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HomeMy WebLinkAboutMiscellaneous - 335 BERRY STREET 4/30/2018r ?/vals %4'"19(! �. I * MAP # LOT #____. PARCEL # STREET �O.NE-TRU{��.ONiA HAS PLAN REVIEW FEE BEEN D NO PLAN APPROVALm DATE APP. BY DESIGNER: PLAN DATE CONDITIONSnr . � . . WATER SUPPLY: ' WELL PERMIT.— WELL TESTS: .� .� ' TOWN DRILLER____ CHEMICAL 1)(11E APPROVE QAClERIA l D()lE UN)RUVE ��� � BACTERIA II DAlE APPROVED________ COMMENTS: , . \ � ���_ / FORM U APPROVALx DATE ISSUED CONDITIONS: FINAL APPROVAL: APPROVAL NO �l8Y ` ALL PERMITS PAID WELL CONSTRUCTION APPROVAL SEPTIC SYSTEM CONSTRUCTION APPROVAL OTHER ANY VARIANCE NEEDED FINAL BOARD OF HEALTH APPROVAL: YES NO YES NO YES NO YES NU YES NO � � DAlE:«��8 �~^U p B IS THE INSTALLER LICENSED? YES NO TYPE OF CONSTRUCTION: NEW f= -AIR NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW YI-S I\lO CONDITIONS OF APPROVAL YES NO (FROM FORM U) ISSUANCE OF DWC PERMIT YES NO DWC PERMIT N0. X33 INSTALLER: BEGIN INSPECTION fYE�SN O EXCAVATIOWINSPECTION: NEEDED: J CONSTRUCTION INSPECTION: NEEDED(^_._____._.__..___. _.._..__..._. . _._... ___..._.._. ....._ __._.__.__ AS BUILT PLAN SATISFACTORY: YES: APPROVAL TO BACKFILL: DATE: l > �� BY� FINAL GRADING APPROVAL: DATE FINAL CONSTRUCTIO APPROVAL: DATE: Commonwealth of Massachusetss Massachusetts System Pumping Record Typo: Emergency Routine Cesspool: No Yes Date of Pumping: z l` 0 J System Pumped By: Wind River Environmental, LLC Contents transferred to: Form 4 -- System Pumping Record DEC 0 9 2005 VN OF NOR' - ANDOVER 4EALTN DEPARVP LENT Septic tank: w Yes Quantity Pumped: /6UCJ6albns Permit #: I VIA Contents Disposed at: waste J%mA L Date: Pumper Signature: Condition of System/other Comments Dep Approved Form - 12/07/95 TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD 9pl, >I'Eti1 OWNER & ADDRESS SYSTEM LOCAT'ON (example: !efc froni of nousty fgof\+- "! E OF PUMPING: /o `�"� (QUANTITY PUMPCD)5ot2 PO0L. NO YES � ATURE OF SERVICE: ROUTINE !!s�FRV:\TION S: GOOD CONDITION HFAVY CREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER > iL'E'I PUMPED BY u,! '�-I CNTS: u� r!:'N F5 TRANSFCRRED TO SEPTIC TANK: NO EMERCENCY -4 J FULL TO COVC'Z BAFFLES IN PLAC1: LEACHFICLD RLNOACK FLOODED Oj�HFR (EXPLAIN) NEW ENGLAND ENGINEERING SERVICES INC October 1, 2002 Socorru Ramos 334 berry Street North Andover, MA 01845 RE: Title 5 inspection 334 Berry Street, North Andover Enclosed is a copy of the Title 5 Report for the above referenced property. The system Passed our inspection. If you have any questions please call. Sincerely, Benjar - C. Osgood r. 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 — NOT FOR VOLUNTARY ASSESSMENTS JVAGE DISPOSAL SYSTEM FORM PART A tTIFICATION U v C g6-0(3© /-41e'CJ24At -- 02e L)�� ,4,fl ;e disposal system at this address and that the information reported of the inspection. The inspection was performed based on my maintenance of on site sewage disposal systems. I am a DEP 15.340 of Title -'5 (310 CMR 15.000). The system: Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: _ C 6=1- Date: OZ, The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _33-C 6 E2Xv ,U o / ;nY dhN D 6J6- ivt dl Owner: Z'rcoejzu 24m o S Date of Inspection: Inspection Summary: Check AAC,D or E / ALWAYS complete all of Section D AL� 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 replaced or L The system, upon completion of the replacement or repair, as approved by the Bmrdof Health, will pass. Answer yes, n not determined (Y,N,ND) in the for the following sta is If `blot determined" please explain. The septic tank is in and over 20 years old* or the septic whether metal or not) is structurally unsound, exhibits substantial ' tration or exfiltration or tank fail is imminent. System will pass inspection if the existing tank is replaced with a ' g septic tank as approv by the Board of Health. *A metal septic tank will pass inspedi ' it is structurally und, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years is avails ND explain: Observation of sewage backup or eak out or high water level in the distribution box due to broken or obstructed pipe(s) or due to a broken ed or uneven distributi x System will pass inspection if (with approval of Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ND explain. The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: .33 SZ Owner: !iocneaulLr9�t oS Rate of Inspection: C. ""�rther Evaluation is Required by the Board of Health: tions exist which require further evaluation by the Board of Health in order to etermine if the system is failing to tett public health, safety or the environment. 1. System�-"unless Board of Health determines in accordance with 0 CMR 15.303(l)(b) that the system ctioning in a manner which will protect public healt safety and the environment: _ Cesspool or priVX is within 50 feet of a surface water ' _ Cesspool or privy within 50 feet of a bordering vegetated w and or a salt marsh 2. System will fail unless the Board of H h (and 'c Water Supplier, if any) determines that the system is functioning in a manner that protec e p lic health, safety and environment: _ The system has a septic tank and soil absc tion. em (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface er supe The system has a septic tank and S and the SAS is widiin a Zone 1 of a public water supply. The system has a septic tank SAS and the SAS is within 50 feet�f a private water supply well. The system has a septic private water supply well* j and SAS and the SAS is less than 100 feet god used to determine distance feet or more from a **This system passes ' the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volat' organic compounds indicates that the well is free from pollution from that facility and the presence of onia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria a triggered. A copy of the analysis must be attached to this form. 3. Other: r Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 33 /3G 11,/ .S —aee —,, JU 0 &_D4 D d J l .lZ ivc �4 Owner: S e C n 2 2U /1 AA40 S Date of Inspection: 3 Z D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: Yes No _ i✓ 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 I✓ 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 '/z 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. _ An portion of a cesspool or privy is within 50 feet of a private water supply well. 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. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd l'pd. You must indicate either "yes" or "no" to each of the following: (The -following criteria apply to large systems in addition to the criteria above) yes no the system is wi ' 00 feet of a surface drinking waterLsuthe system is within 200 feet of a ' tary to a ce dg water supply _ the system is located in a nitrog sttive area Wellhead Protection Area — IWPA) or a mapped Zone II of a public water s y well If you have answer to any question in Section E the system is consider�niea�r answered "yes" in Section D above the large system has failed. The owner or operator oered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:_ 33L ,gcRlLy S—fl2ee7- ,VOA -T7? Owner: ; D C Or 'W 44M O S Date of Inspection: Check if the following have been done. You must indicate "yes" or "no" as to each of the following VYNo 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 ? 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: 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: Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): L/cSy Number of current residents: S Does residence have a garbage grinder (yes or no): Is laundry on a separate sewage system (yes or no): [if yes separate inspection required] Laundry system inspected (yes or no): — Seasonal use: (yes or no): Water meta readings, if available (last 2 years usage (gpd)): w i t_ Sump pump (yes or no): _,A10 Last date of occupancy: C=,, rr« t COMMERCIAIJINDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd- Basis ndBasis of design flow (seats/persons/sgfletc.): 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 meta readings, if available: Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: geci R S Was system pumped as part of the inspection (yes or no): 410 If yes, volume pumped: _ gallons -- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank, distribution box, soil absorption system _ Single cesspool _ Overflow cesspool _ Privy _ Shared system (yes or no) (if yes, attach previous inspection records, if any) _ Innovative/Altemative 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: _ r3✓i i /�l%Z Were sewage odors detected when arriving at the site (yes or no): X4) l Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3 3 .S k2o /Li7( Ax,, 0 0,j& . itA j4 Owner: _ Soc r22v Date of Inspection: 3 V-0 BUILDING SEWER (locate on site plan) Depth, below grade: Materials of construction: cast iron 40 PVC _other (explain): Distance from private water supply well or suction line: 2 ib Comments (on condition of joints, venting, evidence of leakage, etc.): C) f E- Ii0 Z) a -_ 6c> a 9 ) r B 5 Lf M t( [�f� . SEPTIC TANK: _ (locate on site plan) r Depth below grade: J Z Material of construction: y�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: / S'v o G-14yG0 ,.vS Sludge depth: Z" Distance from top of sludge to bottom of outlet tee or baffle: Z8 " Scum thickness: Z " I. Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: –,S' How were dimensions determined: 4 &gwcu g=F 57 z i< Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): IS �6-000 Lc?ND�7l�l�l lc�NC�Z C� %SES !N G-�S �7(&j C v -) D 1-7)'0 V - GREASE TRAPy�ovate on site plan) Depth below grade: _ Material of construction: _concrete _metal _fiberglass _polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: r JG/L M✓i Owner: S aC 0,zg,_, S Date of Inspection: 011b -z- TIGHT TIGHT or HOLDING TANK: &d- (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: Alarm Date gallons order (yes or no): switches, etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): _ 9r,x ,ti a✓. ronV+�l0n 4� ix,414 61 1N O�2 by1 D7r,r?u17 Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3 B c R2y sire c Owner: Date of Inspection: aZ 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: innovativelalternative system Typetname of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): #Y,61 O r CESSPOOLS:A/# (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: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Page 10 of 1 I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: �33,_� Q&4y _iU0lLT7� �l,,iJ d cJr'Y1 �c p4 Owner: Date of Inspection: a 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. OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .PART C SYSTEM, INFORMATION (continued) Property Address: Z 25— DE128tj N u ant tf D O,3 C- 2, ItA A Owner: Sac P -14M05 Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water G feet Please indicate (check) all methods used to determine the high ground water elevation: -V- Obtained from system design plans on record - If checked, date of design plan reviewed: Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Checked with local excavators, installers- (attach documentation) Accessed USGS database -explain: You mast describe how you established the high ground water elevation: -T C S m ASS ► Nplc of B ELew G2r�}y nr3icYy 'PL't+NS Itgg ICA -0Z wrtT CIA. y` BFLa �� sTL�n.c h --- --- ---- r a I hFFN,I.G.CHH .j. � Irl �F""flp;ll EO v+uv� FWA do 1 HIYNiT bvm, 9W4 y I a g p7r1Nu6pNli ��� -- — a OW 'A I � o>< �voR � I —A n7`7j, i I i 1 , NDTES. kw WOU. 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U a (P r O TZ m 40 -mm>* -mo, Z '>-nW0 c N D N D m r D p m A < 0 Z � D N r cn z W A --i m 9 z o � z = 0 D Z v 0 Z m D➢➢ D D D D D D D D➢ D D➢ D D U U m O N O N ? m N J N N UAI � -WLO � W C f'1 r 0 D � y , n L — 0Ox= 3 OM zaxx r m m p Dm „V,�< z <n O m 2 S00T D O O m = m x O y < N D a=yz z :r aC)oT y x F 0 y m z z O c O x = m'D 0 I m D = z z O 1 t o z cr O Z S m 1 9 mx n <O o m D v M Do D -1m < OZ r mm < m m D (n D yyb <O y N D x 4m 0 y T e n J z0 D -q" p 1111" _ 0 m D cn b r � ® c-.. m - r C- CZ < N F Z r m Nom= C) - D a m Z�M CU C2 vm Co 1 mn z (n m a () Z -i -n -C r n day/ OS 7 � 01 O C z 0 r o N Q � .9 -A 01 7 5,1 (0 Department of Env' on 'Management iv ^� orf ofWater Resources . �.,�r WATER WELL COMPLETION REPORT 1 t WELL LOCATION Address LO IR` City/Town G.S. Quadrangle Map Grid Location Addr WELL USE Domestic Public ❑ Industrial ❑ CONSOLIDATED WELL Other Type of Water -bearing Rock .. MethLDDrilld t ��R Water -bearing Zones 1)From To3 Date -2) FromTo 3) From To_ CASING i 4) From To Length�� ' Diameter ��+ Depth to Bedrock Type UNCONSOLIDATED WELL STATIC WATER Materials • Feet below land surfa e :'ate �Gravel: Sand: fine ❑ medium ❑ cdarse ❑ measured fine ❑ medium ❑ coarse ❑ NLWater-bearing GRAVEL AC Screen: Yes ❑ Slot lengthfromto Split Screen (or 2nd screen) WATER QUALITY TESlog lenqthfromChemical ❑ BioloDepth to To Bedrock PUMP TEST i:;rawdownaR feet after pumping days hours at ))� GPM' ;-tow measured --� Recovery feet after hours. LOG of FORMATIONS COMMENTS: (On well or water) Materials From To Cb QRILLER—11 QJ Firmer _j - Address Cite Registration No 'Wase print rrm I'lly �Perat�®rsgnature CUSTOMER COPY 15M-2 84%176471 _ r , L 27 — � c Department of Environmental Management/Wyision of Water Resources '• t � � � � ,+z WATER WELL COMPLETION REPORT i :�..""".. ""' mtB.Yat...we+wu++gry'i,ReA'Sb,Wtwrww�l�li -fib 41�Lau�.-. .r.'-ItlINl.�4 I Grid Location__- Addressa WELL USE CONSOLIDATED WELL Domestic I jr pubiic [j }ndustrial � ! Type of Water -bearing Rock__ - UiFQr._ ---- , Water -bearing dorjec� "Jiathptirii`«atj ] } i-rc�m_ ./' / s7c_.. SS to C,3•illt;d 3) prom From - CASING Depth to Bedrock Type ^. UNCONSOLIDATED VUpf.L S-rAT 1C WA; PR LEVE I_ Alater•bearing Mlateriais Feet below grid surface.,„_ _ Sand- fine D medium [D coarseC Bate mentlueed .� Gravel, fine 0 medium q coarse[] mow-+• �.•.a��...,W.,..,. GRAVhL BACK, WELL Screen, Yes �![�t �rlprtgth �fr!aM— ____to Y - -_ -- --�- SON*, Screen (or 2nsf screen) WATeRQUA.LIT*,' TESTS MADE length frorrj------ts�- rhernical r; oik iuc]i �a3 J 0-001 f"' To Bedrork t PUMP TESTJ� 'After PumPtn9_days hour3at _... GPM «r„�eCovery�feet after. ' �._..�._.. urs SR A etS COMMElt M ,'On well,.,r water) e Fro to _ DRILLER S r -i1 f Andres } Registration No.�_-_�� 1 . €ase prfnt 9jrrrr±+wvr. PareVr S Signklire. CVSTCAUA COPY p ,s Applicant Town of North Andover, Massachusetts BOARD OF HEALTH Form No. 1 41 6 0 bloc 9— ft` APPLICATION FOR SITE TESTING/INSPECTION Site Location Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time Fee_ /.sem • "= S.S. Permit Np-2p.(--a D.W.C. No.s C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts BOARD OF HEALTH �VTETWEII-11 • DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM uce Touma Applicant R' ding Realt Trust Site Location Lot 4, /e3rrv,..St., io . Reference Plans and Spec . Permission is gra in accordance wi Fee 0, ted fIr an individual soil absorption i reg lations of Board of Health. No GN Form No. 2 system to be installed Site System Permit No. i' - 603-893-4260 i c LTD �• 1-800-637-2366 NEW ENGLAND RADON, 373 Main Street Salem, New Hampshire 03079 ' WATER ANALYSIS RESULTS i NAME: E.M. YOUNG ART. WELL CO. DATE:- 12 -Jun -91 36 PELHAM ROAD SALEM, NH 03079 I ` SAMPLE LOCATION: CHANNEL BUILDERS LOT 4A - BERRY ROAD _Ii NORTH ANDOVER, MA --------------------------------------------------------------------------- - TEST RESULT REQUIREMENTS ' STANDARD MIN. MAX UNITS i* Secondary H RDNESS............. 119.7 0 75 mg/1 I'ON................. 0.09 0 0.3 Mg/1 Secondary MINGANESE............ 0.003 0 0.05 mg/1 Secondary IROGEN SULFIDE..... 0 0 0.3 mg/1 Secondary 1 7 6.5 8.5 Secondary ................. • . TII6SIDITY............ 0 0 5 FTU PRIMARY I C#LORIDES............ 35 0 250 mg/1 Secondary NITRATES ............. 0.3 0 10 mg/1 PRIMARY I N TRITES ............. 0.006 0 1 mg/1 PRIMARY C PPf=R........_-••••• 0.03 0 1 mg/1 Secondary SkDIUM... I........... 21 0 250 mg/1 Secondary TOTAL DISOLVED SOLIDS 183 0 500 mg/1 Secondary COLIFORM BACTERIA.... 0 <1 Colony/100 ml PRIMARY i NON -COLIFORM BACTERIA 0 <2pfl Cols./100 ml PRIMARY WbTER MEETS Tested by: ESA STANDARDS --- - FbR SAFE DRINKING WATER. l �i c • • H • N 1.13 I�JS gQ311 • M . 3 DATE Sheet ( of BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW FEE � 600 PERMIT # DATE RECEIVED APPLICANT 'PtOt Aq Cc --b,( �; f ASSESSOR'S MAP ADDRESS ENGINEER 7C'ic {,oz ADDRESS A41 <fj-O K� PLAN DATE PARCEL # LOT # STREET 4nt'CEP-U MA REVISION DATE ? CONDITIONS OF APPROVAL: APPROVED DISAPPROVED X J--�-c ov� . -VC:) 41 r Gt,,c,ou,T-c I_co uli i -1 osl St. N Y �•: ul,eion. SAA 01949• P .:otii 77•1-2772 \ERv G� 5 FILE # SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION i i - i ADDRESS OF PROPERTY: 3 Lvrr. PROPERTY OWNER'S NAME: e DATE OF INSPECTION: L�9lf%S • THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY • ' I PART A CHECKLIST Check if the following have..been done:. Pumping information was requested of the owner' occupant, and Board of Health.' None of the system'.'components have: been" pumped' for at' least two weeks and the system has' been ;receiving normal flow, rates during that period. Large volumes of.Vater:have•not been introduced into the system recently,or as'part of this inspection.:' As built plans have been obtained and examined. Note if they are not available with N/A. The 'facility or dwelling was. inspectedfor,'signs.of sewage back -,UP. The site was inspected'•for signs of.breakout. • . I A11 system components.,... excluding the 'SAS have site. , been located on the i✓ The septic tank,manholes.were•uricovered, opened, and the interior the . septic tank. was inspected for condition .O•f •baffles or tees, of material .of construction,•dimensiond,.depth of.'-JiJ'id, depth of sludge, depth of 'scum..,.: . The size and .location• of " the •SAS o .n'.the site has*'been determined based on -existing information or approximated by.nori-intrusive methods. The facility*owner•(and.occupants,'if different from owner were Provided with information on the proper maintenance of SSDS. CURB M SEPTTr k. TDA... F5A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM' PART B SYSTEM INFORMATION i FLOW CONDITIQNS• f residential _ number of'bedrooms number of current residents NO garbage grinder, yes or cs laundry connected tos stem, or no. �a season4l use, yes or .If nonresidential, calculated flow: �E"i Ja W e Water meter readings, if available: q(r�Ch 'Last date of occupancy Pumping' )rhe)cord GENERAL INFORMATION• d J _ ,PS system pumped as part of ins ectio if yes, volume pumped / p�U n' es r no Reason for pumping: IV q Type system Septic tank/distribution b Singl.e cesspool ox/soil absorption system Overflow cesspool Privy Shared system (yes or no.) (if;y.es, attach previous -inspection records, if any) Other (explain) Approximate age of all components. Date installed informat ioq� , if known. Source of sewage odors detected when arriving at the site, yes CURRIER SEPTIC & DRAINS; INC. X �Fle� /0/295 SUBSURFACE SEW AGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM YSTEM INFORMATION coatiaued SEPTIC TANK: ytiS (locate on site plan) depth below grade: material. of construction: • v � concrete metal FRP ---- _.___ether(explain) dimensions: S `Deelo DC �W;d2 k • , �� 6u E-i�� r5 a- � sludge depth 8a;91e, D distance from top of slue to�b ttomf iootlet tee or baffle scum thickness -�" distance from top of scum to top of outlet tee or baffle •"L'!distance from bottom of scum to bottom of outlet tee or baffle Comments: (recommendation;•for pumping, condition -of inlet and outlet tees or baffles depth of liquid level in relation to outlet invert, structural in evidence of leakage,-recormpndations for repair , etce) " tegrity, /h Gi c-aU 7l Of /1;;� Sa LL / r un vt i' DISTRIBUTION BOX:Z=L ��, a<< t (locate on site plan) Dao i3e��`� G� • a depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids evidence of leakage into or out of box, recommendation for repairs etc. carryover, i� cQ ) J-l�ol� is vs .•ra u PUMP ';CHAMBER: /v&4 (locate on site plan) O'v-'�_r" / r-_. -/- Depf t% PumPs�i working order, Comments: (notejcondition of pump chambe recommendations for maintenance yes or no ition of p pairs, /.......viii[,' r 2JC� a-& C I e—" G and appurtenances, MrRRTVP cvnmyn r __ SUBSURFACE`SEWAOE DISPOSAL SYSTEH SOIL ABSORPTION (locate on site approximated by PART. D SYSTEM' INSPECTION FORM .INFORMATION COUtinued SYSTEM (SAS) :;�, j planif possible_ ; excavation, not required,* but may be non- intrtisive; methods) . If not determined to b pXe.sent,�!3�cplain::: Type lleaching pits and number-' eaching chambers and number leachin alleries and nu 56"'a,.. t number, . length ing fields, numberflow cesspool amens ons P , number Comments: (!note conA 'ti Ce�c�;ns Tej G►�c ---------------- i on of soil, .,signs .of 'hydraulic failure condition of vegetation, .recommendati'ons for ma •level of pondi4g, intenance or repairs,.etc.) CESSPOOLS (locate on site- -plan)*.. number and con -figuration depth -top of liqd_.-to inlet invert depth of solids layer1 dgpth of sCum.layer dimensions of cesspool materials of construction in of groundw eg inflow.(cesspoo st be Part of in ion) cents : `(note condition of soil. condition of vegetation, i PRIVY: /l/(/ (locate on site plan) material cc dimensions depth of solids i comments: (note condition condition o e struction Pumped as i�ep f k 'r Blow .............. . . . . . . . . . . . . . . . . . . . . . . . . signs, of- hydraulic. failure, level• of recommendations for•maintenance or repairs,�etc.) moil, . signs of, hydraulic fa getation, recommendations for 1aintenaneeeor of ponding, repairs,etc.) F�l•e,� j� �2q5/� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM • ' PART B I SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM-:-. include ties to at least two permanent references:landmarks'or benchmarks locate all wells within 1001. 0- P k 3367,-Rer7 S.V -- •u, ghc%av I ----- DEPYH TO GROUNDWATER aer-r�— s ti 7Z "tu depth t� groundwater method of d renin tion or approximation:'. ,2n A�-o c : 3 7 T3+oC- D ,ti'3" r3fo0 !Indicate yes, determination SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE'CRITERIA Lk Backup of not or not in all instances ain�df notxdaterm�ined�� ' Describe basis of ., explain why not) sewage into.fadil ty? ,-=�- Discharge or ponding of effluent to the surfs surface waters? ce of the ground or static liquid Liquid' depth flow? i level in the -distribution box above outlet invert? in cesspool <61''below invert or'available volume< 1j2 day Required pumping 4 times o number of. times pumped ore in the last year? '1" Septic tank is met 1? cracked? i infiltration? substantial.exfiltration?atankufailure iubstant�ial mminent. /I , Is any portion of the SAS, cesspool -or privy: below the high groundwater elevation? '/ v .'within 50 feet of(/ a surface water? /L/o �P�ri uJ4 �e� i�r . Lit •'s xe4 61'a (4x /V within.100 feet of a surface wO water supply? ater supply or tributary to a surface I !A" within a Zone I of ai ubli P c.well? _�Vwithin '50 feet of a bordering vegetated wetland -or salt ma (cesspools and privies only"o, the SAS)? rsh within 50 feet of a private water supply well? less than 100 feet but greater than 50 feet from a private supply well with -no aoceptable.wateranalysis?P vaIf water has been anilyzed'to be acceptable, attachCOPYl If the well for coliform bacteria, volatile organic compounds, ammoniates analyse and nitrate nitrogen, nitrogen ' [:iiRl?T�D evnn.t.. SUBSURFACE SEWAGE DISPOSAL SYSTEH INSPECTION FORM PART D CERTIFICATION Name of Inspector Company Name CURRIER SEPTIC & DRAIN SERVICE Company Address 107 FOREST ST. MIDDLETON, MA Certification Statement I certify that I have personally inspected the sewa e•dis osalsystem this.address and that the information reported is true, accurateandat complete as of the time of �nspection...The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training'and experience in the proper.function and manitenance,.of on-site sewage disposal systems. VChek one: I I have not -found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15.303. Any failure criteria -not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that -the systemfails to protect PUblic.health and. the environment as defined' in 310 .CMR' 15..303. The basis for :this determination'is form, provided in the FAILURE CRITERIA section of this Inspector's' Signature Date 0a/V41- /Z� original to system owner f ( COPY Copies to: Buyer (if applicable) Approving authority R NEW ENGLAND ENGINEERING SERVICES INC -F(;,-V. d OF NORTH A BOARD OF x2002 October 1, 2002 North Andover Board of Health Town Hall Annex 27 Charles Street North Andover, MA 01845 RE: TITLE V REPORT: 334 Berry Street, North Andover, MA Dear Sirs: Enclosed is a copy of the Title V report for the above referenced property. The system PASSED our inspection. If there are any questions please call me at my office, 686-1768. Sincerely Benjam2l . Osgood, 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONME A ECTION TITLE 5 OCT OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: :335 &e ,Zav S i n.C& , iV 0 R-77! t\- A2 poje.2 n.A Owner's Name: S o e -,- O %Lc) QRA4 0 S Owner's Address: 33_5- V 3.s,U n pz7X AN D Qy F,)Z, no A Date of Inspection: !Z / 3 f5% -z- Name Name of Inspector: (please print) _ be 47/a-AA„v Company Name: P&,U 1 ti6t,.4yp E, vg Ar(r Mailing Address: & o c c,/oa, 2-1c) Telephone Number: q Z q— (y S b l7h 9� CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000 The system: asses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: .30 1 0Z, The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 6�3.S' 6 Efzrcy -S e T Owner: a c c o, v i2vt o s Date of Inspection: a Inspection Summary: Check A B C,D or E / ALWAYS complete all of Section D A �m 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 tobe-replaced or 1. The system, upon completion of the replacement or repair, as approved by the Boardof Health, will pass. Answer yes, n or not determined (Y,N,ND) in the for the following statem�e6ts. If "not determined" please explain. The septic tank is m and over 20 years old* or the septic whether metal or not) is structurally unsound, exhibits substantial in tion or exfiltration or tank failur is imminent. System will pass inspection if the existing tank is replaced with a com g septic tank as approved by the Board of Health. *A metal septic tank will pass in ti it is structurally und, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years is available. ND explain: Observation of sewage backup or break out or high statgwater level in the distribution box due to broken or obstructed pipe(s) or due to a broken, led or uneven distributioit�ox. System will pass inspection if (with approval of Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 33 S 9 c M -y i wee Ny%L�� i'1'ti%,c7aJc/1 M.T4 Owner: scxa22v 2�4�ufly ate of Inspection: !�Zj Fzz�& z C. Fitrther Evaluation is Required by the Board of Health: Coh4itions exist which require further evaluation by the Board of Health in order to etermine if the system p is failing to tett public health, safety or the environment. 1. System ass unless Board of Health determines in accordance with �- 0 CMR 15.303(l)(b) that the system is not ctioning in a manner which will protect public heaIt, safety and the environment: Cesspool or pri'vkis within 50 feet of a surface water /f Cesspool or privy within 50 feet of a bordering vegetated w/etland or a salt marsh 2. System will fail unless the Board of He h (and Pub4c Water Supplier, if any) determines that the system is functioning in a manner that protec the p}t�lic health, safety and environment: _ The system has a septic tank and soil abso ti6h, ystem (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface ater supply. The system has a septic tank and S and the SAS is within. a Zone 1 of a public water supply. The system has a septic tank � SAS and the SAS is within 50 fdet of a private water supply well. The system has a septic private water supply well**/ and SAS and the SAS is less than 100 feetbu`t0 feet or more from a god used to determine distance **This system passes}f 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 ofmonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: /-y S� mac' (� c� ►'L�1-/ AA1 p d J E—)t -44 /4 Owner: S b C r7 2 je k4,A 0 S Date of Inspection:�/3 fife, 2 D. System Failure Criteria applicable to all systems: You must indicate `yes" or `no" to each of the following for all inspections: Yes i000/ _ _ 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 LI/ 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 %i day flow ✓Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. f Ai_y portion of a cesspool or privy is within 50 feet of a private water supply well. y 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. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd gpd• You must indicate either "yes" or `no" to each of the following: (The .f lowing criteria apply to large systems in addition to the criteria above) yes no _ the system is wi 00 feet of a surface drinking water su _the system is within 200 feet of a tary to a urface drinking water supply _ the system is located in a nitroge sitive area inter Wellhead Protection Area — IWPA) or a mapped Zone II of a public water s y well If you have answer to any question in Section E the system is considered a signi-threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 33s 5z /Z2Y= S-t12eei A0 0/1-72� /-HN2 D Jc/� art Owner: D 5 Date of Inspection: Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Y,/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 ? -V-/- —Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ? 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: Yew 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 b of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): 3 Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 4A5_0 Number of current residents: 3 Does residence have a garbage grinder (yes or no):rp Is laundry on a separate sewage system (yes or no): [if yes separate inspection required] Laundry system inspected (yes or no): Seasonal use: (yes or no): Water meter readings, if available (last 2 years usage (gpd)): w Cl- t_ Sump pump (yes or no): A10 Last date of occupancy: COMMERCIAIJINDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sgft,etc.): Grease trap present (yes or no): _ Industrial waste holding tank present (yes or no): _ Non -sanitary waste discharged to the Title 5 system (yes or no): _ Water meter readings, if available: Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: ce, ,2 5 Was system pumped as part of the inspection (yes or no): �t___p If yes, volume pumped: gallons - How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM �C Septic tank, distribution box, soil absorption system _ Single cesspool Overflow cesspool Privy _ Shared system (yes or no) (if yes, attach previous inspection records, if any) _ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) _ Tight tank _ Attach a copy of the DEP approval Other (describe): Approximate age of all components, date installed (if known) and source of information: 0✓it i 1119,2 - Were sewage odors detected when arriving at the site (yes or no): XL2 Page 7 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3 3 .!;- /2o 2l'71 AN 9 ouE4 -L.4,4 Owner: 5 d c OtU,-/ /-4A40S Date of Inspection: 3 Z c� ° BUILDING SEWER (locate on site plan) Depth, below grade: Materials of construction: ✓cast iron _40 PVC other (explain): Distance from private water supply well or suction line: 2 lb Comments (on condition of joints, venting, evidence of leakage, etc.): E1 PE- L-c>D//,s 6�b9 f 3 ►$SL A,(&�,V-r SEPTIC TANK: _ (locate on site plan) Depth below grade: Material of construction: concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of certificate) Dimensions: L S'y o Sludge depth: Z`' Distance from top of sludge to bottom of outlet tee or baffle: L8 `• Scum thickness: Z Distance from top of scum to top of outlet tee or baffle: -5- Distance from bottom of scum to bottom of outlet tee or baffle:_ How were dimensions determined: 466A<'u p 5i1 ci< Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): /yNc (Z 6-7 2�7 I C Es r,,U 6-0 S ►7 /tvAJ0 7)nAI GREASE TRAP11%ocate on site plan) Depth below grade: _ Material of construction: _concrete _metal _fiberglass _polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:-�rR /L s Innp e r X11+0 (L�( N JGA nit .7 Owner: S a c v,Z / A4&S Date of Inspection: a z 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: Q �v 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.): —J1 ZDx t.1 0I% rc'/IV 60O'n- /tom Lef4KA-C-C In. O"2 i7c> r';4'Y-11 �--1 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) Property Address: 33.E 0c ?A L7 -/r c; AiQ61W A. .«/Z Jt Owner: 52L-09LI. /I4M05 Date of Inspection: a 02– SOEL 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: 6 y,2 i w cK 6-,r leaching fields, number, dimensions: overflow cesspool, number: innovativelalternative system Typetname of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): #tC J9� (Dr S y,5 i[ M AAD i�M.fl L CESSPOOLSAZ4 (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: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Page 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: J;5,5- 13ZMY -S7,Y-e—( V olLTlf �u Jr7 d cJG%2 Owner: o tL/ 4AA ps Date of Inspection: 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. W CLL_ i Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Z2-5- a C Z n S i rt e, 10 n IZ:n-f A-A5P00eA Nt A Owner: oco 9,gA4oS Date of Inspection: D SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water G feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record - If checked, date of design plan reviewed: Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Checked with local excavators, installers- (attach documentation) Accessed USGS database -explain: You must describe how you established the high ground water elevation: MAP E i ?J Pic d -r t.y 4q = /L } ,. 0, g cl taw G-/Li�O 6.2 i t, N 19L-0 6j> 1kip I C A} 2 w a 107 Forest St. Middleton, MA 01949 (508) 774-2772 sEP�SE�v cE FILE# ) O 95' A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PROPERTY OWNERS NAME: C o M e qrd PROPERTY ADDRESS: %335 B e r r v a+dn, A n d o ve_ r Ala ADDRESS OF OWNER: (if different) DATE OF INSPECTION: o C 4 o b e r !a, 1 9 qE; NAME OF INSPECTOR: > 1? Q n L (, j SC -1 n rnI-) M • THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: Address of Owner: Date of Inspection: Oc+-. /Zj l9g5_ (If different) Name of Inspector: 2)e., G, �Hscov►,S.J Company Name, Address and Telephone Number: FILE# )C, I Q q 64) Currier Septic & Drain Service, Inc. 107 Forest Street, Middleton, MA 01949 (508) 774-2772 I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature:� Date: �e�U�e� 1z,, /4767 The System Inspector sha I submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of dtermination in all instances. If "not determined", explain why not The septic tank is metal, cracked structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) FILE# i() /a9,5 A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (cm+TiMuEd) B) SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced %C The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Iy Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a. surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D) SYSTEM FAILS: _ I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. �v Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. (revised 8/15/95) 2 FILE# 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) D) SYSTEM FAILS (continued) Static liquid level in the distribution box above oulet 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. n Required pumping more than 4 times in the last year iM due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. II V Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply... Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: `'The following criteria apply to large systems in addition to the criteria above: �- The design flow of system is 10,000 gpd or greater (Large System) and the -system is a significant threat to public health and safekand the environment because one or more of thg following conditions exist: the system is with ' 400 feet of a surface the system is within 200 fee a tributan the system is located in a.nitrogen se Zone II of a public water supply well) supply to a surface drinking water supply area (Interim Wellhead Protection Area (IWPA) or a mapped The owner or operator of any,such system shall bring the system and fadlity into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult, cal regional office of the Department for further information. -- (revised 8/15/95) 3 FILE# I O l a q 5A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: i Pumping information was requested of the owner, occupant, and Board of Health r 1' None of the system'components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. r The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non -sanitary or industrial waste flow. 1� The site was inspected, for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. r The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non -intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SubSurface Disposal System. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION RESIDENTIAL: Design flow: gallons Number of bedrooms:_ Number of current residents: Garbage grinder (yes org):IZz- Laundry connected to system (�ie or no):Y—C6 Seasonal use (yes or o Water meter readings, if available: Last date of occupancy: re n+ i ype o aonsnment: Design flow: alions/day Grease trap present: e r not) Industrial Waste Holding Tan - went: (yes or no Non -sanitary waste discharged to the -"T4 5 systE Water meter readings, if avialble: Last date of occupancy: OTHER: (Describe) Last date of occupancy: PUMPIN FLOW CONDITIONS or no) GENERAL INFORMATION System pumi ped as'par If yes, volume pumped: Reason for pumping: a- FILE#101a95A ql N yrs olds TYP OF SYSTEM / Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or()�j 6 (revised 8/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SEPTIC TANK:eS (locate on site an Depth below grade: 1 511 Material of construction: concrete Metal _FRP other(explain) Pre_, ('0'Gq C'r)r-)r)rr'Tr 15nn Dimensions: �I_dee'r2 Y / W1 *Oleo x I p , LgOA Baffle Depth Below Outlet I Sludge depth: 11 Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 6'' Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: /F1" Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid structural integrity, evidence of leakLe Le c Ta•� k / I _ . ♦ . __ SZ, / GREASE TRAP: /VO (locate on site pan) Depth below grade: Material of construction: _concrete _metal FRP —other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee Distance from bottom of scum to bottom of � ee or ffle�_ FILE# ) 0 / �;, q 5,4 i nyer� t' 7 A it in relation to outlet invert, Outlet Invert: Comments: (recommendation for p ing, condition of inlet and outlet tees or baffles, depth of liquid vel el in.relation to outlet invert, structural integri idence of leakage, etc.) (revised 8/15/95) 6 1 --FILE# /0 1 Q 9 5,-q SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) TIGHT OR HOLDING TANK: AJ6 (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments s' (condition of inlet toe ondition of alarm and float switches, etc.) DISTRIBUTION BOX: 'Vea (locate on site plan) Depth below grade: � Depth of liquid level above outlet invert: Ze.o Dimensions of D-Box:/z"x 32" Depth of Sump: 6" r /Sr"nt y' Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER: (locate on site plan Depth below grade: \ Pumps in working order:(yes Comments: (note conditions of pump chamber, Gond (revised 8/15/95) etc.) i FILE# ) 0 )_ a Q 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM (SAS): YeS (locate on site plan, if possible excavafion not required, but may be approximately by non -intrusive methods) Depth to bottom of SAS: •3G (Stone or Pit) Ap ox If not determined to be prese ;K_S Type: leaching pits, number: Zeaclw ea 's -9',r60 � leaching chambers, number: leaching galleries, number: leaching trenches, number, length: 6 — 6O.4-44c4s'"p Te.�ck leaching fields, number, dimensions: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) CESSPOOLS: "0 (locate on site p7an) Depth below grade: Number and configuration: Depth -top of liquid to in et-inveij; Depth of solids layer: a . Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groyndwa er: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:LC/Q (locate on site plan) Materials of construction: Depth of solids: Comments: (note condition of soil, failure, level o-f'pondiQZ condition of vegetation, etc.) (revised 8/15/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100'61f0eep Well sfers /coo D-3oK FILE# I() /a 95A A +o C = 3 7' 22 T%+9 C-!: 34' A+ --D= 4513" Ts to D5n C+OD= 6, i NecP-//4 �l�l t�q�ker Berry S�- /l�, /-�iJOfa✓�2r' DEPTH OF GROUNDWATER Depth to groundwater: 7 -ZX F"t feet method of determination or approximation: Frew" orlc;na i 4,rGL� G..aAr' C,,jas e -Z -f- fke 7z"+ &D" fHa-A z r�P./ci stiaWS Cicr,t nf- t.c;.,e i�s:��,✓ r_. s,,.e_:L 1L�. Ll� / - -- -- �•-- (revised 8/15/95) 9