HomeMy WebLinkAboutMiscellaneous - 328 FOREST STREET 4/30/2018North Andover Board of Assessors Public Access
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T'owxi oEWdrth Andovor
Ftoard o€ Asst, s rs,
Page 1 of 1
Property
Record Card
Parcel ID: 210/106.A-0014-0000.0 Community: North Andover
Location: 328 FOREST STREET
Owner Name: FENNELLY, D MICHAEL
DEIRDRE A FENNELLY
Owner Address: 328 FOREST STREET
City: NORTH ANDOVER State: MA ZIP: 01845
Neighborhood: 6 - 6 Land Area: 0.86 acres
Use Code: 101 - SNGL-FAM-RES Total Finished Area: 2052 sqft
ASSESSMENTS CURRENT YEAR PREVIOUS YEAR
Total Value: 505,900 539,500
Building Value: 300,300 312,000
Land Value: 205,600 227,500
Market Land Value: 205,600
Chapter Land Value:
LATESTSALE
Sale Price: 277,900 Sale Date: 09/16/1996
Arms Length Sale Code: Y -YES -VALID Grantor: MESSINA DEVELOPMENT
Cert Doc: DOC 63889 Book: 00095 Page: 0377
http://csc-ma.us/NandoverPubAcc/j sp/Home.j sp?Page=3&Linkld=1181031 3/31/2008
6955
Gf NORT :,y
• i� � ,.. o ; ., roc
Town of North Andover
,; HEALTH DEPARTMENT
CMU5�4 p
CHECK #: 1 l 4 A DATE: I
LOCATION:
H/0 NAME:
CONTRACTOR NAME:
Type
of Permit or License: (Check box)
❑
Animal
$
❑
Body Art Establishment
$
❑
Body Art Practitioner
$
❑
Dumpster
$
❑
Food Service - Type:
$
❑
Funeral Directors
$
❑
Massage Establishment
$
❑
Massage Practice
$
❑
Offal (Septic) Hauler
$
❑
Recreational Camp
$
❑
Sun tanning
$
❑
Swimming Pool
$
❑
Tobacco
$
❑
TrashlSolid Waste Hauler
$
❑
Well Construction
$
SEPTIC Systems:
❑
Septic - Soil Testing
$
❑
Septic - Design Approval
$
❑
Septic Disposal Works Construction (DWC) $
❑
Septic Disposal Works Installers (DWI)
$
❑
-6
Title 5 Inspector
Title 5 Report
$
$
❑
Other. (Indicate)
$
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
rl 114114 �,� r►��,r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
MATTHEW BIELIK
Property Address
328 FOREST STREET
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 06/28/14
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
reb
A. General Information
Inspector:
John J. Souc
Name of Inspector
Soucy's Sewer Service, Inc.
Company Name
78 North Broadway
Company Address
Salem
City/Town
603-898-9339
Telephone Number
B. Certification
M
State
13397
License Number
03079
Zip Code
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs 5wtler Evaluation by the Local Approving Authority
06/28/14
Date
The system inspector shall submit a'copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
MATTHEW BIELIK
Property Address
328 FOREST STREET
Owner's Name
N. ANDOVER MA 01845 06/28/14
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E /always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
MATTHEW BIELIK
Property Address
328 FOREST STREET
Owner's Name
N. ANDOVER
City/Town
B. Certification (cont.)
nnn niaal;
Q LCLV uN vVuc
06/28/14
Date of Inspection
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if (with approval of Board of Health):
❑
broken pipe(s) are replaced
❑ Y
❑ N
❑
ND (Explain below):
❑
obstruction is removed
❑ Y
❑ N
❑
ND (Explain below):
❑
distribution box is leveled or replaced
❑ Y
❑ N
❑
ND (Explain below):
❑ 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 ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
MATTHEW BIELIK
Property Address
328 FOREST STREET
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 06/28/14
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ 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 fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes
No
❑
®
Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑
®
Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑
®
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
t5ins • 3/13
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M MATTHEW BIELIK
Property Address
328 FOREST STREET
Owner Owner's Name
information is
required for every N. ANDOVER MA 01845 06/28/14
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® 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 fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the
questions in Section D.
Yes
No
❑
❑
the system is within 400 feet of a surface drinking water supply
❑
❑
the system is within 200 feet of a tributary to a surface drinking water supply
❑
❑
the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area — IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M MATTHEW BIELIK
Property Address
328 FOREST STREET
Owner Owner's Name
information is N. ANDOVER
required for every
page. Citylrown
C. Checklist
MA 01845
State Zip Code
06/28/14
Date of Inspection
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
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?
Was the facility owner (and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
Existing information. For example, a plan at the Board of Health.
Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms):
4
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M MATTHEW BIELIK
Property Address
328 FOREST STREET
Owner
Owner's Name
information is
N. ANDOVER
required for every
Is laundry on a separate sewage system? (Include laundry system inspection
page.
City/Town
D. System Information
Description:
Number of current residents:
MA 01845 06/28/14
State Zip Code Date of Inspection
Does residence have a garbage grinder?
®
Yes
❑
No
Is laundry on a separate sewage system? (Include laundry system inspection
❑
Yes
®
No
information in this report.)
Laundry system inspected?
❑
Yes
❑
No
Seasonal use?
❑
Yes
®
No
Water meter readings, if available last 2 ears usage d
9 ( Y 9 (gP ))�
WELL
Detail:
RECOMMEND REMOVAL OF GARBAGE GRINDER
Sump pump?
❑
Yes
®
No
Last date of occupancy:
Current
Date
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Gallons per day (gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present?
❑
Yes
❑
No
Industrial waste holding tank present?
❑
Yes
❑
No
Non -sanitary waste discharged to the Title 5 system?
❑
Yes
❑
No
Water meter readings, if available:
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M MATTHEW BIELIK
Property Address
328 FOREST STREET
Owner Owner's Name
information is N. ANDOVER
required for every
page. City/Town
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
MA 01845 06/28/14
State Zip Code Date of Inspection
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
CURRENT
Date
Soucy's Sewer Service 6/28/14
1500
gallons
Maintenance and Ins
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
® Yes ❑ No
❑ 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) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other (describe):
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17
• Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M
'5 MATTHEW BIELIK
Property Address
328 FOREST STREET
Owner Owner's Name
information is N. ANDOVER
required for every
page. City/Town
State Zip Code
06/28/14
Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1996 (18 YEARS)
Were sewage odors detected when arriving at the site?
Building Sewer (locate on site plan):
Depth below grade: 5.5'
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other (explain):
Distance from private water supply well or suction line: n/a
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
® concrete ❑ metal
5'
feet
❑ Yes ® No
❑ fiberglass ❑ polyethylene ❑ other (explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate)
Dimensions: 10.5'X 6'
Sludge depth: 3
❑ Yes ❑ No
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
MATTHEW BIELIK
Property Address
328 FOREST STREET
Owner Owner's Name
information is N. ANDOVER
required for every
page. City/Town
D. System Information (cont.)
Septic Tank (cont.)
MA 01845
State ZiD Cod
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
36"
2,
4"
14"
06/28/14
Date of Inspection
How were dimensions determined? Tape and sludge tool
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
ALL IN GOOD CONDITION, RECOMMEND INLET AND OUTLET EXTENSION RISERS TO
GRADE.
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal
Dimensions:
Scum thickness
feet
❑ fiberglass ❑ polyethylene ❑ other (explain):
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
t5ins - 3113
Date
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
MATTHEW BIELIK
Property Address
328 FOREST STREET
Owner Owner's Name
information is N.. ANDOVER
required for every
page. City/Town
MA 01845
State Zip Code
06/28/14
Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass
Dimensions:
Capacity:
Design Flow:
Alarm present:
Alarm level:
gallons
❑ polyethylene ❑ other (explain):
gallons per day
❑ Yes ❑ No
Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
MATTHEW BIELIK
Property Address
328 FOREST STREET
Owner's Name
N. ANDOVER
City/Town
D. System Information (cont.)
MA 01845 06/28/14
State Zip Code Date of Inspection
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
a
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.):
NEW "D" BOX INSTALLED PRIOR TO INSPECTION. SEE ATTACHED PERMIT.
Pump Chamber (locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM MATTHEW BIELIK
Property Address
328 FOREST STREET
Owner Owner's Name
information is N. ANDOVER
required for every
page. City/Town
D. System Information (cont.)
Type:
MA 01845
State Zip Code
06/28/14
Date of Inspection
❑ leaching pits
number:
❑ leaching chambers
number:
❑ leaching galleries
number:
❑ leaching trenches
number, length:
® leaching fields
30'X 74'
number, dimensions:
❑ overflow cesspool
number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
NO SIGNS OF HYDRAULIC FAILURE.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth — top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M MATTHEW BIELIK
Property Address
328 FOREST STREET
Owner
Owner's Name
information is
N. ANDOVER
required for every
page.
City/Town
MA 01845
State Zip Code
06/28/14
Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17
• Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°w MATTHEW BIELIK
Property Address
328 FOREST STREET
Owner Owner's Name
information is N. ANDOVER
required for every
page. City/Town
MA 01845 06/28/14
State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand -sketch in the area below
❑ drawing attached separately
---- --- ----
N0 n 5-rf4 .)(,e 5 ro wci � S
P>o RD o � µCNv1i4 C u_v
_ ...-0.- S 8 a ois —V Svsi
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17
•� Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM MATTHEW BIELIK
Property Address
328 FOREST STREET
Owner Owner's Name
information is N. ANDOVER
required for every
page. City/Town
D. System Information (cont.)
Site Exam:
®
Check Slope
®
Surface water
®
Check cellar
❑
Shallow wells
Estimated de th to hi In round water•
MA
State
01845
Zip Code
a
06/28/14
Date of Inspection
p g g feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
.1
■
1
If checked, date of design plan reviewed: Date
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health - explain:
Checked with local excavators, installers - (attach documentation)
Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
DUG HOLE WITH AUGER IN LOW AREA (4' NO WATER)
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17
•� Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
MATTHEW BIELIK
Property Address
328 FOREST STREET
Owner Owner's Name
information is N. ANDOVER
required for every
page. City/Town
MA 01845
State Zip Code
E. Report Completeness Checklist
06/28/14
Date of Inspection
❑ Inspection Summary: A, B, C, D, or E checked
❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
❑ System Information — Estimated depth to high groundwater
❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17
I
Pp'
�F XAQ R - qti
F FILE�COPY
PUBLIC HEALTH DEPARTMENT
Town of North Andover
Coirununity Development Division
CERTIFICATE OF
COMPLIANCE
As of: 6/26/2014
This is to certify that the individual subsurface disposal system received a
SATISFACTORY INSPECTION of the:
Complete Repair of D -Box
By: John Soucy
At:
328 Forest Street
Map 106.A Lot 0014
North Andover, MA 01845
of thine i iaat shal�,pot be construed as a guarantee that the system will function satisfactorily.
M1 ichele Grant
Public Health Agent
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
4&
North Andover Health Department
Community Development Division
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: 328 Forest St. MAP: 106.A LOT: 0014
INSTALLER: John Soucy
DESIGNER:
PLAN DATE:
BOH APPROVAL DATE ON PLAN:
INSPECTIONS
INSPECTION: 6/26/14 D -Box
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
Comments:
SEPTIC TANK
❑ Contractor reports any changes to design plan
❑ Existing septic tank properly abandoned
❑ Internal plumbing all to one building sewer
❑ Topography not appreciably altered
❑ Building sewer in continuous grade, on
compacted firm base
❑ Cleanouts per plan
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ 1500 gallon tank has been installed
H-10 loading
❑ Monolithic tank construction
❑ Water tightness of tank has been achieved by
visual testing
❑ Inlet tee installed, centered under access port
Comments:
PUMP CHAMBER
Comments:
CONTROL PANEL
Comments:
DISTRIBUTION -BOX
❑ Outlet tee installed, centered under access port
(gas baffle/effluent filter)
❑ inch cover to within 6" of finish grade
installed over one access port
❑ Hydraulic cement around inlet & outlet
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ 1500 gallon Pump Chamber installed
❑ H-10 loading
❑ Monolithic tank construction
❑ Inlet tee installed, centered under access port
❑ Pump(s) installed on stable base
❑ Alarm float working
❑ Pump On/Off floats working
❑ Separate on/off floats
❑ Drain hole in pressure line
❑ cover at final grade installed over pump
access port
❑ Water tightness of tank has been achieved by
testing
❑ Hydraulic cement around inlet & outlet
❑ Alarm & Pump are on separate circuits
❑ Alarm sounds when float is tripped
❑ Location of control panel: basement
❑ Alarm signal located inside: basement
X Installed on stable stone base
X H-20 D -Box
X Inlet tee (if pumped or >0.08'/foot)
X Hydraulic cement around inlet & outlets
X Observed even distribution
X Speed levelers provided (not required)
X Schedule 40 PVC Pipe
Comments: Did not bed the pipes yet
�. 6833
Of ,NORT .1h
AL
O
; Town of North Andover
...... :: �' HEALTH DEPARTMENT
,SSACHU`S
CHECK #: �^^�� qq DATE:
LOCATION:
H/O NAME:'(C
CONTRACTOR NAME:
Type
of Permit or License: (Check box)
❑
❑
Animal
$
❑
Body Art Establishment
$
❑
Body Art Practitioner
$
❑
Dumpster
$
❑
Food Service - Type:
$
❑
Funeral Directors
$
❑
Massage Establishment
$
❑
Massage Practice
$
❑
Offal (Septic) Hauler
$
❑
Recreational Camp
$
❑
Sun tanning
$
❑
Swimming Pool
$
❑
Tobacco /
l
$
❑
Trash/Solid Waste Hauler
$
❑
Well Construction
$
SEPTIC Systems:
❑
Septic - Soil Testing
$
❑
Septic - Design Approval
$
u
?—<
Septic Disposal Works Construction (DWC)
$
Septic Disposal Works Installers (DWI)
$
❑
Title 5 Inspector
$
❑
Title 5 Report
$
❑
Other: (Indicate)
$
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
a
Commonwealth of Massachusetts Map -Block -Lot
106.A0014
BOARD OF HEALTH ----------- Permit No ------------
North Andover - BHP -2014-0669 ----------------------
P.I. FEE
F.I. $125.00
-----------------------
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted John_Soucy-_------___ _______________
--------- -------------------------------------------------------------
to (Construct) an Individual Sewage Disposal System. b.— ?- )k
at No 328 FOREST STREET
--------------------------- -------------------------
as shown on the application for Disposal Works Construction Permit No. BHP -20 4�0�66 �D tedun�e 2 2014
y "'
Issued On: Jun-24-2014
-----------------------------------------------------------------------
---------------------------------------------------
BOARD OF HEALTH
A
pTM Application for Septic Disposal System
` P.Construction Permit - TOWN OF
ORTH ANDOVER, MA _ 01845
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
; AM
2LA4
TODAY'S DATE
$ 250.00 — Full Repair
$125.00 - Component
Application is hereby made for a permit to:
❑ Construct a new on-site sewage disposal system*
❑ Repair or replace an existing on-site sewage disposal system*
❑■ Repair or replace an existing system component —What? DISTRIBUTION BOX H-20
A. Facility Information
328 FOREST STREET
Address or Lot #
N. ANDOVER
City/Town
2.- *TYPE OF SEPTIC SYSTEM*:
❑ Pump ❑■ Gravity (choose one)
***If pump system, attach copy of electrical permit to application***
❑� Conventional System (pipe and stone system)
❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system.
❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement)
❑ Pressure Dosed (D -Box Present) S.A.S. I�tEGElV'�
2. Owner Information w a�
MATTHEW BIELIK
Name
328 FOREST STREET
Address (if different from above)
N.ANDOVER
City/Town
3. Installer Information
JOHN SOUCY
Name
78. BROADWAY
Address
SALEM
City/Town
4. Designer Information
N/A
Name
Address
City/Town
r I"
MA 01845
State Zip Code
339-201-1552
Telephone Number
SOUCY SEWER SERVICE INC
Name of Company
NH
State
603-898-9339
03079
Zip Code
Telephone Number (Cell Phone # if possible please)
Name of Company
State
Zip Code
Telephone Number (Best # to Reach)
Application for Disposal System Construction Permit - Page 1 of 2
QTN Application for Septic Disposal System
` .Construction Permit - TOWN OF
.4NORTH ANDOVER. MA 01845
PAGE 2 OF 2
A. Facility Information continued....
5. Type of Building: ■❑Residential Dwelling or ❑Commercial
B. Agreement
6/23/14
TODAY'S DATE
$ 250.00 - Full Repair
$125.00 - Component
The undersigned agrees to ensure the construction and maintenance of the afore -described
on-site sewage disposal system in accordance with the provisions of Title 5 of the
Environme tal Code, as well as the Local Subsurface Disposal Regulations for the Town of
North do er, and not to place the system in operation until Certificate of Compliance has
bee �ssu by this Boar of Health.
E
Name Date
Application Appr ed By: (Bo of Health Representative)
Namek, Date
Applic/ionisapp//d th following reasons:
For Office Use Only:
1.
Fee Attached.
Yes
No
2.
Project Manager Obligation Form Attached?
Yes
No
3.
Pump System? Ifso, Attach copy ofElea cal Permit
Yes
No
4. Foundation As Built? (new construction ronly).
(Same scale as approved plan)
Yes No
5. F1oorMws?(new construction only). Yes No
Application for Disposal System Construction Permit • Page 2 of 2
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O` MORT :1M
' 320
Town of North Andover
,,,,,.: HEALTH,IDEPARTMENT
,SSACMUSf�;
CHECK #: DATE: Q
LOCATION:
H/O NAME:
CONTRACTOR NAME:
Type
of Permit or License: (Check box)
❑
Animal
$
❑
Body Art Establishment
$
❑
Body Art Practitioner
$
❑
Dumpster
$
❑
Food Service - Type:
$
❑
Funeral Directors 1
$
❑
Massage Establishment
$
❑
Massage Practice
❑
Offal (Septic) Hauler
$
❑
Recreational Camp
$
❑
Sun tanning
$
❑
Swimming Pool
r $
❑
Tobacco
$
❑
Trash/Solid Waste Hauler
$
❑
Well Construction
$
SEPTIC Systems:
❑
Septic - Soil Testing
$
❑
Septic - Design Approval
$
❑
Septic Disposal Works Construction (DWC)
$
❑
Septic Disposal Works Installers (DWI)
$
itlenspector
❑ Tls°I
�� 5 Report
®
$
$ '
Title
❑ Other: (Indicate) $
Health Agent Initials,
White - Applicant Yellow - Health Pink - Treasurer
Commonwealth of Massachusetts
Title 5 Official Inspection For
R�'
Subsurface Sewage Disposal System Form - Not for Voluntary Asse smenOAR 2 S
zoo8
328 Forest Street
Property Address HEALTH DEPARTMEONTER /
Mike Fennelly V
Owner Owner's Name
information is
required for No Andover MA 01845 3/25/08
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important:
When filling out A. General Information
forms on the
computer, use 1. Inspector:
only the tab key
to move your Benjamin C. Osgood, Jr.
cursor - do not Name of Inspector
use the return
key. New England Engineering Services, Inc.
Company Name
� 1600 Osgood Street Suite 2-64
Company Address
No. Andover MA 01845
City/Town State Zip Code
978-686-1768
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
asses ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
Inspe c9A
Signature Date F
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 1 of 15
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
328 Forest Street
Property Address
Mike Fennelly
Owner's Name
No Andover MA 01845 3/25/08
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes:
have not found any information. which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If "not
determined," please explain.
❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating 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
TITLE 5 FORM 2007.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 15
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
328 Forest Street
Property Address
Mike Fennelly
Owner's Name
No Andover MA 01845 3/25/08
City/Town State Zip Code Date of Inspection .
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if (with approval of the Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 15
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
328 Forest Street
Property Address
Mike Fennelly
Owner's Name
No Andover MA 01845 3/25/08
CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes
No
❑
iE/
Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑
M
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
❑
Lj--'
Liquid depth in cesspool is less than 6" below invert or available volume is less
than'/2 day flow
❑
Eg,/
Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑
[l]�
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.
TITLE 5 FORM 2007.DOC • 08/06
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 15
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
328 Forest Street
Property Address
Mike Fennelly
Owner's Name
No Andover MA 01845 3/25/08
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ Ek^
Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ �-
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ L� The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ [9�- the system is within 400 feet of a surface drinking water supply
❑ 0� the system is within 200 feet of a tributary to a surface drinking water supply
❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area - IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 15
L
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
328 Forest Street
Property Address
Mike Fennelly
Owner's Name
No Andover
City/Town
C. Checklist
MA 01845 3/25/08
State Zip Code Date of Inspection
Check if the following have been done. You"must indicate "yes" or "no" as to each of the following:
Yes
No
R
❑
Pumping information was provided by the owner, occupant, or Board of Health
❑
2
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)
[O'
❑
Was the facility or dwelling inspected for signs of sewage back up?
Lg
❑
Was the site inspected for signs of break out?
LAY
❑
Were all system components, excluding the SAS, located on site?
Ek
❑
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?
L!�
❑
Was the facility owner (and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
❑ Existing information. For example, a plan at the Board of Health.
❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 15
N Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M
328 Forest Street
Property Address
Mike Fennelly
Owner Owner's Name
information is
required for No Andover MA 01845 3/25/08
every page. City/Town
D. System Information
Residential Flow Conditions:
State . Zip Code
Date of Inspection
4-
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:
Does residence have a garbage grinder?
❑
Yes IBJ
No
Is laundry on a separate sewage system? [if yes separate inspection required]
❑
Yes NJ
No
Laundry system inspected?
❑
Yes K
No
Seasonal use?
❑
Yes (Q
No
Water meter readings, if available (last 2 years usage (gpd)):
L, R_
L_ L_
Sump pump?
❑
Yes 5a
No
Last date of occupancy:
�'�
Date
r&en__-
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Gallons per day (gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present?
❑
Yes ❑
No
Industrial waste holding tank present?
❑
Yes ❑
No
Non -sanitary waste discharged to the Title 5 system?
❑
Yes ❑
No
Water meter readings, if available:
Last date of occupancy/use: Date
Other (describe):
TITLE 5 FORM 2007.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M
328 Forest Street
Owner
information is
required for
every page.
Property Address
Mike Fennelly
Owner's Name.
No Andover
City/Town
D. System Information (cont.)
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
3/25/08
Date of Inspection
N eac ia 5. d t.✓ N KfZ
gallons
Type of System:
4 Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
[:1 Yes R] No
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other (describe):
Approximate age of all components, date installed (if known) and source of information:
49,x,17- 1!7 g (., ?r, 2 A -s " ?iv i c,T in�
Were sewage odors detected when arriving at the site? ❑ Yes X No
TITLE 5 FORM 2007.DOC • 08/06 - Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M
328 Forest Street
Property Address
Mike Fennelly U
Owner Owner's Name
information is
required for No Andover MA 01845 3/25/08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer (locate on site plan):
Depth below grade: feet
Material of construction:
❑ cast iron D6 40 PVC ❑ other (explain):
Distance from private water supply well or suction line:
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
A.00 f ��ov lA-�l �AS.-uC l
Septic Tank (locate on site plan):
Depth below grade: y
feet
Material of construction:
FX[ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
--------------------------------------------------------------------------------------------------------------------------
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
v
tr
RC-
�mG
TITLE 5 FORM 200TDOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 15
Su
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
328 Forest Street
Property Address
Mike Fennelly
Owner's Name
No Andover MA 01845 3/25/08
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
K tN lroaO Ty —160— lti
(noJr-> 6zvG0nnen.t> tnrsiII4W#41J.,/ U F=
r, I.% erz j o i• r L C, —7 ,44"j o o vr',67- UP ,.0 c! yc .
/J(A Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
N /#4 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):
TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 15
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5.Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
328 Forest Street
Property Address
Mike Fennelly
Owner's Name
No Andover MA 01845 3/25/08
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
N1�-Tight or Holding Tank (cont.)
Dimensions:
Capacity:
Design Flow:
Alarm present:
Alarm level:
gallons
gallons per day
❑ Yes ❑ No
Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
* Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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.):
r--Z)x ,,, ;.Oos e, vN n.7 p,�, r -,y /s i ;z L) -/? L) ,I % IJ4L -,� k-*)
Ll
6✓1 ne- cc rnf– O, -f o%z. OX—
Al jA- Pump Chamber (locate on site plan):
Pumps in working order:
Alarms in working order:
❑ Yes ❑ No
❑ Yes ❑ No
TITLE 5 FORM 2007.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 15
wo
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
328 Forest Street
Property Address
Mike Fennelly
Owner's Name
No Andover MA 01845 3/25/08
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑
leaching pits
number:
❑
leaching chambers
number:
❑
leaching galleries
number:
❑
leaching trenches
number, length:
leaching fields
number, dimensions:
❑
overflow cesspool
number:
❑
innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Citc.99;N $V-44 G•JVKJ VV 4W of O 9L-) I r> e,� I-- :r—
Vfa b1 0 UPJ aAU F & —7u.�
TITLE 5 FORM 2007.DOC • 08/06 Title.5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 328 Forest Street
D. System Information (cont.)
3/25/08
Date of Inspection
/t )k Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth — top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Al1,4 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.):
TITLE 5 FORM 2007.DOC - 08/06 - Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 15
Property Address
Mike Fennelly
Owner
Owner's Name
information is
required for
No Andover MA 01845
every page.
City/Town State Zip Code
D. System Information (cont.)
3/25/08
Date of Inspection
/t )k Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth — top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Al1,4 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.):
TITLE 5 FORM 2007.DOC - 08/06 - Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
328 Forest Street
�M
Property Address
Mike Fennelly
Owner Owner's Name
information is
required for No Andover MA 01845 3/25/08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building. s L"i
X0
N DAG >TW 10 LE 5 -7b w e S
PL,} o�
W LA/
TITLE 5 FORM 2007.DOC • 08/06 - - Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 15
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
328 Forest Street
Property Address
Mike Fennelly
Owner's Name
No Andover MA 01845 3/25/08
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑
Check Slope
❑
Surface water
❑
Check cellar
❑
Shallow wells
Estimated depth to ground water:
feet
Please indicate all methods used to determine the high ground water elevation:
AM
Obtained from system design plans on record
If checked, date of design plan reviewed: I le 6
Date
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health - explain:
Checked with local excavators, installers - (attach documentation)
Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
5 s Tim
L-/ te- I E Q.
TITLE 5 FORM 2007.DOC - 08/06 Title 5 Official Inspection Form: Subsurface. Sewage Disposal System - Page 15 of 15
Insurance Adjustment Service, Inc.
139 Billerica Rd
Suite A-1
Chelmsford, MA 01824
(978) 256-3334
Fax (978) 256-3354
UNDER MASSACHUSETTS GENERAL LAWS CHAPTER 139 SECTION 3B
Date: October 22, 2005
TO: Town of N. Andover
Board of Health/Building Inspector 2 %
N. Andover, MA 01845 3,,
RE: Insured: Mark & Maryann Biondi
Property Address: PO Box 364
North Andover, MA 01845
Date of Loss:
Policy Number:
Type of Loss:
10/19/2005
H012182958
water
File or Claim Number: 27154
0 C T 2 6 2005
Claim has been made involving loss, damage or destruction of the above captioned property, which may either
exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6, to be applicable.
If any notice under Mass. Gen. Laws, Ch. 139, Sec. 38 is appropriate, please direct it to the attention of the
writer and include a reference to the captioned insured, locations, policy number, date of loss and claim or file
number.
Thank you for your cooperation.
Very yours,
colt O' e1
Adjuster
Ext. 129
51 Fl
4-"P, 10 JJNA
INA. Z 1,
W".
itiotII
11 %
i Kj I- i
oo
rr 4
!-if,I
, , � 'i (5
V, fri fr'- F: Ie j!
of
I 5{
�w " , 1ij E �' It,"/
Commonwealth of Massachusetts
City/Town of North Andover RECEIVE®
System Pumping Record
` Form 4 JUN 11 2008
M
DEP has provided this form for use by local Boards o' Health. Other forms may I a used, but the
information must be substantially the same as that pr � A�frF�roI �� tis form, check with your
local Board of Health to determine the form they use. rd must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer, use 328 Forest St
only the tab key Address
to move your NorthRo� 4��'MA '4
cursor - do not '�' -,—
use the return City/Town State Zip Code
key. 2 System Owner:
D. Fennelly
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system:
❑ Other (describe)
6/4/08
Date
State
978-957-5992
Telephone Number
2. Quantity Pumped
❑ Cesspool(s) ® Septic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes ® No
5. Condition of System:
Good - Sellina House
6. System Pumped By:
Jason Elliott
Name
Jason Elliott Septic Pumpina
Company
7. Location where contents were disposed:
Zip Code
1500
Gallons
❑ Grease Trap
If yes, was it cleaned? ❑ Yes ❑ No
L90-471
Vehicle License Number
Signature of Receiving Facility
Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1