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HomeMy WebLinkAboutMiscellaneous - 325 SUMMER STREET 4/30/2018 (2)kt,v-1 C-,� -t- C,;;� � b �- C-r—GIMOROMOM NOTFS- Commonwealth of Massachusetts North Andover, Massachusetts System Pumping Record System Owner & Address: Paul Diorio 325 Summer Street North Andover, MA 01845 Location of system: Front yard . _ Date_of Pumping: _ __ .May_ 06, 2013 _ Type of system: Septic Tank Gallons Pumped: 1000 gallons System pumped by: Service Pumping & Drain Co., Inc. S Hallberg Park North Reading, Ma License #: BHP -2013-0098,0100,0765,0096,0097,0099,0101 Contents transferred to: Greater Lawrence Sanitary District f '15 2013 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT This is PROPRIETARY and CONFIDENTIAL information that may be used only by the Board of Health 'for regulatory purposes A -A , - , TOWN OF SYSTEM PUMPING RECORD c DATE: SYSTEM OWNER & ADDRESS EIVED DEC 0 2 2005 TOHEA�7H DEQTM NORTII TER SYSTEM LOCATION (example: left front of use) �Q DATE OF PUMPING: QUANTITY PUMPED: GALLONS CESSPOOL: NO V YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER. BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED By,, Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste ,00,W '47, 45' 47,45' J3.09' C04 cy) 0 H- C" > ,5 r �' - L5 eki'J �S ech N-0 STRE yob ! C �) i iC.i-� � ii � � '�}i �.. U�C' ia� t a..4 �L`�St�h� �.•id 1 � W { 'T`I�.! i I�� too s re t -A { ® Pew- oLt-.`f IDN -*-,ra ar Tt- TZ I 1 !PG 10= S r yob ! C �) i iC.i-� � ii � � '�}i �.. U�C' ia� t a..4 �L`�St�h� �.•id 1 � W { 'T`I�.! i I�� too s re t -A { ® Pew- oLt-.`f IDN -*-,ra ar Tt- TZ I 1 !PG 10= S 0 m y t NEW ENGLAND ENGINEERING SERVICES INC RECIVED May 5, 2005 MAY 3 2005 TOWN OF IVORTFI� DOVER t Paul Dloro HEALTH DEPARTMENT 325 Summer Street ��%- North Andover, MA 01845 Re: Title 5 inspection: 325 Summer Street, North Andover, MA Dear Mr. Dioro, Enclosed is a copy of the Title V report for the property referenced above. The report indicates that the system PASSED the inspection. A copy of this report has been sent to the Town If there are any questions regarding the report, please call me at my office, 686-1768. Sincerely, c:9 Benjamin C. Osgood Jr., P.E. Certified Title 5 inspector 60 BEECHWOOD DRIVE -.NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 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' 132 5�uMMc�2 %2tG! /jDiZTf( Owner's Name: ,f'Ay I- Fl>l ney Owner's Address: _3Z,5; , nZA S"T 0 00 %i2 M-09 Date of Inspection: Name of Inspector. (please print) Benjamin C. Osgood, CompanyName:New England Engineering Services MailingAddress:60_Beechwood Drive, North Andover, MA 01845 Telephone Number: 978-686-1768 RECEIVED Jr. MAY 3 1 2005 Inc. & y "/,0 %�_ TOWN Oi HEALTH DEPA TMENT - 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 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: � Date: z /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. Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: .32.5- S,,7AjA4 Fez <--7 - i Owner: Date of Inspection: 61Z Inspection Summary: Check A B C D or E / ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: r' V 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: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 3 3� 5,�, ,tlb�R - 72ez J le77e 14A,),0,-)UQ2 M,4 Owner: thio izo Date of Inspection:/ C. Further Evaluation is Required by the Board of Health: A10 Conditions exist which require fiuther 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 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. Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 9 z, s L.; "lm L-Yz Owner:_ EjgvL- .Pioy-U Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate "yes" or `%o" 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 surfacewaters due to an overloaded or clogged SAS or cesspool Z 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 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. -A,::f 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 few 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 mast be attached to this form.] No (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 SPd. You must indicate either `yes" or "no" to each of the following: (The following\la apply to large systems in addition to the 'aabove) yes no _ — the system is withal 400 feet of a surface drinking water supply _ the system is within 2" -*&-a & a tributary to a surface drinking water supply _ the systems located m a nitrogen sensitiv area (Interim Wellhead Protection Area - IWPA) or a mapped �Z nedl of a public water supply well If you have answered "yes" to any question in Section E the system's onsidered 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. Page 5 of 11 OFFICIAL INSPECTION FORM -- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: P P'j L D i a iZo Date of Inspection:_/Z Check if the following have been done. You must indicate'W or "no" as to each of the following: Yes No V7 — Pumping information was provided by the owner, occupant, or Board of Health _ _V' 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) _ 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 ? ZWas 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 /ho Existing information. For example, a plan at the Board of Health. _ ZDetermined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) L3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 3`ZS S4:M n�2 sc NO 2 Owner: F4U L D1 e ALJ Date of Inspection: 6-74oui- FLOWCONDITIONS RESIDENTIAL Number of bedrooms (design): -- Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example:110 gpd x # of bedrooms): Number of current residents: P,_ Does residence have a garbage grinder (yes or no): E� Is laundry on a separate sewage system (yes or no): IUV— [if yes separate inspection required] Laundry system inspected (yes or no): = Seasonal use: (yes or no): A1D Water meter readings, if available (last 2 years usage (gpd)): Sump pump (yes or no): A� a Last date of occupancy: c,,, rr�e a.� - --- -- -- ----- -- -- COMMERCIAUINDUSTRIAL 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: ETHER (describe): GENERAL INFORMATION Pumping Records Source of information: Re'a IEP1 2-S A-GIO Fe1Z O L4J n Was system pumped as part of the inspection (yes or no): If yes, volume pumped: Qallons - 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) _ InnovativetAlteinative 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: auf r,� 1.-7 -7 c. . Were sewage odors detected when arriving at the site (yes or no): La Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 32.E SA=M m g e; /t/y r271�/ a4nl.e� O� e/L i1n� Owner: Date of Inspection: BUILDING SEWER (locate on site plan) Depth, below grade: Materials of construction: cast iron 40 PVC other (explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): (3 ILKouo IS—sHte 0 wAL1- SEPTIC TANK: _ (locate on site plan) Depth below grade: I Z'• 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: / v U o G l9 i e n nt '�= c� J' i - z c c P&?jr'V6- Sludge depth: '/ �,,,,�.��,� g�rc/ti w�•Lk,., Distance from top of sludge to bottom of outlet tee or baffle: 1F Scum thickness: 41 „ Distance from top of scum to top of outlet tee or baffle: 4-. . Distance from bottom of scum to bottom of outlet tee orb e: _ How were dimensions determined: _gyp. s;� �Z 6:1)c I,, - Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): GREASE TRAP:/+y Nocate 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 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 577 ti� ��i7/ ��a>n u.e✓L. �e9 Owner: p Au L_ 0109 - Date faRJDate of Inspection: 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: i;allons/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 openedxlocate on site plan) Depth of liquid level above outlet invert: b 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.): aox �.< �,iL C� ►�I,T�a✓1 Z3x kG1.S f'Gpw B. ueLE2S ,P'-siPi13 ui)D�. �QvAL. Nu L w D pA c e �,r t, b^,<AW f Al0 eo.�T oh ¢Ff2/1Youe2� I- PUMP CRAM ER: JL& (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.): a Page 9'of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3Z.57 ;I,- _,00 -47Y %_,00 47Y -V^J P alP/L ,Kt+ Owner: PAL).17fov_o Date of Inspection: _ . Q Z.% ate-. 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: / r/E[-ice overflow cesspool, number: innovativelalternative system Typelname of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): " NJ i l>CNf G o t' 1-761MOOV ! e7��.r„ ,� S � /G� Dig j �.vv5s✓ � tiCC-+ cam CESSPOOLS: �/ (cesspool must be pumped as part of inspectionxiocate 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: AWocate 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 111 of 11 OFFICIAL INSPECTION FORM = NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:term iLtGi2 5-; Owner: F)}v t_. j> 0 (z Date of Inspection: -2- SKETCH 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. 150 M AAn Page If of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: s t AJo rz7k(?vr R- .vi a9 Owner• ��AU t, ()?. C) PD Date of Inspection: !Q z% SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water —�/ _ feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record - If checked, date of design plan reviewed: Observed site (abutting property/observation hole within 1 So feet of SAS) Checked with local Board of Health -explain: Checked with local excavators, installers- (attach documentation) Accessed USGS database -explain: You mast describe how you established the high ground water elevation: * S KsTEnn AAe)l - 3- 71D e- c= i RD AA O V L4 NEW ENG AND ENGINEERING SERVICES INC. MAY 0 6 2005 TOWN OF NU i H ANLiOVER HEALTH DEPARTMENT May 5, 2005 North Andover Board of Health Town Hall Annex 27 Charles Street North Andover, MA 01845 RE: TITLE V REPORT: 325 Summer Street., North Andover, MA Dear Sir or Madam: Enclosed is a copy of the Title V report for the above referenced property. The system PASSED our inspection. If there are any questions please call me at my office, 686-1768. Sincerely Benjamin C. Osg d, Jr., P.E. Certified Title 5 inspector 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 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: _ 3 2 6 Sv M M C i2 i �Cc Na�2frr ANao-u Owner's Name: _ Pf}y I— ID i p2 c, Owner's Address: _3Z,S,,�� S/ o Gov i-' 2. •vt ti Date of Inspection: Name of Inspector. (please print) Benjamin C. 0Sgood. Jr. Company Name: New England Engineering Services Inc. Mailing Address:60 Beechwood Drive North Andover, MA 01 A45 Telephone Number: 978-686-1768 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 1.5.340 of Title 5 (310 CMR 15.000). The system: V Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: ' Date: �Qa� 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 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ,3 S. 5 c1 M F •2 c i4 c— �i ^tea c2 i7f fi-NP t L' E 2 �lfi Owner.. Date of Inspection: Inspection Summary: Check A B C D or E / ALWAYS complete all of Section D A.. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes. 'k L� 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 pipes) 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 tunes 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 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 325 S�l.►� rr � 2 S__2cc �i A44 Owner: Date of Inspection: C. Further Evaluation is Required by the Board of Health: /10 Conditions exist which require finther 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 surface water supply or tributary to a surface water suppler. _ 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. Page 4 of 11 OFFICIAL INSPECTION FORM -- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:> s �-v�� i2 -.712e-07 Vcv r27H Owner: e i v i- , V i m fZ o Date of Inspection: 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 1/ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool k- 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, . 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 lindicates 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.] ti (Yes/No) Ile system fails. I have determined that one or more of the above failure criteria exist as described is 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 l;pd. You mus(indicate either "yes" or "net' to each of the following: (The folloing criteria apply to large systems in addition to the�above) yes no — — .the system ��win 00 feet of a surface drinking water supply the system is within 20�butary to a surface drinking water supply the systemy,i i&ated in a nitrogen sensitive'Kea (Interim Wellhead Protection Area – IWPA) or a mapped Zgnefil of a public water supply well If you h ve answered "yes" to any question in Section F the sys\tem`is considered a significant threat, or answered `Yes" in Section D above the large system has failed. The owner or opeerr for 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 11 OFFICIAL INSPECTION FORM -- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: N� �Tll sFi�;�Cl4e2 ill.'¢ Owner: (' l L t? i u Kto Date of Inspection: Check if the following have been done. You must indicate `fires" or "no" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health — Were any of the system components pumped out in the previous two weeks ? _ Has the system received normal flows in the previous two week period ? /Have large volumes of water been introduced to the system recently or as part of 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 ? ZWas 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: Y /ino �/ Existing information. For example, a plan at the Board of Health. ZDetermined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) 1310 CMR 15.302(3)(b)J Page 6 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: rl/o11 17f,,n L/L �vtf9 Owner: Date of Inspection: z FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): -- Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): Number of current residents: a_ Does residence have a garbage grinder (yes or no): E5 Is laundry on a separate sewage system (yes or no): A)O— [if yes separate inspection required] Laundry system inspected (yes or no): -- Seasonal use: (yes or no), My Water meter readings, if available (last 2 years usage (gpd)): Sump Pump (yes or no): N- D Last date of occu a2 .__.. —-- - ----------- - — --- ----- — COMMERCIAUINDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): - Bpd Basis of design flow (seats/persorWsgketc.)-. 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. lav m �!zcV- a o a 25 A -C, -o Pell O nff-p— Was system pumped as part of the inspection (yes or 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) _ InnovativelAlternative technology. Attach a copy of the cement 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: Were sewage odors detected when arriving at the site (yes or no): &0 Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Addr�s: 3z -5 ,vl 9 < rz-17-t Owner: PA-)i- Date A-)s-Date of Inspection: _ Zzl BUHZING SEWER (locate on site plan) Depth, below grade: Materials of construction: cast iron 40 PVC other (explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): f-K(As!) IS-q,.s ae 0 w ALL, SEPTIC TANK: _ (locate on site plan) Depth below grade: L Z Material of construction: __v concrete metal fibaglass _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: /Uy o G- /9 i e o v C� i e -c r c roc Sludge depth: depth: 6� ° v r�E,2_ �K�c/� w�► k. Distance from top of sludge to bottom of outlet tee or baffle: lt- Scum thickness; y „ Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle - How were dimensions determined: m Gla. �, a e s.Ile ,4 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7Ati GREASE TRAP:/V Nocate on site plan) Depth below grade: — Material of construction: — metal 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 umpingComments (oar 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 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: --32:.t;- Owner: -32.5Owner: r> t i2�o Date of Inspection: 2 f Zit TIGHT or HOLDING TANK-. LL (tank must be pumped at time of inspedionxlocate on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polyethylene other explain): Dimensions: Capacity: - gallons Design Flow: gal1ons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: _()� Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): CQuAt- AA7 w FNcc nT 1.EgKAtsC I'V' ovT PUMP CHAMBER: Ljft- (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.): Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ;Z5 - Owner: Z Owner: PAoc_ DiQ Date of Inspection; _ �'/ z 1;,,57 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: innovativelalteinative system Typelname of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 11_)Q ' or--�i�i4:> t-00 KS �l/u�^ �v1,4G NJ r✓% �cN� 4 t CFSSPOOIS;/lf/%" (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 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _ > s ,Im lyv iz:-1 / v M,,f Owner: r-Wy t_ .pi G (2C Date of Inspection: 2 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. -�, V`. t � ' V' �vM AA&1r2 c4-(2 G4: t t, " Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: � Z-5. •� .� ,2 St h%v (ZTf Owner: izd U t-- i 12c� Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water —,Y__ feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record - If checked, date of design plan reviewed: Observed site (abutting property/observation 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 tiS`TE M AAE►33 r% �1 i -Z �' ✓Li�.�tti R J A- GNL N System Owner: Paul DiOrio 32.5 .Summer Street North Andover FORM 4 - SYSTEM PUMPING RECORD Commonwealth of Massachusetts North Andover, Massachusetts System Puming-Record System Location: front yard Date of Pumping: October 24, 2000 Quantity Pumped: 1000 gallons Cesspool: No /X/Yes / / Septic Tank: No / / Yes /X/ System Pumped by.: Service Pumping .& .Drain Co..., Inc,. License # 109-0013 Contents transferred to: Lawrence Treatment Plant Date: October 24, 2000 Pumper: B.L. This is PROPRIETARY and CONFIDENTIAL information that may be used only by the Board of Health for regulatory purposes. r t. NEW ENGLAND ENGINEERING SERVICES INC January 9, 1998 North Andover Board of Health Town Hall Annex 30 School Street North Andover, MA 01845 RE: TITLE V REPORT 325 Summer Street. --• �r-,•I 80 E,�D QE HEAL' 'j �/ ANI 2 1898 Enclosed is the Title V report for 325 Summer Street, North Andover, MA. The system passes our inspection. As you know this system was inspected by another inspector as a conditional pass. It is the opinion of this inspector that the system did not need to be inspected by the Board of Health and the installation of flow levelers in the distribution box at the time of our inspection returned the system to an equal flow to each pipe condition. This inspector did not witness the same conditions of backflow from some pipes that were sited in the previous inspectors report. If there are any questions please call me at my office, 686-1768 Yours truly, Ben' C. Os ood Jr/ J g President 33 WALKER RD. - SUITE 22 - NORTH ANDOVER, MA 01845 - (508) 686-1768 1trlLL1Ak! F WELD Govcmo: CO'vtMONNVEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENN,IRONMENTAL PROTECTION ONE WINTER STREET. BOSTON. NIA 02106 617-292-5500 ARGEO PAUL CELLUCCI Lt. Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 325 5o,",wee 5t N <l,v c6,)CZ Address of Owner: Date of Inspection: (if different) Name of Inspector: BENJAMIN C. OSGOOD JR. ' I am a DEP approved system inspector pursuant to Section 15.340 of Title S (310 CMR 15.000) Company Name: NEW ENGLAND ENGINEERING SERVICES, INC. Mailing Address: 33 WALKER ROAD, NORTH ANDOVER, MA 01845 Telephone Number: 508-686-1768 TRUDY COXE Secrcur% DAVID B. STRUHS Commissioner CERTIFICATION STATE94ENT ' I cenify that t have personally inspected the sewage disposal system at this address and that the information reported below is true. accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: LLasses _ Condtttonalk Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: The System inspector shall submit a copy of this inspection report to the Approving Authoritywithinthirty (30) days of completing this inspection. Y 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 repon 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 btFyer, if applicable. and the approving authority I INSPECTION SUMMARY: Check A, B, C, or D: AI SYSTEM PA S: I have not iound any information which indicates that the system violates any of the failure criteria as defined in 317 CMIZ 15.303. 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. 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. (r --d 04/2S/77) p.0. 1 or 10 SUBSURFACE SEWAGE OISPOSAI. SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 3 2v�4,6 Owner: dam Cc�✓1A O' Dale of Inspection: BI SYSTEM CONDITIONALLY PASSES (continued) _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(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): i broken pipe(s) are replaces obstruction is removed Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which reouire iurther evaluation by the Board of Health in order to determine if the system.is failing to protea 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 ENVIRON LENT: Cesspool or prix-• is within 50 feet of a surface water Cesspool or prov 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: t 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 1 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 So 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 S ppm. Method used to determine distance (approximation not valid). 3) OTHER (r—i•.d 04/2s/9?) P.q. ] of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 3 a5-- S v A. ,r. e 4 0-, A). 4-VO()-'CA- Owner: -VOv✓C/Z- Owner: pt9M COV^/ O d(iy Date of Inspection: D) SYSTEM FAILS: You must indicate either -Yes- or -No- as to each of the following: I have determined that the system violates one or more of the f6llowing 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 to 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 floe+•. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of tunes 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 ponion of a cesspool or privy is within a Zone 1 of a public well. Am porton of a cesspool or privy is within 50 feet of a private water supply well Amy porton 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 baclfria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: I I You must indicate either -Yes- or -No- as 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 go or greater (Large System) and the system is a significant threat to public health and saiety 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 04/25/971 Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: J& 5u..i.irl2 S7�' N ,/�tipo✓e2 Owner: Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each -of the following: Yes No _ 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 parr of this inspection ✓ _ As built plans have been obtained and examined. Note d 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 manholers 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 tand occupants, if diiierent from owners were provided with information on the proper maintenance of Sub -Surface Disposal System. _ Existing information. Ex.tPlan at B.O.H. t _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (I 5.302(3)(b)) I (revia•d o4/75/97) pays 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION -FORM PART C SYSTEM INFORMATION Property Address: Owner: /tea Date of Inspection: c."""��� RESIDENTIAL: FLOW CONDITIONS ' Design flow: e.p.dJbedroom for S.A.S Number of bedrooms:, Number of current residents: Garbage g►ecder (yes or no?:e3 Laundry connected to system (yes or no)� 5 Seasonal use (yes or no):/VD Water meter readings, if available (last two (1) year usage (gpd): /%a•l t'_ " [ALJ e/� Sump Pump (yes or no):/,./c Last date of occupancy:,ea /- PN-/` COMMERCIA ANDUSTRIAL• Type of establishment: Design flow: Qallons/dav Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: eves or no)_ Non -sanitary waste discharged to the Title i system tyes or not_ Water meter readings, if available Last date of a-cupancy: OTHER: (Describe) Last date of occupanc i-. PUMPING RECORDS and source of information 1 GENERAL INFORMATION v ..+- e_ O System pumped as pan of inspection: (yes or no) _z1_/p I( yes, volume pumped: gallons 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) Other VA Technology etc. Copy of up to date contract? APPROXIMATE AGE of all components, date installed (if known) and source of information: /'r- —&'m- Sewage ,/jam,m- Sewage odors detected when arriving at the site: (yes or no) L (r...t..a 04/25/») Pay 5 of 10 O vnc/Z I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 32S- suM.HK dfi 'V, Avo.0voe Owner: Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: ✓cast iron _ PVC _ other, (gxplain) .L Distance from private water supply well or suction hoc Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:_ (locate on site plane Depth below grade:1� Material of construction: ✓oncrete _metal _Fiberglas; _Polyethylene —other(explain) If tank is metal. list age Is age confirmed by Cendreate of Compliance _ (Yes/No) Dimensions: /DOD Cf/fLLU Al Sludge depth: L/ " i/ Distance from top of sludge to bottom of outlet tee or baifig:� / Scum thickness: •�/ • � Distance from top of scum to top of outlet tee or baffle:_ Distance from bottom of scum to bonom of outlet tee or baiile: Zo How dimensions were determined: < 77',- Comments: 7' 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.) ZAAI/X a /,y 6-00 D Gtr na,D/77 (%ti• 1-60-S cs /'os ,gliiGLEs / A,' leo )0 co,.,,t7,no,v Rtrc-o ,-E•y/� _tLJC scf/ !e6 7-2?'e:3 , �1J 17'/ "VA 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 bonom of scum to bottom of outlet tee or baffle Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tee or baffles. depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (r.vi..d 04/75/97) P.9. 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner:N• AN . Po,f„ Cv.,., o// 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 gallon,Jdak Alarm level Alarm in working order _ Yes. _ No Date of previous pumping: Comments: (condition of inlet tee. condition of alarm and float switches. etc.) ) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note ii level and distribution is equal, evidence of solids carryo+er, evidence of leakage into or out of box, etc.) ) D ,tR a x 4-S I .v {-d n D ✓ h ft o ✓l71 ri L) SM. I. O P S w erc- eUGr1 !iw �Q A / /J.__, I -es �' a 4,0 _O '�L 7' �: ,- 'SD . X rl-D7' Li IS f'—' kv AAs a G rf- of -r c i.., % n e c h'V – , /v V-) l e uefel-s el'e- i'.s 17, //1 1-4' –✓ iS r)o w ett v -d tD 4// PUMP CHAMBER:_ (locate on site plan) Pumps in working order: (Yes or Not Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (—i—d 04/75/97) Paq• 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 144o c� Owner: F0 ,..t n.• O�`j Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers. number:_ leaching galleries. number: ! leaching trenches. number,length: ' leaching fields, number, dimensions: / 2.5" X �i 7 overflow cesspool, number: Alternative system: Name of Technology: Comments: ' (note condition of soil, signs ofraulic failure, level of ponding, condition of vegetation, etc.) fil-eA- .0 'e -6 ell be�✓� /`,,r,�,/ �'�•��� f/ p/�. Amu /S %r — A'D✓e G .eiei.f Ana t.fcu . CESSPOOLS: _ (locate on site plan) Number and configuration Depth4op of liquid to inlet inven: Depth.of solids layer: t Depth of scum layer: Dimensions of cesspoo!: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as pan of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: _ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil• signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (r—i—d 04/2s/97) P.9.. a of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3ES- S,) er sN. AN,D6,f/2, Owner: }�Con.( A Date of Inspection: 1-7-q7 " 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) I &Z we -d 13G, To -yep C TRoIC e (r•vir•d 04/25/971 / 1 Peq• 9 of 10 A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propertv Address: 3ZJ Sv w� r�,A &-h Owner: Date of Inspection: �AM fd.✓n/6 t,t `f Depth to Groundwater feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record --Obsmatlon of Site (Abuning property, observation hole, basement sump etc.) Determine it irom local conditions Check w!th !oca! Board of health Chea FEMA neaps Check pumping records Check local excavators, installers I Use USGS Data Describe in your own words how you established the High Groundwater Elevation.! (Must be completed) f e! m f / Cc. 6 O ,1,G cc. cY 4 c �' I _. I� �✓' 4 `' J i (r•vi•.d 04/21/97) P•q• 10 or 10 WILLIAM F. WELD Governor ARGEO PAUL CELLUCCI Lt. Governor COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE W'I'NTER STREET, BOSTON. NIA 02108 617-292-5500 /t`"/te TRUDY COXE Secretarn 'DAVID B. STRUHS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION Property Address:3z-+rn01- ��-j(7Jv:='� Address of Owner:(1k� Date of Inspection: DEC 9t)v, Iqo) (If different) Name of Inspector: £ZICi-s !2. N 1TZSC}{L am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: N o c, "I 44 - t�QS w___"1\, Mailing Address: ZS . t Gr SY- ' 1,QOFE jt_�.e?rCA (1'1%A Q)aq Telephone Number: hlb) Com, -q� 3b CERTIFICATION STATEMENT certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes l F er Eval 'on By the Local Approving Authority Inspector's Signature: Date: The System Inspector shall submit a copy of is inspection report to the Approving Authority within thirty. (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of. Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. 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. 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) Paye 1 of 10 DEP on the World Wide Web: http:/ANww.rnagnet.state.ma.us/dep e'j Printed on Recycied Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 325 5-%(nn)E7iZ, Owner: k C=N )erq + }?Arr).=IA fJl+Ju.� Date of Inspection: —(D.C. % IJ , tc)y) B] SYSTEM CONDITIONALLY PASSES (continued) ,N4 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 syste n required pumping amore than four times a year due to broke, 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: 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 A CERTIFICATION (continued) Property Address: 'mmc�?�T N• ��7u Owner: G?.11,1L13•j y- rr (1000LI,`f Date of Inspection:-Der�L C)*10� 1:)g� D] SYSTEM FAILS You must indicate ei;!,er "Yes" or "No" as to each of the following: 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 112 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. E] LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as 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 II 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 04/25/97) Fags 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property ddress: 3Z6 n 1Z ' �J- AQDCwM Owner: TEP06 % d-�►�O�i.`r Date of Inspection: DZ Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No _ 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 L"N►NKY )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. v _ 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. 4 Existing information. Ex. Plan at B.O.H. `r _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) 115.302(3)(b)) 40, �3r.fc�v�Ic wvtr- �—ytt5� t.1��2 �� 4i�t't��i�", No:.xu�-�� m )S 1447- I►a uS%F- AOO 00) _'( Qb�ED T)oZ1K_�c) E_M -V4eVjCj r5, ' �vemA� ?,Ruu X00- D " T►zz '-6-0- A, (revised 04/]5/97) Page 4 of 10 Property A dress: U5 Owner: 'lJl>tnN 1+ Date of Inspection:"DeC SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 'S, m m 1Z ��' �r�=z.A. G "Jo(„q FLOW CONDITIONS RESIDENTIAL: Design flow: g.p d./bedroom for S.A.S. Number of bedrooms: Ll Number of current residents: Garbage grinder (yes or no): `( _ Laundry connected to system (yes or no):�b Seasonal use (yes or no): n10 Water meter readings, if available (last two (2) year usage (gpd): Sump Pump (yes or no): N tJ Last date.of occupancy:9f`��T COMMERCIAUINDUSTRIAL: / Ji Type of establishment:_ Design flow: gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non -sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last nate of occupancy: OTHER: (Describe) _ Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: /lntO��i2 S�-crc laquy t�►yz, X993 , d t.�It.���t i9`�W System pumped as part of inspection: (yes or no) '` 5 If yes, volume pumped: 1u c' o gallons Reason for pumping: `fit AIZT CC— t 05?emoi \ Q v z 5120 cit, t9AL t h?tc��Rt j`� LEAKI�,�c 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) VA Technology etc. Copy of up to date contract? Other i APPROXIMATE AGE of all components, date installed (if known) and source of information: �J513�.t�.�' � AS%SK'0'. -' 21 \f Pas— Sewage odors detected when arriving at the site: (yes or no) N 0 (raviaad 04/25/97) Pago 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM j INFORMATION (continued) Property Address: '375�tnm��� N" ANDotjQ� Owner: K6jPer4 -.i,a a0a% Y Date of Inspection: -D C , 9 -ti o (9q) BUILDING SEWER: (Locate on site plan) Depth below grade: 26"4 Material of construction:/ cast iron —40 PVC _ other (explain) SC.sZ,LPLL 02- 219'z MORE O$ A fASi TKuo P -AT j p -T4AO A w,( d TKZP, -1 hD - Distance from private water supply well or suction line T#AA-7to AL IS \) ZZ'( Diameter y" Comments: (condition of 'oints, venting, evidence of leakage etc) �ucam; - r -P� Pi A�,� �i5T1zt-b0 - I0 0 71 P�F-s Azc c Er5AG , 1T IS '1'NAT `9j�1�Ut1�G) ` eW '(L 6 ALSO 1"3CAC'l{ CS.,4iRl�i SEPTIC TANK:_ (locate on site plan) _ tt Depth below grade: Material of construction:` --r concrete _metal _Fiberglass _Polyethylene —other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _ fYes/Nn1 Dimensions: S(' :t OtDE Sludge depth: _3-.-4" Distance from top of sludge to bottom of +ee or baffle: Scum thickness: Distance from top of scum to top of -e or baffle:y}'-'' Distance from bottom of scum to bottom of outlet tee or baffle: IUt How dimensions were determined: -MPC- ME-AGQQE 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-) t-MukD LkNtZ 1160-W(i A; %�' il�t 3" :iCiQ Acs 71az BaVIF,cES. Si1ZVc �vQA� 1NTEiP1� ( k,),) Z5 SuttD ili uuC,>Jyt,t_ -TW, S14N5 CCF u--AXB,f\t_ GREASE TRAP: Or A (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: (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 04/25/97) page 6 of 20 1 . a. 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property ddress: ,3Z� �'m��v�`i" /�1.RJ�O QL Owner: CG OIJJ Uk•`( Date of Inspection: '�C G. ()fid` PA -7 TIGHT OR HOLDING TANK: P4'' (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/day Alarm level: Alarm in working order Yes; _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: _0-1. Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) �� IFjN71ui� �j�X )S (-CV's.._ Ac--AQ'V (5UI(hl.)(Z oC Sv�-►D CANS c)Ji=ft A1>D QAC 151.( CJWZ WA7rf­ a-cn( _ Vt. 1015-rR16„-no>, ?Ipcs AZtr ZQ AL. A,-, i-) s1c;05 OF zw of 5W9(,% Im ►?I93_ 'D.-6*)-;- 1S -P '50LtD. 14U S14L;,5 cyF:- veA?r,,kc,c- ��-jj4 i c.R300» = 'Zo3".19:-Ctej�fS ALL >1�� 1, 3,� 5 E�htltSri3 tech taw. ��f�r y Sryo�s Na Ftow .�IP� 2 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.) (reviaad 04/75/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFOR TION (continued) Property iA�ddress: 3Z S c3 -'mm G-Ei' ?IJ Owner: fi�-'�j oe'T}J * +)� TELA X300l,CT Date of Inspection:'D--C. C�`h O ) jggl SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: 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.) �C St�,NS of �Y9wC��IC i�C�IU��.QRpJoD C' \")Lz (x' SaJZT Q , Q.t O `�o uDt ►.i �, . TJ C C, Z �i�r `( S` u "T0 w KT0 ---T- 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) Materials of construction: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/75/97) Page 8 of 10 . Dimensions: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3zS S'Mm� /n� �"=C�T �- LmvF'L Owner: KtT1�IC'r� �- � 1�� WNQOLL� Date of Inspection:—Z10) I cil 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 su ply comes into house) TO P 2\v ATS W ZL 13cm` W43M Sic 'A►.) K Com:►-��` T6 �bo>„ �liZ�_ S'z:" Sc-vnc -ro�� aa=c�^ Vc�wsnc rS , . jvva C,A�-w v S KK O I watK *tl. ` .5 4 A5,&-) Kr i A r.4 So Yn (revised 04/25/97) Page 9 of 10 V SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: %�J►JcT�I� CC3�Jl,l� Date of Inspection:'L 9 y. (Ul 1o)I fl Depth to Groundwater 3-q Feet Please indicate 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.) a Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) RoM -'Ids 'b3A;Zo OF 4e3\Q qk ) 4 - -z>z WAS ���A'112 (qA-1�.'j QC 5151"'-TV1 T WAS s-tIATEF"s -*I- 12S & MMr6� ': � c�cAC��1� AS A (11oV w0o—> n &wow ►q�l�_ C�,cK�-� 1.w. N A's �t\�S ►�cG-rv2S Coavtm�u3 - 1� L 5--,RO0C,0( Z Cr ,nMCN7 -fuW Co ����,�� 'FAsnl\-y a-;Y�uu . TAC CA2i,Ac,\- G1171 rJ0�12M %)y� iLT i'w+� Z 13;s i - 'l�j� I�JC �� lC�iG�li 1✓i� F) t"ZD 1S ?R0?E9q S12;w ►tires7r`�� f4op-MAS- AA10� R o 'k 61Az-?'Ac,c Z) WcrA ildc ArnootT or= Rccorvyv, Pj�� -TNS of A A055SL ri c.-rr-,2 � 'mP� c, N� Cc,� I � 5,II c�f TNS .� ux �jv m P, J�=;� i1A A��UuQ) 1,-1 -N-- C-cA,- �a20 c� N�-nA �� ily Cs.s�= ,a3c, c;F 71) -CIF 'Dt S�Zt '�', ►"fir S SKuLo Slh Pc> C.-- 0?,JO CA Z -TO- k-F9Am11JA--r►v'v, TN1S COULD -T14t (zaviaid 04/25/97) Page 10 of 10 FORM 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 or requirements. *************************APPLICANT FILLS OUT THIS SECTION PHONE APPLICANT 1 LOCATION: Assessor's Map Number -_-1 L7 PARCEL I �" SUBDIVISION LOT (S) _ ST. NUMBER STREET *"****OFFICIAL USE ONLY ,TIONS OF T ATION ADMINISTRATOR COMMENTS TOWN PLANNER COMMENTS FOOD INSPECTOR -HEALTH sFpxic INSPECTOR -HEAL COMMENTS ENTS: DATE APPROVED DATE REJECTED. DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE__ yq 1l l t I 1 n t 1 2,po 5 8 I �•=�.1 r-� tib' � �.;'�"' rs �.,� �1.�'_..!_s,•k ('1"�G."+ � - z k��< 1�tL/�5� lb���•i INV 00T,o hIlC CNV o 'rot D. ice,, ' V(ZE��jo a plspc.:7 .>f1..� 8 I �•=�.1 r-� tib' � �.;'�"' rs �.,� �1.�'_..!_s,•k ('1"�G."+ � - z -pNVT Z4R F FORM 4 - SYSTEM PUMPING RECORD Commonwealth of Massachusetts No. Andover, Massachusetts System Pumping Record System Owner Ken Connolly 325 Summer Street North Andover, MA Date of Pumping: March 29, 1997 Cesspool: No /X/ Yes /—/ System Location Front. yard Quantity Pumped: 1000 gallons Septic Tank: No /—/ Yes /X/ System Pumped by: Service Pumping & Drain Co., Inc. License # 636 Contents transferred to: GLSD Date: March 29, 1997 Pumper: S.B. This is PROPRIETARY and CONFIDENTIAL information which may be used only by the Board of Health for regulatory.purposes. rmy appuai snau oe tileq within (20) days after the. date of filing of this Notice in the Office of the Town Clerk. ' • ,SS�CHu5t�4y • TOWN OF NORTH ANDOVER MASSACHUSETTS BOARD OF APPEALS NOTICE OF DECISION Property: 325 Summer St. NAME: Pam & Ken Connolly Date: 9117197 ADDRESS: 325 Summer St. Petition: 030-97 North Andover, MA 01845 Hearing: 919197 RECE{VED JOYCE BRADS -HAW TOWN CLERK NORTH ANDOVER SEP 18 ( .59 PH '97 i ne board or Hppeais nein a regular meeting on i uesaay evening, September 9, 1997 upon the application of Pam & Ken Connolly, requesting a Variance from Section 7, Paragraph 7.3 for a side setback in Table 2. Said premises is a building located at 325 Summer St., with frontage on the North side which is in R-2 Zoning District. The following members were present and voting: William Sullivan, Walter Soule, Robert Ford, John Pallone, Scott Karpinski, Ellen McIntyre. The hearing was advertised in the Lawrence Tribune on 8/26/97 and 9/2/97, and all abutters were notified by regular mail. Upon a motion made by Scott Karpinski, and seconded by John Pallone, the Board of Appeals unanimously voted to GRANT relief of 2.9 feet on the North side of the existing structure for the family room addition and deck. Voting in favor: William Sullivan, Walter Soule, John Pallone, Scott Karpinski, Ellen McIntyre. The petitioner has satisfied the provision of Section 10, Paragraph 10.4 of the Zoning Bylaw and that the granting of these variances will not adversely affect the neighborhood or derogate from the intent and purpose of the Zoning Bylaw. Note: The granting of the Variance and/or Special Permit as requested by the applicant does not necessarily ensure the granting of a Building Permit as the applicant must abide by all applicable local, state and federal building codes and regulations, prior to the issuance of a building permit as requested by the Building Commission. BOARD OF APPEALS, William J. Sullivan, Chairman nestdeGs FORM 4 - SYSTEM PUMPING RECORD Commonwealth of Massachusett wmnv vr nrau n North Andover, Massachusett NOV 101995 System Pumping Recur System Owner Ken & Pam Connolly 325 Summer Street North Andover System Location Front yard Date of Pumping: 10/18/95 Quantity Pumped: 1000 gallons Cesspool: No /-X/ Yes L/ Septic Tank: No Yes /X/ System Pumped by: Service Pumping & Drain Co.. Inc. License #: 592 Contents transferred to: Greater Lawrence Sanitary District Date 10/18/95 Pumper J. N. Confidential Business Information NORTH ANDOVER BOARD OF HEfLTH INSTALLATION CHECK LIST APP OVER DATE DISAPPROVED DATE tXCAVATION OK FONS -�z- 3 1 FAIL I OK 1. Distance To: Wetlands Drains —Well e Water ine Loc 1io n P `� ,.-/a — 0 3. No PUC Pipe Septic Tank Tees - Length & To Clean Out Covers Cement Pipe to Tank -- On Both Sides of Tank 5. Distribution Box fiver & Box - No_Crac.�ts Lines �`lii n� EQual Amounts 6. Leach Field or Trench �mensions ane Depth Ca .ped Ends an Double Washed Stone 7. Leach Pits Dimensions Stone Depth Splash Pads Tees Cement Pipe to Pit - Both Sides Clean Double Washed Stone No Garage Disposal na Gr_ ading Inspect -i. ,,'I0/' Barra red System - Built Submi Dimensions of System Location with Regard to Pere Test Elevations Water Table SOIL PROFILE _& PERCOLATION TEST ,I)ATA �r Town/City' _ No.&Stree t�-„.►��,- Lot No., Loc./Subdiv» Plan Owner 00 C/ Investigato&4_-Iiaaalle) �.. Observer If SOIL PROFILES -DATE 1' Elev»_ ?' Elev. 3'Elev. i--Elev. 0 ----- ---- 0 0 1 2 3 4 W, 0 7 WE 9 is 2 3 4 5 M 7 0 6 1 2 3 4 5 6 7 Wo 9 10 �-10 10 I ��� 10 Benchmark Location Elevation Datum PPeercco�lyation Tests -Date v/ �7 Pit Number 1 2 3 4 5 Start Saturation /U:JL Soak -Mins. �S Start Test -Time / Drop of 3” -Time DroD of 6" -Time Mins» lst 3"Dro J;00 Mins.2nd 3"Dro iv lJ ac S&etCnes on back Frank C. Gelinas & Associates, North And. p o�_11 soz .e, t SUBSURFACE DISPOSAL SYSTEM CHECK LIST NORTH ANDOVER BOARD OF HEALTH APPROVED DATE PROVIDED DISAPPROVED DATE TIME REASON 77,11-7ot( Title 5 Reg. 2.5 j Reg. 6 Fail The submitted plan must show as a minumum: —(- the lot to be served (area,dimensions,lot #,abutters) (Planning Board files) —{-�-}- location and log of deep observation holes -distance to ties location and results of percolation tests -distance to ties r(-d7y_ design calculations & calculations showing required leaching area —(-e-� location and dimensions of system (including reserve area) existing and proposed contours -� location of any wet areas within 100' of the sewage disposal system or -disclaimer (check wetlands mapping) .`(T)'surface and subsurface drains within 100' of sewage disposal system or disclaimer — location of any drainage easements within 100' of sewage disposal system or disclaimer (planning board files) known sources of water supply within 200' of sewage disposal system or disclaimer ! --�k�}—location of any proposed well to serve the lot (100' from leaching facility) --4-14 location of water lines on property (10' from leaching facilities) location of benchmark - driveways garbage disposers no PVC is to be used in construction -- a profile of the system (elevations of basement, plumbers) pipe septic tank, distribution box inlets and outlets, � distribution field piping and any other elevations) maximum ground water elevation in area of sewage disposal .system plan must be prepared by a Professional Engineer or i other professional authorized by law to prepare such plans SeDtiX Tanks (a�' Capacities- 150% of flow, water table, tees, depth of tees, access, pumping, (b) Cleanout Nc10' from cellar wall -or inground swimming pool 25' from subsurface drains Reg. 10. Reg -,10.y Reg. 11. -1 Reg.11.4 Reg.11.1 Reg.11.1 Reg. 15.1 Reg. 15.1 Reg. 15.4 Reg. 15.8 Reg. 3. 7 Reg.14.1 Reg.14.3 Reg.14.4 14.5 Reg.14.6 Reg.14.'7 Reg.14.1 Reg. 9.1 Reg. 9.6 r Fail OK Dis (b� ;eibution Boxes Slope greater than 0.08 Sump Leaching Pits Leaching pits are preferred where the installation is possible (a) Calculations of leaching area (minimum 500 S.F.) (b Spacing (c� Surface drainage 2% (d) Cover material Leaching FiPlH RoGreater than -20 minutes/inch - (b) Area (minimum 900 S.F.) (c) Construction of field (d) Surface drainage 2% (e) 20' from,cellar wall or inground swimming pool Leaching Trenches (a) Calculations of leaching area (min. 500 S.F.) NSpacing (4 ft. min. 6 ft. with reserve between) Dimensions (d) Construction (e) Stone (f) Surface drainage 2% Dow hill Slope a) Slope y/x = (to be shown) (b) y/x X 150 = (to be shown) Pumpo' (a) Approval (b) Stand-by power i SOIL PROFILE & PERCOLATION TEST DATA Board of Health -North Andover, Mass. Street &44U4� Lot No. 5 Subdivision Owner_ Investigator 4410A Observer L . P%ru_1101 SOIL PROFILES 1. Date 2. Date 3. Date Elev. Elev. Elev. Feet Inches 0 0 4. Date Elev. Ties to Test Pits 1. 2.- 3. 4. 5. (6( Note: Top & subsoil depth; depths of other soil types; 'depth of water table; depth of refusal. PERCOLATION TESTS Datel/r-77T Date Date Date nat-P Pit Number 1 2 3 4 5 Start Saturation 3:r Soak' Mins. Start Test -Time Drop of 3" -Time 3 Drop of 6" -Time Mins. 'Ist 3" Drop j2 Mins. 2nd 3" Drop5 Rate Min. In. SUILr-A,,C.S DISPO$AL- P L=7-r 2 '�'"T• Q0. . /ANc� o cslz Nu PR EPAR�O 0 YSTEM i SIGN �uUy �15 ,I` is p2AN1t C GE1_tNAS ANp i', SA'T S ENc�t+,4E.T--RS Ar`+o AQ.c.wITtczS N o s�-r►a Ar•,t� c�.� E. sz O G c- � � � P,scz..K., Noe -r" Ar+aov��,M s ot84S DESIGN DATA j CALCULATIONS r SOlLbasERVATIO1 s 15Y- J. WITNESS L' PNta5 PERCOLAT10N TEST NO. 1 2 3 4 $ DA -T E Co 1-11_-78 SF/LF GALS I Sr = GAL.ILIN.FT• - To?-ELEVA'T`ION tog. o GAL./ UvA.FT. _ T AL -MEN C•H l...E4,CV4I NG CAPAC ITY _ _ - - - - GAL,/ LIN . PT. B O'TTOM - E LF- VA'T I Ohl IOU -0 __ _ _ -L.F.-TRFiJCNES REQ'D. U SE. L NOTES: SAT•URATION -MINS. is IV—►9".DR.OP-MINS, 1 WATER TA'%L *1 PERI. ,RtZ z7E -MIN./,IN. QDNy (af�pM IS SOIL PROI"ILp.-DI`EP PIt No. 1 2 3 4 - DATE DATE 51,16118 SF/LF GALS I Sr = GAL.ILIN.FT• - ToP-ELEVATION 10 1, GAL./ UvA.FT. _ T AL -MEN C•H l...E4,CV4I NG CAPAC ITY _ _ - - - - GAL,/ LIN . PT. -TOPSOIi. - k:.U" __ _ _ -L.F.-TRFiJCNES REQ'D. U SE. L NOTES: SUB501L PARENT SOIL. �• I ~� Tn WATER TA'%L *1 QDNy (af�pM --0 WATER -TABLE E LEVATION I 0S. o SorToM ELEVATION loo !1 E.R.,aR x 150 GAL. JUNIT GcJ GPD FLOW_.. 0 C -.PD R -O\,v Y- LSD- 9d GPD USE 1000 GALS ItPT►C-7ATAK LIrACH 1 Ncz AREA se - 6,00 G -PD FLOW x I SF1GAL..= ISO SF SFD PITS TYPE 4 Mv:R- (TYP.) SID7Tt, RE SF BOOAREA SF % CrALS.1 SP X GALS./SF TAL PIT LEAs kc -f CAPACITY USE ''0© SF GPD GPD C-rPD /PIT CrP D FLOW ; --_ GPD%P1T- PITS READ. USS._.,_ PITS 7R F -M Cvi E.5 SIDEWALL EA SF/LF GALS I Sr = GAL.ILIN.FT• P$O-f'T AREA SV/LF X C-rALS/SF = GAL./ UvA.FT. _ T AL -MEN C•H l...E4,CV4I NG CAPAC ITY _ _ - - - - GAL,/ LIN . PT. . Q,'PD FLOW AL4LI1 -PT.= __ _ _ -L.F.-TRFiJCNES REQ'D. U SE. L NOTES: PAGE 2 o1r fl f ! { �o z � q p1 cw Z 3 OL Ld a uoil, v {C{ Q J J u x !fitn r�Ip�LL! U LL �l ART.L -11d3 rT --IV !D avo ( - f �o z � q p1 cw Z 3 OL a 4 MMM L OLAB ELEV. 1�111 = 1 c>Q.. P3 to o �, l "• TI i h w HH V U), I ' o.z -a fn c r.. r- m 0 0 4 CD i Z O r 7 v rn ' n" n. '" Pi M Ti in 0 I4 o f � Z G � 4 L OLAB ELEV. 1�111 = 1 c>Q.. P3 to o �, l "• TI i h HH V U), I ' o.z -a fn c r.. r- m 0 0 4 CD i Z O r 7 v rn ' '" Pi M Ti in I4 � G 4 0 r m 4 01 Pi Ti in I4 � r rnN � t � NN M ' : D U1 o 0 m rl A �