HomeMy WebLinkAboutMiscellaneous - 336 SHARPNERS POND ROAD 4/30/2018 (2)t 3� TOWN OF NORTH ANDOVER °f ,►ORTN 7 Office of COMMUNITY DEVELOPMENT AND SERVICES o ``t +., ° HEALTH DEPARTMENT 400 OSGOOD STREET NORTH ANDOVER, MASSACHUSETTS 01845 CHU Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone978.688.9542 —FAX Public Health Director E-MAIL: healthdept@townofnorthandover.com WEBSITE: hqp://www.townofnorthandover.com April 11, 2005 To all Sharpeners Pond Road Residents: Please note that it has come to the attention of the Health Department that many residents are leaving their trash barrels and trash bags out at the curbside for days, or weeks at a time. Empty trash barrels blowing about in the road are a safety hazard, and trash and debris along the roadway is a health hazard. Please be mindful of this, as the Health Department will conduct periodic inspections of the area to determine who is in violation, and fines will be issued if protocol is not followed. The Board of Health follows the State Sanitary Code regarding Human Habitation, 105.CMR.410, Section 1: 410.600 (A): Garbage or mixed garbage and rubbish shall be stored in watertight receptacles with tight- fitting covers. Said receptacles and covers shall be of metal or other durable, rodent -proof material. Rubbish shall be stored in receptacles of metal or other durable, rodent -proof material. Garbage and rubbish shall be put out for collection no earlier than the day of collection. (B): Plastic bags shall be used to store garbage or mixed rubbish and garbage only if used as a liner in watertight receptacles with tight -fitting covers as required in 105 CMR 410.600(A), provided that the plastic bags may be put out for collection except in those places where such practice is prohibited by local rule or ordinance or except in those cases where the Department of Public Health determines that such practice constitutes a health problem. For purposes of the preceding sentence in making its determination the Department shall consider, among other things, evidence of strewn garbage, torn garbage bags, or evidence of rodents. 410.602 (A) Land. The owner of any parcel of land, vacant or otherwise, shall be responsible for maintaining such parcel of land in a clean and sanitary condition and free from garbage, rubbish or other refuse. The owner of such parcel of land shall correct any condition caused by or on such parcel or its appurtenance which affects the health or safety, and well-being of the occupants of any dwelling or of the general public. (D) Common Areas. The owner of any dwelling abutting a private passageway or right-of-way owned or used in common with other dwellings or which the owner or occupants under his control have the right to use or are in fact using shall be responsible for maintaining in a clean and sanitary condition free of garbage, rubbish, other filth or causes of sickness that part of the passageway or right-of-way which abuts his property and which he or the occupants under his control have the right to use, or are in fact using, or which he owns. tf Residents should know the following: The Town has a mandatory paper and cardboard recycling ordinance that requires residents to separate these items from their household trash. Paper and cardboard are collected every other week on the same day as the household's normal trash. Residents can call the DPW at 978.685.0950 to get their recycling schedule. • Residents are responsible for picking up loose trash left at the curb after collection. Banned Items and Recycling Requirements: Please refer to the DPW website for a complete list of all the recycling requirements: http://www.northandoverrecycles.com. Please contact the Health Department if you have any additional questions. Thank you. ZSincere / an Y. Sawyer, REHS/RS Public Health Director File 107 FOREST STREET MIDDLETON, MA 01949 (978)774-7122 FILE # 32902A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PROPERTY OWNER'S NAME: DOLLOF PROPERTY ADDRESS: 336 SHARPNERS POND RD.NORTH ANDOVER,MA ADDRESS OF OWNER: SAME (IF DIFFERENT) DATE OF INSPECTION: MARCH 29 2002 NAME OF INSPECTOR: THOMAS CHIGAS THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION PROPERTY ADDRESS: 336 SHARPNERS POND RD. NAME OF OWNER: DOLLOF NORTH ANDOVER,MA ADDRESS OF OWNER: SAME DATE OF INSPECTION: MARCH 29, 2002 NAME OF INSPECTOR: (PLEASE PRINT) THOMAS CHIGAS COMPANY NAME: CURRIER ENVIRONMENTAL SOLUTIONS, CORP. MAILING ADDRESS: 107 FOREST STREET: MIDDLETON, MA 01949 TELEPHONE NUMBER: (978) 774-7122 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 INSPECTION. THE INSPECTION WAS PREFORMED BASED ON MY TRAINING AND EXPERIENCE IN THE PROPER FUNCTION AND MAINTENANCE OF ON-SITE SEWAGE DISPOSAL SYSTEM. I AM A DEP SYSTEM APPROVED INSPECTOR PURSUANT TO SECTION 15.340 OF TITLE 5 (310 CMR 15.000). THE SYSTEM: PASSES YES CONDITIONALLY PASSES YES NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY FAILS INSPECTOR'S SIGNATURE: �� DATE: MARCH 29, 2002 THE SYSTEM INSPECTOR SHALL SUBMIT A COPY OF THIS INSPCTION 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. NOTES AND COMMENTS: THE D -BOX IS LOCATED UNDER WALKWAY,AND THE WALKWAY HAS SETTLED AN PUSH BOX INTO GROUND.THE D -BOX IS IN POOR CONDITION AND OUTLET LATERALS ARE PITCHING THE REVERSE DIRECTION. **** 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. REVISED 6/15/2000 PAGE 1 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (CONTINUED) PROPERTY ADDRESS: 336 SHARPNERS POND RD. OWNER: DOLLOF DATE OF INSPECTION: MARCH 29.2002 INSPECTION SUMMARY: CHECK A, 0,©D ORE/ ALWAYS COMPLETE ALL OF SECTION D A. SYSTEM PASSES: NO I HAVE NOT FOUND ANY INFORMATION, WHICH INDICATES THAT ANY OF THE FAILURE CRITERIA DESCRIBED IN 310 CMR 15.303 OR 310 CMR 15.304 EXIST. ANY FAILURE CRITERIA NOT EVALUATED ARE INDICATED BELOW. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: YES ONE OR MORE SYSTEM COMPONENTS AS DESCRIBED IN THE "CONDITIONAL PASS" SECTION NEED TO BE REPLACED OR REPAIRED. THE SYSTEM, UPON COMPLETION OF THE REPLACEMENT OR REPAIR, AS APPROVED BY THE BOARD OF HEALTH, WILL PASS. ANSWER YES, NO, OR NOT DETERMINED (Y, N, OR ND) IN THE FOR THE FOLLOWING STATEMENTS. IF "NOT DETERMINED," PLEASE EXPLAIN. NO THE SEPTIC TANK IS METAL AND OVER 20 YEARS OLD OR THE SEPTIC TANK (WEATHER 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 PAS INSPECTION IF IT IS STRUCTURALLY SOUND, NOT LEAKING AND IF A CERTIFICATE OF COMPLIANCE INDICATING THAT THE TANK IS LESS THAN 20 YEARS OLD IS AVAILABLE. ND EXPLAIN: YES OBSERVATION SEWAGE BACKUP OR BREAKOUT OR HIGH STATIC WATER LEVEL IN THE DISTRIBUTION BOX IS 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 THE BOARD OF HEALTH). NO BROKEN PIPE (S) ARE REPLACED NO OBSTRUCTION IS REMOVED YES DISTRIBUTION BOX IS LEVELED OR REPLACED ND EXPLAIN: NO 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): NO BROKEN PIPE (S) ARE REPLACED NO OBSTRUCTION IS REMOVED REVISED 6/15/2000 PAGE 2 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (CONTINUED) PROPERTY ADDRESS: 336 SHARPNERS POND RD. OWNER: DOLLOF DATE OF INSPECTION: MARCH 29.2002 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: YES 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 IN ACCORDANCE WITH 310 CMR 15.303 (1)(B) THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: N/A CESSPOOL OR PRIVY IS WITHIN 50 FEET OF SURFACE WATER N/A CESSPOOL OR PRIVY IS WITHIN 50 FEET OF A BORDERING VEGETATED WETLAND OR A SALT MARSH. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF ANY) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH, SAFETY AND ENVIRONMENT: NO 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. NO THE SYSTEM HAS A SEPTIC TANK AND SAS AND THE SAS IS WITHIN A ZONE I OF PUBLIC WATER SUPPLY. NO THE SYSTEM HAS A SEPTIC TANK AND SAS AND THE SAS IS WITHIN 50 FEET OF A PRIVATE WATER SUPPLY WELL. YES THE SYSTEM HAS A SEPTIC TANK AND SAS AND THE SAS IS LESS THAN 100 FEET BUT 50 FEET MORE FROM A PRIVATE WATER SUPPLY WELL. METHOD USED TO DETERMINED DISTANCE -97'. THIS SYSTEM PASSES IF THE WELL WATER ANALYSIS, PERFORMED AT THE 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. 3) OTHER: NO REVISED 6/15/2000 PAGE 3 OF 1 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (CONTINUED) PROPERTY ADDRESS: 336 SHARPNERS POND RD. OWNER: DOLLOF DATE OF INSPECTION: MARCH 29 2002 D. SYSTEM FAILURE CRITERIA APPLICABLE TO ALL SYSTEMS: YOU MUST INDICATE "YES" OR "NO" TO EACH OF THE FOLLOWING FOR ALL INSPECTIONS: YES NO YES BACKUP OF SEWAGE INTO FACILITY OR SYSTEM COMPONENT DUE TO AN OVERLOADED OR CLOGGED SAS OR CESSPOOL. NO DISCHARGE OR PONDING OF EFFLUENT TO THE SURFACE OF THE GROUND OR SURFACE WATERS DUE TO AN OVERLOADED OR CLOGGED SAS OR CESSPOOL. YES STATIC LIQUID LEVEL IN THE DISTRIBUTION BOX ABOVE OUTLET INVERT DUE TO AN OVERLOADED OR CLOGGED SAS OR CESSPOOL. N/A LIQUID DEPTH IN CESSPOOL IS LESS THAN 6' BELOW INVERT OR AVAILABLE VOLUME IS LESS THAN % DAY FLOW. NO REQUIRED PUMPING MORE THAN 4 TIMES IN THE LAST YEAR NOT DUE TO CLOGGED OR. OBSTRUCTED PIPE (S). NUMBER OF TIMES PUMPED NO ANY PORTION OF THE SAS, CESSPOOL OR PRIVY IS BELOW THE HIGH GROUND WATER ELEVATION. N/A ANY PORTION OF A CESSPOOL OR PRIVY IS WITHIN 100 FEET OF A SURFACE WATER SUPPLY OR TRIBUTARY TO A SURFACE WATER SUPPLY. N/A ANY PORTION OF A CESSPOOL OR PRIVY IS WITHIN A ZONE I OF A PUBLIC WELL. N/A ANY PORTION OF A CESSPOOL OR PRIVY IS WITHIN 50 FEET OF A PRIVATE WATER SUPPLY WELL. N/A ANY PORTION OF A CESSPOOL OR PRIVY IS LESS THAN 100 FEET BUT GREATER THAN 50 FEET FROM A PRIVATE WATER SUPPLY WELL WITH NO ACCEPTABLE WATER QUALITY ANALYSIS. [THIS SYSTEM PASSES IF THE WELL WATER ANALYSIS, PERFORMED AT A DEP CERTIFIED LABORATORY, FOR COLIFORM BACTERIA AND VOLATILE ORGANIC COMPOUNDS INDICATES THAT THE WELL IS FREE FROM POLLUTION FROM THAT FACILITY AND THE PRESENCE OF AMMONIA NITROGEN AND NITRATE NITROGEN IS EQUAL TO OR LESS THAT 5 PPM, PROVIDED THAT NO OTHER FAILURE CRITERIA ARE TRIGGERED. A COPY OF THE ANALYSIS MIST BE ATTACHED TO THIS FORM.] NO (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 TO 15,000 GPD. YOU MUST INDICATES EITHER "YES" OR "NO" TO EACH OF THE FOLLOWING: (THE FOLLOWING CRITERIA APPLY TO LARGE SYSTEMS IN ADDITION TO THE CRITERIA ABOVE) NO 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 NO THE SYSTEM IS WITHIN 400 FEET OF A SURFACE DRINKING WATER SUPPLY NO THE SYSTEM IS WITHIN 200 FEET OF A TRIBUTARY TO A SURFACE DRINKING WATER SUPPLY NO 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. REVISED 6/15/00 PAGE 4 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PROPERTY ADDRESS: 336 SHARPNERS POND RD. OWNER: DOLLOF DATE OF INSPECTION: MARCH 29, 2002 CHECK IF THE FOLLOWING HAVE BEEN DONE. YOU MUST INDICATE "YES" OR "NO" AS TO EACH OF THE FOLLOWING: YES NO YES PUMPING INFORMATION WAS PROVIDED BY THE OWNER, OCCUPANT, OR BOARD OF HEALTH. NO WERE ANY OF THE SYSTEM COMPONENTS PUMPED OUT IN THE PREVIOUS TWO WEEKS? YES HAS THE SYSTEM RECEIVED NORMAL FLOWS IN THE PREVIOUS TWO-WEEK PERIOD? NO HAVE LARGE VOLUMES OF WATER BEEN INTRODUCED TO THE SYSTEM RECENTLY OR AS PART OF THIS INSPECTION? N/A WERE AS BUILT PLANS OF THE SYSTEM OBTAINED AND EXAMINED? (IF THEY WERE NOT AVAILABLE NOTE AS N/A) YES WAS THE FACILITY OR DWELLING INSPECTED FOR SIGNS OF SEWAGE BACK UP? YES WAS THE SITE INSPECTED FOR SIGNS OF BREAK OUT? YES WERE ALL SYSTEM COMPONENTS, EXCLUDING THE SAS, LOCATED ON SITE? YES 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? YES 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 NO EXISTING INFORMATION. FOR EXAMPLE, A PLAN AT THE BOARD OF HEALTH. NO 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)] REVISED 6/15/2000 PAGE 5 OF 1 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION PROPERTY ADDRESS: 336 SHARPNERS POND RD. OWNER: DOLLOF DATE OF INSPECTION: MARCH 29,2002 FLOW CONDITIONS RESIDENTIAL: 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 NUMBER OF CURRENT RESIDENTS: 4 DOES RESIDENCE HAVE A GARBAGE GRINDER (YES OR NO): NO IS LAUNDRY ON A SEPARATE SEWAGE SYSTEM (YES OR NO): NO [IF YES SEPARATE INSPECTION REQUIRED] LAUNDRY SYSTEM INSPECTED (YES OR NO): N/A SEASONAL USE (YES OR NO): NO WATER METER READINGS, IF AVAILABLE (LAST 2 YEARS USAGE (GPD)): WELL ON SITE. SUMP PUMP (YES OR NO): NO LAST DATE OF OCCUPANCY: CURRENT COMMERCIALANDUSTRIAL: TYPE OF ESTABLISHMENT: DESIGN FLOW (BASED ON 310 CMR 15.203): GPD BASIS OF DESIGN FLOW (SEATS/PERSONS/SQ. FT, 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: OWNER WAS SYSTEM PUMPED AS PART OF INSPECTION (YES OR NO): NO IF YES, VOLUME PUMPED: GALLONS - HOW WAS QUANTITY PUMPED DETERMINED? REASON FOR PUMPING: THERE'S REPAIRS NEEDED TO BE DONE. TYPE OF SYSTEM YES SEPTIC TANK, DISTRIBUTION BOX, SOIL ABSORPTION SYSTEM NO SINGLE CESSPOOL NO OVERFLOW CESSPOOL NO PRIVY NO SHARED SYSTEM (YES OR NO) (IF YES, ATTACH PREVIOUS INSPECTION RECORDS, IF ANY) NO INNOVATIVE/ ALTERNATIVE TECHNOLOGY. ATTACH A COPY OF THE CURRENT OPERATION AND MAINTENANCE CONTRACT (TO BE OBTAINED FROM SYSTEM OWNER) NO TIGHT TANK ATTACH A COPY OF THE DEP APPROVAL N/A OTHER (DESCRIBE): APPROXIMATE AGE OF ALL COMPONENTS, DATE INSTALLED (IF KNOWN) AND SOURCE OF INFORMATION: ORIGNAL SYSTEM.HOUSE BUILT IN 1986, OWNER WERE SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE (YES OR NO): NO REVISED 6/15/2000 PAGE 6 OF 11 SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C SYSTEM INFORMATION (CONTINUED) PROPERTY ADDRESS: 336 SHARPNERS POND RD. OWNER: DOLLOF DATE OF INSPECTION: MARCH 29.2002 BUILDING SEWER (LOCATE ON THE SITE PLAN) DEPTH BELOW GRADE: 15" MATERIAL OF CONSTRUCTION: 4" CAST IRON 40 PVC OTHER (EXPLAIN) DISTANCE FROM PRIVATE WATER SUPPLY WELL OR SUCTION LINE: FROM THE TANK IT'S 97' COMMENTS: (CONDITION OF JOINTS, VENTING, EVIDENCE OF LEAKAGE, ETC.) THERE WAS NO SIGNS OF LEAKAGE IN OR AROUND PIPE.SOILS WERE CLEAN AND DRY. SEPTIC TANK: YES (LOCATE ON SITE PLAN) DEPTH BELOW GRADE: 6" MATERIAL OF CONSTRUCTION: YES 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: 101 X 5'W X 5'H OUTLET INVERT @ 51 "= 1593 GALS SLUDGE DEPTH: 12" DISTANCE FROM TOP OF SLUDGE TO BOTTOM OF OUTLET TEE OR BAFFLE: 22" SCUM THICKNESS: 2" DISTANCE FROM TOP OF SCUM TO TOP OF OUTLET TEE OR BAFFLE: 9" DISTANCE FROM BOTTOM OF SCUM TO BOTTOM OF OUTLET TEE OR BAFFLE: 14" HOW WERE DIMENSIONS DETERMINED: SLUDGE JUDGE.ROD,AND RULER COMMENTS (ON PUMPING RECOMMENDATION, INLET AND OUTLET TEES OR BAFFLES CONDITION, STRUCTURAL INTEGRITY, LIQUID LEVEL AS RELATED TO OUTLET INVERT, EVIDENCE OF LEAKAGE, ETC.): THE TANK NEEDS TO BE PUMPED.THE INLET AND OUTLET TEE BAFFLES ARE CEMENT CONSTRUCTION AN THERE INTACT.THE INLET AND THE OUTLET ARE @ THE SAME HIGHT WITH NO SEPERATION.THE OUTLET PIPE WAS INSTALLED A LITTLE HIGH.TANK IS NOT LEVEL.THE LIQUID LEVEL WAS n THE OUTLET HIGHT,THERE WAS NO SIGNS OF LEAKAGE. GREASE TRAP: N (LOCATE ON SITE PLAN) DEPTH BELOW GRADE: MATERIAL OF CONSTRUCTION: CONCRETE METAL FIBERGLASS POLYETHYLENE OTHER (EXPLAIN) DIMENSIONS: SCUM THICKNESS: DISTANCE FROM TOP OF SCUM TO TOP OF OUTLET TEE OR BAFFLE: DISTANCE FROM BOTTOM OF SCUM TO BOTTOM OF OUTLET TEE OR BAFFLE: DATE OF LAST PUMPING: COMMENTS (ON PUMPING RECOMMENDATION, INLET AND OUTLET TEES OR BAFFLES CONDITION, STRUCTURAL INTEGRITY, LIQUID LEVEL AS RELATED TO OUTLET INVERT, EVIDENCE OF LEAKAGE, ETC.): REVISED 6/15/200 PAGE 7 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (CONTINUED) PROPERTY ADDRESS: 336 SHARPNERS POND RD. OWNER: DOLLOF DATE OF INSPECTION: MARCH 29, 2002 TIGHT OR HOLDING TANK: NO (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: YES (IF PRESENT MUST BE OPENED) (LOCATE ON SITE PLAN) DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT: 2" DEPTH BELOW GRADE, 15" COMMENTS (NOTE IF BOX IS LEVEL AND DISTRIBUTION TO OUTLET EQUAL, ANY EVIDENCE OF SOLIDS CARRYOVER, ANY EVIDENCE OF LEAKAGE INTO OR OUT OF BOX, ETC.): THE D -BOX WAS IN POOR CONDITION AND IT HAS SETTLED.BECAUSE OF THE WALKWAY.THERE WAS SIGNS OF DECAY,LEAKAGE_AND_SOILD CARRYOVER PRESENT IN BOX.THERE WAS ONE INLET AND TWO OUTLETS ALL SCH2O PVC.THE OUTLET LATERALS ARE IN A REVERSE PITCH. PUMP CHAMBER: NO (LOCATE ON SITE PLAN) PUMPS IN WORKING ORDER (YES OR NO): ALARMS IN WORKING ORDER (YES OR NO): COMMENTS (NOTE CONDITIONS OF PUMP CHAMBER, CONDITION OF PUMPS AND APPURTENANCES, ETC.): REVISED 6/15/2000 PAGE 8 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (CONTINUED) PROPERTY ADDRESS: 336 SHARPNERS POND RD. OWNER: DOLLOF DATE OF INSPECTION: MARCH 29.2002 SOIL ABSORPTION SYSTEM (SAS): YES (LOCATE ON SITE PLAN, EXCAVATION NOT REQUIRED) IF SAS NOT LOCATED EXPLAIN WHY: TYPE: LEACHING PITS, NUMBER: LEACHING CHAMBERS, NUMBER: LEACHING GALLERIES, NUMBER: YES LEACHING TRENCHES, NUMBER, LENGTH: TWO TRENCHLINES TW X 65-L LEACHING FIELDS, NUMBER, DIMENSIONS: OVERFLOW CESSPOOL, NUMBER: INNOVATIVE/ ALTERNATIVE SYSTEM TYPE OF TECHNOLOGY: COMMENTS (NOTE CONDITION OF SOIL, SIGNS OF HYDRAULIC FAILURE, LEVEL OF PONDING, DAMP SOIL, CONDITION OF VEGETATION, ETC.) THERE WAS SIGNS OF STANDING WATER AND SOILD CARRYOVER IN OUTLET LINES.THERE WAS NO SIGNS OF FAILURE OR STANDING WATER IN TRENCHES.THE SOILS WERE CLEAN AND DRY.THE LINES ARE SCH2O PVC CONSTRUCTION. CESSPOOLS: NO (CESSPOOL MUST BE PUMPED AS PART OF INSPECTION) (LOCATE ON SITE PLAN) NUMBER AND CONFIGURATION: DEPTH -TOP OF LIQUID TO INLET INVERT: DEPTH OF SOLID 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: NO (LOCATE ON SITE PLAN) MATERIALS OF CONSTRUCTION: DIMENSIONS: DEPTH SOLIDS: COMMENTS (NOTE CONDITION OF SOIL, SIGNS OF HYDRAULIC FAILURE, LEVEL OF PONDING, CONDITION OF VEGETATION, ETC.): REVISED 6/15/00 PAGE 9 OF 11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (CONTINUED) PROPERTY ADDRESS: 336 SHARPNERS POND RD OWNER: DOLLOF DATE OF INSPECTION: MARCH 29.2002 SKETCH OF SEWAGE DISPOSAL SYSTEM: PROVIDE A SKETCH OF THE SEWAGE DISPOSAL SYSTEM INCLUDING TIES TO AT LEAST TWO PERMAN REFERENCE LANDMARKS OR BENCHMARKS. LOCATE ALL WELLS WITHIN 100 FEET. LOCATE WHERE WATER SUPPLY ENTERS THE BUILDING. q HOu5e 0 1o7' / —__1_,__ 97' $e Ncl "'kw ' link 13 (-n)Y� �� p L.eac1+T re.,cl,cs i i�rnr,� �rd S � v REVISED 6/15/2000 PAGE ]0 OF I1 Well on ® slat: �c�9er j /4 +6 ),� TJ J7' f� -D =y3' 3 �v p =3o' w 11 /o Tat* = q7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (CONTINUED) PROPERTY ADDRESS: 336 SHARPNERS POND RD. OWNER: DOLLOF DATE OF INSPECTION: MARCH 29, 2002 SITE EXAM SLOPE -NONE SURFACE WATER -YES IN BACK YARD 125' CHECK CELLAR -YES AND IT'S DRY. SHALLOW WELLS -YES ESTIMATED DEPTH TO GROUNDWATER 6'+APPROX FEET PLEASE INDICATE (CHECK) ALL THE METHODS USED TO DETERMINE HIGH GROUNDWATER ELEVATION: NO OBTAINED FROM SYSTEM DESIGN PLANS ON RECORD - IF CHECKED, DATE OF DESIGN PLAN REVIEWED: YES OBSERVED SITE (ABUTTING PROPERTY/OBSERVATION HOLE WITHIN 150 FEET OF SAS) YES CHECKED WITH LOCAL BOARD OF HEALTH - EXPLAIN: NO CHECKED LOCAL EXCAVATORS, INSTALLERS - (ATTACH DOCUMENTATION) YES ACCESSED USGS DATABASE - EXPLAIN: YOU MUST DESCRIBE HOW YOU ESTABLISHED THE HIGH GROUND WATER ELEVATION: THE HOUSE DIDN'T HAVE A SUMP PUMP AND THE BASEMENT WAS DRY.THE SYSTEM IS LOCATED ON A BUILT UP AREA.WHILE DIGGING IN AREA THE SOILS WERE CLEAN AND DRY,THERE'S A WELL LOCATED 97' FROM THE TANK.AND THE LEACHING AREA AND D -BOX ARE 107' FROM THE SPOT OF WETLANDS IN BACK YARD.THERE'S NO ABBUTTING PROPERTY'S WELLS OR WETLANDS WITHIN 100' FROM SYSTEM. REVISED 6/15/2000 PAGE 11 OF I 1 TOWN OF NORTH ANDOVER BOARD OF HEALTH Location 1. 4; Q/s Permit Food Service ' $ Retail Food $ Limited Retail $ Seasonal $ Disposal Works Installers $ Disposal Works Construction $ Soil Testing $ Design Approval Permit $ Dumpster Permit $ Burial Permit $ Swimming Pool Permit $ Animal Permit $ Recreational Camp Permit $ Well Construction Permit $ Funeral Directors Permit $ Massage Establishment License $ Massage Practice License $ Suntanning Establishment $ Offal/Trash Hauler $ Other $ Health Agent White - Applicant Yellow - Dept. Pink - Treasurer 577 MAIN STREET HUDSON, MA 01749 800-499-1682 WINDRIVER ENVIRONMENTAL SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PROPERTY OWNER'S NAME: DOLLOFF PROPERTY ADDRESS: 336 SHARPNERS POND RD., NO. ANDOVER, MA ADDRESS OF OWNER: SAME (IF DIFFERENT) DATE OF INSPECTION: June 25, 2002 (REVISED, NAME OF INSPECTOR: THOMAS CHIGAS COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 336 SHARPNERS POND RD. NO. ANDOVER, MA Owner's Name: DOLLOFF Owner's Address: 336 SHARPNERS POND RD. NO, ANDOVER, MA Date of Inspection: June 25, 2002 (REVISED) Name of Inspector: (please print) THOMAS CHIGAS Company Name: Windriver Environmental Mailing Address: 577 Main Street Hudson, MA 01749 Telephone Number: 800-499-1682 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: YES passes Conditionally Passes YES Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date June 25, 2002 The system inspector shall submit a copy othis 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: June 25, 2002,THE DISTRIBUTION BOX WAS REPLACED WITH A 16" X 16" H-10 LOADING SIX OUTLET BOX. INSPECTED BY HEALTH DEPARTMENT WITHIN TITLE V REGULATIONS. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 336 SHARPNERS POND RD. NO. ANDOVER, MA Owner: DOLLOFF Date of Inspection: June 25, 2002 Inspection Summary: Check 0,B,C,D or E / ALWAYS complete all of Section D A. System Passes: YES 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: NO One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. NO The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: NO 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): NO broken pipe(s) are replaced NO obstruction is removed NO distribution box is leveled or replaced ND explain: NO 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): NO broken pipe(s) are replaced NO obstruction is removed ND explain: 'r;.io c T--.,+;-- Aii cilnnn 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 336 SHARPNERS POND RD. NO. ANDOVER, MA Owner: DOLLOFF Date of Inspection: June 25, 2002 C. Further Evaluation is Required by the Board of Health: YES 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: N/A Cesspool or privy is within 50 feet of a surface water N/A Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: NO 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. NO The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. NO The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. YES 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 TAPE MEASURE "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. 3. Other: T41. c T--.,..;-- U,..,,, 411 ci')Ann Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 336 SHARPNERS POND RD. NO. ANDOVER, MA Owner: DOLLOFF Date of Inspection: June 25, 2002 D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: Yes No NO Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool — NO Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool NO Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool N/A Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow NO Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped NO Any portion of the SAS, cesspool or privy is below high ground water elevation. N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. N/A Any portion of a cesspool or privy is within a Zone 1 of a public well. N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well. N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] NO (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 to 15,000 gpd. 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 NO the system is within 400 feet of a surface drinking water supply NO the system is within 200 feet of a tributary to a surface drinking water supply NO 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. Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 336 SHARPNERS POND RD. NO. ANDOVER, MA Owner: DOLLOFF Date of Inspection: June 25, 2002 Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No YES _ Pumping information was provided by the owner, occupant, or Board of Health NO Were any of the system components pumped out in the previous two weeks ? YES Has the system received normal flows in the previous two-week period? NO Have large volumes of water been introduced to the system recently or as part of this inspection ? YES Were as built plans of the system obtained and examined? (If they were not available note as N/A) YES Was the facility or dwelling inspected for signs of sewage back up ? YES Was the site inspected for signs of break out? YES Were all system components, excluding the SAS, located on site YES 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 ? YES 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 YES _ Existing information. For example, a plan at the Board of Health. YES 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)] 'r:.io c T-_.,+;__ W,._ All rlInnn 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 336 SHARPNERS POND RD. NO. ANDOVER, MA Owner: DOLLOFF Date of Inspection: June 25, 2002 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 4 Does residence have a garbage grinder (yes or no): NO Is laundry on a separate sewage system (yes or no): NO [if yes separate inspection required] Laundry system inspected (yes or no): N/A Seasonal use: (yes or no): NO Water meter readings, if available (last 2 years usage (gpd)): WELL ON SIGHT Sump pump (yes or no): NO Last date of occupancy: CURRENT COMMERCIAL/INDUSTRIAL 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: OWNER AND RECORDS Was system pumped as part of the inspection (yes or no): YES If yes, volume pumped: 1,500 gallons -- How was quantity pumped determined? SIZE OF TANK Reason for pumping: CHECK TANK'S INTEGRITY AND REPLACE D -BOX TYPE OF SYSTEM YES Septic tank, distribution box, soil absorption system NO Single cesspool NO Overflow cesspool NO Privy NO Shared system (yes or no) (if yes, attach previous inspection records, if any) NO Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) NO Tight tank _ Attach a copy of the DEP approval Other (describe): Approximate age of all components, date installed (if known) and source of information: ORIGINAL SYSTEM HOUSE BUILT 1986, OWNER Were sewage odors detected when arriving at the site (yes or no): NO Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 336 SHARPNERS POND RD. NO. ANDOVER, MA Owner: DOLLOFF Date of Inspection: June 25, 2002 BUILDING SEWER (locate on site plan) Depth below grade: 15" Materials of construction: 4" cast iron _40 PVC _other (explain): Distance from private water supply well or suction line: FROM TANK, 97' Comments (on condition of joints, venting, evidence of leakage, etc.): THERE WERE NO SIGNS OF LEAKAGE IN OR AROUND PIPE. SOILS WERE CLEAN AND DRY. SEPTIC TANK: YES (locate on site plan) Depth below grade: 6" Material of construction: YES 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: 10'L X 5'W X 5'H OUTLET INVERT @ 50"=1,500GAL Sludge depth: N/A Distance from top of sludge to bottom of outlet tee or baffle: N/A Scum thickness: N/A Distance from top of scum to top of outlet tee or baffle: N/A Distance from bottom of scum to bottom of outlet tee or baffle: N/A How were dimensions determined: ROD AND RULER Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): THE TANK WAS PUMPED. THERE WERE NO SIGNS OF LEAKAGE IN OR AROUND AREA. SOILS WERE CLEAN AND DRY. THE INLET AND OUTLET T - BAFFLES WERE CEMENT CONSTRUCTION AND IN GOOD CONDITION. THE OUTLET PIPE WAS REPLACED WITH SCH40 PVC. GREASE TRAP: NO (locate on site plan) Depth below grade: _ Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 336 SHARPNERS POND RD. NO. ANDOVER, MA Owner: DOLLOFF Date of Inspection: June 25, 2002 TIGHT or HOLDING TANK: NO (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: YES (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0" DEPTH BELOW GRADE 13" 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.): THE D -BOX WAS REPLACED June 25, 2002, WITH A 16" X 16" H-10 LOADING BOX. THE HEALTH DEPARTMENT HAS INSPECTED FOR EQUAL DISTRIBUTUIN AND LEAKAGE UPON INSTALLATION. PUMP CHAMBER: NO (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: 336 SHARPNERS POND RD. NO. ANDOVER, MA Owner: DOLLOFF Date of Inspection: June 25, 2002 SOIL ABSORPTION SYSTEM (SAS): YES (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: _ Leaching chambers, number: Leaching galleries, number: YES leaching trenches, number, length:, TWO TRENCH LINES 3'W X 65'L leaching fields, number, dimensions: overflow cesspool, number: innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): THE LEACH LINES WERE ALL SCH2O PVC AND IN GOOD CONDITION. THERE WERE NO SIGNS OF FAILURE OR STANDING WATER. THE SOILS WERE CLEAN AND DRY. THERE WERE NO SIGNS OF WETLAND VEGETATION IN OR AROUND SAS. CESSPOOLS: NO (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 or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: NO (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: 336 SHARPNERS POND RD. we+Yhnd6' �V NO. ANDOVER, MA Owner: DOL FF Date of Inspe tion: June 25, 2002 SKET . OF SEWAGE DISPOSAL SYSTEM Prov a sketch of the sewage disposal system including ties to at leas two peimanen reference landmarks or benc rks. Locate all wells within 100 feet. Locate where public wat r supply enters he building. lo7' 1---I ov s e 0 SSC L-e.4.� T rer,c.lc3 5ep�rc, QCT) 110017 •.- ;(I (,T. 11 �9er 7-) v 17 =113' 0 P �30' ,,,, N r0 TG,?k = q17 Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 336 SHARPNERS POND RD. NO. ANDOVER, MA Owner: DOLLOFF Date of Inspection: June 25, 2002 SITE EXAM Slope: NONE Surface water: YES, AN AREA IN BACK YARD 125' AWAY Check cellar: YES Shallow wells: YES Estimated depth to ground water 6'+(approx) feet Please indicate (check) all methods used to determine the high ground water elevation: NO Obtained from system design plans on record - If checked, date of design plan reviewed: YES Observed site (abutting property/observation hole within 150 feet of SAS) YES Checked with local Board of Health -explain: NO Checked with local excavators, installers- (attach documentation) YES Accessed USGS database -explain: MAPS You must describe how you established the high ground water elevation: THE HOUSE HAS AN 8' PRE -CAST FOUNDATION WITH NO SUMP -PUMP AND BASEMENT IS DRY. WHILE DIGGING IN YARD, REPLACING D -BOX, THERE WERE NO SIGNS OF HIGH SEASONAL GROUND WATER. THE SYSTEM IS SET HIGHER THAN NORMAL GRADE. THERE IS STANDING WATER IN BACK YARD 125' AWAY FROM SYSTEM. THERE WERE NO SIGNS OF ABBUTTING PROPERTY'S WELLS OR WETLANDS WITHIN 100' FROM SYSTEM, rr;+io c r.,-__+;,.., F,,— Aii cMnnn 11