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HomeMy WebLinkAboutMiscellaneous - 338 SALEM STREET 4/30/2018 (2)N O w 4 0, W D o m Ln F ocn � o � om o � 0 IFJ BOARD OF HEALTH 1600 Osgood Street, Suite 2035 North Andover, MA 01845 978-688-9540 APPLICATION FOR ABANDONMENT OF SUBSURFACE DISPOSAL SYSTEM (SEPTIC SYSTEM) Pursuant to Section 310 CMR 15.354 � Of t� tate Environmental Code, Title V 5-3 � 2 1 Name r, Phone'%^ - Address Contractor hired for work: Name D ?— Phone �— Address ly C�2C6 ��C 3�a Date for scheduled abandonment The septic system at the above address has been abandoned according to Title V specifications. Signature of Contract r Method of septic tank abandonment (check one). O removal O sandfill (/Crush O other Name of Offal Hauler This form must be returned to the North Andover Board of Health. E DO NOT WRITE IN THE SPACE BELOW HEALTH REPRESEN %T7S ON Y A�A � 7 150 In pecting Agentate �s 2212 APPLICATION FOR SEWER SERVICE CONNECTION North Andover, Mass. �L G✓/ �� Application by the undersigned is hereby made to connect with the town sewer main in Street, subject to the rules and regulations of the Division of Public Works, A � The premises are known as No or subdivision lot no Owner 1 G Contractor Street PERMIT TO CONNECT W The Division of Public Works hereby grants permission to to make a connection with the sewer main at subject to the rules and regulations of the Division of Public Works.. Inspected by Date 114'e- /-&/k ER MAIN 4�aK Street D' ision of Public Works By See back for rules and regulations 021 a Pik i s iP.,gy,'� S*r Sesser Service for 338 Salem St. - .xS SEWER SERVICE FOR HOUSE NUMBER 338 SALEM STREET ------------------------------ �" RVC- S6W6✓Z � SMll �7 ----------i ----------------- � 7 _ At 04 e Jib Date Installed: August 4, 2004; Type of Service: Sewer ; Size of Service: 6 "; Length of Serv. 54.5 LF House No. 338; Street: Salem St. Street; Depth to Pipe @ P/L 8.0 VF; Chimney: _ VF NOT TO SCALE J r! NO R T► -r BUILDING PERMIT of T%OR TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received a, �R,TEo gSSacHus' Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATiIQN k7_ (PROPERTY OUVNER� —m . 1 '_�_ -- Pnnt 10Year Structu 0re .: yes in -0, MAP - __ PARG'EL ,m� ZQNING�D1STRICT: T Historic District yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ` ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Q ;Septic 11Wel1 ❑ (Floodplain �' Wetlands_ ❑ Watersheyd rDistnct DESCRIPTION OF WORK TO BE PERFORMED: �vf lyk �Lf ►�� /�as C' �7f1�� GIGV e, �av✓ / env✓� WOLy -Ca-m c, a�yt ons Identi icapon - Please Type or Print Clearly OWNER: Name: ©o aaoe� PhoneD(f-,53J 7I ?S Address: SG/�'/a'► �� /�U�F'�Gi iv r/ ��� �� c��O �ef �J Contra - of ame --- ---_ Phone;._ Address: -- SupervrsorsiConstru:ction}Licens C 1 r 4 _ IHome Elrnprovement'Licen�se ,.,.,___� - _ ARCHITECT/ENGINEER I � r Address: FEE SCHEDULE. BULDING PERMIT: $12.00+ ON $125.00 PER S.F. Total Project Cost:. $ Check No.: NOTE: Persons contracting with uri,���Veaccess to the guaranty fund Signature of Agent/Qwner" Signature of contractor A as Plans Submitted ❑ Plans Waived 0 Certified Plot Plan ❑ Stamped Plans ❑ Typ_B O-SF-VvMP—kGE D1SL'QSAL- ❑ Swanning Pools Public Sewer ElTanning/Massage/Body Art ❑ Tobacco Sales El Food Packaging/Sales El Well El (septic tank, etc. El Dumpster on Site THE FOLLOWING SECTIONS OF OF FORMFICE USE ONLY iNTFRDEPARTMENTAL SIGN PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS Reviewed On Signature Reviewed on Signature Reviewed 4 Signature 4 C> %%fib p G✓ "� Zoning Decision/receipt submitted yes Zoning Board of Appeals: Variance, Petition No: Planning Board Decision: Comments Conservation Decision: Comments Drivewa Permit Water & Sewer Connection/Signature & Date DPW Town Engineer: Signature: iEPAKTIJNMN1 gat l2 Main Street epartment,s i -- Located 384 osgood�Street ono jpstpr,,on,°site 'Eyes SIM 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. Commonwealth of Massachusetts Title 5 Official Inspection F Subsurface Sewage Disposal System Form - Not fo ,Vg1.q%af 338 Salem Street Property Address Suzan De -Los Heros Owner's Name North Andover City/Town MA 01845 State Zip Code -f1Q4�ii IY1{�j�U3P1' 4/2/2014 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. A. General Information 1. Inspector: Neil J. Bateson Name of Inspector Bateson Enterpri Company Name 111 Argilla Road Company Address Andover City/Town 978-475-4786 Telephone Number B. Certification Inc. MA State S115 License Number APR 07 2014 TOWf! OF NGRTH AN' -L,, %o i. -r NIrvlkN1 a 01810 Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes 0 Fails ❑ Needs Further Evaluation by the Local Approving Authority 4/2/2014 Iropelftor47signatureV Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 338 Salem Street Property Address Suzan De -Los Heros Owner Owner's Name information is required for North Andover MA 01845 4/2/2014 every page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins - 3113 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 338 Salem Street Property Address Suzan De -Los Heros Owner's Name North Andover MA 01845 4/2/2014 City/Town 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 obstruction is removed distribution box is leveled or replaced ❑ Y ❑ Y ❑ Y ❑ N ❑ N ❑ N ❑ ❑ ❑ ND (Explain below): ND (Explain below): ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: El Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 338 Salem Street Property Address Suzan De -Los Heros Owner's Name North Andover Cityrrown B. Certification (cont.) MA 01845 4/2/2014 State Zip Code Date of Inspection 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form d Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 338 Salem Street Property Address Suzan De -Los Heros Owner Owner's Name information is required for North Andover MA 01845 4/2/2014 every page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 338 Salem Street Property Address Suzan De -Los Heros Owner's Name North Andover City/Town C. Checklist MA 01845 State Zip Code 4/2/2014 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): N/A Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): A INIF" t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments `e 338 Salem Street Property Address Suzan De -Los Heros Owner information is required for every page. Owners Name North Andover Cityrrown D. System Information Description: Number of current residents: MA 01845 4/2/2014 State Zip Code Date of Inspection Does residence have a garbage grinder? Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) Laundry system inspected? Seasonal use? 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 ❑ Yes ® No ❑ Yes ❑ No ❑ Yes ® No Yes ❑ Yes ® No Current Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'r 338 Salem Street Property Address Suzan De -Los Heros Owner Owners Name information is required for North Andover MA 01845 4/2/2014 every page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Date Never pumped, owner gallons Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Yes 0 No ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins - 3113 Title 5 Official Inspection Forth: 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 338 Salem Street D. System Information (cont.) 01845 4/2/2014 Zip Code Date of Inspection Approximate age of all components, date installed (if known) and source of information: Original to house, owner Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 2 feet Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" Cast iron throuqh wall, 4'Cast iron in house. No leaks visible. Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 1 feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 8'x 4' Sludge depth: 91 ❑ Yes ❑ No t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Property Address Suzan De -Los Heros Owner Owner's Name information is required for North Andover MA every page. Cityrrown State D. System Information (cont.) 01845 4/2/2014 Zip Code Date of Inspection Approximate age of all components, date installed (if known) and source of information: Original to house, owner Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 2 feet Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" Cast iron throuqh wall, 4'Cast iron in house. No leaks visible. Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 1 feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 8'x 4' Sludge depth: 91 ❑ Yes ❑ No t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r< 338 Salem Street Property Address Suzan De -Los Heros Owner Owner's Name information is required for North Andover MA 01845 every page. Cityrrown State Zip Code D. System Information (cont.) 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 4/2/2014 Date of Inspection N/A 2" N/A N/A= Outlet baffle corroded off How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet baffle corroded off. Outlet baffle corroded off. Depth of liquid at outlet invert. No evidence of Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: t5ins • 3113 Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 338 Salem Street ,p Property Address Suzan De -Los Heros Owner Owner's Name information is required for North Andover MA 01845 4/2/2014 every page. Cityfrown 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 338 Salem Street Property Address Suzan De -Los Heros Owner's Name North Andover MA 01845 4/2/2014 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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.): D -box level & distribution not equal. Evidence of heavy carryover, outlet baffle off in septic tank. Evidence of leakage. D -box badly corroded. D -box cover cracked. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'c 338 Salem Street Property Address Suzan De -Los Heros Owner Owner's Name information is required for North Andover MA 01845 every page. City/Town State Zip Code D. System Information (cont.) Type: ❑ leaching pits ❑ leaching chambers ❑ leaching galleries ® leaching trenches ❑ leaching fields ❑ overflow cesspool ❑ innovative/alternative system 4/2/2014 Date of Inspection number: number: number: number, length: 4 trenches 30' number, dimensions: number: Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetation ok. No sign of ponding to surface. Camera leach pipes, liquid above leach pipes. Signs of hydraulic failure. Heavy solids in pipes. Couple of the trenches pipes collapsed 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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 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 338 Salem Street Property Address Suzan De -Los Heros Owner's Name North Andover MA 01845 4/2/2014 Citylfown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins • 3113 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 14 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 338 Salem Street Property Address Suzan De -Los Heros Owners Name North Andover MA 01845 4/2/2014 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately S.e.q 3=� ttii 3 t� k S t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 0 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 338 Salem Street Property Address Suzan De -Los Heros Owner Owner's Name information is required for North Andover MA 01845 4/2/2014 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 1.5 to 3 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: ❑ Checked with local excavators, installers - (attach documentation) ® Accessed USGS database - explain: Essex County Soil Map You must describe how you established the high ground water elevation: Essex County Soil Map, Sheet # 30, Woodbridge Soil, Water 1.5' to 3' Deep. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 338 Salem Street Property Address Suzan De -Los Heros Owner Owner's Name information is required for North Andover MA 01845 4/2/2014 every page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 Summary Record Card generated on 3/26/2014 1:18:23 PM Town of North Ai r Tax Map # 2104 Parcel Id 14809 338 SALEM STREET DE -LOS HEROS 338 SALEM STREET N. ANDOVER, MA 01845 Maureen McAuley dover 373-0055-0000.0 Page 1 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 0.84 Acres FY 2014 UB Mailing Index Name/Address Type Loan N Limber Active/Inact. From Until DE -LOS HEROS Payor 338 SALEM STREET N. ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Na a Active/inactive Bldg Id. 16048.0 - 338 SALEM STREET Last Billing Date 1/7/2014 3160105 03 Cycle 03 Active UB Services Maint. Account No. 3160105 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 41.80 /1 UB Meter Maintenance Account No. 3160105 Serial No Status 16335955 a Active Date 3/5/2014 12/4/2013 9/5/2013 6/7/2013 3/7/2013 12/5/2012 9/6/2012 6/7/2012 3/6/2012 12/8/2011 9/9/2011 6/2/2011 3/4/2011 12/7/2.010 9/3/2010 6/2/2010 3/4/2010 12/4/2009 9/2/2009 6/2/2009 3/6/2009 12/3/2008 9%4/2008 6/3/2008 3/5/2008 12/5/2007 9/12/2007 6/11/2007 3/8/20.07 Reading 923 913 902 893 884 877 872 867 861 855 848 836 817 803 795 766 759 752 740 721 705 691 667 647 635 627 618 606 596 Location 00 Code a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual a Actual f Type METE w Water Consumption Posted Date 10 11 1/17/2014 9 10/15/2013 9 7/24/2013 7 4/22/2013 5 1/9/2013 5 10/15/2012 6 7/16/2012 6 4/14/2012 7 1/17/2012 12 10/13/2011 19 7/20/2011 14 4/13/2011 8 1/12/2011 29 10/15/2010 7 7/15/2010 7 4/14/2010 12 1/12/2010 19 10/15/2009 16 7/20/2009 14 4/29/2009 24 1/20/2009 20 10/10/2008 12 7/16/2008 8 4/11/2008 9 1/22/2008 12 10/12/2007 10 7/20/2007 8 4/16/2007 Size 0.63 0.63 YTD Cons 278 Variance -10% 22% 2% 29% 37% 1% -15% -4% -13% -36% -43% 31% 91% -73% 301% 0% -40% -38% 14% 21% -44% 24% 61% 52% -1.8% -17% 23% 22% -23% NORTH 6738 of ,�.o :•,yc Town of North Andover HEALTH DEPARTMENT �Ss�cMus°� CHECK #: DATE: LOCATION: ` 1') 1,4, 11 'N , #� H/O NAME: _L.X-- 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 Systems ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector Report $ $� Title 5 ❑ Other: (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer " 5 ♦ u s TownoflVorth Andover s�.'•�.,;,; :: MEALTH DEPARTMENT �Ss�cNust� .. CHECK #: �G� DATE: 4 LOCATION: H/O NAME: L_X CONTRACTOR NAME: 678 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 $ ❑ a Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ k ❑ Tobacco $ �- ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: Y ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ' ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) p $ t ❑ Title 5 Inspector $ Title 5 Report $�� ❑ Other. (Indicate) $ Health Agent Initials White - Applicant Yellow Health Pink - Treasurer A.'