
Method Used:
F1 Depth observed standing in observation hole .. .... 77� inches
El Depth weeping from side of observation hole ...... inches
eDepth to soil mottles 3.2.134," inches
El Ground water adjustment ...... . ..... feet
Index Well Number ...... . ..... Reading Date ................... Index well level ..................
Adjustment factor .................. Adjusted ground water level .................. . ...............................
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas
observed throughout the area proposed for the soil absorption system?
If not, what is the depth- of naturally occurring pervious material?
Certification
I certify that on e�5�-9(V' (date) I have passed the examination approved by the
Department of Environmental Protection and that the above analysis was
performed by me consistent with the required training, expertise and experience
described in 310 CMR 15.017.
Signature / f- z - 2
Date
FORNI 12 - PERCOLATION TEST
COMMONWEALTH OF MASSACHUSETTS
�_WM Aktbovf5V_ , Massachusetts
Site Passed 2/"Site Failed El 9
......................................................................... ........
_C� .. . ............... / ......
Performed By: br—s 601)[1-1
Witnessed By: S:Lj �AO F6- VD
t
Comments: ....... ..................... ......... - .... . ... _ .... .... _ ........ ....... -'LL .................
Percolation Test
Date: .&�Z_S 77 Time: ....................
observation Hole #
�P_ (
P- z
Depth of Perc
9-7
lq"-14-111
Start Pre-soak
End Pre-soak
Time at 12"
P I I
Time at 9"
S� I
Time at 6"
Time (9"-6")
L4 H
Rate Min./Inch
h'
2 �'t 1 J4 k(
0
Site Passed 2/"Site Failed El 9
......................................................................... ........
_C� .. . ............... / ......
Performed By: br—s 601)[1-1
Witnessed By: S:Lj �AO F6- VD
t
Comments: ....... ..................... ......... - .... . ... _ .... .... _ ........ ....... -'LL .................
PLAN REVIEW CHECKLIST
ADDRESS 0/e506,e-) ENGINEER
GENERAL
3 COPIES L�-- STAMP LOCUS NORTH ARROW SCALE
CONTOURS L,--' PROFILE L--�,
(Sc) SECTION BENCHMARK '--� SOIL &
PERCS ELEVATIONS WETS. DISCLAIMER Z-�'WELLS & WETS C-��
WATERSHED? 416 DRIVEWAY WATER LINE FDN DRAIN— M&P
SCH40 b-� TESTS CURRENT? SOIL EVAL
SEPTIC TANK
MIN 1SOOG .17 INVERT DROP GARB. GRINDERl� (2 comps +200)
10' TO FDN(--� MANHOLEC,-"' ELEV GW # COMPSJ GB
D -BOX
SIZE # LINES FIRST 2' LEVEL STATEMENT
INLET OUTLET/Tq,�6 17 (2" OR .17 FT) TEE REQ'D?1116
LEACHING
MIN 440 GPD? t"�RESERVE AREAL""'.'4' FROM PRIMARY? tl� 2% SLOPE e--'
100 1 TO WETLANDSk 100' TO WELLS L-' 4 - TO S. H. GW (5 1 >2M/IN)
20' TO FND & INTRCPTR DRAINS L---400' TO SURFACE H20 SUPP
4' PERM. SOIL BELOW FACILITY MIN 12" COVER4----� FILL?
BREAKOUT MET? L --
TRENCHES
MIN 440 gpd SLOPE (min OOS or 611/1001) 1"""� SIDEWALL DIST. 3X EFF.
W OR D (MIN 6 L-- RESERVE BETWEEN TRENCHES? IN FILL? c— MUST
BE 101 MIN. L-' 4 " PEA STONE? L --VENT? (>3' COVER; LINES >501
BOT - 8� 0 - + SIDE- 'f CO/t/-/) -=- tq ",�10 X LDNG /J�3 = TOT 41��-
(L x W x #) (DxLx2x#) (G/ft2)
Copyright 9 1996 by S.L. Starr
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SEPTIC PLAN SUBMITTALS
LOCATION: �-ef
NEW PLANS: YE S L,---" $60.00/Plan
REVISED PLANS: YES $25.00/Plan
DATE: �7
DESIGN ENGINEER: f Kopauocs
When the submission is all in place, route to the Health Secretary
t
'SEPTIC PLAN SUBMITTALS
LOCATION:
NEW PLANS: YES S60.00/Plan
RE VI S ED P L A��-. �-�S $25.00/Ptan
DATE:
DESIGN ENGINEER:
When the submission is all in place, route to the Health Secretary
I
o
SACHU
Town of North Andover, Massachusetts
BOARD OF HEALTH
5'!SP7-
DESIGN APPROVAL FOR
SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Form No.2
00,17
Applicant "'9 0 Test No
Sitel-ocation
Reference Plans and 1.7 A? 7
ENGINEER DESIGN DATE
Permission is,granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
F e e Ac/e 4 ?)
CHAIRMAN, BOARD OF HEALTH
Site System Permit No. �16(f'
TOWN OF NORTH ANDOVER
SEWAGE DISPOSAL SYSTEM JUiq 2
INSTALLATION CERTIFICATION
The undersigned hereby that jhg Soyage Disposal System (N'�constructed; repaired;
by
located a \'0 e -
was installed in conformancer with the North Andover Board of Health approved plan, System
Design Permit #!��r dated. f,�k,�q 7 with an approved design flow of
gallons per day. 'Me materiars-afed v6efe in conformance with those specified on the approved
plan; the system was installed in-accor&nce with the provisions of 3 10 CMR 15.000, Title 5 and
local regulations, and the final gradin-g-*ees substantially with the approved plan. All work is
-accurately represented on the As -built which has been submitted to the Board of Health.
Installer: #: Date:
Design Engineer: Date: s I
t- C>'j P
I
Town of North Andover, Massachusetts Form No. 3
,kORTH BOARD OF HEALTH
0 19
N DISPOSAL WORKS CONSTRUCTION PERMIT
ACHU
Applicant —11LIC&Cea
NAME ADDRESS TELEPHONE
Site Location un(64"'zj
Permission is hereby granted to Construct (L—Y'o"r Repair an Individual Soil Absorption
Sewage Disposal System as shown on the Design Approval S.S. No.
t
Fee �67-�--
a
CHAIRMAN, BOARD OF HEALTH
D.W.C. No. 11!!M6
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE: 4�>t 90 CURRENT INSTALLER'S LICENSE#
LOCATION:
LICENSED INSTALLER:
SIGNATURE: TELEPHONE# C)
CHECK ONE:
REPAIR:.
NEW CONSTRUCTION:
IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT.
Administrative Use Only
$75.00 Fee Attached? Yes No
Foundation As -Built? Yes No
Floor Plans? Yes No
Approval Date: