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HomeMy WebLinkAboutMiscellaneous - 31 BRIDGES LANE 4/30/2018 / {r 31 BRIDGES LANE _ J 210�104D-01�1-0000.0 \` I / I f 1 i i I I I I II r I 4 { i r i - J N o • a Sox zm .,a ',a u?` w Co 3© �Jp . y a . s Commonwealth of Massachusetts, RE IVED 7 w Title 5 Official Inspection Form ��� Subsurface Sewage Disposal System Form - Not for Voluntary Assessmen s JUN - 7 2007 31 Bridges Lane Property Address HEALTH DEPARTMENT Daniel and Lynne Follansbee w�.s Owner Owner's Name �l information is required for No. Andover MA 01845 6/5/07 v` every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: When filling out A. General Information forms on the computer, use 1. Inspector: only the tab key to move your Benjamin C. Osgood Jr. cursor-do not Name of Inspector use the return key. New England Engineering Services, Inc. Company Name tab 1600 Osgood Street Suite 2-64 Company Address No. Andover MA 01845 Brun City/Town State Zip Code 978-686-1768 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority C Insp tor's Signature V Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 31 BRIDGES LN NO ANDOVER.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 31 Bridges Lane Property Address Daniel and Lynne Follansbee Owner Owner's Name information is required for No. Andover MA 01845 6/5/07 . every page. City/Town 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: ,M I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating g 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 31 BRIDGES LN NO ANDOVER.DOC-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 31 Bridges Lane Property Address Daniel and Lynne Follansbee Owner Owner's Name information is required for No. Andover MA 01845 6/5/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 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. 31 BRIDGES LN NO ANDOVER.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 31 Bridges Lane Property Address Daniel and Lynne Follansbee Owner Owner's Name information is required for No. Andover MA 01845 6/5/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria 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 ❑ Q Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1h day flow ❑ � Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Q Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ F Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 31 BRIDGES LN NO ANDOVER.DOC-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 31 Bridges Lane Property Address Daniel and Lynne Follansbee Owner Owner's Name information is required for No. Andover MA 01845 6/5/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ N Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ �] Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ 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 ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well 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. 31 BRIDGES LN NO ANDOVER.DOC-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 31 Bridges Lane Property Address Daniel and Lynne Follansbee Owner Owner's Name information is required for No. Andover MA 01845 6/5/07 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ [9 Were any of the system components pumped out in the previous two weeks? ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) 19 ❑ Was the facility or dwelling inspected for signs of sewage back up? Z ❑ Was the site inspected for signs of break out? ❑ Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: [� ❑ Existing information. For example, a plan at the Board of Health. ❑ © Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 31 BRIDGES LN NO ANDOVER.DOC-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 IIS Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 31 Bridges Lane Property Address Daniel and Lynne Follansbee Owner Owner's Name information is required for No. Andover MA 01845 6/5/07 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: L Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): GPC> Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d `10 G-P D 9 ( Y g (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: c ' r 1,<-C1 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? ❑ Yes ❑ No Industrial waste holdingtank resent? Yes No p ❑ ❑ Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 31 BRIDGES LN NO ANDOVER.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 31 Bridges Lane Property Address Daniel and Lynne Follansbee Owner Owner's Name information is required for No. Andover MA 01845 6/5/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: PO VIA Des 2 Q-a.i✓t Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 8v, Fro orw� lig Were sewage odors detected when arriving at the site? ❑ Yes [Q No 31 BRIDGES LN NO ANDOVER.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 31 Bridges Lane Property Address Daniel and Lynne Follansbee Owner Owner's Name information is required for No. Andover MA 01845 6/5/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: �B feet Material of construction: cast iron 40 PVC other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 21 PC 014% 1N 3A-21 -�NIEry 1 Septic Tank(locate on site plan): Depth below grade: feet Material of construction: 15d concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: LSJo G-r4LLo rZ S Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 33 Scum thickness +r Distance from top of scum to top of outlet tee or baffle `5 Distance from bottom of scum to bottom of outlet tee or baffle i 31 How were dimensions determined? M EAS�Q E S?1�t� 31 BRIDGES LN NO ANDOVER.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 31 Bridges Lane Property Address Daniel and Lynne Follansbee Owner Owner's Name information is required for No. Andover MA 01845 6/5/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): v A- Grease Trap(locate on site plan): Depth below grade: feet 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: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): AtIll 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): 31 BRIDGES LN NO ANDOVER.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments A, 31 Bridges Lane Property Address Daniel and Lynne Follansbee Owner Owner's Name information is required for No. Andover MA 01845 6/5/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert D ,. 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.): riDn ►ry alp C 3>1i1® et 0 S �c.koS Cka4. O j f4 oa. L.C-"ll .`[- J5,TALL9'0 Fero w J.e-eLC 2 5 -1 Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 31 BRIDGES LN NO ANDOVER.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Massachusetts Commonwealth of W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM A v 31 Bridges Lane Property Address Daniel and Lynne Follansbee Owner Owner's Name information is required for No. Andover MA 01845 6/5/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: [�- leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ 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.): A-aZ4 o7 FF rr-S L-0 O iU No 0.4n.4-L P O co 3(i .,, 'T o r.-1b N t 31 BRIDGES LN NO ANDOVER.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 31 Bridges Lane Property Address Daniel and Lynne Follansbee Owner Owner's Name information is required for No. Andover MA 01845 6/5/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) AJIJA 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 1, I/} 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.): 31 BRIDGES LN NO ANDOVER.DOC-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 31 Bridges Lane Property Address Daniel and Lynne Follansbee Owner Owner's Name information is required for No. Andover MA 01845 6/5/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. I � � T g X)SrR�`Es w A-- D'3 w �2 p 31 BRIDGES LN NO ANDOVER.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sew m•P 1 f 1 p age Disposal System age 4 0 5 Commonwealth of Massachusetts �M w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 31 Bridges Lane Property Address Daniel and Lynne Follansbee Owner Owner's Name information is required for No. Andover MA 01845 6/5/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water N b J'F ❑ Check cellar ni¢ .9,A,%*F ❑ Shallowwells No�� Estimated depth to ground water: fee Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: S C>-L %6S"t2 nr J 1�r, A-03-Ac e 6a S i TP77" —T' LX—AZ 6i= -T R4> Sc 31 BRIDGES LN NO ANDOVER.DOC•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFF DEPARTMENT OF ENVIRON soA N yt w � MAS TITLE 5 - OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A //�� // CERTIFICATION Property Address: A r l/ae!U , Owner's Name: Owner's Address: . R Arj' e2 Date of Inspection -A7-1f7-0!q Name of Inspector: (please print) AaSO Company Name:. tJUrtS -3&44/; , Seroce, Mailing Address: ,ID SO hi) L 1'Sl'Qd holm Telephone Number:�-y Y,7// CERTIFICATION STATEMENT 1 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: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature:J"-. Date: � 4 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. Title 5 Inspection Form 6/15/2000 page 1 r > _ Page 2 of I 1 �• OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ,,/CERTIFICATION(continued) Property Address: /U PS Lane, y Owner: D//Of?5 h to d: Date of Inspection: 5-17-D 14 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: 1//.-:: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: 9A. One or more system components as described in the"Conditional Pass"section need to be replaced or repaired:The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a 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: 2 r . Page 3 of I l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 7� (( CERTIFICATION(continued) Property Address: ., 1 R C!r)des U_a t P Owner: F—DlICr S h-P zo /- iZ� , m rr Date of Inspection:5—!7 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 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 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: 3 •. Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: .3 1 /'l<.a qe Za 1? Owner: Date of Inspection: //7/0 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No L-""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 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ ✓Liquid depth in cesspool is less than 6"below invert or available volume is less than'/s day flow `Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _ Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface ✓ water supply. _ .Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. 17 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 compomads 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.] p (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: . .To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• , You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of 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 I1 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. 4 Page 5 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS .SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: ire,. A- 0Nn12V P- , MO Owner:ISD j/a/V,Sh zee Date of Inspection: 51/7/Qq Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health ere any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? -Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the/baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? �/— Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yep/no Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] 5 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ,3) 8 r l dJ es L n e ��lAlboYiP K, W. Owner: �D�/Q -: /hee Date of Inspection: 5// 7/� BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction t iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): J61 ,11 T S t a u D ('0 W P 1-F1 Q'A-/ SEPTIC TANK:LI61-111ocate on site plan) Depth below grade: r Material of construction:_concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: / r Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 3� Scum thickness: Z "` Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle:_j 4 How were dimensions determined: 0A1 5,/7--;e Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): L �v� / e-r G -j ( TD GREASE TRAPf (locate 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.): 7 • �Page 8 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6rldae s 1_ n/ Owner: E-0n�0►h4IZ/n)�� Date of Inspection:4 / G 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�—' (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:i�-Wldl 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.): ,C0 0 l'Cj /D /%Cr -G PUMP 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.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: e' /r, -o- Owner: Date of Inspection:-9//7 O SOIL ABSORPTION SYSTEM(SAS): r (locate on site plan,excavation not required) If SAS not located explain why: Type �eaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: 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.): /2-G L !J4? -f 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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:,-:?/F6 Ila r/�1�P� 41-6. Owner: Date of Inspection:-6112 64 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. �G Q� J O JL p B ° . A° , 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEMINFORMATION(continued) Property Address: .3 Brl dna S Lon� Owner:�Dai7_SY4rae_ Date of Inspection: 5117ZLY SITE EXAM Slope Surface water Check cellar Shallow wells 1 Estimated depth to groundwater feet Please indicate(check)all methods used to determine the high ground water elevation: L,"OObtained from system design plans on record-If checked,date of design plan reviewed: 3 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: lase P�Z 12 11 i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: !, to /V / N Owner's Name: Q Owner's Address: Date of Inspection: D Name of Inspector: (please print) lam, C �J2,Q Company Name• e Mailing Address: G Telephone Number: - 1 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 to 15.340 of Title 5(310 CMR 15.000). The system: y Passes Conditionally Passes Needs er valuation by the Local Approving Authority "inspection. Inspector's Signature: Date: rd� The system inspector shall ubmre ort to the Approving Authority(Board of Health or DEP)within 30 days of mpletsystem 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 regiona�office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicab a and the approving authority. \ t c 1 P Notes and Comments QQ� ****This report only describes conditions at the time of inspection and unde`r¢the condit' of use at that time.This inspection does not address how the system will perform in the future r the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: iffy-OR< d Owner: J4gIJ5 JS�P e-- Date Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. SystPasses: =- I have not found any information which indicates that any of eefailiire criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired:The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. 5 Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): � broken pipe(s)are replaced I 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): 4 broken pipe(s)are replaced obstruction is removed ND explain: 2 N t Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 2 CERTIFICATION(continued) Property Address: ✓ /� //Y y Owner: Date of Inspection: C. Further Evaluation is Required by the Board of Health: i Conditions;pxist which require further evaluation by the Board of Health in order to determine if the system y is failing to protect public health, safety oMe trivironme it: 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 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 p _.�,....:��3.� **This system passes f the well water analysis,per iformed at a`DEP certifie, laboratory,for coliform P 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: 3 Page 4 of 11 d OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Itl C -e V Owner• g .. Date of Inspection: -D D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No l F 'A ,. ,ackup 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 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or /^cesspool i/ iquid depth in cesspool is less than 6"below invert or available volume is less than '/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 Arty portion of the SAS,cesspool or privy is below high ground water elevation. j Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply: _ y portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. TVAny 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.] IV D (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 3l0 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 Wrapped Zone II 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST l Property Address-. :?/�//�-�' J Owner: -1 Q ^� Date of Inspection: Check if the following have been done.You must indicate`yes"or"no"as to each of the following: ..; e jXNo Pumping information was provided by the owner,occupant,or Board of Health t _ `Were any of the system components pumped out in the previous two weeks V _ Has the system received normal flows in the previous two week period? J/Have large volumes of water been introduced to the system recently or as part of this inspection? vt Were as built plans of the system obtained and examined?(If they were not available note as N/A) �Was the facility or dwelling inspected for signs of sewage back up Was the site inspected for signs of break out? ' Were all system components,excluding the SAS, located on site? _V/— 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? V _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems of The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no Existing information.For example,a plan at the Board of Health. _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance a is unacceptable)[3 10 CMR 15.302(3)(b)] 5 r Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 4 PART C SYSTEM INFORMATION Property Address:—?/ �' G6✓ Owner: IQ A .9 e Date of Inspection: A '4 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN.flow base_don 310 C .15203 (for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no):�Q Is laundry on a separate sewage system(yes or no):/VO[if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): Water meter readings,if available(last 2 y acs usage(gpd)): Sump pump(yes or no):/(/ Last date of occupancy:�/aP COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system 1p�umped4as.parWf the-'nspection(yesgor no): ._ �. If yes,volume pumped:/g_ ga[Ions--How was qua°ati umped detei�r'bineil ��,►' - Reason for pumping: N 4? TYPE F SYSTEM _Jeogieptic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool =Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval Other(describe): Approx' to age of all co m onents,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no)://4 6 ,,,. ..._..,., ,�w..M. �..-v.� ..- .,j,N.�.:-�,.... _. ..,.. ,.w n...'.sr ^e.r.r..ro..... A+..,'�.,{.., .�.r.)n ri1n vnr.. .. .. •.. .. � Page 7 of 11 . d OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM k PART C SYSTEM INFORMATION(continued) Property Address,,?/ Owner: h< / A! � Date of Inspection: t , BUILDING SEWER(locate on site plan) ' 'I j! .,. Depth below gradd:. , s fi Material's of construction:_ ast iron _40 PVC other(expla ): - (! Distance from private water supply well or suction line:, Comments(on condition of joints,venting,evidence of leakage,etc.): r, SEPTIC TANK:�ocate on site plan) Depth below grade: Material of construction:_ oncrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) , Dimensions:, S'"SX /O Sludge depth-.— Distance epth:Distance from top of#dge to bottom of outlet tee or baffle: _ Scum thickness: If Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to botto of outlet tee or�baffl�e�: ' How were dimensions determined: G/p� /YiLcI<6 L Comments(on pumping recommendatio , inlet and outlet tee or baffle con ion,sity, liquid levels as related tooutlet invert,evidence of leaka a etc.): n AVL.., o f-Z 14 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 scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: 3 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.): 7 ^ ` IQ! , ` Page 8 of 11 OFFICIAL INSPECTION FORM—NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM//INFORMATION(continued) G Property Address: / /�j Owner: Q.0. A0 P ' Date of Inspection: rr 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): i Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:I1/dfma A t c Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leak- 5471t eak-age into or out�ef bo ,etc.): > /V d Sa/ r�R r r �u.�r' N d' Ze e_ PUMP CHAMBER: (locate on site plan) Pumps in working drdr(yes,mho):� �(' r f« Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): « e'er Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: l 1-,J Owner: 2— , w Date of Inspection: ^L9 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why;,# Type V leaching pits,number; leaching chambers,number: leaching galleries,number: leaching trenches,number, length: 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. : D ✓'GZ U C l G U 1 ;nc ?" 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 cgnstructionn � 4 Indication of groundwater inflo (v�nomk 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.): 9 +ter' Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: (� . �✓ s .. Owner. Date of Inspection —0/ x SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of tfi'asewage dispo al syste%n hncl�ding ti,s to at leasvtwd,permanent reference landmarks or, ° benchmarks.Locate all wells within 100 feet.SLocite where public watersupply ei3ters the building. Ca E t � 66 ' r� 10 r Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Lnc 4^ - G Owner: lQ N t 'c• .� Date of Inspection: SITE EXAM # � �. Slope Surface water Check cellar 0Shallow wells �� f Estimated depth to ground water/-7—feet Please indicate(check)all methods used to determine the high ground water elevation: Y Obtained from system design plans on record-If checked,date of design plan reviewed: 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 Z de ibe how stablis d the hi h gtoungl water elevation: 70 0 It 4 4 0 Dg('t c,7 &o-L (PLaN S T P FL-ev = HS-, o -Fez rP 77 20 l y µ 11 _ I fira/ P� COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON. MA 02108 61'7-292-5500 .i V WILLIAM F.WELD TRUDY COXE Govemo: Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION ,� Property Address: 17r y L.- Address of Owner: Date of Inspection: /b (If different) Name of Inspector: I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: 6 '0 Mailing Address: L/-? f2 p/c�le-0,0n 5,- /01/W Telephone Number: �- ,(yG sa GC, 7-0,7.r 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 inspection. The inspection was performed based on my training and experience in the proper function•and maintenance of on-sitesewage disposal systems. The system: ✓ Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: girl _ Date: �j' The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 god or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTE PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: BI 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. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web http:/twww.magnet.state.ma.us/dep Printed on RecyGed Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: :.' 3 / Nor-/ '9 6"z44-'y Owner: /'J,y� Date of Inspection: X:7f GAl-141 40, SOIL ABSORPTION SYSTEM (SAS):_/ e (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: eI75 leaching chambers, number: leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) ena C_ Via. CESSPOOLS: (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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plan) Y4 Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page a of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: / /)�,�!_� c,/ t//�O Owner: Date of Inspection: TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or 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/dav Alarm level: Alarm in working order_Yes; _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) J DISTRIBUTION BOX: -P5 (locate on site plan) Depth of liquid level above outlet invert:/e u/2 Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) �/G G Q G PUMP 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.) (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: -31 Owner: Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade: U ' Material of construction: _ t iron _40 PVC _other (explain) Distance from private water supply well or suction hr-E, Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) e jw �!?5 Cv �o✓J SEPTIC TANK: J (locate on siteelan) Depth below grade- L Material of constructiof n: _concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: 10,4 Sludge depth: 5" Distance from top of sludge to bottom of outlet tee or baffle:_ Scum thickness: i Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: L71–/ S-/l Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) S' Gr+o9 0Tis c 4-e�a�s S' 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 scumto top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation.for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 04/2S/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C y� SYSTEM INFORMATION Property Address: 3 U1? /Q9 C/-- y Al A—ZIV 0 ✓ Owner: . , Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow:_ ep.d./bedroom for S.A.S. Number of bedrooms: Number of current residents: Garbage grir-:der (yes or no):-�:90 Laundry connected to system (yes or no):— Seasonal o):—Seasonal use (yes or no):�L/4 Water meter readings, if available (last two (2) year usage (gpd):A,4 Sump Pump (yes or no):0p Last date of occupancy: ��� COMMERCI.4UINDUSTRIAL• �ff Type of establishment: �7 • Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title i system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)-V,.-3 If o) •.- If yes, volume pumped: /!Ca y gallons Reason for pumping 1114 e Crc- TYPE 0 Y'STEM k. 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) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known)and source of information: y Sewage odors detected when arriving at the site: (yes or no)'--I-/. (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 3 f �% a (/� C� S A/ 0 Owner: L •/ o Date of Inspection: /-� 9 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Y� No i _ Pumping information was provided by the owner, occupant, or Board of.Health. _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. - As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ — The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. _✓ _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)J (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: / / t2 f n G 3' �'�! z,;, a v Owner: /9A-Z—A j�v Date of Inspection: (/ D) SYSTEM FAILS: You must indicate ather Yes" or"No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. EJ LARGE SYSTEM FAILS: You must indicate either "Yes /9as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/2S/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 31 Owner: Date of Inspection: 7— B] SYSTEM CONDITIONALLY PASSES (continued)YW Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: 1T' Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet to.a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 { SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C F SYSTEM INFORMATION (continued) Property Address: 31 15'r/,!S�,� fi•� / � ��/p p v--C_. Owner: Date of Inspection: C•�' Depth to Groundwater A/ Feet Please i to all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site(Abutting property, observation hole, basement sump etc.) y" Determine it from local conditions c/ Check with local Board of health t heck FEMA Maps 6 Q e Check pumping records Check local excavators, installers Use USGS Data i 9• Describe in your own words how you established the High Groundwater Elevation. Must be completed) 6;,'44 o "/y j /'.�ed te+ fes/ F/j v (r*vimed 04/2S/97) Page 10 of 10 ti t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C Q SYSTEM INFORMATION (continued) Property Address: 3 Owner: 0 Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) Ip 4 3 (revised 04/45/97) Page 9 of 10 t Nt' _, P kt' _��� �, � T�... � �+�• i .. .I�.Q i. �(,.i�-' 1.-; i. ,. i , � M���J � �. �>`� Li _('�''�_ �'Jlr Foot ! Playr�c � JtC�' ���,. L�s':l_�"`� '`+ ! {0'i`i• ��. 3�. J 4...'��x�.l} F.:.! �I 11 11 F.L ` i I. 1 0 .., i� et I(: r _ } .! ! _ '! t. ✓ �4 i C-O.Y. C.�. : AA r I s I � � : _�. ! ._ i .__. _ice_;l_. . i l �' D r'•,�.� �Lx.3l.o riJ�'�,;Y � I 18 SPP i � L_ L :_L__ J._...— ---- _-.... I. i... �`ti�.vcGtSC,►.iL`L?YYL .�.. .I I ,. i. .- G:'[il Sv). ._..i�Q_si . i. C f : I � l I i L : �.. , I ! x. --- I I ..i._ If : rI , : x'A1C 'A. leC, cl a6 I � r, : I : : - I : I } : �.0 ' I I 5 I I I3a1 I i , t I I , l i I i I T • I• • : , : i r , I� , I : , • 11 : • I : , I 1 : i : : , I _ i I _ I I I : i I : I l \ , : r I � r I , , : I I , : I O► ;-D :5 l t*L-1l ,�y r ij I r r , r , r i . ir I ;I 1 r r r , i r r r I r 1 i � I I r r 1 r r , A ►` 1 I : 6. r , 1 r r \JYJ , r , r r ! Commonwealth of Massachusetts IV64 Massachusetts t;El�lED UTAN 101011 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT System min ec rd System %%mer bystern Location 12o bic,,H Date of Pumping:1217 bo Quantity Pumped: /�sd p gallons Cesspool: No ❑r Yes . ❑ Septic Tank: No ❑ Yes RAGGS SEPTIC SERVICE, INC. System Pumped by: d.b.a. E. A. COMEAU SEPTIC License r: Contents transferred to: WATER SOLUTIONS GROUP, TAUNTON Datel�f 7�� D Inspector RAGGS SEPTIC SERVICE, INC. FORM - U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all-necessary aProval/pennits from Boards and Departments having jurisdiction have been obtained.This does not relieve the applicant and or landowner from compliance with any applicable requirements. - - - APPLICAZ60 a t-0 CtCU156!c PHONE�� ASSESSORS MAP NUMBER LOT NUMBER 0 f SUBDIVISION LOT NUMBER ASTREET �` LSTREET NUMBER 31 OFFICIAL USE ONLY RECOMMENDATIONS OF TOWN AGENTS DATE APPROVED CONSERVATION ADNIINISTRATOR DATE REJECTED CONAIENTS DATE APPROVED TOWN PLANNER DATE REJECTED CONffv1ENTS DATE APPROVED FOOD INSPECTOR-HEALTH DATE REJECTED DATE APPROVED SEPTIC INSPECTOR-HEALTH DATE REJECTED coNIMErITs . ;7"/G 1, -; PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMTr DATE APPROVED FIRE DEPARTMENT DATE REJECTED COMMENTS RECEIVED BY BUILDING INSPECTOR DATE CekPAf-An J-1 TO: NORTH ANDOVER, MASS —.�'d V .27. 19 `x' BOARD OF HEALTH I Re: Soil Absorption Sewage FROM: DESIGN ENGINEER System Inspection This is to certify that I have inspected .the construction of the said disposal system at f '7 Ar North Andover, Mass. SITE LOCATION The grades and construction are as specified'in my plans and specifications dated tv o A v •o cg, n cr/Ye ni lan a Board of Health 'north AnOovar MH Sa. SEPTIC SnTEH ; INSTALLATICK CHECK LIST �P CNID DATE DI SAPPR6M DATE EXAVATINOK FAIL -z� easDast FALL OK 1. Distance Tot a. Wetlands (I-Zz. b. ` Drains C.. Well 2. Water Line Location . 3- No PVC Pipe }s. Septic Tank a. Tees --Length do To Clercs Out Covers. b. Cement Pipe .to Tank On Both Sides of Tank 5. Distribution Box a. Covers & Box _ No Cracks b. All Lines Flowing Equal Amounts c- No Back Flow 6. Leach Field or Trench a. Dimensions b. Stone Depth c: Capped Inds d. Clean Double Washed Stone 7. . Leach Pits` -- -- - ions b. Stone Depth c. Splash Pads d. Tees e. Cemt Pipe to Pit fen :,,- .Both Sidss . .Clean Double Wasfiod Stone 8. No Garbage Disposal 9. ` - is.a,1 Grading :Inspection 10: Ba)r3cading,,Co' red.'Sy$tard 11. As Ilii 1 t,!Snbmi'ttod,, i -zt45 - a. Lot Location b. Dimensions of System c. Location with Regard-to Perc Fest d. 'Elevations e: Water Table Doarci of j:� SQBsURFACE DISPOSAL DEgIM CHECK LIST LOT �LI n 5. DATE DISAPPROVED DATE ' --= Reasons: f 04- I') ," 4- I'• ." C V _ FAIL CK -. R._ 2.5 The submitted plan must show as a minitm,m; - a the lot to be served-area dimensions lot #,abutters - ( cation-and log deep observation ho es-distance to ties location and results percolation tests-distance to ties fd,.d-sign calculations &_ calcul=ations showing required leaching area location and dimensions''of—syst ,-including reserve area f)= xisting and proposed contours location any vat areas �t}►in 100' of-sevage disposal system or - disclaimer-check--wetlands rapping I _ surface and- subsurface drams within 1.00' of ser�',age disposal � . system or ch-scla3�r any 1 di.5 sal !9--In ovation drzinage Basemen Board Y`i1.e S of s�r-�.,cg�ystem or disclairyr-Planning (J)knos.a sources of �.2ter supply xitdn 200' of sfsSragE sPt> ° - �— system or disclEd—mer -- - - (*),, cation-of any- proposed �,-e11. to serve lot-lOJ_frc71 leaching facili s{1-)-'location of -,ester lines on prnpErty-101 from leaching fac�13 y�-- I .,(m)'location of benchmark (n) drive-w-ays (o)-garbage disposals I (p).-fw PVC to be used in construction (q) profile of sssste-r elevations of basem—ent, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and O4-ter elevations ;(r �max�anm ground water elevation in area s---"age dispos,,l system I _,,(s)-`plan must be prepared by a Professional Engineer or ot}1er ' professional authorized by law to prepare such plans Septic Tanks capacities-150%' of fl W.. vater table, tees, depth of tees, raccess, pining h) cleanout (c). 10' from cellar v-all or inground si,'--zIng P001 ,(d) 251 from subsurface drains fi 1Q.� Distribution Boxes (a) slope greater than 0.08 10.t. I b) soap Subsu face Design Chh_ecck List Page 2 FAIL OK Leaching Pits Leaching pits are preferred where the installation is possible Reg 11.2 a calculations of leaching area-ndmim�+ 500 eq ft 12.4 spacing 11.10 c surface drainage 2% 11.11 d) over material ' Vx2'A" splash pad f),�tee at elbow } no bends in pipe from d-box to pipe Leaching Fields Reg 15.1 a) no greater t 0 minutes/inch b) area- 900 sq ft 15.4 c) cons tion of field 15.8 d) surtakee drainage 2 % 3.7 e) 201 from cellar wsn or inground a-Amn .ng pool Leaching enc rI___ leg 11.1 a)-_C �qp" Teaching area-rain 500 eq ft 14.3 b) spacin ft min 6 ft with reserve between 1.4.4 c) diSpAidons 14..6 d) 90hstruction 14.7 e) stone 1Z;.10 f) surface drainage 2% Dounhill Sloe ----------- a) slope yx (to — b e shown) -- — h)=y/x Ito he--shown) :eg 9.1 _ a) _ _ raVa1 --- -- - - - = 9.6 6b -stand-by power:.-- - ower — _-- - —_-_ -- _ f --- lS uJ i T�V,' I; i' I' ------ -------------T ------- ii i ii I:1 11 I it .�rr.wrrwi PLQ IL1 - OWiw47 __. 7"E 7 -.4o oliticov by SccT T G,LEs /Y•E:• S ' PRORO,6 'D .SUQSl1*F44S 5EWA,*& b/SPas e_ sySTEM /Vo . /.,/t�L,9ND (.t!/f/+IN /44 'OC ,Z/SPCS.4t System 14"AD t _..D:e411vs 9 s skz,w ti.- .__ P.po,00.4eb Lor 49AEAb/,l/6 tWrE = 3 - 27 -8y OW.t/se= RFl/ISS a N• - 4 -8y IL �G ,ZX • $ 'a = /98•�C <7+: � . AN.DoV��Ct. /Y1RSS • 6 14 X 'G r� s k t I•t?'i . P, D . LOCA T/off/ To7•AL _ n�a • s �.p. ,� . L o T 73 R 1,0 GES .L-q N E .r Jo-$ECW J. BA�e8A4ArZ .o , RS. �•�;y� � Ir ESTWAA?b ClRGL.E A1.0. A7EA4,lAle, , 44Ass. 7E4. 4&S IQ Al DA TA TYPE dF 8!//LG1A1lw: +e.R• A • G;,494GE 4f,CE4"9 Ake1N,51AlCv FW&/T/ES: y' the 5_4% StEMIAGE FLOW EST/.NATO-: '�<o o h ` SEPT/G TANK• . /Sao G!-? L ` .r . � -. �� �'� 4` •i� I /� � i4QSG1EOT/ON AREA =��2 �•F• Qo f• � a �f5•t 5it1E 0 ZPEA�O"Tlo.AJ T�573 i i iyN 40' !� ` ' // Q,4TE 3-az-BAO 3 -2z-,Ou ,N S 7VP E4EI147-/Dv/ I4S'• S' I y 7•6 s.. `"" 8�7TOk/ ElE✓ATil7.v 1�{t 5 4 � F cSr4TLl,eAS_ M/ti/. IT/oAl / 7 M/N. ,y/N. 4 5 M/Av R'RlcoeAT/ON RATE ! /o� / ,� .,t R CI Msr P/TS *t.3 41*¢ DA TE 3 TOP ECH/ATAW , s• ca /AlL 1 '< U..TSP t- 36"'r t w ' -SOIL TYPES S �" w ut AA/D ►A, *ikt, 11'6ef f �6. 4 WArE,e TABLE wNtER kAe��= COCA 7-/O N l l• c '� �" 133 -S d3a. 0 147- NEBOTTOM ELEf/ATlON I a • a / 3 3• a TEsTs COVDaGrEo BY Al' Ra ,5,g7-1 �.�3 3 RcM of :• e< —2 PZa,c/ Mraoaucnn�xevctxv..tirvr.��w.wow..v.�ri�+wv•:yra►•�r�r.wrr.Yv..a4�++r+a.ur.�riun�aurwxnntn �IY�16'lC�lf1T]r11R[�RiL^tMlfA+."I6rWY.Y.6YlR41XlTlld�Y.1YM1.V.lI.�Y.'.IYSn•R•:.VMMAnW1MMYAlMOT.iwe�..r uawS6v0Y[MHA.1.84T1�1�Cy(!ZS�iY'.- PRECASr CDNG,2E7E SEEPAGE PIT ` 7W 38" WASHED CCU5146o S7t�.c.SE Z" �L1AX/�slG'M CDYE.� "r?-,/I2" WASHED Ck-41-WE6 S .),VE —� �DflUBLE NNiASNED -AASHO SPK.. T-i/-Gd� �Z y ifilAX/ti1t/wJ COVE,2 1AALE-7- PIPE F rv�rN rEE) 'O O 43 O O O O O d 2'X 2'X 3" D.VLRe7_c � O O O O 3-r O O O d vPGAShN PAD O O O O O O O O cry // o p C, �4 JC 7 /¢' -� UEE WAGE P/T- �E;Cr/opt/ A-A cSEEP4GE Ar- cSEC r/om B-B c�CALE 3/8 = •-Q,� cSCAGE -3-B,•-�•-O„ ¢"�CA5rl2ocl, S=.oos SEEPAars ,4,eEA = �'6 O P/7" /Sd0 SAL SE-0711C TAAlAC it SOL/D P.(/. •, SEALED TOIAJrS, S=.00S 3 SHAC.LOW SEEPAGE P/7` - as5 t 8J 4 r 04 CD lot a ' � oc oo � � 3G"•• L/43 !43 � w o - ! 4, Ld LI 14-41 — ! 38 ` S• f/ IN• /33 •s - �3� L.,4 V3(* SEEPAGE PT -- PCT/ - - t K• G-R• SCALE -T �iPQ�/L E Fi N• .�s-�d C4LE HOR. P_ 40 YEe7 " ¢� /�ieDF/LE -' cSEEP<#GE P/T PGAAJ 4AjD SECT/OkIs c�N ET 1rB,piwlYTnU