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Home My WebLink AboutMiscellaneous - 336 BOSTON STREET 4/30/2018Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form ��EryE® p Subsurface Sewage Disposal System Form - Not for Voluntary Assessments JUL 10 2017 336 Boston Street TOWN OF NORTH ANDOVER Property Address All * r-PAPR Mark Ustik Owner's Name No Andover Ma 01845 3-8-17 City[rown State Zip Code Date of Inspection C. Checklist 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 been determined based on: this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not approximation of distance is unacceptable) [310 CMR 15.302(5)] 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): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17 PUBLIC HEALTH DEPARTMENT Town of North Andover Community and Economic Development Division CERTIFICATE OF COMPLIANCE As of: March 20, 2017 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Repair of D -Box Sewage Disposal System By: J and S Development Corp. Stewarts Septic At: 336 Boston Street Map 107.D Lot 25 North Andover, MA 01845 The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. Michele Grant Public Health Agent ELE COPY 120 Main St., North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.9542 Web www.northandoverma.gov Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. 'Jr Commonwealth of Massachusetts Title 5' Official Inspection Form [Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 336 Boston Street Property Address Mark Ustik Owner's Name No Andover CitylTown MA 01845 State Zip Code 3-8-17 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. RECEIVED A. General Information MAR 2 9 2017 Inspector: TOWN OF NORTH ANDOVER John DiVincenzo HEALTH DEPARTMENT Name of Inspector J and S development Corp. / Stewarts Septic Company Name 58 South Kimball St Company Address Bradford MA 01835 Cityrrown 978-372-7471 Telephone Number B. Certification State s113386 License Number 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needy Fprthej Eal ation byAfiie Local Approving Authority 3-20-2017 Date TMe 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 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.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 m Owner information is required for every page. Commonwealth of Massachusetts Title 5' Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 336 Boston Street Property Address Mark Ustik Owner's Name No Andover Cityrrown R. Certification (cont.) MA 01845 State Zip Code 3-8-17 Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: '4- Date . ® 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: Replaced dbox and inspected by town 3-20-2017 RecQmend removal of garbage grinder 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.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17 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 ❑ Ne9ds/FurlheAvalua� by the Local Approving Authority 1k 3-8-17 Date The system inspector shall mit a copy of this inspection report to the Approving Authority (Board of Health or DEP) wit days of completing this inspection. If the system 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.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Commonwealth of Massachusetts f . Title SOfficial Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 336 Boston Street Property Address Mark Ustik Owner Owner's Name information is required for every No Andover MA 01845 3-8-17 page. Cityrrown 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. RECEIVED Important: When A. General Information filling out forms 7 MAR � Q �01'� on the computer, use only the tab key to move yourTOWN 1. Inspector: OF NORTH ANDOVER cursor - do not the John DiVincenzo HFAI.TH DEPARTMENT use return key. Name of Inspector J and S development Corp. / Stewarts Septic r� Company Name 58 South Kimball St Company Address Bradford MA 01835 City/Town State Zip Code 978-372-7471 s113386 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: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Ne9ds/FurlheAvalua� by the Local Approving Authority 1k 3-8-17 Date The system inspector shall mit a copy of this inspection report to the Approving Authority (Board of Health or DEP) wit days of completing this inspection. If the system 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.doc • rev. 6/16 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 336 Boston Street Property Address Mark Ustik Owner's Name No Andover MA 01845 3-8-17 Cityrrown 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: Recomend removal of garbage grinder 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.doc - rev. 6/16 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 336 Boston Street Property Address Mark Ustik Owner's Name No Andover MA 01845 3-8-17 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ 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): dist box coroaded around outlet inverts ❑ 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.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 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 336 Boston Street Property Address Mark Ustik Owner's Name No Andover MA 01845 3-8-17 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 % day flow t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 336 Boston Street Property Address Mark Ustik Owner Owner's Name information is required for every No Andover MA 01845 3-8-17 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.doc • rev. 6/16 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 336 Boston Street Property Address Mark Ustik Owner Owner's Name information is required for every No Andover MA 01845 3-8-17 page. City/Town State Zip Code Date of Inspection C. Checklist 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): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 330 gpd t5ins.doc - rev. 6/16 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 336 Boston Street Property Address Mark Ustik Owner Owner's Name information is required for every No Andover page. City/Town MA 01845 3-8-17 State Zip Code Date of Inspection D. System Information Yes ❑ Description: ❑ Yes ❑ No ❑ Yes ❑ No Number of current residents: 4 ppl Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ® Yes ❑ No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) ❑ Yes ❑ No Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts M� W Title 5 Official Inspection Form m' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 336 Boston Street Property Address Mark Ustik Owner Owner's Name information is required for every No Andover MA 01845 3-8-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other (describe below): Date General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Stewarts 1500 gallons site quage on truck ® Yes ❑ No Reason for pumping: inspect tank Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) 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.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 336 Boston Street M Property Address Mark Ustik Owner Owner's Name information is No Andover MA 01845 3-8-17 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 35+ Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: feet Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): 102' Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): ❑ Yes ® No Septic Tank (locate on site plan): Depth below grade: 30"feet Material of construction: ® 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: t5ins.doc • rev. 6/16 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 336 Boston Street Property Address Mark Ustik Owner Owner's Name information is required for every No Andover page. City/Town D. System Information (cont.) MA 01845 3-8-17 State Zip Code Date of Inspection Septic Tank (cont.) 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 9 0 6" 15" How were dimensions determined? Tape measure, sluge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Both baffle good, no leakage, liquid level good Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: feet ❑ fiberglass ❑ polyethylene ❑ other (explain): 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: t5ins.doc • rev. 6/16 Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 336 Boston Street Property Address Mark Ustik Owner Owner's Name information is required for every No Andover MA 01845 3-8-17 page. 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.): 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.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 336 Boston Street Property Address Mark Ustik Owner Owner's Name information is No Andover required for every page. City/Town D. System Information (cont.) MA State 01845 3-8-17 Zip Code Date of Inspection Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 9 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.): Box needs replacing leakage around outlet inverts, crumbling around top , no sluge carry over 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.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 336 Boston Street Property Address Mark Ustik Owner Owner's Name information is required for every No Andover MA 01845 3-8-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system 2- pits Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No hydraulic failure , no ponding , no damp soils 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.doc • rev. 6/16 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 336 Boston Street Property Address Mark Ustik Owner Owner's Name information is required for every No Andover page. City/Town D. System Information (cont.) nnn 01845 3-8-17 Zip Code Date of Inspection Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 336 Boston Street Property Address Mark Ustik Owner Owner's Name information is required for every No Andover MA 01845 page. Cityrrown State Zip Code 3-8-17 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 t5ins.doc • rev. 6/16 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 336 Boston Street Property Address Mark Ustik Owner Owner's Name information is required for every No Andover MA 01845 3-8-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells r- +i11 tdd tht hh d tra R] s ma a ep o ig gf wa e . feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record 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: Dulled file ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Taken from title 5 10-8-96 no water in cellar, no pumps in cellar, cellar floor aprox 3' below pits Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc - rev. 6/16 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 �M 336 Boston Street MA State E. Report Completeness Checklist nlnnr uN -v 3-8-17 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.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 Property Address Mark Ustik Owner Owner's Name information is required for every No Andover page_ City/Town MA State E. Report Completeness Checklist nlnnr uN -v 3-8-17 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.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 s,rf E 8 """ Ooto , u®r1r0-0021 C'malow - 11 &� 7�j Ll r __ A Of pORTM 1h 90 Town of North Andover HEALTH DEPARTMENT CMUStt CHECK DATE:: LOCATION: -336 O S TG/ � H/O NAME: 0,51;h ✓ 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 $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Sustems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ Title 5 Report $ ❑ Other: (Indicate) $ Head Agent Initials White - Applicant Yellow - Health Pink - Treasurer • -' Application for Septic Disposal System Construction Permit - TOS OF NORTH 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. Application Is hereby made for a permit to: ❑ Construct a new on-site sewage disposal system* Az 0 / 7 Toi§Ayt IJATE $350.00 - Full Repair $975.00 - Component ❑ Repair or replace an existing on-site sewage disposal system* jCepair or replace an existing system component — What? l,.)t:S i 1G A. Facility Address or Lot # Fir's -11 FED Cityrrown 2.- *TYPE OF SEPW SYSTEM*: MAR L o 2017 ❑ Pump Btravity (choose one) ***If pumps tem, attach copy of electrical permit to application*'" TOWN OF NORTH ANDOVER ➢ (OConventional System (pipe and stone system) HEALTH DEPARTMENT ➢ ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system.) 9 ❑ Pressure Distribution S.A.S. (No D -Box) D ❑ Pressure Dosed (D -Box Present) S.A.S. 9 ❑ Does the system require an effluent filter? Yes No If yes, does plan specify make and model of filter? YES = (no further into. needed) NO = (installer must specify brand of filter before DWC issuance) What is the Make? U%atis the Model? 2. Owner Information �Q.r 1t V sfic c� Name Address (if different from above) City/Town Email address 3. Installer Information State Telephone Number Name Name of Company sh6m k >( Sr City/Town 4. Designer Information Address Zip Code 1%1d ale 3d State Zip Code Telephone Number (Cep Phone#Ypossibleplease) Name of Company City/Town state Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 • Application for Septic Disposal System Elk"; Construction Permit - TOWN OF TODAY'S DATE $350.00 - Full Reir NORTH ANDOVER, MA 01845 $175.00 - Component PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: residential Dwelling or ❑Commercial B. Agreement 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 Environmental Code, as wo as the Local Subsurface Disposal Regulations for the Town of NortlyA dover. nde and that until a final Certificate of Compliance has been issued by this rd f 1 e installed system is not approved. 0 12 e Date T/ Application Approved By: (Board of Health Representative) Name Application Disapproved for the following reasons: For Office Use Only: RECEIVED mAR 2 0 2017 Date TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 1. Fee Attached. Yes No 2. Project Manager Obligation Form Attached? Yes No 3. Fump System? If so, Attach co,ey ofElecttical PenWt Yes No Applicant deceived copy of `EkctricalInspection Notes for Septic Systems" Yes No Handout? 4. Reviewed approval letter, all paperwork received. Yes No Missing.• 5. Foundation As Built? (new construction only).- (Same nly).(Same scale as approved plan) Yes No 6. Floor Plans? (new construction only). Yes No Application for Disposal System Construction Permit - Page 2 of 2 PUBLIC HEALTH DEPARTMENT Community B Economic Development TOWN OF NORTIi ANDOVER SEPTIC DISPOSAL SYSTEM — INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System ( ) constructed; (tired; RECEIVE® r iJJy" -- 10 1017 y�,� (Print Name) Located at: �TOWN OF NORTH ANDOVER (installation Address) HEALTH DEPARTMENT Was installed in confonnance with the North Andover Board of Health approved plan, originally dated and last revised on , with a design flow of gallons per day. The materials used were in conformance with those specified on the approved plan; the system was installed in accordance with the provisions of 310. CMR 15.000, Title 5 and local regulations, and the final grading agrees substantially with the approved plan. All work is accurately represented on the As -built which has been submitted to the Board of Health. Bottom of Bed Inspection Date: Engineer Representative (Signature) And — Print Name Final Construction Inspection Date: _ Engineer Representative (Signature) And — Print Name Installer: M ) rU (Signature) Dater/✓�4 And — Print Name Engineer: (Signature) Date: And — Print Name 120 Main Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.9542 Web http://www.northandoverma.gov SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONNS As the North Ando *er licensed installer for the construction for the septic system for the property at: �() go 'L) '�)r (Address of septic system) Por plans by (1;ngineer) , r Relative to the application of IQ Le- (Installer's name) And dated 3holl? ngtna ate Dated o a}'s ate) \N% P North Andover Health Department [ommunity and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 336 Boston Street INSTALLER: Stewarts Septic DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: MAP: 107.D LOT: 25 DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ 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 ❑ 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 Comments: PUMP CHAMBER ❑ 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 Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION -BOX ® Installed on stable stone base ® H-20 D -Box ❑ Inlet tee (if pumped or >0.08'/foot) ® Hydraulic cement around inlet & outlets ® Observed even distribution ® Speed levelers provided (not required) ® Schedule 40 PVC Pipe Comments: 3/20/17 D -Box SOIL ABSORPTION SYSTEM (General) ❑ Bottom of SAS excavated down to C soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 40 Mil HDPE barrier installed ❑ Laterals installed and ends connected to header (and vented if impervious material above) ❑ Elevations of laterals and chambers installed as on approved plan ❑ Retaining wall (boulder / concrete / timber/ block) ❑ Final cover as per plan Comments: SOIL ABSORPTION SYSTEM (Gravel -less Chambers) ❑ Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ❑ Number of chambers per row: ❑ Number of rows (trenches): Comments: Total Chambers = FINAL GRADE ❑ Loamed ❑ Seeded ❑ Cover per plan Comments: DOCUMENTS NEEDED ❑ Certification of Installation Form submitted By engineer and signed and dated by Engineer and installer ❑ As -Built Plan BM = HR= HI = SYSTEM ELEVATIONS ROD AS -BLT INVERT ELEVATION ELEV DESIGN INVERT ELEV Benchmark Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 TOP Lateral 1 INVERT Lateral 2 TOP Lateral 2 INVERT Lateral 3 TOP Lateral 3 INVERT Lateral 4 TOP Lateral 4 INVERT Lateral 5 TOP Lateral 5 INVERT Lateral 6 TOP Lateral 6 INVERT Top of Chamber Bottom of Bed/Chamber SKETCH PLAN CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback 1 Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws Tank SAS Sewer ® Property line 10 10 -- ® Cellar wall 10 20 -- ® Inground pool 10 20 -- ® Slab foundation 10 10 -- ® Deck, on footings, etc 5 10 -- Waterline 10 10 101 ® Private drinking well 75 1002 50 ® Irrigation well 75 100 ® Surface Water 25 50 ® Bordering Vegetated Wetland , Salt Marsh, Inland / Coastal Banka 75 100 ® Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ® Trib. to surface water supply 325 325 ® Public well 400 400 ® Interim Wellhead Prot. Area ® Reservoirs 400 400 ® Drains (wat. supply/trib.) 50 100 ® Drains (intercept g.w.) 25 50 ® Drains (Other) Foundation 10 (5) 20 (10) ® Drywells 20 25 1 Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws I Y North Andover Health Department Community and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 336 Boston Street MAP: 107.D LOT: 25 INSTALLER: Stewarts Septic DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS Lj F TANK INSPECTION: 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 ❑ 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 Comments: PUMP CHAMBER ❑ 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 Comments: CONTROLPANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION -BOX Installed on stable stone base H-20 D -Box ❑ Inlet tee (if pumped or >0.08'/foot) Hydraulic cement around inlet & outlets Observed even distribution [✓]� Speed levelers provided (not required) Schedule 40 PVC Pipe Comments: 1 t 1eXcavated d°Wn to M lGenerorn of SPS \an as per On n pan Y� dot sago V p goo °��Sp,S eX°a \ed, �fi speed d to r e o, �nsta\ sta\\ eote f SiZ sand p5 00 in �a� o°nn materia\ p aid e eN�O�; as on 40 Mf\ 1s \nsta\\ ted if \rnp rs insta\\ed �atera d ve Gnambe I U O heaagr teca d) b°vel °{ \a onorete tD; �\evao ea p\a lb°U\der I ° Q � app a\ning wa\s'PeC p\ar to '' Flet °°veC a oo F;na\ tandard QU`Gk S Ghat bets){ _,,,bet. abet S el �e5 ode\ s G�av and M tuber r°v0 . $ys'cEM grana�rat°r Shampers Peel; p �pN 4 ��f�l e 0 cha S0R rube r°wS lt�erch gptL AB o Nu ber °{ 0 bers \ Gram °ta meats _ G0m ttco,.. C04 `i surd. acc Q -'j a� supP atcrs). .v I `9rca A, 55, 46, Sp 1 2S N�G'_'Ft \,°arc o Seeder per 9\2,n GO\j0 G°mments. 0 ub,�rtted Q� S NEE sta\\atr°n n a ted by oo�v drficat\on °and srgne d a 0 6e y e,4\ne and \nsta\ PS guy\t oan 0 w od for P�Suantto rills a / 1CL 5211(3) �a �so2 Iso by A14 yN14 I 03/20/2017 North Andover Health Department Community and Economic Development Division Address: 336 Boston Street All North Andover Residents with Septic Systems and Garbage Disposals Please note that due to a recent review of a Title 5 Report, your property has been identified as maintaining a working garbage disposal that is being used in conjunction with a septic system. The Health Department is concerned for the longevity of your septic system. Garbage disposals are never recommended where septic systems are used, but if they are installed, the system must be specifically designed to handle the waste from them; your system can not handle the waste as designed. Please note that continued use of this disposal could to quickly cause apre-mature failureHealth Depat recommends th t you large mo petdfrom your replace it. The North Andover p home as soon as possible. Some information regarding regular maintenanceyourseptic call te Health Department at 978.688.9540 if you have any questions, or e-mail your questions to healthdeptknorthandoverma. gov. Thank you for taking the time to consider the impact that your current setup has on your septic system and the environment. Sincerely, Brian LaGrasse, CEHT Director of Public Health 120 Main Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.9542 Web http://www.northandoverma.gov sysTEM VA Buil Chmark an Setip er our PSeptic Tankank /N - Pour UmpCp Chamber /, DiS�hamb IN ��tribUti°n 8 °UT UU017 gQ °k IN ca Lai ra/ � ooh taral T pP tater INv of < Lata //V SRT ateral 3 �� 3 T �P Cat t cl t°ra/ 4 TgRTOp Z,,- to tate a/ SVERT bra/S�N�TOP �atea/ 6 atara/ g RT OP r /NVRRT' ' T° RtOm Of B°arm ha I f t L, ECFV°D \r_ ATIA , ON F�E� FRT I DFStG� I nS iS- f1Ler� M4 16ao/ 7-0 612 4 y :�r, Lo7T z L:/ 'V vs/oivs..14LL Tu C E.v 7- 0 o o -000 lo9L �� j iSU.oa 0 Fq" M Fou, , ' ' Q - n.7 MAY,. i G4Sr �. .C)vc� \ oc.)c) _ 00 7 C�A�'T en S > , S EA`iK TA l ll( > . Al >< Ul GDac ETE EPA6E . FIT lU AFILE No SCALE O1 1-103 5 Rc _TEST T�sT: DAZE 'v'ATU T -)2 l5 M s k3sa� 3P�" S-ZO-7� 17,111-91,i i IY� Tc q1'—Co" �SMIN, V7 J if .. dog 7 r,.. 7 c ! � �� }• •, - --- "106 \ \ .1 Tt _koo \�v - t r i :nCasinFe harF-1;=4r-1 IFn r c I ♦A/L:Ct-\A/ 3 N cn ..1 \�v - t r i :nCasinFe harF-1;=4r-1 IFn r c I ♦A/L:Ct-\A/ 3 N ..1 M 1 _ 57 card C i r r• I �a In n _ r- sa va ri i n r•a nn ca 4e ec SOIL ABSORPTION SYSTEM (General) ❑ Bottom of SAS excavated down to C soil layer, Seeded as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 40 Mil HDPE barrier installed ❑ Laterals installed and ends connected to header (and vented if impervious material above) ❑ Elevations of laterals and chambers installed as on approved plan ❑ Retaining wall (boulder / concrete / timber/ block) ❑ Final cover as per plan Comments: SOIL ABSORPTION SYSTEM (Gravel -less Chambers) ❑ Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ❑ Number of chambers per row: ❑ Number of rows (trenches): Comments: Total Chambers = FINAL GRADE ❑ Loamed ❑ Seeded ❑ Cover per plan Comments: DOCUMENTS NEEDED ❑ Certification of Installation Form submitted By engineer and signed and dated by Engineer and installer ❑ As -Built Plan BM = _ HR = HI = SYSTEM ELEVATIONS ROD ELEVATION AS -BLT INVERT DESIGN INVERT ELEV ELEV Benchmark Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 TOP Lateral 1 INVERT Lateral 2 TOP Lateral 2 INVERT Lateral 3 TOP Lateral 3 INVERT Lateral 4 TOP Lateral 4 INVERT Lateral 5 TOP Lateral 5 INVERT Lateral 6 TOP Lateral 6 INVERT Top of Chamber Bottom of Bed/Chamber SKETCH PLAN CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback ' Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws Tank SAS Sewer ® Property line 10 10 -- ® Cellar wall 10 20 -- ® Inground pool 10 20 -- ® Slab foundation 10 10 -- ® Deck, on footings, etc 5 10 -- ® Waterline 10 10 101 ® Private drinking well 75 1002 50 ® Irrigation well 75 100 ® Surface Water 25 50 ® Bordering Vegetated Wetland , Salt Marsh, Inland / Coastal Banka 75 100 ® Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ® Trib. to surface water supply 325 325 ® Public well 400 400 ® Interim Wellhead Prot. Area ® Reservoirs 400 400 ® Drains (wat. supply/trib.) 50 100 ® Drains (intercept g.w.) 25 50 ® Drains (Other) Foundation 10 (5) 20 (10) ® Drywells 20 25 ' Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws II North Andover MIMAP March 20, 2017 107.D-0005 � 107.8-0030 r„o �hW 0 m 314 BOSTON ST / 107.D-0024322 BOSTON ST r r r� i I jI I 336 BOSTON ST 107.D-0025 11 107.6-0085 107.D-0114 _ 10 OLD CART WAY 107.D-0002 30 OLD CART WA 107.D-011'6, [3 MVPC Bo �.0 Municipal Boundary Horizontal Datum: MA Stateplane Coordinate System, Datum NAD83, — Rail Line Interstates AORTH Meters Data Sources: The data for this map was produced by Merrimack Valley Planning Commission (MVPC) using data provided by the Town of c Interstate — Major Road Of 't'to '6. q� CD North Andover. Additional data provided by the Executive Office of Environmental Affairs/MassGIS. The information depicted on this map is ? ee p - for planning purposes only. It may not be adequate for legal boundary - Roads r Easements 0 _ v, definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING ❑ Parcels M >f • i ^ !w THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT n Hydrographic Features i► o� ; ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF Streams 'jI o��t�c '..`y THIS INFORMATION -. Wetlands ,SSACNUS�t O Exempt Lands 1" = 63 ft ^�° t: S , p.. f e1 Y{•4 �l1'yk �bF�Y Y: r - Af Zi'F- (� 1i /LM ,, `Lta�;r .sk{b nf.1t ;,j _ ,��1..•t 1 y, .c. ,Y ; ✓ 17�,�1��' � 6a t �_ rl = e r f jI -•e: ar 'W , tS. X rr 'f. « 3 `` i ii"r`'. f ,J. r}'I, r y e t J - . S r'7 f 1 ra I~ 1 .:r+ tom' i. 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( ..1.1.W ) . �E$'/�Jl/... .L'`.NCr/1`% �``f+�. %Y?. r,:. \ t .Ipr il ,Qv Y.1�j�i >->' ->i_ i. ,�thl ._, . t- ,.t 1 CEkl.Y �: S. S. 1.r '� , `r5�', i '( ?Nr-sem, +' : + fi 1 - r I y. y: �r7 /MS•Ti9GG$i ti' y f r/ n 4 c"G o_A� i✓/ rI �, "T J �C . I I . F rt nt ; ?r L z t{ r q +' I. r! { ' ! Y?r + 1 L i,� r t� < !' r .-'f 5 i y 1 " b '„ � ~ t .�_ ~~ t ..r ''. I . rr r ♦� ( t w( 1 4 Y r t r P , I 'r }r S Td r ( ti `FMf t t 2 ApA QN, r . x,. 7 r �� 4 ' f v.�+..+w . V. t . w _ 2. s. i t r u '(. I e .g , ! ti r, J< w r a G r or + y rr 4 1- i - .t 2 , l./S4 � D'? r ' o f t : , < 4 �'- 1 ): r. ,�'* •y Het t Fr's/ ' :'._ i , w .i ; v' 1 t � 3 u ON, L 1 /7% .. . ....... q kt y"i tII y, q kt y"i q kt A d William F. Weld Governor Trudy Coxe Seentary, EDEA David B. Struhs Comminioner Commonwealth of Massachusetts Execufive Office of Environmental Affairs Department of Environmental j,, DRTH RI ` fOWiV 0 r,q OF �-.L_Hr -, BOA. E 1 Protection SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 7 PART A 2 CERTIFICATIOiN�1��[/ 0Property Address: 3 3 0S 7-0 � �J /,/,Address of Owner: Date of Inspection: 46; (If different) Name of Inspector: Company Name, Address and Telephone Number: / ,q0 00 f 2. �<--p ;kfG 41-) 2#/ 4.a -o4 a 5-1- CERTIFICATION 1CERTIFICATION STATEMENT /_V�&,-rY'ti l / /r 1qA 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 py1per function and maintenance of on-site sewage disposal systems. The system: �/ Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fail Inspector's Signature: At4r Date: The System Inspector shall 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]M PASSES: 1 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: t( 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 determination 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) One Winter Street a Boston, Massachusetts 02108 a FAX (617) 556-1049 a Telephone (617) 292-5500 i Printed on Recycled Paper V \ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: (a V Py Owner: Date of Inspection: r Ile 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 distributioA 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 C] FURTHER EVALUA ION IS REQUIRED BY THE BOARD OF HEALTH:`" bf t 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: Cess dol Q, privy is within 50 feet of a surface water Cesspool o piivy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL U LESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNC ONING 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 fee! 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_votatile.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 determPned that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis Y B for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or dogged 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) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATI0 (continued) Property Address: 33 6 Owner: / �� Date of Inspection: D] SYSTEM FAILS (continued): Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the 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. f 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. El 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 safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST �3 Property Address: Owner: Date of Inspection: Check if the foil wing have been done: Pu ping information was requested of the owner, occupant, and Board of Health. XndNoneofthe system components have been pumped for at least two weeks and the system has been receiving normal flow rates g that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. suilt plans have been obtained and examined. Note if they are not available with N/A. <hefacility or dwelling was inspected for signs of sewage back-up. �he system does not receive non -sanitary or industrial waste flow The site was inspected for signs of breakout. -<A .system components, excluding the Soil Absorption System, have been located on the site. Th "septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or �tk�es, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. Thesize and location of the Soil Absorption System on the site has been determined based on existing information or aroximated by non -intrusive methods. The facility o%, ner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub - Surface Disposal System. (revised 8/15/95) 4 0 Property Address: Owner: Date of Inspection: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 3 'ps f v.y Sr . Q • %;-,moi D / 0 ep-fG Ht Ile W RESIDENTIAL: Design flow: gallon' Number of bedrooms: Number of current residents: Garbage grinder (yes or no): Laundry connected to system yes or no): Seasonal use (yes or no):� 41 Water meter readings, if available: m, ,e do Last date of ry� occu an G v P I c occupancy: FLOW CONDITIONS COMMERCIAUINDUSTRIAL: 1 Type of establishment: /` f Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non -sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) _ Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: ✓1 X y System pumped as part of inspection: (yes or no)_ If yes, volume pumped Qallons Reason for pumping: PJ Af- 0'4+°) �% 1rh1 /f �'�► TYPE % STEM 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 no) _ (revised 8/15/95) u SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: S r Owner.: /a. dee f //P Date of Inspection: /-7/f ! SEPTIC TANK: I05 (locate on site plan) Depth below grade: ; r Material of construction: concrete _metal _FRP —other(explain) Dimensions: 3 0 W `f Sludge depth: 1W" i 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: 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.) 7-0 R k Alo G -P 2 -t - GREASE TRAP:_ 14-9. (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Scum thickness. Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum t� bottom of outlet tee or battle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 8/15/95) 6 1� i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: (��4 . �F DO Owner: � f Date of Inspection: /0 TIGHT OR HOLDING TANK:_ (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: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ e' (locate on site plan) / Depth of liquid level above outlet invert: 'fv Comments: (note if level and distributor i< equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) A40 t- e J44 2-1-C PUMP CHAMBER:_ (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C l SYSTEM INFORMATION (/continued) Propecty`Address: 3 rO OS T a q r' �►'7 1'P G V f I/ Owner: Date of Inspection: / !� SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible, excav tion not required, but may be approximated by non -intrusive methods) If not determined to be present, explain: Type. t - leaching pits, number: Uzi /( leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) CESSPOOLS: _ (locate on site plan) Number and configuration: Depth -top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) PropeAddress: Own10 s.- ! 1 e Date o� Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' •I 5,T (Le C -r ! 4 ..rr.rw. 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