HomeMy WebLinkAboutMiscellaneous - 327 FOREST STREET 4/30/2018 (2)U.
Commonwealth of Massachusetts FWP""
City/Town of OCT zi`2013
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left / Right front of house, Le/ Right rear of h e, Left /right side of house, Left /
Right side of building, Left / Right front of building, e i rear of building, Under deck
Address
-7�s <—!)-
Cityrrown
2. System Owner.
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
a_�_
State
Zip Code
State'Zip Code
Telephone Number
Date 2. Quantity Pumped:
Gallons
Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No
5. Conditioof}System-
�.
t.�
6. System Pumped By.
Neil Bateson
Name i
Bateson Enterprises Ince
Company
7. Location ere contents were disposed:
Waste Water
If yes, was it cleaned? ❑ Yes ❑ No.
F5821
Vehicle License Number
Date
5Q b C�� I .�
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
�,M s � Zp11
DEP has provided this form for use by local Boards of Health. Ot e faA' A be used,
information must be substantially the same as that provided here � v 86%
local Board of Health to determine the form they use. The Syste u MIM
the local Board of Health or other approving authority.
the
:ck with your _-
submitted to
A. Facility Information
1. System Location: Left fro house, right front of house, left side of house, right side of house, Left
rear of house t rear of hous�left side of building, right rear of building, under deck.
Cityrrown State Zip Code
2. System Owner:
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
Date
Cesspool(s)
4. Effluent Tee Filter present? ❑ Yes 2-90
5. Conditio of S stem / ?j(
6. System Pumped By:
Neil J. Bateson
Name
Bateson Enterprises Inc.
Company
7. LocAtlon,wkhere contents were disposed:
G. L. S. D.
Signature
Stat��� r Z�ode
Telephone Number l
— 2. Quantity Pumped
Septic Tank
Gallons
❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No
(1
F5821
Vehicle License Number
Date
t5form4.doc• 06/03
System Pumping Record •Page 1 of 1
Commonwealth of Massachusetts
City/Town of
a ° System Pumping Record
Form 4
1.1Sey`e
APR 27 2410
TOWN QP NOWN ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left side of house, Right side of house, Left front of house, Right front of house,
Left rear of hous Ri t rear f ho eft rear of building. Right rear of building.
zo 2:�? �s
Address
Cityrrown State Zip Code
2. System Owner:
Name
Address (if different from location)
City/Town State C( Zip Code
l' o� c ZI
Telephone Number
B. Pumping Record
1. Date of Pumping iy 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) E2 Septic Tank ❑ Tight Tank
❑ Other (describe): '
4. Effluent Tee Filter present? ❑ Yes Mo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
D Lowell Waste Water
of
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
Important:
When filling out
forms on the
computer, use
only the tab key
to move your.
cursor - do not
use the return
key.
Commonwealth of Massachusetts
City/Town of RECEIVED
System Pumping Record MAY 2 6 2009
Form 4
TOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. Other ornhI9
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left front, left rear, left side of house. Right fro tright rear right sid house.
Address "
City/Town
2. System Owner:
Name
Address (if different from locatic
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system:
State
State'7q L -f
Telephone Number v
2 Qti P '
Date Uan d
Zip Code
ty Umpe Gallons
Cesspool(s) Er --Septic Tank Tight Tank
Other (describe):
4. Effluent Tee Filter present? El Yes 0 --KO
5. Conditidn of
If yes, was it cleaned? 0 Yes L] No
� e'u-42i V'% 5 k
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Locatio re contents were disposed:
�.L. .D2 Lowell Waste Water
F 5821
Vehicle License Number
of H u r Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
VQ
1�1
Commonwealth of Massachusetts
City/Town of RECEIVE®
System Pumping Record
Form 4 SEP 2 7 2007
DEP has provided this form for use by local Boards of Health. Other r I riE�
information must be substantially the same as that provided here. B with your
local Board of Health to determine the form they use. The System Pumping Record m be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location -
Address
Cityrrown State �(V Zip Code
2. System Owner. ��'�����
Name
Address (if different from location)
Cityrrown
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
Zip/ 9 e
Telephone Number
Date 2. Quantity Pumped: Gallons
Cesspool(s) eptic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes t- Ito If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: iplaA'e-A
6. Syste P mid By:
Name Vehicle License Number
Company
7. Location a contents re
\ k, A
Signature
Date
'(-6--'-7
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
r_ F w,EIVE
City/Town of
System Pumping Record
Form 4 MAY 2 2 2006
NORTH ANDOVER
DEP has provided this form for use by local Boards. of Health.. Thel System PumpihbvRLiEor must
be submitted to the local Board of Health or other approving authority. .
A. Facility Information
.Important:
When filling out
forms the
1. System. Location:
,\
computeto r, use
only the tab key
to move your�p
Address
cursor - do not
use the:retum
Cityrrown
State I Zip Code
key.
.
2. System Owner:
mil
Name
Address (if different from. location)
ode'
City/TownState
Telephone Number
B. Pumping Record
1.. .Date. of Pumping Date 2. Quantity Pumped
3. Type of system: ❑ Cesspool(s) eptic Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes L9"No
Gallons
❑ Tight.Tank
If yes, was it cleaned? ❑ Yes ' ❑ No
aignaruryr or rauier
hftp://www.mass.gov/dep/waterlapprovalt./t5fon-ns.htm#inspect
t5form4.doc• 06103
Date
System Pumping Record • Page 1 of i
TOWN OF
SYSTEM
DATE: 5- 01365
SYSTEM OWNER & ADDRESS
MAY 2 5 2005
ANDO SER
TOHE �iH DEPA TMEN
SYSTEM LOCATION
(example: left front of house)
11rntS-e'_
DATE OF PUMPING: !S QUANTITY PUMPED: 0 GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE i 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: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.S.D V Lowell Waste
Q
TOWN OF
SYSTEM
DATE:
SYSTEM OWNER & ADDRESS
Se5tAA, (/,eA S Cv\
N•
ING RECORD � RF-CEIVE—D
SYSTEM LOCATION
(example: left front of house)
kc.
DATE OF PUMPING. QUANTITY PUMPED:
MAY 3 12005
ANDOVER
i=E-PARTMENT
GALLONS
CESSPOOL: NO 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
LEACIOULD RUNBACK
FLOODED
OTHER (EXPLAE- )
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste
TOWN OF
SYSTEM PUMPING RECORD��`i'uu
B00'3
DATE: q " o D 0`�
,g ro
SYSTEM OWNER & ADDRESS SYSTEM LOCATION'` -
(example: left front of house)
2
J j
DATE OF PUMPING: .2 QUANTITY PUMPED: 1 S O b GALLO
CESSPOOL: NO YES PTIC TANK: NO YES
7 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: Bateson Enterprises, Inc.
COMMENTS:
C
CONTENTS TRANSFERRED TO: G.L.S.D 'Lowell Waste
TOWN OF Aiirl- vtf-
SYSTEM PUMPING RECORD __ NOV
- -- -
DATE:
SYSTEM OWNER & ADDRESS
f5a�'�cw��
3a�
SYSTEM LOCATION
(example: left front of house)
l�ebLZCL
DATE OF PUMPING: QUANTITY PUMPED: 'I 500 GALLONS
CESSPOOL: NO Z- 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
LEACIOULD RUNBACK
FLOODED
OTHER (EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO:
Commonwealth of Massachusetts
tri ,—, Massachusetts
System Pumping Record
System Owner
�k3 C L& C C
Date of Pumping: M-
Cesspool.-
No Yes 1..1
System Location
Quantity Pumped: gallons
Septic "Tank: No Yes
n
System Pumped by: gctt`edea ,w&,rhtided License #
Contents transferrred to : Greater -Lawrence Sanitary District
llate:
Inspector-
--A1-ati
OF
it JAL
I 1 L. 11 L.10
Cr►irur»rm enitll of MOSSnOlUsells
, Massachuse
�;�sler�i 1'unrtls�' liLecord
Dote or Pumping ' C l (�/ Qu61111ty Pumped,
Cesspool: No ,� Yes FJgrnflr Tanl•I N'- �] 'Yes
a�eS o,n
S%-Slenl Pumped by: License N:
Contents transferred to: i S
Date
Inspector
Commonwealth of Massachusetts
Massachusetts
System Pumping Record
System Owner
rt sCv
System Location
TO bFof NOR HBOARD OF
5
Date of Pumping: Quantity Pumped: gallons
cospgol: NoK Yes 11 Septic T : No El Yes
System Pumped by: 64&4" gativ� License #
Contents transferrred to: Greater Lawrence Sanitary District
Date:
Inspector:
FORN14 - SYSTEM PU.N PL\G RECORD
Commonwealth of Massachusetts
, Massachusetts
System Pumping Record
�ner
')10�c J 2)
Date of Pumping
Cesspool: No
Quantity Pumped
Yes ❑ Septic Tank -
SN stem
ankS}'stem Pumped br:
Contents transferred to:
No ❑
Date Inspector
l gallons
Yes 21
License #:
4
� S &U iL r SSto fj6E -DISPOSAL PLAN
F'oe mp-.� MRS- tBEHT'TIE
FoPE-5r. STP- EEr
No►2rN hcoovej M gss
0
h
�...__.--�-�---...._. C ..a
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: 3Z-1 Fv 2r QT- s t .
tj- A-n)flC>0C 12
Owner's Name: p F�ot 0 M A s CC :
Owner's Address: -_3-;z 7 Fo tZgSTT S"7
N 2 N►R
Date of Inspection: i I I o t
Name of Inspector: (please print) CNSA,%A i C (ns &-ooD Z --1L
Company Name:1QtFw ENVyA D EN(,v-tN Ei 2ia c,—
Mailing
YMailing Address: 6 o BCiF c H 9 v—
A AvJD o.E2 ,KA
Telephone Number: 4? _ 6z h —/ Zr
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 fimction 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:
V Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date:
The system inspector shall submit a copy of this in ion report to the Approving Authority (Board of Health or
DEP) within 30 days of completing this inspection. 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
lnN)k NErOf Nrw TE(y Oti O✓Tl lc i /L- /.uSUfzt; ! /�Pe^l2 ✓C j10, -11V CT.
****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.
..f ._ ...._....�.. _. _ _. _ ., _ _... _......_.v...w
Page 2 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
PROPERTY ADDRESS: 327 Forest Street
North Andover, MA
OWNER David Masucci
DATE OF INSPECTION: 5/11/01
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:
e or more system components as described in the "Conditional Pass" section need to be.T¢ ced or
repaired em, upon completion of the replacement or repair, as approved by ZuBoard ealth, will pass.
Answer yes, no or not det fined (Y,N,ND) in the for the following statementermined"please
explain.
The septic tank is metal and over 0 years old* or the septic tank ether metal or not) is structurally
unsound, exhibits substantial infiltration filtration or tank failur 'imminent. System will pass inspection if the
existing tank is replaced with a complying sep 'c ttank as approv y the Board of Health.
*A metal septic tank will pass inspection if it is s�"lly so d, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is avail4l
ND explain:
Observation of sewage backup or brc#out or high static water vel in the distribution box due to broken or
obstructed pipe(s) or due to a broken, setd or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
oken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The syst required pumping more than 4 times a year due to broken or obstructed pipe(s). Thb system will
pass inspecti f (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)
'ROPERTY ADDRESS: 327 Forest Street
North Andover, MA
OWNER David Masucci
DATE OF INSPECTION: 5/11/01
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 C)KR 15.303(1)(b) that the
system is not functioning in a manner which will protect public health, saf/e�'(and the environment:
I or privy is within 50 feet of a surface water
of or privy is within 50 feet of a bordering vegetated wetl d or a salt marsh
2. System will fail unless the Boa of Health (and F p lic Water Supplier, if any) determines that the
system is functioning in a manner that rotects the p blic health, safety and environment:
_ The system has a septic tank and soil a tion system (SAS) and the SAS is within 100 feet of a
surface water supply or tributary to a surfs supply.
_ The system has a septic tank and AS and the SA is within a Zone 1 of a public water supply.
The system has a septic d SAS and the SAS is within 50 feet of a private water supply well.
The system has a septig Tank and SAS and the SAS is less th 00 feet but 50 feet or more from a
private water supply wel/*. Method used to determine distance
"This system pass if the well water analysis, performed at a DEP certifi�iAa ratory, for coliform
bacteria and vola ' e organic compounds indicates that the well is free from polllion from that facility and
the presence o onia nitrogen and nitrate nitrogen is equal to or less than 5 provided that no other
failure criter' =are A copy of the analysis must be attached to this form.
3.
....................
Page 4 of I 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
'ROPERTY ADDRESS: 327 Forest Street
North Andover, MA
OWNER David Masucci
DATE OF INSPECTION: 5/11/01
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
/ 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''/ 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.
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 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
(Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as
described in 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.
Large Systems:
To be sidered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
You must indicate ' er `yes" or `1no" to each of the following:
(The following criteria ap o large systems in addition to the criteria a ve)�
yes no
the system is within 400 feet of a ce g water supply
_ _ the system is within 200 feet �-tllbutary tid`&, dace drinking water supply
the system is locaia nitrogen sensitive area (Int ellhead Protection Area — IWPA) or a mapped
Zone II of a p}iblic water supply well \
If you have answer/ed "yes" to any question in Section E the system is considered a si i cant threat, or answered
"yes" in Section D above the large system has failed. The owner or operator of any large 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
?ROPERTY ADDRESS: 327 Forest Street
North Andover, MA
OWNER David Masucci
DATE OF INSPECTION: 5111101
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
f 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 ?
v/ Have large volumes of water been introduced to the system recently or as part of this inspection ?
V _ 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 ?
i
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 baffies or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ?
_ Was the facility owner (and oceupanis if different from owner) provided with information on the proper
maintenance of subsurface sewage disposal systems ?
The size and location of the Soil Absorption System (SAS) on the site has been determined based on:
Yes no
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)]
Page 6 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
PROPERTY ADDRESS: 327 Forest Street
North Andover, MA
OWNER David Masucci
DATE OF INSPECTION: 5/11/01
.OW CONDTITONS
RESIDENTIAL
Number of bedrooms (design): Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms):
Number of current residents: 5_
Does residence have a garbage grinder (yes or no): acs
Is laundry on a separate sewage system (yes or no): t, )O [if yes separate inspection required]
Laundry system inspected (yes or no): —
Seasonal use: (yes or no): VO
Water meter readings, if available (last 2 years usage (gpd)): LA -1 61,
Sump pump (yes or no): _.1Va
Last date of occupancy: Ga t,�
CONIMERCULANDUSTRIAL
Type of establishment:
Design flow (based on 310 CMR 15.203): and
Basis of design flow (seats/persons/sgf ,etc.):
Grease trap present (yes or no): _
Industrial waste holding tank present (yes or no): —
Non -sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER (describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the spection (ybs or no): _
If yes, volume pumped: Qailons -- 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 allcomponents, date installed (if known) and source of information:
L
Were sewage odors detected when arriving at the site (yes or no):
Page 7 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
PROPERTY ADDRESS: 327 Forest Street
North Andover, MA
OWNER David Masucci
DATE OF INSPECTION: 5/11/01
BUILDING SEWER (locate on site plan)
Depth below grade: Z y
Materials of construction: ,/cast iron _40 PVC _other (explain):
Distance from private water supply well or suction line: 3o'
Comments (on condition of joints, venting, evidence of leakage, etc.):
E
SEPTIC TANK: _ (locate on site plan)
Depth below grade: I2 `(
Material of construction: t/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: /000 -rA-t'o N s
Sludge depth: 2—
Distance
Distance from top of sludge to bottom of outlet tee or baffle: f//g_
Scum thickness: �Q
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: A114 -
How were dimensions determined: sne -,-
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, efc.):
n 9-, CDS n C01u
I ti s i /Y1,tl O n. D r PL) G -re—&F
wRtt2 k" e)-1Le:; ?,Fe P,-? e- i—v r -1 -fir SLopL of F"Rif —/D 0-t3zaX
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:
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.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: n
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.):
13aX //-N 0 t-. cokip- AID l: NC i= oil enc 4 (4,A(sC I Au d,Z
a,.r _- /✓r. l'f A19OL) i 21 6--c iJAL
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.):
Page 8 of l l
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
r ;
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
h
SYSTEM INFORMATION (continued)
PROPERTY ADDRESS: 327 Forest Street
North Andover, MA
OWNER David Masucci
DATE OF INSPECTION: 5/11/01
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: n
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.):
13aX //-N 0 t-. cokip- AID l: NC i= oil enc 4 (4,A(sC I Au d,Z
a,.r _- /✓r. l'f A19OL) i 21 6--c iJAL
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.):
Page 9 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'ROPERTY ADDRESS: 327 Forest Street
North Andover, MA
OWNER David Masucci
DATE OF INSPECTION: 5/11/01
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: I
overflow cesspool, number:
innovativelalternative system Typdname of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
LAR EtT OF ¢i Ct,a to o K -tea P
CESSPOOLS: Sk(cesspool must be pumped as part of inspectionxlocate 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:Ailblocate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Page 10 of I 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'ROPERTY ADDRESS: 327 Forest Street
North Andover, MA
OWNER David Masucci
DATE OF INSPECTION: 5/11/0l
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
Page I 1 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
c'*70TEM INFORMATION (continued)
'ROPERTY ADDRESS: 327 Forest Street
North Andover, MA
OWNER David Masucci
DATE OF INSPECTION: 5/11/01
STTE EXAM
Slope %olo
Surface water w c , �
Check cellar u o 5 -j. -to
Shallow wells N J /k, L
Estimated depth to ground water > 6 feet
Please indicate (check) all methods used to determine the high ground water elevation:
Obtained from system design plans on record - If checked, date of design plan reviewed:
_ 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)
j Accessed USGS database -explain:
You must describe how you esntablished the high ground water elevation: n
.vi ag.5 � ..� c c �_�rc9 . � is -7 6-6
CERTIFICATION STATEMENT
Y, / h 0rr7Qs D. A,rris , Registered
Sanitarian #L10
hereby
certify
that I have
observed
the con-
struction of .the
sewage
disposal
facility. at
and that it has been
constructed according to the plans submitted to the Board of Health
for approval, and for which said Board of Health had issued a
Sewage Disposal Permit, and in accordance with the provisions of
Title 5 of the State Environmental Code.
OF
9
mTHOM�C_MORIS
R�
�10
0.
-�
.
t__
t'.1 I.'2'Y'""�� �•_.... Nn R Cf ro�� � _ `..n� �itS� i -
r
Loc /Subdiv.- Plan Owner
Invest] -gator - _. Observers_ f �---
SOIL PROFILES -DATE
1• t Elev. 3' Elev. 4`Elev.
Elev• f _ —
0 0 0
-- Ties to Test Ats
�encbmark
elevation
2
3
4
5
6
'11/
� 1
2
3
4
5
6
3
2
3
4
5
6
_
oak. -Mins.
Start Test -Time
7 7 7'
$ 8
9 9 9
10 10 10
Location`
Datum
Percolation Tests -Date_
i. F.
Dater_____
it Number
'11/
� 1
2
3
4 S
tart Saturation
oak. -Mins.
Start Test -Time
Drop of 3" -Time
Drop of 6" -Time
Dins. 1st. 3"Dro��
Mins.2nd 3_ "Drop
F
"
Percolation Rate
/:�, `•-
%�
Notes Bc Sketches on Back
.,i Ani ;,�rlaaaa.
V
X/6; �.9�2P• �fsi'
FAn
SEPTIC SISTER
INSTALLATICK CHBCB LISP
1
easonsf G eFLU— Z
,LOT cTi e-- U -i
OK
1. Distance Tot 1�►1��
s a. Wetlands
b. Drains
:c. Well _r
2. Water Line Location
3• No PPC Pipe
!t. Septic Tank -
a. _Tees -_Length & To Clean 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 Ends
d. Clean Double Washed Stone
7. Leach Pits
a. ons
b. a Depth
c. Olash Pads
Tees
e. Cement Pipe to Pit - Both Sides
f. Clean Double Washed Stone
8. No Garbage Disposal
9. Final Grading Inspection dd
10. Barricading Covered System
11 As Built Submitted '--; F
�a. Lot Location t1��( t�2,
b. Dimensions of System
c. Location with Regard -to Pere Test
d. Elevations
e: Water Table
f
►+
rs
0
. It
,W
leo
��,414v e
s
�} �
IS
::�-- �Z-
i
♦ ♦ � 1. 1 iL 1 _ � � _ i - v. . y a ..+ ��
�.:i't.� t.: i�..L.f � �• .C1t: tE :. iLr_ Lot. :\L
` L
ivc/Su�div. Pland —Owner.--
Investigator
wnerInvestigators:' Observer'
f
SOIL PROFILE DATES
7—Eley— 2.Elev 3.Elev 4.El.ev
n
Benchmark
Elevation
0
1
2
3
4
5
6
7
8
9
10
iiiT.riutil
0
1
2
3
4
5
6
7
8
9
10
Location
Datum
PERCOj,ATION TESTS
r.; L! ! D 14/L4- +. 'i
0
1
2
3
4
5
6
7
8
9
10
Ties tqsTest
Pit
Pit Number
1 J 2 3
4 5
Start Saturation
Soak -Minutes
i .Y
Start e
),JL
Drop of 3" -Time
Drop of 6" -Time
Mims. Ist 31' drop
Mins.2nd " Drop
Percolation
WELL DATABASE
ADDRESS:
AGE OF WELL: WELL DRILLER:
WELL PERMIT r: WELL LOCATION:
WELL PERMIT DATE: DEPTH OF WELL:
TYPE OF WELL: Ca-- DRILLED b. DUG c. UN NI O
TYPE OF WATER BEARING ROCK -
WATER ANALYSIS DATE: ?
HIGH IRON: Y N OTHER CONT
GH MANGANESE: Y N
ffiVA1NTS Y N
WELL DATABASE
ADDRESS: 7b
AGE OF WELL: JF" �� WELL DRILLER: yj�—a �
J
WELL PERMT #: WELL LOCATION:
WELL PERMIT DATE. ��.a ` �% DEPTH OF LL:
TYPE OF WELL: a.. DRILLE DUG c. UNKNOWN
TYPE OF WATER BEARING ROCK:
�_
WATER ANALYSIS DATE: ,7
9— HIGH MANGANESE: Y N
HIGH IRON: N OTHER CONTA- HANTS: Y ON
SOIL Tz.0 `IiE & E COIATZON' 'TEST D,•.
North rr4o:=er, Mass. Street No i r� '` E • 1a r'YJ�- IAt No
Loc/Subdiv. Pland Owner
Investigator Observer
SOIL PROFILE DATES
1_*Elev 2.Elev 3.Elev 4.Elev
0 0 y 0
2
2
3 : ,3
4
4
5
.1 2 3 $ 5
5
Start Saturation
5
Soak -Minutes
Start
-
Drop of 311 -Time .
Drop of 6" -Time
6
6
-
6
Mins.2nd " Drop
Percolation
7
17
8
-. - 8
p
$/
9
1
Benchmark
Elevation
10
DATES
r 09
g•
4
5
F]
10
F
Location
Datum
PERCOLATION TESTS
f
Pit Number
.1 2 3 $ 5
Start Saturation
Soak -Minutes
Start
-
Drop of 311 -Time .
Drop of 6" -Time
Mins.lst 3" drop
-
Mins.2nd " Drop
Percolation
w .nth
L.•. �*: � �z �r,�:t:.sa
SUBSURME DISPOSAL DESIM CMK LIST
DISAPPROVED DATE_
Reasons:
E
LOT r + %` r t,7 --
T
+7"_7 1
Title V
FAIL
09
Reg 2.5
The submitted plan must show as a ni nitmtm:
a) the lot to be served-area,dimensions lot i,abnttera -�_��
b location and log deep observation holes -distance to ties--
c location and results percolation tests -distance to ties
d design calculations & calculations showing required leaching area
e) location and dimensions of system -including reserve area — ?
f) existing and proposed contours
location any wet areas within 100' of sewage disposal system or
o(g)
. disclaimer -check wetlands mapping
h) surface and subsurface drains within 1JDO' of sewage disposal
system or disclaimer
(i) location any drainage easements within 100' of sesage disposal
system or disclaimer -Planning Board files
(j) knows sources of water supply within 200' of sewage disposal o
system or disclaimer
(k) location of any proposed well to serve lot -100' from leaching facility
location of water lines on property -10' from leaching facility
��km)
location of benchmark
driveways
o garbage disposals •
no PVC to be used In construction
(q) profile of system -elevations of basement, plumb, pipe, septic tank,
distribution box inlets and outlets, distribution field piping and
+,r
Other elevations
r) maximum ground water elevation in area sewage disposal system
(s) plan must be prepared by a Professional Engineer or other
professional authorized by law to prepare such plans
Reg 6
�(a)
Septic Tanks
capacities -150,% of flow, water table, tees, depth of tees,
access, pumping
b) cleanout
lA' from cellar wall or ingroun.d swimming pool
(d) 25' from subsurface drains
Reg 10.2
Reg 10.4
Distribution Boxes
a) slope greater than 0.08
b) sump
e DeSiE= Check List
I FAIL I ass
Page 2
Leaching Pits
Leaching pits are preferre where the installation is possible
a) calculations of leac g area -minimum 500 sq ft
b) spacing
c) surface 2%
d) cover materi
e) 2' x2' A" sh pad
f) tee at x
g) no bends in pipe from d -box to pipe
LeachingFields
U) no grea20 minutes/inch
b area -minimum mum 900 aq ft
c� construction of field `
�9} vaarrface drainage 2 %
e) 20, Brom cellar wall or inground swimming pool
teachin IN"enche
a) calculations o eaching area -min 500 aq ft
b) spacing -4 ft 6 ft with reserve between
C) dimensio
d) construpAon
drainage 2%
W=hill S122e
a) slope y x to be shown)
b) y/x X 150 - (to be shown)
stand-by power
tS0 CeP•�- ��� c -t
Eti►a2�rcD T� d.C�C.c�KAU"a'�
p��A Ea4�bV i•'x� �—
c i%trAN �E-iA
Sf:J lc,�ar'r1u Ij qF a-yA7G- 5�-�1 t.et✓ +Ut`-t �..
N. pNrO,tt-q-