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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617).292-5500
TRUDY CORE
ARGEO PAUL CELLUCCI ' Secretary
Governor DAVID B. STRUHS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
noo
fo r o- CERTIFICATIONnh r0s
Property Address: Name of Owemi'
Date of Inspection: /�•'�" Address of O`
Name of Inspector: (Please Printf
I am a D app stem KIIspecta Pursuant to Section 15. ,of Title 5 (310 CMR 15.000)
Company Name: \ ee'V-A h CZ
Mating Address: o f
Telephone Number:
24
CERTIFICATION STATEMENT
I certify that 1 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:
jeoPasses
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fail
HInspectors Signature: fo���
Date: ��� -`
The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)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.
NOTES AND COMMENTS E S eq
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Arc) S;
revised 9/2/98
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Page 1 of 11
C, PnMed on Regcled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
S -V CERTIFICATION (continued)
Property Address:
Date of Ihs( n:
INSPECTION SUMMARY: A, B, C, o/ A
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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.
Indicate yes, no, or not determined.(Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection: or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
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
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
sa'
revised 9/2/98 Page 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
Pr Addr �✓ 3 �5 r�� J � CERTIFICATION (continued) `
N. �1� O\j
owner:
Date of Inspect.on: � o 2 6 I98
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N/A
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to prote
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 (1)(b) THAT THE S%
IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
x
revised 9/2/98 Page 3of11
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
3
Fohe-,&
Property Addy , a e\ i . V �,N\\`( �^Date of Inspechon� t 6'j
v`S (J`�}� �+\f
D. SYSTEM FAILS: 2-6
You must indicate either "Yes" or "No" to each of the following:
1 have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes _Nor
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
/\ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
F Number of times pumped _.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
�( Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
(` Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a public
water supply well) ".
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 Page 4of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Address: 3 s Fo V-eSA S+' x
Property � � t� �� l� C'
Owner:
av e�
Date of Inspection:
Ap
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
No
Pumping information was provided by the owner, occupant, or Board of Health.
0
_
None of the system components have been pumped for at least two weeks and the system has been receiving normal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
_
The facility or dwelling was inspected for signs of sewage back-up.
_
The system does not receive non -sanitary or industrial waste flow.
_
The site was inspected for signs of breakout.
\ _
All system components, excluding the Soil Absorption System, have been located on the site.
_
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
Existing information. For example, Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
11 SM2(3)(b)]
_
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
SubSurface Disposal Systems.
P't
revised 9/2/98 Page 5of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: _ j
Focesi �r-
Owner:
Date of Inspection: 1 p�
.j FLOW CONDITIONS
RESIDENTIAL -
Desi n flow:
Design g.p.d.lbeV
m.
Number of bedrooms (design):Nmber of bedrooms (actual):_y ( `preTotal DESIGN flow 4
Number of current residents:_
Garbage grinder (yes or no):
A-0
Laundry (separate system) (yes or no)" If yes, separate inspection required
Laundry system inspected(yesor no) „� n
Seasonal use (yes or no): 1`�b 1V 1 1 Aj
Water meter readings, if available (last two year's usage (gpd):
`�
Sump Pump (yes or no) ------
Last
b
Last date of occupancy
�-
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: qpd ( Based on 15.203)
Basis of design flow
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:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)_ �+
If yes, volume pumped: 1�Q gallons
Reason
Reason for pumping:'
TjTE OF SYSTEM
o
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
VA Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
t.. APPROXIMATE AGE of all components, date installed (if (nown) and source of information: / 7-5—
Sewage odors detected when arriving at the site: (yes or no) -!� 0
revised 9/2/98 Page 6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMA ON (continued)
Property Ad
Fore
m
\\�
Owner:
Date of Inspection:
BUILDING SEWER:
(Locate on site plan) /
Depth below grade: 3
a+� Material of construction: %cast iron IC 40 PVC _ other (explain)
Distance from private water supply well or suction line
Diameter /i - °
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:_ ves
(locate on site plan) 99,
Depth below grade: Cp
Material of.construction: XIoncrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance _ (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 outle tee or baffle:
How dimensions were determined:
Comments:
(locate on site plan)
Depth below grade:_
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.) Pe
revised 9/2/95 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
y� SYSTEM INFOR ATION (continued)
Property Address: Fc) 1 � (iw er
Owner: "
Data of Inspection:
t6
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade:_
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order: Yes _ No_
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
1 `
DISTRIBUTION BOXY'e—�
(locate on site plan)
Depth of liquid level above outlet invert: c)
I
Comments: j�f k
(note if level and distribution is equal, evidence of soli s carryover, evi ce of kage in o or out of box, etc.) �`�'
Ny-
PUMP CHAMBER:__�k V ��-w es
(locate on site plan) SYS e'er Cs S)
a
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.)
e
revised 9/2/98 Page 8of11
a
l�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Addr :�ar�s�si'•�
Owner:o�
Date of Inspection: /
SOIL ABSORPTION SYSTEM (SAS) -_Y S
(locate on site plan, if possible; excavation no required,
ccjatio mebe proximated b non -intrusive methods)
If not located, explain:�G��
Type:
leaching pits, number:_
leaching chambers, number:
leaching galleries, number:_
leaching trenches, number, length:
leaching fields, number, dimensions: e,
overflow cesspool, number:_
Alternative system:
. Name of Technology:
Comments: '
(note conditipn of
CESSPOOLS- _
(locate on site plan)
-qts \Is� H L��e
61
level of ponding, damp
Number and configuration:
Depth -top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
(Q -9W Cache
condition of ve9etation, etc.) ,t-3
�-r L— 1T3z arc rV
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: tc
Comments:
(note conditionofsoil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
revised 9/2/98 Page 9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
YSTEM INFORMATION (continued) i ��
Property Address• � �^ I V �� ow 1
Owner:
Date of Inspection: w
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
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revised 9/2/98��6'hiws� Page to of 11
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OwnerPro:
Add _,ls q Q,` ` ` 3 s
Owner: ((vv;;��
Date of Inspection:
® 264
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
St. N' N*SQve1 ((
N
NRCS Report name i-.»UUA 17
Soil Type_
Typical depth to. groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow
SITE EXAM Slope
Surface waterC
1/ v
Check Cellar
Shallow wells
Estimated Depth to Groundwater Feet
Moderate Deep,
u�.-�Sac�t•��iar� ezc ose� �eP�i�1
Please indicate all the methods used to determine High Groundwater Elevation:
S
_ Obtained from Design Plans on record
�Observed Site (Abu ting property, observation hole, basement sump etc.)
j_
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators, installers
SOAUsed USGS Data Q l(\ S (J` � ` 2 C �
Describe how you established the High Groundwater Elevation. (Must be completed)
n
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et.
revised 9/2/98 Page 11 of 11
FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
*--*—� *•-**********'-**-******APPLICANT FILLS OUT THIS SECTION*—/,V
APPLICANT f��GG E�rG���is
PHONE
PARCELLOCATION: Assessors Assessor's Map Number
SUBDIVISION LOT (S)
STREET 33J ��T ST. NUMBER
;F(
******OFFICIAL USE ONLY*'*' *'**"`**RECOMME A I SW AGEN S,I�`� ,,
ONSERVATIOWACfMINITrRATOR
COMMENTS
�TATEAPPROVED
DATE REJECTED_
TOWN PLANNER
COMMENTS
FOOD INSPE
R-HEALTH�—
TI SPECTOR-HEALTH
COMMENTS
DATE APPROVED
DATE REJECTED_
DATE APPROVED
DATE REJECTED_
DATE APPROVED
DATE REJECTED_
PUBLIC WORKS - SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR
DATE
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10-14-1999 07:17AM FROM
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9
Towyn of North Ando rer, Mie,
Watershed Septic System
servicing Report
Date : _ , OL `_(�:'
Homeowner: �2 J pit PumpE_r (3 v\,
Street fd� P�S� �—� Address : i�
Phone : t&q— PhonE: L&S 1 I� j
Nature of Service: Routine
Emergency
Observations: Good Condition W�
Full to Cover
Baffles in P1acE:
Leachfield Runback ►y0
Excessive Solids; m
Heavy Grease
Roots NQ
Other (Explain)
Description of Work: I 1
Comments:
FORM 4 - SYSTEM PUMPING
CURRIER
SEPTIC & DRAIN SERVICE
107 FOREST STREET; MIDDLETON, MA 01949
(978) 774-2772
COMMONWEALTH OF MASSACHUSETTS
k- 4M -vac , MASSACHUSETTS
SYSTEM PUMPING RECORD
SYSTEM OWNER:
/�G 11.11 J3 - '.
-33!;- %v1 -e5+ 5-f A- AAIPI tpl-
3 % 4
DATE OF PUMPING: �U " 2 /
C)
SYSTEM LOCATION:
T
C(-. lir /-c'
G
QUANTITY PUMPED:_ GALLONS
CESSPOOL: NO F --j YES 0 SEPTIC TANK: NO 0 YES
SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE
CONTENTS TRANSFERRED TO:
DATE: INSPECTOR:
Commonwealth of Massachusetts
City/Town ofP
a System Pumping Record
w Form 4 DEC '14 2M
DEP has provided this form for use by local Boards of Health. Other apff � Tif P R
information must be substantially the same as that provided here. B ' with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left front of house, right front of hous side of ho right side of house, Left
rear of house, right rear of house, left side of building, right rear of building, under deck.
Cityrrown State Zip Code
2. System Owner:
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
s(n(�--coo aIUY
Telephone Number
'�5- - -3-/v
Date 2. Quantity Pumped:
Cesspool(s) eptic Tank
Gallons
❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes Qo I If yes, was it cleaned? ❑ Yes ❑ No
5. ConditioW
ystem: �'e J� k� V
` \
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
_Bateson Enterprises Inc.
Company
7. Lo tiaQ here contents were disposed:
L.S.
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
�.:..��+ I^_� ti3��� i�1 j
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"� �';;r is 3:i
-.,v,. muco Lnis land issue for us, it would be most
appreciated. It's been such a pain for my parents and at this point they
have hit a dead end. Here is the full story as I know.
it...
A law was going to be passed in North Andover which prohibits the
building on any lot that is less than 2 acres. If anyone wanted to
build on smaller lots, the subdivision had to be filed before a certain
date and the smaller lot would then be grandfathered in`.as.a buildable
lot.
My parents are Mykolas and Janina Gavelis. They live at 335 Forest
Str-eet, FzA.
On April 15, 1987, Christiansen Engineering, Inc, surveyed my parents' 7.
acre property and subdivided it into three parts. This subdivision was
filed on April 30, 1987 and received by Charli2 Trombly (jr?).
The original lot was on plan 38295A (title #7352). The subsequent
�• `
subdivisions can be seen on Plan 38295B. TYie lot in question is listed
as L.C. no. 41886A, Cert. no.10229 and referred to as "Lot 1" on plan
38295B.
Other notations on the plan i have show that the Essex North Registry
District received the subdivision for Registration+at 11:40am on April
4, 1989. I do not know why the subdivision is recorded in 1987 and
-
registered w/ the county in 1989.
On April 22, 2002, my parents received a letter from the local building
inspector (Michael McGuire) stating that lot 1 is not Vgaldable due to
its size. He did not recognize lot 1 as being grandfathered in as a
buildable lot. •
Anyway, my parents have been paying taxes on lot 1 as a buildable lot
since 1987. What they would like to have happen, is that lot 1 be
recognized as a buildable lot at its current dimensions. Should this
not be possible, they would like to be reimbursed the 15 years of
overpayment of property taxes.
My parents have hit a dead end in this matter. If you could help us
out, we would greatly appreciate it.
It you have any questions, please call me on my cell phone (617)233-2129
(or my mother: Janina Gavelis 978-688-7077).
I
Mark H. Rees
Town Manager
TO:
FROM:
DATE:
RE:
TOWN OF NORTH ANDOVER'
TOWN HALL is
120 MAIN STREET
NORTH ANDOVER, MASSACHUSETTS 01845
MEMO
Robert Nicetta, Building Commissioner
Mark H. Rees, Town Manager
July 26, 2002
Land Status Inquiry
Telephone (978) 688-951C
LL
FAX
(678),68&-9556
Y Lt
A member of the Board of Selectmen forwarded me an inquiry the member received from a
resident regarding the status of a certain parcel of land on Forest Street. Could you please review their
inquiry/concern and respond to me by August I" with your department's position on the matter. ;
Thank you for your continued assistance.
MHR/kar
Enclosure
Cc: Heidi Griffin, Community Development Director
Rees, Mark
to: Wendy Wakeman
Subject: FW: Land Status Inquiry — 335 Forest Street
FYI
-----original Message -----
From: Nioetta, Robert
Sent: Tuesday, July 30, 2002 4:56 PM
To: Rees, Mark
ca Griffin, Heidi; D'Agata, Donna Mae
Subject: Land Status Inquiry -- 335 Forest Street
Mark; I received your inquiry for the status of the above parcel or land in this afternoon's mail. I will not be able to
respond to your query by August 1st as I am leaving for vacation tomorrow the 31st. I phoned Mrs. Janina Gavelis's
daughter Rita Gavelis and asked permission to answer her zoning question when I return from vacation on August 19th.
Ms. Gavelis was kind enough to extend the response time until I return. Hope this meets with your approval. Thanks,
Bob
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