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06/09/2005 13:36 9786888476 HEALTH
BOARD OF HEALTH
400 OSGOOD STREET
NORTH ANDOVER, MA 01,845
TELEPHONE# (978) 688-9540
APPLICATION ,FOR ABANDONMENT
OF SUBSURFACE DISPOSAL SYSTEM
(SEPTIC SYSTEM)
Pursuant to Section 310 CMR 15.354
of the State Environmental Code, Title v
Name 2
ggyge—k Phone
Address .7y3 s eat sl -r— .
Contractor hired for work:
Name., 1,
Address
Jct ae�
PAGE 04/04
JUN 2 4 2005
QWN OF NORTH ER
HEALTH DEPARTMENT
NT
Phone.C/�--
Date for scheduled abandonment
The septic system at the above address has been abandoned according to Title V
specifications.
Signature of Contractor
Method of septic tank abandonment (check one). ( ) removal () sandfill ( sh
( ) other
Name of Offal Hauler,!!
This form must be returned to the North Andover Board of Ifealth.
PLEASE DO NOT WRITE IN THE SPACE BELOW FOR HEALTH
REPRESENTATIVE'S USE ONLY.
Inspecting Agent
Date
BOARD OF HEALTH
400 OSGOOD STREET
NORTH ANDOVER, MA 01845
TELEPHONE# (978) 688-9540
APPLICATION FOR ABANDONMENT
OF SUBSURFACE DISPOSAL SYSTEM
(SEPTIC SYSTEM
Pursuant to Section 310 CMR 15.354
of the State Environmental Code, Title V
Name Phone
Address '-)'/ 'j
Contractor hired for work:
Name Phone -1-7 F y 3 Z
Address
Date for scheduled abandonment az-2-1D-'5
The septic system at the above address has been abandoned according to Title V
specifications.
Signature of Contractor
Method of septic tank abandonment (check one). O removal O" sandfill Xcrush
( ) other
Name of Offal Hauler
This form must be returned to the North Andover Board of Health.
PLEASE DO NOT WRITE IN THE SPACE BELOW FOR HEALTH
REPRESENTATIVE'S USE ONLY.
4ectingAgent Date
vP
J, 2017
APPLICATION FOR SEWER SERVICE CONNECTION
North Andover, Mass.
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. 1-11) r
The premises are known as No.
or subdivision lot no.
Owner
'A1
Contractor
Address
Addr
p ant's Signature
PERMIT TO CONNECT WITH SEWER MAIN
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
By
See back for rules and regulations
Street
Street
Division of Public Works
7 x
PETER F. REILLY �=
136 ANDOVER STREET
ANDOVER, MA 01810 "U"' 1 0 2003
(978) 375-3750 r " ; "
Lee -
TITLE V
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION
Property Address:
343 Salem Street, North Andover, MA 01810
Name of Owner:
Patricia Russell
Address of Owner:
same
Name of Inspector:
Peter F. Reilly
Company Name:
same
Mailing Address:
136 Andover Street, Andover, MA 01810
Telephone Number:
(978) 375-3750
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of inspection. The inspection
was 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
N/A Conditionally Passes
N/A Needs Further Evaluation By the Local Approving Authority
N/A Fails
Inspector's Signature: Date: May 24, 2003
Pe r F. Reilly
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within thirty (30) days of completing this inspection. If the system is a shared
system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall
submit the report to the 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 a the time of inspection and under 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 (See attached Disclaimer).
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION (continued)
Property Address: 343 Salem Street, North Andover
Owner's Name: Russell
Date of Inspection: 5/24/03
INSPECTION SUMMARY:
A. SYSTEM PASSES: Check A, B, C, D, or E / ALWAYS complete all of Section D
✓ I have not found any information which indicates that the system violates any of the failure criteria as
defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
The system met the Pass Criteria of Title V.
B. SYSTEM CONDITIONALLY PASSES:
N/A One or more system components as described in the "Conditional Pass" section need to be replaced or
repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,
will pass.
Answer yes, no, or not determined (Y, N, ND). Describe basis of determination in all instances. If"not determined",
explain why not)
N The septic tank is metal, and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass
inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of
Health. *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 a sewage backup or breakout or high static water level in the distribution box is due to
broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass
inspection if (with approval of the Board of Health):
N/A broken pipe(s) are replaced
N/A obstruction is removed
N/A distribution box is leveled or replaced
ND explain:
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):
N/A broken pipe(s) are replaced
N/A obstruction is removed
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION (continued)
Property Address:
343 Salem Street, North Andover
Owner's Name:
Russell
Date of Inspection:
5/24/03
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 the public health, safety and environment.
System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
N/A Cesspool of privy is within 50 feet of a surface water
N/A Cesspool or privy is within 50 feet of a bordering vegetated wetland or 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:
N/A The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to
a surface water supply or tributary to a surface water supply.
N/A The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply well.
N/A The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
N/A The system has a septic tank and SAS the SAS is less than 100 feet but 50 feet or more from a
private water supply well.**Method used to determine distance N/A
This system passes if the water well water analysis, performed at a certified DEP 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. A copy of the analysis must be attached to this form.
3. Other
N/A
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART A - CERTIFICATION (continued)
Property Address:
343 Salem Street, North Andover
Owner's Name:
Russell
Date of Inspection:
5/24/03
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 an overloaded or clogged SAS or cesspool.
No Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool.
No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
N/A Liquid depth in cesspool less than 6" below invert or available volume <'/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: once
No Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
N/A Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water
supply.
N/A Any portion of a cesspool or privy is within a Zone I of a private water supply well.
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well.
N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply
well with no acceptable water quality analysis. (This system passes if the well water analysis, performed
ata DEP laboratory, for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate
nitrogen is less than 5 ppm, provided that no other failure criteria are triggered. A copy of the
analysis must be attached to this form).
N/A The system fails. I have determined that one or more of the above failure criteria exist as defined in 310
CMR 15.303, therefore the system fails. The property owner should contact the Board of Health should be
contacted 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 a large system in addition to the criteria above)
N/A The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat
to public health and safety and the environment because one or more of the following conditions exist:
Yes No
N/A The system is within 400 feet of a surface drinking water supply
N/A The system is within 200 feet of a tributary to a surface drinking water supply
N/A The system is located in a nitrogen sensitive area (Interim Wellhead 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 such 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.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART B - CHECKLIST
Property Address:
343 Salem Street, North Andover
Owner's Name:
Russell
Date of Inspection:
5/24/03
Check if the following have been done. You must indicate either "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 flow in the previous two week period ?
No Have large volumes of water been introduced to the system recently or as part of this inspection?
N/A Were as built plans of the system obtained and examined ? (If they were available note as N/A)
Yes Was the facility or dwelling was inspected for signs of sewage backup ?
Yes Was the site was inspected for signs of breakout ?
Yes Were all system components, excluding the SAS, have been located on the site ?
Yes Were the septic tank manholes uncovered, opened and the interior of the septic tank inspected
for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of
sludge, depth of scum ?
Yes Was the facility owner (and occupants of if different from the owner) provided information on the
proper maintenance of subsurface sewerage 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.
N/A Determined in the field if any of the failure criteria related to Part C is at issue (approximation of
distance is unacceptable) [15.302(3)(b)].
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION
Property Address:
343 Salem Street, North Andover
Owner's Name:
Russell
Date of Inspection:
5/24/03
FLOW CONDITIONS
RESIDENTIAL:
Number of bedrooms (design):
Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203
(for example: 110 gpd x # of bedrooms:
Number of Current residents:
Does the residence have a garbage grinder (yes or no):
Is the laundry on a separate sewerage system (yes or no):
Laundry system inspected (yes or no):
Seasonal use (yes or no):
Water meter readings, if available (last 2 years usage [gpd]):
Sump Pump (yes or no):
Last date of occupancy:
COMMERCIAL/INDUSTRIAL:
Type of Establishment:
Design Flow gpd (based on 15.203):
Basis of Design Flow (seats/persons/sq.ft., etc):
Grease trap present (yes or no):
Industrial waste holding tank present (yes or no):
Non -sanitary waste discharged to the
Title 5 system (yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER: (Describe)
PUMPING RECORDS
unknown
4
unknown
2
yes
no (if yes, separate inspection required)
N/A
no
100 gpd average
no
current
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
GENERAL INFORMATION
Source of Information: owner
Was system pumped as part of inspection (yes or no): no
if yes, volume pumped (gallons): N/A
How was quantity pumped determined ? N/A
Reason for pumping: N/A
TYPE OF SYSTEM
✓ Septic tank/distribution box, soil absorption system
Single cesspool
Overflow cesspool
Privy
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 the 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: original tank and SAS
about 30 years old.
Were sewerage odors detected when arriving at the site (yes of no): no
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address:
343 Salem Street, North Andover
Owner's Name:
Russell
Date of Inspection:
5/24/03
BUILDING SEWER: (locate on site plan)
Depth below grade: about 8" - 12"
Materials of construction: ✓ cast iron 40 PVC other (explain)
Distance from private water supply well or suction line N/A
Diameter: 4"
Comments: Condition of joints, venting, evidence of leakage, etc.)
Building sewer was watertight and appeared sound at foundation.
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: about 0" - 6"
Material of construction: ✓ concrete metal Fiberglass Polyethylene other (explain)
If tank is metal, list age N/A Is age confirmed by Certificate of Compliance N/A (Yes/No)
Dimensions: Rectangular - 1,250 gallons
Sludge depth: 2"-4"
Distance from top of sludge to bottom of outlet tee or baffle: 25"
Scum thickness: 1 "-2"
Distance from top of scum to top of outlet tee or baffle: 7"
Distance from bottom of scum to bottom of outlet tee or baffle: 15"
How dimensions were determined: observation
Comments: (on pumping recommendations, of inlet and outlet tees or baffle condition, structural integrity,
liquid level as related to outlet invert, evidence of leakage, etc.)
Tank was watertight. Outlet tee was missing and was replaced following inspection.
GREASE TRAP: N/A (locate on site plan)
Depth below grade:
material of construction: concrete metal FRP other (explain)
Dimensions: N/A
Scum thickness: N/A
Distance from top of scum to top of outlet tee or baffle: N/A
Distance from bottom of scum to bottom of outlet tee or baffle: N/A
Date of Last Pumping: N/A
Comments: (on pumping recommendations, of inlet and outlet tees or baffle condition, structural integrity,
liquid level as related to outlet invert, evidence of leakage, etc.)
N/A
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address:
343 Salem Street, North Andover
Owner's Name:
Russell
Date of Inspection:
5/24/03
TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection) (locate on site plan)
Depth below grade:
material of construction: concrete metal
Dimensions:
Capacity:
Design Flow:
Alarm Present (yes or no):
Alarm level:
Alarm in working order (yes or no)
Date of last pumping:
N/A
Fiberglass Polyethylene other (explain)
N/A
N/A gallons
N/A gallons per day
N/A
N/A
N/A
N/A
Comments: (condition of alarm and float switches, etc.)
N/A
DISTRIBUTION BOX: ✓ (locate on site plan)
0" depth of liquid above outlet invert
Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage
into or out of box, recommendation for repairs, etc.)
D -box was level. Three lines leading to SAS were appear to be accepting effluent evenly. D -box was
about 8" - 10" below surface.
PUMP CHAMBER: N/A (locate on site plan)
Pumps in working order (yes or no) N/A
Alarms in working order (yes or no) N/A
Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.)
not applicable
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address:
343 Salem Street, North Andover
Owner's Name:
Russell
Date of Inspection:
5/24/03
SOIL ABSORPTION SYSTEM (SAS): ✓ (locate on site plan, if possible; excavation not required)
If SAS not located, explain why:
Type
leaching pits, number
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
✓ leaching fields, number, dimensions
overflow cesspool, number
alternative system (name of technology)
N/A
N/A
N/A
N/A
1 field, 3 lines, est. size 20'x 50'
N/A
N/A
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.)
Soils in area of SAS looked good, no evidence of ponding, damp soil, or breakout.
CESSPOOLS: N/A (locate on site plan)
Number and configuration
N/A
Depth -top of liquid to inlet invert
N/A
Depth of solids layer
N/A
Depth of scum layer
N/A
Dimensions of cesspool
N/A
Materials of construction
N/A
Indication of groundwater inflow (cesspool
must be pumped as part of inspection)
N/A
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
recommendations for maintenance or repairs, etc.)
not applicable
PRIVY: N/A (locate on site plan)
Materials of construction N/A
Dimensions N/A
Depth of solids N/A
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
recommendations for maintenance or repairs, etc.)
not applicable
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address: 343 Salem Street, North Andover
Owner's Name: Russell
Date of Inspection: 5/24/03
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Provide a sketch of the sewerage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100'. Locate where public water supply enters the building.
B
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C serf; � fay k
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Ppprax.
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SEPTIC TANK TIES:
D -BOX TIES:
NOTE:
SRL F -M STR EET
A to Center (C) 33'6" B to Center 23'0"
A to Box 30'6" B to Box 2810"
The system is in the right side yard.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM
PART C - SYSTEM INFORMATION (continued)
Property Address:
343 Salem Street, North Andover
Owner's Name:
Russell
Date of Inspection:
5/24/03
SITE EXAM
Slope flat to gently sloping in area of system
Surface water none observed
Check cellar dry
Shallow wells none observed
Estimated Depth to Groundwater >1" (below bottom of SAS)
Please indicate (check) all methods used to determine the high ground water elevation:
N Obtained from Design Plans on record - if checked, date of design plan reviewed: N/A
Y Observed site (abutting property, observation hole within 150 feet of SAS)
Y Check with Local Board of Health - explain: information on file
Y Check local excavators, installers - (attach documentation)
N Accessed USGS Database - explain: website too complicated
You must describe how you established the high ground water elevation.*
The soils and grade changes in the area indicate no groundwater in the SAS. However, the precise
groundwater elevation cannot be determined for certain without a soil evaluation test.
*Inspector's Note: Soil Evaluation is the currently recognized method for determining
or establishing the high groundwater elevation. Since I am not a licensed or certified
soil evaluator, I am not qualified to determine or establish the high groundwater
elevation beyond the public information available, such as recent design plans of the
site or the nearby area. My estimation of the high groundwater elevation is based on
a due diligence effort to obtain all available information both on and off the site and my
experience as a certified subsurface disposal system inspector. (see attached
Disclaimer)
L
DISCLAIMER
This passing septic inspection under Massachusetts Title V is in no way a guaranty
or warranty of the inspected septic system. The inspection is a "snapshot in time" and
does not constitute a complete assessment of the quality or potential longevity of the
septic system. The pass/fail criteria are specific and outlined in detail in this report.
Under the limited criteria of a Title V inspection, it is impossible to determine how long
any septic system will last. The inspector made a diligent effort to certify the septic
system based on the criteria required under Title V.
Under Massachusetts Title V, soil evaluation is the accepted method of determining
the high groundwater elevation. This inspector is not a certified soil evaluator and is
therefore not qualified under Title V to determine or establish the high groundwater
elevation. The method used to estimate the high groundwater for this inspection was
based on the public records and methods of observation described on the previous
page. Groundwater levels can vary greatly from season to season, year to year and
soil evaluation is considered the most reliable method of groundwater determination
under Title V.
Peter F. Reilly
Inspector
May 24, 2003
3�4
APPLICATION FOR SEWAGE DISPOSAL INSTALLATION
HEALTH DEPARTMENT - NORTH ANDOVER, MASS.
I hereby mak application for a permit for a sewage disposal installation at
45, . I will install this system in ac-
cordance with all the laws of the Commonwealth of Massachusetts and regulations of
the Board of Health of the Town -of North Andover.
Further, I will construct the house sewer of bell and spigot pipe, the minimum
diameter being 4 inches, and will maintain a minimum grade of 1/ until 10 feet pre-
ceding the septic tank, where the grade shall not exceed 2%. I will install a con-
crete septic tank of / a 2e��in size. A manhole (s) permitting easy cleaning
will be provided with removable cover (s) of iron or concrete within 12 inches of
the ground surface. I will provide subsurface disposal field with 4 inch perforated
or open jointed pipe and laid in a er1es of trenches, the bottom of which will pro-
vide a minimum ofG_ A./3o7rt & &&li� uare) feet of effective absorption area.
The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging
in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar
material to a height of 2 inches above the crown of the pipe. The joints of these
pipes will be protected from clogging and before filling the trench, 2 inches of
gravel or stone 1/8" to 1/4" (dia.) will be placed over the course gravel or stone.
The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single
tile line will exceed 100 feet in length and in any case, two lines of tile will be
installed. A minimum of 6 feet will be maintained between the center lines of the
disposal field trenches and the average depth of trench shall not exceed 36 inches.
No part of the installation will be less than 100 feet from any private water supply,
25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line.
I further agree not to cover any portion of this installation until approved by the
inspection officer, as provided below, and to incorporate any additional requirements
that may be attached to the permit. Plot Plans must be submitted with application.
DATE ' 3 -71
Signature of Applicant
I hereby issue the above permit for the Board of Health of the Town of North
Andover, Massachusetts.
DATE J - -7/
Signature of Health Agent
I have inspected the uncovered system indicated above and find everything done
as described
DATE �1 1 A t
.0
Signature of n sting Officer
Percolation Test
Garbage Grinder
BOARD OF HEALTH OF NORTH ANDOVER, MASSACHUSETTS
SEWAGE DISPOSAL
NAME OF APPLICANT Thomas Hennessey
LOCATION 343 Salem St.
Address of lot no.
BUILDING: Dwelling X Other
SYSTEM: New
DATE
Repair X - Add ed 2 bedrooms
GENERAL DESCRIPTION OF LAND high
SUBSOIL: Clay Gravel Sand
PERCOLATION TEST minutes per inch.
MINIMUM INSTALLATION RECOMMENDATIONS
CONCRETE SEPTIC TANK 1500 gallon capacity.
LEACH FIELD 130 lineal feet of drain pipe.., to
present system.
William J. Dris 11' Engineer
Board of Health
BOARD OF HEALTH
TOWN OF NORTH ANDOVER, MASS.
0-
2)
G c6
1. NAME4i�l A j L) bj Q SSV DATE 3 0 rl
2. ADDRESS 34_7', <3k-CILj -->71: LOT NO. TEL.
3. NO. OF BEDROOMS DEN YES '� NO
4. GARBAGE GRINDER YES NO `l�
5. SHOW DIMENSIONS OF HOUSE
6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES
7. SHOW DIMENSIONS OF LOT
8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL
9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM
10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC.
11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE
NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY.
,d K.
1 77s
i
-` •' A. DeFu.sco
� V,3 Lot 343 Salem St,
APPLICATION FOR SEWAGE DISPOSAL INSTALLATION
HEALTH DEPARTISM--NORTH ANDOVER, MASS.
I hereby make application for a permit for a sewage disposal installation at
-. Lot X43 Salem St. 1 will install this system in
accordance with all the laves of the Commonwealth of Massachusetts and regulations
of the Board of Health of the Town of North Andover.
Further$ I will construct the house sewer of bell and spigot pipe# the minimum
diameter being 4 inches# and will maintain a minimum grade of 1% until 10 feet
preceding the septic tanks, where the grade shall not exceed 2%. 1 will install a
concrete septic tank of 1000 Gal. in size. A manhole (s) permitting easy
cleaning will be provided with removable cover (s) of iron or concrete within.12
inches of the ground surface. I will provide subsurface disposal field with open
jointed bell and spigot Ackron pipe at least 4 inches in diameter and laid in a
series of trenches,, the bottom of which will provide a minimum of 280 lineal
(sem) feet of effective absorption area. The pipes will be laid on a 6 inch
layer of washed gravel or crushed stone ranging in size from 3A to 1-1/2 inches
(dia.) and the pipes will be surrounded by similar material to a height of 2 inches
above the crown of the pipe. The joints of these pipes will be protected from
clogging and before filling the trench# 2 inches of gravel or stone 1/811 to 1/4t'
(dia.) will be placed over the course gravel or stoneThe disposal field will be
installed at a grade of 4 to 6 inches/l00 feet. No single tile line will exceed
100 feet in length and in any case# two lines of the will be installed. A minimum
of b feet wM be maintained between the center lines of the disposal field trenches
and the average depth of trench shall not exceed 36 inches. No part of the in-
stallation will be less than 100 feet from any private water supply., 25 feet.from
any stream# 20 feet from any dwelling or 10 feet from any property line. I further
of�icer# as provided b
may be attached to th
e rermit. Plot Plans must be submitted with application.
DATE a 1/19/58 y 2 \... _
�/
Signature of Applicant
I hereby issue the above permit for the Board of Health of the Town of North
Andover.. Massachusetts.
DATE 1/19/58
Si nature of Health Agent
I have inspected the uncovered system indicated above and find everything done
as described.
S'
DATE
Signature of pecting Officer
Percolation Test 5 min. Sandy -clay
Garbage Grinder No
.__a
BOARD OF HEALTH
TOWN OFF NORTH ANDOVER: MASS.
SA-VIII-17
1�v
,-I, �a�.0
}b' tc'
Z a° ms
Ad. AL nv
1. NAME . ./:l >,C; 4 PA FJ -S DATE
: DATE
2. ADDRESS :SA tS; .. .' . LOT N0. , . . TEL. .
3. NO. OF BEDROOMS . 4% DEN YES NO.
/4. GARBAGE GRINDER YES . `iNO.
5. SHOW DIPltEWSIONS OF HOUSE lit o t� �+ . �7 F—r• 'Dz:s t cl pje o Foe
6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINESc 0 17a o w1
7. SHOW DIMENSIOTZ OF LOT
8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL
9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM,
10. SHOW LOCATION OF BROOKS., STREANS9 DITCHES.. LEDGE OUTCROPt ETC.
ll. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FRO14 HOUSE
NOTE: LOCAL REGULATION'S SHOULD BE READ CAREFULLY.
I V v G cv c-� e, cy o 4-� 0. p c' c7 v a, eu 4z�r) 4 v 4;"- rs M,
�1
4
� W
December 20, 1958
Miss Mary Sheridan R. N.
Health Agent
Board of Health
North Andover, Mass.
Dear Miss Sheridan
An examination was made as requested in order
to determine the suitability of the soil for the
subsurface disposal of sewage on the proposed
Salem Street building site (Lot #343) of Mr. Al DeFusco.
The subsoil in the area was of a sandy clay con-
tent and a 5 -minute percolation test was conducted.
The land in general is high.
It is recommended that a 1,000 gallon concrete
septic tank be installed together with 280 lineal feet
of drain pipe.
WJD:hd
Very truly yours,
IBJ`
William J. D Coll
APPLICATION FOR SEWAGE DISPOSAL INSTALLATION
HEALTH DEPARTkOU--NORTH ANDOVER, MASS.
A. DeFusco
Lot 343 Salem St.
I hereby make application for a permit for a sewage disposal installation at
Lot 343eE St. .,. I will install this system in
accordance with all the lags of the Commonwealth of Massachusetts and regulations
of the Board of Health of the Town of North Andover.
Further, I will construct the house sewer of bell and spigot pipe., the minimum
diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet
preceding the septic tants' where the grade shall not exceed 2%. I will install a
concrete septic tank of 10x0 Cmc. in size. A manhole (s) permitting'easy
cleaning will be provided with removable cover (s) of iron or concrete within 12
inches.of the ground surface. I will provide subsurface disposal field with open
jointed bell and spigot Ackron pipe at least 4 Inches in diameter and laid in a
series of trenches, the bottom of which will provide a minimum of _ '280Uneal
( ) feet of effective absorption area. The pipes will be laid on a b inch
layer of washed gravel or crushed stone ranging in size from 3/4 to 14/2 inches
(dia.) and the pipes will be surrounded by similar material to a height of 2 inches
above the crown of the pipe. The joints of these pipes will be protected from
clogging and before filling the trencht 2 inches of gravel or stone 1/8" to 1/4"
(dia.) will be placed over the course vel or stone. The disposal field will be
installed at a grade of 4 to 6 inches feet. No single tile line will exceed
100 feet in length and in any case, two lines of the will be installed. A minimum
of 6 feet will be maintained between the center lines of the disposal field trenches
and the average depth of trench shall not exceed 36 inches. No part of the in—
stallation will be less than 100 feet from any private water supply, 25 feet from
any stream, 20 feet from any dwelling or 10 feet from any property line. I further
officer, as provided below, and to incorporate any additional requirements tha
may be attached to the permit. Plot Pians must be submitted with application.
DATE VP158
Signature of Applicant
I hereby issue the above permit for the Board of Health of the Town of North
Andover, Massachusetts,
DATE 1/19/58
Signature of Health Agent
I have inspected the uncovered system indicated above and find everything done
r as d cribed.
DATE •
Signature of IsJating Officer
Percolation Test 5 min• Sanc3y�clay
Garbage Grinder No
WILLIAM F. WELD
Govemor
ARGEO PAUL CELLUCCI
Lt. Governor
_ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL,AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON, MA 02108 617-292-5500
91 1 r
TRUDY CORE
- f
I Secretary
DAVID B. STRUHS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �" Commissioner
PART A
CERTIFICATION
Property Address:
243 Salem St. Address of Owner:
N.Andover, MA
Date of Inspection: 11 -'P — 9 7 (If different)
Name of Inspector: James W. Wright Jr.
am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: R.J. ins ections
Mailing Address: 1 Osqood St., Methuen, MA 01844
Telephone Number:. _978 681-8759
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
_✓ passes
Conditionally Passes
_ etg_e ds Further Evaluation By the Local Approving Authority
Inspector's Signature:'" —�-'- - Date: 1 C<
The System Ins,,;/
ns r shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If, t� 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 t e appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 31.0 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
B] SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) page l of 10
DEP on the World Wide Web: http:/Avww.magnetstate.ma.us/dep
ej Printed.on Recycled Paper
1�)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION_ FORM
_ . PART A
CERTIFICATION (continued)
Property Address: 343 Salem St. , N. Andover, MA.
Owner: Bernadette Doherty
Date of Inspection: 11-7-97
BI 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). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution. box is levelled or replaced
The system required pumping more than four times a year, due to broken or obstructed pipe(s). The system will pass
inspection if (with approval of the Board of Health):
broken pipes) are replaced
obstruction is removed
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 the
public health, safety and the environment.
1) . SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
.WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
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 APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
The system has a septic tank and -soil absorption system and the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
(revised 04/15/97)
\1)
Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 343 Salem St. , N. Andover, MA
Owner: Bernadette Doherty
Date of Inspection: 11-7-97
D] SYSTEM FAILS:
You must indicate ei;!ier "Yes" or "No" as to each of the following:
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.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
_ Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped _.
_ Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility. into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97)
1�)
Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION_ FORM
PART_ B
CHECKLIST
Property Address: 343 Salem Street, N.Andover, MA
Owner: Bernadette ' Soherty
Date of Inspection: 11-7-97
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes /No
//� _ Pumping information was provided by the owner, occupant, or Board of Health.
✓ _ None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
i
As built plans have been obtained and examined.. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non -sanitary or industrial waste flow.
The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
/- The size and location of the Soil Absorption System on the site has been determined based on:
t/ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub -Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [15.302(3)(b)]
(revised 04/25/971
1�
Fags 4 of 10
-- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 343 Salem street, N. Andover, MA
Owner: Bernadette Soherty
Date of Inspection: 11-7-97
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction: _ tract jron _ 40 PVC _ other (explain)
Distance from private waters g� y4ell or suction line
Diameter � /
Comments: (condition of joj ts, venting, evidence of leakage, etc.)
SEPTIC TANK:_
(locate on site plan)
Depth below grade: ��
Material of construction: _cd/oncrete _metal _Fiberglass _Polyethylene —other(explain)
If tank is metal, list age
i— Is age confirm --Jed by Certificate of Compliance _ (Yes/No)
S
Dimensions: �7� X S X
Sludge depth: -3 '+e
Distance from top of sludge to bottom of outlet tee or baffle: an' ,e
Scum thickness: / ,,
se
Distance from top of scum to top of outlet tee or baffle:_
Distance from bottom of scum to bottom of outlet tee oz baffle: :2oD
d%f/ z
How dimensions were determined: �
Comments:
(recommendation for pumping, condition of
integrity, evidence of leakage, etc.) z
GREASE TRAP:
(locate on site plan)
and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
4:`v /
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Scum thickness: / (,oj
Distance from top of scum to pop of ut t; ee or baffle:
Distance from bottom of scum to b o of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 04/15/97) Page 6 of 10'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
343 Salem Street, N.Andover, MA
Property Address:
Owner: Bernadette Doherty Date of Inspection: 11-7-9 7
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Capacity: gallons
Design flow: gallon day
Alarm level: Alarm in w rki rder _ Yes; _ No
Date of previous pumping:
Comments: U
(condition of inlet tee, condition of alarm and float switches, etc.)
ri
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if levYel. and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
17L7 D
14 r'Ar
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, cond' o of u' 1 s �nd appurtenances, etc.)
(revised 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
' PART C
SYSTEM INFORMATION (continued)
Property Address: 343 Salem street, N.Anodver, MA
Owner: Bernadette Doherty
Date of Inspection: 1 1- 7- 9 7
SOIL ABSORPTION SYSTEM (SAS):_
(locate on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:_
leaching chambers, number:_
leaching galleries, number:
leaching trenches, numberle
,ngth: S ¢
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic_ failure, level of ponding, condition of vegetation, etc.)
/!/ G ���! /✓�' � f/'� l �' �� �/l%l%r/ r �/ lig J�� �� S C/� // it %//// C��! �i
CESSPOOLS: _
(locate on site plan)
Number and configuration: _
Depth -top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction: j
Indication of groundwater:
inflow (cesspool must be pumped as part/of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY: _
(locate on site plan)
Materials of construction:
Depth of solids: %"
Comments: /(f
(note condition of soil, signs of hydraulic failuy�
(revised 04/25/97)
of ponding, condition of vegetation, etc.)
Page 8 of 10
Dimensions:
r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
- PART C
SYSTEM INFORMATION (continued)
Property Address: 343 Salem Street, N.Andover, MA
Owner: Bernadette Doherty
Date of Inspection: 11 7- 9 7
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks '
locate all wells within 100' (Locate where public water supply comes into house)
3"7x
�\
A
,o
(revised 04/25/97) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 343 Salem street, N.Andover, MA
Owner: Bernadette Doherty
Date of Inspection: 11-7-97
FLOW CONDITIONS
RESIDENTIAL:
Design flow: g.p.d./bedroom for S.A.S.
Number of bedrooms: /o
Number of current residents:
Garbage grinder (yes or no):Jn61-
Laundry connected to system (yes or no):
.v
Seasonal use (yes or no)::!LC'
Water meter readings, if available (last two (Z) year usage (gpd):
Sump Pump (yes or no):
Last date of occupancy
COMMERCIAUI N DUSTRIAL:
Type of establishment:
Design flow: gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non -sanitary waste discharged to the /title S system: (yes or no)_
Water meter readings, if..avai(351e1, f
Last date of occupancy:
OTHER: (Describe) _
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)_
If yes, volume pumped: gallons .
Reason for pumping:
TYPE O�S�TEM
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)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)
(revised 04/25/97) Page 5 of 10
Wat2�rs;hed Septic System
Servicing Report
N' 14-{
Homeowner:—
Street
omeowner:_Street
Phone
Nature of Service:
Observations:
Routine
Emergency
� OG ► - 3 tg95 ��
Pumper : IC Y 1 V Mj
Address:
Phone �,• q �1�(j�
Good Condition tQ<
Full to Cover t
Baffles in Place
Leachfield Runback
Excessive Solids\►�J
Heavy Grease j
Roots ks
Other (Explain)
rn
Description of Work; i 6
, Sj
Comments:
SEPTIC SYSTEM INSPECTION FORM
ADDRESS 12Q3
DATE INSPECTED (�`do
PROPERLY FUNCTIONING? & N
WEATHER CONDITIONS
COMMENTS:
WATER Qt3ALI T Y rrES I Eb ? RESULTS?
DYE TEST PERFORMED? Y N
DATE?
SKETCH:
f�
!/!•L_ Cc , 0 ! fL
Please forward us as. much of the following information that is possible;
1. Type of system
w A gre
3. T..,ocat ion, a.$ e -
4- Maintenance records and date of last pumping out
Las r ru �ej
— Oe r
vw �R� ea &r/d, /Y �
Documentation of repairs and reconstruction
bA Site conditions
C-4001 / J'qS1 ✓ S -
7e Builder of system
8. Enzineer who approved:
— Site
— System
9. Install,ation Procedure
10. Problems,
- 2"
WATERSHED RESIDENTS QUESTIONNAIRE
1. Name J P�
2. Street Address
_:FV3 -!��
3. How many members are in your household?
4.
What type of sewage disposal system do you have?
❑ cesspool
Q� septic tank and leaching area
❑ connection to municipal sewer
❑ other (describe)
❑ do not know
5. Are the plans (drawings) for our sewage _disposal system on file with the Board of Health?
❑ yes ❑ no do not know
6. How old is your sewage disposal system? ❑ 0-5 years ❑ 6-10 years ' 11-20 years
❑ over 20 years ❑ do not know
7. Has your sewage disposal system been rebuilt or repaired?
❑ yes M" no ❑ do not know
If yes, approximately how long ago? years. What was done?
8. frequently is your sewage disposal system pumped out? El annually
Ho
every 2-4 years ❑ ,every 5-10 years ❑ over 10 years ❑ never
9. Have you had any problems with your sewage disposal system? El yes
If yes, what problems?
❑ repeated pump -outs needed
❑ system clogs, backs up, or drains slowly
❑ odors
❑ sewage surfaces through ground
10. How many of each appliance are connected to your sewage disposal system?
washing machine dishwasher garbage disposal
dehumidifier drain sump pump toilet
roof/pavement drains shower/bathtub -s2_
11. Please state the brand and type (liquid or -powder) of detergent you use for:
dishwasher s g gcie-
clotheswasher CA Peg
12. Does your property have a lawn? yes ❑ no
If yes, approximately what size?
❑ less than 1/4 acre ❑ 1/4 acre ❑ 1/z acre ❑ 3/4 acre ❑ 1 acre
C" more than 1 acre (Specify) L-3— acres
13. How often do you fertilize your lawn? N&velz-
No. of applications per year
Season(s) of the year
14. Please state the/brand and type (liquid or granular) of lawn fertilizer you use:
L9' no _
❑ Check here if your lawn is maintained by a professional landscape contractor.
3 t3