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Miscellaneous - 340 SUMMER STREET 4/30/2018 (3)
4' �� Of MORTN 'IM Town of North Andover HEALTH DEPARTMENT SACH s CHECI LOCA H/O t CONT 71 59 Tyne 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 $ ❑ TrashlSolid 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 x ;�-- $ ❑ Other: (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer 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. tL�l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 340 Summer Street Property Address Richard Lan Ic Owner's Name North Andover Cityrrown MA 01845 State Zip Code z1f Y'0�< 11/7/2014 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 Enterprises Inc. Company Name 111 Argilla Road Company Address Andover MA _ 01810 Cityrrown State 978-475-4786 S115 Telephone Number B. Certification 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. 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 q VEL! ❑ Needs F wther Evaluation by the Local Approving Authority 11/7/2014 Inspe or Si nature Date /17//1' NOV 1 2014 r JUvnB yr NORTH ANDOVER HEAL 4 �-1 MnAr . 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 • 3113 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 340 Summer Street Property Address Richard Langlois Owner Owner's Name information is required for North Andover MA 01845 11/7/2014 every page. 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: 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 - 3/13 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 340 Summer Street Property Address Richard Langlois Owner's Name North Andover MA 01845 11/7/2014 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ 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: ❑ 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 340 Summer Street Property Address Richard Langlois Owner's Name North Andover MA 01845 11/7/2014 Cityrrown 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 '/2 day flow t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 E) Large Systems: Tobe 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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 340 Summer Street Property Address Richard Langlois Owner information is Owner's Name required for North Andover MA 01845 11/7/2014 every 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: Tobe 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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 340 Summer Street Property Address Richard Langlois Owner Owner's Name information is required for North Andover MA 01845 11/7/2014 every page. Cityrrown 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): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 600 t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 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 340 Summer Street Property Address Richard Langlc Owner's Name North Andover City/Town D. System Information Description: Number of current residents: MA State 01845 11/7/2014 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? Seasonaluse? 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 • 3113 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 340 Summer Street 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: Type of System: Date Pumped 2013, owner 1500 gallons Measured tank Inspect tank & tees 1117/2014 Date of Inspection ® 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 8 of 17 Property Address Richard Langlois Owner Owner's Name information is required for North Andover MA 01845 every page. Cityfrown State Zip Code 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: Type of System: Date Pumped 2013, owner 1500 gallons Measured tank Inspect tank & tees 1117/2014 Date of Inspection ® 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 8 of 17 Owner information is required for every page. Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 340 Summer Street Property Address Richard Langlc Owner's Name North Andover MA 01845 11/7/2014 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: 30 years old, 9/9/1984, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 1.3 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 through wall, 3" PVC in house, no leaks visible Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal .3 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: 10' x 5'x 4' Sludge depth: 2" ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 340 Summer Street Property Address Richard Langlois Owner Owner's Name information is required for North Andover MA 01845 11/7/2014 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 31" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 12" 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.): Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. Grease Trap (locate on site plan): Depth below grade: feet 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: Date t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System . Page 16 of 17 Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 340 Summer Street Property Address Richard Langlois Owner Owner's Name information is required for North Andover MA 01845 11/7/2014 every page. Citylrown 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 ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: 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 340 Summer Street Property Address Richard Langlois Owner's Name North Andover MA 01845 11/7/2014 City/town 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 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D -box level 8r distribution equal, has flow levelers. No evidence of leakage. Evidence of light carryover, pumped d -box to clean. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: F1' 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 Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins • 3113 Title 5 Official Inspection Folin: 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 340 Summer Street Property Address Richard Langlois Owner information is required for every page. Owners Name North Andover MA Cityrrown State 01845 11/7/2014 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 1 field 16' x 88' 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.): Soil ok. Vegetation ok. No sign of ponding to surface. 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 Folin: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 340 Summer Street Property Address Richard Langlois Owner Owner's Name information is required for North Andover MA 01845 every page. Cityrrown State Zip Code 11/7/2014 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 Form: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,340`Summer Street Owner information is required for every page. Property Address Richard Langlc Owner's Name North Andover MA 01845 1117/2014 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 t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 15 of 17 Q Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 340 Summer Street Property Address Richard Langlois Owners Name North Andover Cityrrown D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells MA 01845 11/7/2014 State Zip Code Date of Inspection Estimated depth to high ground water: >4feet 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: 5/10/1984 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Design plan ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: As per design plan test pit data 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 t Title 5 Official Inspection Form Subsurface Sewage Disposal System Foam - Not for Voluntary Assessments 340 Summer Street Property Address Richard Langlois Owner Owners Name information is required for North Andover MA 01845 1117/2014 every page. Cityrrown 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 - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 ' Summary Record Card generated on 10/29/2014 10:03:59 AM by Karen Hanlon Page 1 Town of North Andover Tax Map # 210-107.A-0161-0000.0 Parcel Id 17986 340 SUMMER STREET LANGLOIS, RICHARD 340 SUMMER STREET NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.01 Acres FY 2015 UB Mailing Index Name/Address Type Loan Number Active/lnact. From Until LANGL.OIS, RICHARD Payor 340 SUMMER STREET NORTH ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 14243.0 - 340 SUMMER STREET Last Billing Date 9/4/2014 2100239 02 Cycle 02 Active UB Services Maint. Account No. 2100239 Service: Code Rate Charge Multiplier/Users • MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 34.20 /1 UBMeter Maintenance Account No. 2100239 Serial No Status Location Brand Type Size YTD Cons 36391897 a Active ERT HH b Badger w Water 0.63 0.63 215 Date Reading Code Consumption Posted Date Variance 8/4/20.14 218 aActual 9 9/11/2014 270/6 5/5/2014 209 a Actual __ . 7 6/12%2014 7% 2/4/2014 202 a Actual - _ 7 3/17/2014 -34% 10/31/203 195 aActual 10 12/20/2013 -13% 8/1/2013 185 aActual 11 9/18/2013 59% 5/6/2013 174 a Actual 7 6/18/2013 -12% 2/7/2013 167 a Actual 9 3/13/2013 -21% 10/30/2012 158 a Actual 10 12/13/2012 -4% 8/3/2012 148 a Actual 11 9/26/2012 32% 5/212012 137 a Actual 8 6/20/2012 -23% 2/3/2012 129 a Actual 11 3/14/2012 -11% 11/1/2011 118 aActual 12 12/15/2011 -8% 8/2/2011 106 a Actual 13 9/14/2011 14% 5/3/2011 93 a Actual 11 6/13/2011 -21% 2/4/2011 82 a Actual 15 3/15/2011 -43% 11/1/2010 67 aActual 25 12/13/2010 2% 8/3/2010 42 a Actual 25 9/13/2010 77% 5/3/2010 17 a Actual 14 6/9/2010 23% 2/1/2010 3 aActual 3 3/11/2010 -100% 1/9/2010 0 n New Meter 3/11/2010 -100% 1/8/2010 0 n New Meter 0 3/11/2010 -100% 1/8/2010 4273 r Replacement 9 3/11/2010 -100% 11/2/2009 4264 aActual 15 12/11/2009 50% 8/3/2009 4249 a Actual 10 9/11/2009 11% 5/4/2009 4239 a Actual 9 6/16/2009 -36% 2/2/2009 4230 m Manual estimate 14 3/16/2009 0% MSG 11/3/2008 4216 aActual 14 12/10/2008 -10% 8/4/2008 4202 a Actual 16 9/12/2008 13% Commonwealth of Massachusetts City/Town of System Pumping- Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be'used, but the information must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility. Information 1. System Location: Left / Right front of house, Left / Right rear of house, Left > ' side of house, . eft / Right side of building, Left / Right front of building, Left / Right rear of building, Under ec t Address City/rown state Tip Code 2. System Owner. c Address (if different from location) Citylrown ' Zip Co Telephone Number 3 j 1 B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): L C-7-1 Date 2. Quantity Pumped: Cesspool(s) eptic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes G-Ao If yes, was it cleaned? ❑ Yes ❑ Na 5. Condition stem: 6. System Pumped By: Neil. Bateson Name Bateson Enterprises Inc- Company ncCompany 7. Location where contents. were disposed: F5821 Vehicle License Number 41 t5form4.doo• 06103 System Pumping Record • Page 1 of 1 o MAN . W. .. o � G GX Z .1 P/ = !oa / ..-. SL4'Mm P, st r — — i IN 1148 7` Af,t5vA7'/4/VS dox ....� °�_.__�°�1l /ERA • s 3 4 r /Soo �. �� •�'I i�1,ER S tk E� t — Commonwealth of Massachusetts _ City/Town of System Pumping Record Form 4 AUG 05 2013 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left / Right front of house, Left / Right rear of house, Left / ht sideVeec�'� Left / Right side of building, Left / Right front of building, Left / Right rear of building, Un er Address City/Town State Zip Code 2. System Owner. to Name Address (if different from location) CitylTown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ 4. Date Cesspool(s) ❑ Other (describe): Effluent Tee Filter present?' ❑ Yes o Telephone Number — 2. Quantity Pumped: D-S`eptic Tank Code Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No. 5. Conditionf stem: ^ . �j 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location—where contents were disposed: G L'S.D _ Lowell Waste Water F5821 Vehicle License Number Date t5fomi4.doc• 06/03 System Pumping Record • Page 1 of 1 - commonwealth of Massachusetts �iVED City/Town of 1 ETOWN System Pumping Record 4 Form 4 Y 2006 ORTH AN(�DEP has provided this form for use by local Boards of Hystem�PZ NRecord t besubmitted to the local Board of-Health or other approving authority. . A. Facility Information Important: When filling out forms on the 1. System Loca-tio computer, use only the tab key to move your Address r� —1 %� U - d� cursor - do not use the;retum Cit !town ty State Zip Code key. 2. System Owner: 'Name Address (if different from location) CityfTown . State . Zip Code' Telephone Number B'. Pumping Record 1; Date of Pumping Date 2. Quantity` Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other (describe)` 4. Effluent Tee Filter present? ❑ Yes ❑--lam` If yes, was it cleaned? ❑ Yes `❑ No 5: Condition of System: 6: System Pumped By° Name /'� � Vehicle License Number Company 7. Location where Contents were disposed:: L gn u of Hauler Date h ttp://www. mass. g6.v/dep%water/approvals/t5forms. htm#inspect t5form4.doc• 06103 System Pumping Record • Page 1 of 1 COMMONWEALTH OF MASSACHUSETTS z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS �p DEPARTMENT OF ENVIRONMENTAL PROTECTION 1TOWN OF NORTH ANDOVER/ BOARD OF HEALTH ►JUN 10' 2001' � j TITLE 5 . J OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: _340 Summer Street North Andover Owner's Name: _Tom Massinino D D Owner's Address: 340 Summer Street_ North Andover_ r Date of Inspection; _5/17/2001_ Name of Inspector: _Neil J Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address: _111 Argilla Road_ _Andover, Ma. 01810 Telephone Number: _( 978 ) 475-4786_ 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: Passes _X_ Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: _5/17/2001 ,A, _ The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 340 Summer Street North Andover— Owner: Massinino Date of Inspection: _5/17/2001_ 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: _X_ 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. Needs outlet tee in septic tank & d -bog. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. _N_ 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: _N 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 ND explain: N_ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 340 Summer Street_ North Andover — Owner: Massinino Date of Inspection: _5/17/2001 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 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 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: Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 340 Summer Street —North Andover— Owner: Massinino Date of Inspection: 5/17/2001_ 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 _No_ Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z 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. _ No Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. No Any portion of a cesspool or privy is within a Zone 1 of a public well. _No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _No_ 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 — 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. Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 340 Summer Street_ North Andover— Owner: Massinino Date of inspection: _5/17/2001 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. 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)] Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 340 Summer Street _North Andover— Owner: Massinino Date of Inspection: _5/17/2001_ 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 bedro_oms): _600_ Number of currant residents: _7 Does residence have a garbage grinder (yes or no): _Yes_ Is laundry on a separate sewage system (yes or no): _No [if yes separate inspection required] Laundry system inspected (yes or no): _ Seasonal use: (yes or no): _No Water meter readings: _N/A Sump pump (yes or no): Yes_ 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: _Pumped last year, owner_ Was system pumped as part of the inspection (yes or no): Yes_ If yes, volume pumped: _1500_gallons -- How was quantity pumped determined? Measured tank. _ Reason for pumping: _Inspect tank & tees._ TYPE OF SYSTEM X Septic tank, distribution box, soil absorption system _ Single cesspool _ Overflow cesspool _ Privy _ Shared system (yes or no) (if yes, attach previous inspection records, if any) _ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) Tight tank _ Attach a copy of the DEP approval Other (describe): Approximate age of all components, date installed (if known) and source of information: _17 Years old. 9/9/1984 As built plan._ 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: 340 Summer Street _North Andover— Owner: Massinino Date of Inspection: _5/17/2001_ BUILDING SEWER (locate on site plan) X Depth below grade: _18" Materials of construction: —X—cast iron _X_40 PVC other (explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): _4" Cast iron to tank. 3" PVC in house. No leaks. SEPTIC TANK: X locate on site plan) Depth below grade: 6" Material of construction: —X—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' x 5' x 4' Sludge depth1" Distance from top of sludge to bottom of outlet tee or baffle: N/A Scum thickness: _2" Distance from top of scum to top of outlet tee or baffle: _N/A_ N/A = Outlet tee broken off. Distance from bottom of scum to bottom of outlet tee or baffle: _N/A_ How were dimensions determined: _Subtract scum & sludge depth to tee length. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): _Pumped septic tank. Inlet tee ok. Outlet tee broken off, needs replaced. Depth of liquid at outlet invert. No evidence of leakage. GREASE TRAP: _(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 l l OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 340 Summer Street- - North treet__North Andover - Owner: Massinino Date of Inspection: _5/17/2001_ TIGHT or BOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polyethylene other(explain): Dimensions: Capacity: _ gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: —0 — Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): _D -box level & distribution equal. Evidence of leakage. Evidence of solid carryover, pumped d -bog to clean. D -box needs replaced, has corrosion holes. PUMP CHAMBER: (locate on site plan) Pumps in working order (yes or no): Alarms in working order (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 340 Summer Street North Andover— Owner: Massinino Date of Inspection: 5/17/2001 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: _ leaching chambers, number: leaching galleries, number: leaching trenches, number, length: _X_ leaching fields, number, dimensions: _1 Field 16' x 88'_ 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.): —Soil ok. Vegetation ok, No sign of ponding to surface. _ 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 or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Page 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _340 Summer Street North Andover — Owner: _Massinino Date of Inspection: _5/17/2001_ SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 10. Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 340 Summer Street North Andover — Owner: Massimo Date of Inspection: _5/17/2001_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water _4 feet Please indicate (check) all methods used to determine the high ground water elevation:. X Obtained from system design plans on record - If checked, date of design plan reviewed: _5/7/1984_ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Checked with local excavators, installers- (attach documentation) Accessed USGS database -explain: You must describe how you established the high ground water elevation: _As per design plan. _ Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 340 Summer Street, North Andover Owner: Massinino Date of Inspection: 5/17/2001 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system NePi iBat son Bateson Enterprises, Inc. e COMMONWEALTH OF MASSACHUSETTS Z f EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION F ti Q Q+M 5+0 TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: _340 Summer Street_ _North Andover_ Owner's Name: _Tom Massimino_ Owner's Address: _340 Summer Street _North Andover, Ma. 01845_ Date of Inspection: 6/28/2001_ Name of Inspector: Neil J. Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address: _111 Argilla Road_ _Andover, Ma. 01810_ Telephone Number: _( 978 ) 475-0786_ 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: _X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fai C Inspector's Signature: 4f Date: _6/28/2001_ The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments: After permit from B.O.H. & installing new outlet tee in septic tank & new pipe to d -box & new d -box with flow levelers, system now passes Title 5 Inspection. ****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. ro w Z c O o Z O f o a w O LL w N w W rd = O \ LL.0 Z m Cie c O Z 4' W ro Z Q 0 CL V1 O U y J `�� � Q Q ce w `�. a y W H o Q O Q 'O ZLL- Q ocn c O O U v a Q z m \ 3 U a O c J CC, fff��l O c 3 O N d LA N ro p a`o E LU � T un z tu � b t N 1 n v, O LA J r•° • ,<<w f • E ro o�M01 r** CL Q (n 0- N u- s APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: CURRENT INSTALLER'S LICENSE# LOCATION: LICENSED INST R: a C9 -d i4'e Sd ti SIGNATURE: �ZJ �� TELEPHONE# CHECK ONE: , -0 lg,-;� REPAIR: `' NEW C NSTRUCTION: '0_ ©1. 1Z4 rt`--ee- IF NEW CONSTRUCTION, PLEASE AT CH FOUNDATION AS -BUILT. Administrative Use Only �S $-1*0:66 Fee Attached? Yes No Foundation As -built? Yes No Floor plans on file? Yes No Approval /-'�� ��_ Date: �� �j INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the property at < 0 J t.�,..w, r Sf relative to the application of eSwdated cle / for plans by dated with revisions dated I understand the following obligations for management of this project: and 1. As the installer I am obligated to call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system is not ready then item two shall be applicable. 2. As the installer I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Tile 5 and the Board of Health Regulations may result in a $50.00 fine being levied against my company. a) Bottom of Bed - generally fust inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As -built or verbal OK from engineer must be submitted to Board of Health, after which installer calls for inspection time. Installer must be present for this inspection. With pump system all electrical work must be ready and able to cause pump to work and alarm to function. c) Final Grade — Installer must request inspection when all grading is complete. Does not have to be on site. 3. As the installer I understand that persons or companies not associated with my company may not perform the work required by my company to complete the installation of the system identified in the attached application for installation. I further understand that work by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system, and/or revocation or suspension of my license in the Town of North Andover plus significant fines to all persons involved. 4. As the Installer I understand that I must be on site during the performance of the following construction steps: a) Determination that the proper elevation of the excavation has been reached. b) Inspection of the sand and stone to be used. c) Final inspection by Board of Health staff. d) Installation of tank, D -box, pipes, stone, vent, pump chamber, retaining wall and other components. 5. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Unde,rgrgn ,ad Licensed Septic Installer Date: 6 — /( —p i Disposal Works Construction Permit # TO: NORTH ANDOVER, MASS C:Y ` C% 19 BOARD OF HEALTH FROM: DESIGN ENGINEER Re: Soil Absorption Sewage System Inspection This is to certify that I have inspected the construction of the said disposal system at M /" 67 & 15'i4 North Andover, Mass. SITE LOCATION The grades and construction are as specified in my plans and specifications dated Q F - V -7-18 19-4— Board of Health North AndoverZHaae• • SUM11 szmc szsTEH INSTAI.T.ATICK CHBJCK LIST LOT ' i� S(I,O ' l A ) AVATI CN Og FSI L tXMUVri unl� - - — 1— ea eons t �� (C ��� f�f�,,v►v�"� �CUnI� -� � Tip � � �I—('C� F�IZ OK 1. Instance Tot a.1 Wetlands b. Drains c.. Well 2. Water Line Location 3. No PVC Pipe . 4. Septic Tank a. Tees -_Length & To Clean Out Covers b. Cement Pipe to Tank - on Both Sides of Tank 5. Distribution Box a. Covers '& Box = No- Cracks , b. All Lilies Flo Ang Equal Amounts c. No Back Flow 6. Leach Fieldor Trench N a. Dimensions b. 'Stone . Depth . c'. Capped olds' d.,: Clean',,.Double Washed Stone' 7. Leach Pits a...Disensions, „. b.Stone. Depth c e . Splash Pads d. Tee e. Cerant .Pipe 'to. Pit - .Both Sides f. Clean Double Washed Stone 8. No 'Garbage Disposal 9. -Anal Grading Inspection . 10. Barricading Covered System 11. As Built Submitted a. Lot Location b. Dimensions of System c. Location -vdth Regard -to Perc Test J d., Elevations e: Water Table r t t ' Boardof Health SUBSURFACE DISPOSAL DE.GN CSECg LIST jlJlS-�-�: h LOT # 1 t Sc:1LIZ5T DATE b -. z �y DISAPPROPID I "APPRCNm DAZ'S-1 Reasons: Provided: ►�� ecu S iA3[;-r�': f rw1JC_> t6=I f3D Title Q FAIL :. Reg 2.5 The submitted plan must show as a minis a) the lot to be served -area., dimensions lot #,abetters 'b location and log deep observation holes -distance to ties ;.- c location and results percolation teats -distance to ties '!design calculations & calculations showing required IP -aching area r (e) location and dimensions of system -including ceserve area ) existing and proposed contours tem g) location WW vet areas within 100' of sewage disposal Sys or :' () disclaimer -check wetlands napping surface and subsurface drains within 100' of sewage disposal (i) system or disclaiIIsr location any drainage easements within 100' of stege disposal system or 8iselairsr-P anning Board Sales known sources of �.ater supply within 200' of serge disposal e _ y. j- - -- -----43ocation-of system or disclaimer -an- proposed v,'�1�to serve lot -100 from leaching fact from leaching Saciii location of water lines on property -10' .. location of benchmark drive"'ays r _ " .77 garbage disposals { q) no PVC to .be, used in construction. mPiP es septic tan -eeaion-of ban' -distribution, box inlets and outlets, distribution field piping am otter elevations maximum groimd water elevation in area serwage disposal system (s) plan mist be prepared by a Professional. R gineer or ocher professional authorized by l.au to prepare such plans :. Peg 6 s(a) Septic Tanks eapacit es -150%, of flow, a er. table, tees, depth of tees, access, ping cleanout 10' from cellar w-aU or inground sig pool (d) .25' from subsurface drains ;. Reg 1002 / Distribution &axes 0.08 fil a) slope greater than . Reg 10.4 b) D 40 6,q1,,g4 7-r 1 SOIL t' 0 'll,E & ?North l�ndover, Nass. Street Lot No t N L.)c/Subdiv. Pland Owner Inv estiE3ator 5'8 • Observer SOIL PROFILE DATES, - 2 . El ev 3. El ev 4 . El ev- 1 v 71 511,1 o 0 0 0 -64r -D 9 - ----- 10 - Benchmark Elevation — 2 3 4 5 — 6 — 7 8 9 10 _---- 2 3 4 5 6 7 8 9 10 I Location _ Data= PjKRCOj-ATl0N TES`T'S 1 . Ti -a3 tq Te: Pits 2 3 4 i 7 8 9 10 DATES �/ 2 3_— Pit Number — 1 I 2 /— 3 4 Start Saturation � — Soak -Minutes -- -Start - 3r�� --- — ---- Drop of 311-Tire— —� -- Drop of 6"-T-,re— N�_%s.Ist 3" drop Percol a l-ioll ;. Sgbs�face Design Check List Page 2 FAIL 19 ' Leac Pits Leaching pits are preferred where the installation is possible Reg 11.2 a) calculations of leaching area-mlni mz= 500 eq ft n.4 b) spacing 11.10 c) surface drainage 2% 11.11 d) cover material + e) 2 �1. x40 splash pad f) tee at elbow 1 g) no bends in pipe from d -box to pipe k Leaching -Fields Reg 15.1 a) no greater than 20 minutes/inch b area -minimum 900 sq ft 15.4 c construction of field k 15.8 d) surface drainage 2 % 3.7 e) 202 from cellar will or inground swinning pool r r Leachin �r�ches -- ; Reg 14.1 a)—calculauons of leaching area -min 500 sq ft 14.3 b) spacing -4 ft min 6 ft with reserve between _ 14.4 c) dimensions 1 14.6 d) construction R 14.7 e) stone 3.1.10 f) surface drainage 2% '. Downhill Slop e ' a) slope y x - to be shown) b) y/x x 1500 (to be shown)._ "Purrs - 'approval Meg 9.1 - - a) 9.6 b) stand-by power William F. Weld Governor Trudy Coxe Secretary, EOEA David S. Struhs Commissioner Commonwealth of M=s ochusetts Executive Office ,of Environmental Affoirs Department f ver n mental l tec iom SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CFRTiFICATION Property Address: —s %✓J dry /fHdGvt'2, /rIq'Address of Owner. Date of Inspection: 9 jJ� ,i7_s� (if different) Name of Inspector: 51.:—:v CsGa o0.,t'a. Company Name, Address and Telephone Number: )o 9 a- ,< riL411 t HGr erg✓ Cr,, c— �El✓' � �?'`"� 33 �°®(7 CEF.T'IFICATION STATEMENT I certify that l have personally inspected the sewage disposal sysi:em at this address and that the information reported below is true, accurate and complete as of the time of inspection, The inspection was i.erformed based on my training and experience in theproper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local :' )proving .Authority Fails Inspector's Signature /'< ���` Date: c��j 9", L/ ?hr S stem Inspector shall submit a copy of this inspection repc, t to the Approving Authority within thirty (30) days of completing this InSpection. If.the system is a shared system or has a design flog• of 10,000 gpd or greater, the inspector and the system o•,vner shall submit the report to the appropriate regional office of the Department c,' Environmental Protection. Tiw wiginai should be sen; w the s\stem owner anti Copie x,' tFhc buyer, if apphcabl(t and thC' INSPECTION SUMMARY: Check' 8, C, or D A) SYSTEM PASSES: y l I have not found any information which indicates that he system violates any of the failure criteria as defined in 310 CMR 15.303 Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate ves, 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 i, the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) 1 One Winter Street s Boston, Massachusetts 02108 a FAX (617) 556-1049 ® Telephone (617) 292 -SSW %JPrintedonRecycled Paper .. _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Poe Property Address; Owner: Date of Inspection: 4:ij B)SYSTEM CONDITIONALLY PASSES, (continued" Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health)! broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced k -r. \N- ill .1 or obstructed pipe�s), The system: -pass i he systern. required purmping more than (our times a vear due to broke, inspe� . -li-o" if (++ith approval of the Board of Healthl. broken pipe(0 are replaced obstruction is removed C1 FURTHER EVALUATION 15 REQUIRED BY THE BOARD OF HEALTH: Conditions exisz vhich reaulrlii further evaluation by the Board of Health in order to determine if the system is failing to protect the public heaith, safe,y 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: Cesspool oi Pri-, within 50 feet of a surface water Cessp,)-,i of privy is within 50 ieet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL- FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DE7ER-AilNES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT! Tile- Sf'.�' \NMIW uis) jtJC tjjnK a.",a Sol .r ^c tar -.k and soil absorption �yslem and Is ',%'i t b i r, a Zone I of i public water sappiv V101. lie t\tem Fa a septic tank and soil absorption systemand is within 50 feet of a private water supply we!! -a 0 lank and soil absorption systern and is less than 100 feet but 50 feet or more from pri% waler i ha� & ta 5-uppi,., well, unless a well water analysis for coliform bacteria and volatile organic compoundsnitrate indicates that t". well is m free frcrn pollution fro, that facility and the. presence of ammonia nitragen and nitr ppm. DI SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary . to correct the failure. Backup of sewage Jnto facility or system component due to an overloaded or clogged SAS or cesspool, Discharge or ponding of effluent to the surface oVthe ground or surface waters due to an overloaded or clogged SAS or cesspool (revised 81"I519.' i SUBSURFACE SEWAGE DISPOSALSYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: .Z P 57 4,0,1 Ss 4y�il 4vil Date 'of Inspection: DJ.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. _T 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 Sol Absorption System, cesspool or privy is below the high groundwater elevation. Am portion of a cesspool or priory is within 100 feet of a surface water supply or tributary to a surface water supply. Anv portion of a cesspool or privy is within a Zone I of a public well Any portion of a cesspool or privy is within 50 feet of a private water supply well, Any portion of a cesspool or privy is less than 100 feet but greater than 50, feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: The, `oi!oti:mg criteria appir to large systems ;n addition to the criteria above 'hp. UP? �" C '. c� ytr r . ,.. i 0,000 gpd er greater !Larg? S,, Ste r, and t`'e c, c?nim i5 a significant threat to public health and safety and the er�v;ronrnent because one or more of the failav•!ng conditions ea st, _ the system is within 400 feet of a surface drinking water supply the system s 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 MArPA) or a mapped Zone II of a pubhc 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 focal regional office of the Department for further information. (revised E/1`r'95: 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST ire /*0/� Property Address: Owner. Date of Inspection: Check if the following have been done; Y Pumping information was requested of the owner, occupant, and Board of Health. ///,None of the system cornponents have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently oras part of this inspection. LfAs built plans have been obtained and examined. Note if they are not available with N/A, The facility or dwelling ,yas inspected for signs of sewage back-up. e"TIne system does not receive non-sanitan• or industrial waste flow The. site was inspected for signs of breakout All system components, excluding the Soil Absorption Svstem, have been located on the site. k The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction; dimensions. depth of, liquid, depth of sludge, depth of scum. /'The.size and location of the Soil Absorption System on the site has been determined based on existing information or approximated b`; non-in'r.rusive method ere provi0ea rh irformar,nn on the oroper maintenance Of Sub - Surface D+sposal Svstem. 4 (:evase:d 8/15/951 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: y� um/I �L'�� �j/����i✓1401�L�lt� %L��, 0/ ��� Owner: . 2 et S'/C' D I QUA Date of Inspection: 9'/q :> I/ q,, FLOW CONDITIONS RESIDENTIAL: Design flow:_�gallons Number of bedrooms:_ Number of current residents: Zei, Garbage grinder (yes or no): - Laundry connected to system (yes or no): Seasonal use (yes or no): /M' Water meter readings, if available: .C/o t�/"li`,ga--/Z= Last date of occupancy: 'f . �P 'E Z'l t COMMERCIAIJINDUSTRIAL: Type of. establishment: Design flow:__ _gallons/day Grease trap present: (ye's or no)_ Industrial WaMe 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 cf occupy _ GENERAL INFORMATION PUMPING RECORDS and source of information: �v LI / - a cyca� e i /-h, � System pumped as pan of inspection; kyes_,or na) If yes, volume p. mhed .'a 40 gaM!'ons. Reason for pumping IV ��G�i14 OF 1A1 7d,-, c TYPE OF SYSTEM _ A-' Septic tank:'distribi.;hon bousoil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no; (if yes, attach previous inspection records, if any) Other (explain) go o ecj 044.7t)" APPROXIMATE AGE of all components; date installed (if known) and source of information: Sewage odors detecled -lien arrii\ Ing at the site: (yes. or no) !� (revised 9/15/95: 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property . Address: 0"J'W'oe Vo e Owner: Date of inspection: SEPTIC TANK: (locate on site plan) Depth below grade: J - material of construction: Vconcrete —metal —FRP —other(explain) Dimensions: Sludge 'depth: o? " Distance from top of sludge to bonorn of Outlet tee or baffle. Scum thickness Distance from top of , Scum to top of o6tie!.tee or baffle: li' Distance from bottom Of Scum to bosom of outlet tee or baffle: 0 Comments: (recommendation.. for pumping, condition of inlet and outlet tees or baffles, depth of liquid- level in relation to outlet invert, structural integrity, evidence . ence of leakage,etc.i a k, )ees g#,X-Algls Oe -40," ,:'eo A�l rj 0 �r*'-- 1,0 P the n -Box 'OA40Oei GREASE TRAP:. llocate onsite p!af,) Depthbelow grade:_ Material of construction:. concrete _metal FRP .6ther(explaini Distance from top of scum 10 IOP of outlet.tee or,baffle:— f botT= to r`,It'n— ci OUtle! lf?P or baf?!A'1 Conimeni5 -ilet and outlet tees o on, i!,or, of it r baffle5, depth of liquid level in relation to outlet invert, structural (recommendation for pump" c ntegri I ty, e� idence of ieakapc e!( revised 6 5/55; 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property;Address. 3,16) SUM�1l�� S, lG'dk�% �ly, doves, /f1 ¢ o/ Pys . ;Date of Inspection: -'s TIGHT s TIGHT OR HOLDING TANK:— (locate onsite plan) Depth below grade: Material of construction: ,concrete ___,metal —FRP —other(explain) Dimensions: Capacity: a! Ion.; Design flow: gailons/da; Alarm • level: Comments ;cor clition of inlet tee, cond!don of alarm and float svvitches, etc,) DISTRtBUT1ON BOX: (locate on site plan! Depth of liquid level above outiet invert: (f' Comments: of leakaee into C r out of bm: etc D Z3oJx 1S�y��� ,'1� tLJ �l/i02rG/1 Od ����� ovr��c. D r?ox c'uv¢e�s'eGLy��o 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 6/15,195) 7 N.. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1 7 0,ygh,9n Si.Pil?,'Qlle Own&:. Date of Inspection: c� SOIL ABSORPTION SYSTEM (SAS):.'' (locate on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods) !f not determined to be present, explain: T , ype leaching pits, number:_ leaching chambers. number:— leach ing'gal ler ies,, number: leaching trenches, number,length:_ 6 -T ,j J);egl-c"Oog S, leaching fie!ds, number, dimensions: 0verflo,^, cesspool, nijniber.. (note c on(JI, -;n 01 soli, signs of hydraulic failure, level of ponding, condition of vegelaOcin.etc '61 421 CESSPOOLS: — OoCat , e an site plan) Number and configuration: oeoth.top of liquid to inlet ;nverl� Depth of solids laye"— L7iepth of scum laver of cessl)06 t e, r; a! of construc-,inr, inflow (cessr)on" be ournoed as par-, of inspection) Comments: (note cond!tiorl 0, saii, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY; (locate on site plan; Dimensions: Materials of constrOclion:_---� Depth' of ,solids comments; (note condition of soil, signs of hydraulic failure, level of ponding, condition of v . egetation, etc 2,revised 8/1S/95) 8 Con none ealth of Massachusetts ` ,Massachusetts System Pumping Record ISystem Owner System Location 3Lto Date of um piI n =: ' I � � � �Quairiity Pumped: � � gallons Cesspool.- No Yes LJ Septic Tank: No Yes «� System Pumped by: F(I red4a ge&,7 taa License # Contents transferrred to : Greater Lawrence Sanitary District Date: __ Inspector- D- OARD nspector: Dn4RD OF HEALTH AUG - 51999 Commonwealth of Massachusetts A N, , Massachusetts System Pumping Record System Owner P ! 0,53. Date of Pumping: Cesspool: No [.]�� Yes [ ] System Pumped by: Va&"W saavww System Location -3 1� C-) S V, VAQ-�- S+-. Quantity Pumped: 6j��gallons Septic Tank: No [ ] License # Contents transferred to: Greater Lawrence Sanitary District Date: Inspector: Yes [4 -- System Owner Commonwealth of Massachusetts Massachusetts System Pumping Record System Location C c S� - - Date of Pumping:. q/ — L4 — q 6 Quantity Pumped Cesspool: No Yes ❑ Septic Tank: No ❑ System Pumped by: gwwe t 5O&TA44W License # Contents transferrred to : Greater Lawrence Sanitary District Date: Inspector: 9��llons Commonwealth of Massachusetts Ziassachusetts stem I'urnping Record System 6%vner Date of Pumping: 3 - 13, --� 9 Cesspool: No LYes L. -I System Location (Quantity Pumped: / b j gallons Septic Tank: No Ll Yes System Pumped by: Stewart 9iI.&NwOP,d License # Contents transferrred to : Greater Lawrence Sanitary District Date: Inspector: TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: SYSTEM LOCATION (example: left front of house) ('\ Ate- 19� C�(Z- C --),k- DATE OF PUMPING: QUANTITY PUMPEDtv`<�� GALLONS CESSPOOL: NOYES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE, EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: COMMENTS: FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) ��cd'c�'Ca4 �C vV'N QF SPF Tr- !�i� bi '.� 'v:Y:cha�s Y1 L=- CONTENTS TRANSFERRED TO:°SAY I Q ?Ilni .... t Commonwealth of Massachuse- City/Town of System Pumping Record Form 4 �M DEP has provided this form for use by local Boards of Ht MIN, p>$e < , but the information must be, substantially the same as that providto ,check with your local Board of Health tct determine the form they use. The System Pumping Record must be submitted to the local Board of Health ouothler approving authority. A. Facility Information 1. System Location: Left side of hous Right side of hou Left front of house, Right front of house, Left rear of house, Right rear of house. a rear of building. Right rear of building. Address Cityrrown State Zip Code 2. System Owner. Name Address (if different from location) City/Town B. Pumping Record `7-- [A -CD 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): Date Cesspool(s) 4. Effluent Tee Filter present? ❑ Yes a No 5. Condition of System: 6. System Pumped By: Neil Bateson Name Bateson Entemrises Inc Company 7. Locati w ere contents were disposed: G.L.S. �I „ Lowell Waste Water State Zip Code Telephone Number 2. Quantity Pumped: eptic Tank Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No F5821 Vehicle License Number Date _i 6 _lb t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 zz r Iii VI n ni � � vty iol J h� o U4 Ku GO r4 n 01 IZ V'S V --4Q w�Z {,. Q � 4 • • • • p W 3 � Q 4 w►. � Q � � ►. 0 � � � I. 1. � D W 4t 4• v �a10 4. t. o R 4c � O v � o� ��QwWop � � � _ _ � ►• 4 Q� ► I �I V lU a i i i h ice` Q ri WW W C'J ., I_ i �I a i i i h �I 3 I ® J � � a ct �� a