Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Miscellaneous - 347 HILLSIDE ROAD 4/30/2018
r I t a� V c C i cts e y � E a m cn _ 3 a� c C cts e w E r m cn U J 0 d a 3 w y coa -0 0 0 rn N 0 LO W °' H r/1 o E O O (D 0 w H N U � � o Al `o 0 rn m a a� C O ctl y Z ro Z0 O r- / N c °w' O \\ m y Q a m 3 �A a Q 3 O ci v y w Q Ip y C C Cc,- J 00, cry E d a w y w y J Z Z Z w y coa -0 0 0 rn N 0 LO W °' H r/1 o E O O (D 0 w H N U � � o Al `o 0 rn m a O ctl y Z ro Z0 O r- / N O \\ m y Q a ti L; a 00 3 O e0 c d a 9 g Ip y C C cn C9 J w y coa -0 0 0 rn N 0 LO W °' H r/1 o E O O (D 0 w H N U � � o Al `o 0 rn m a Of "ORT.,'4 w Town of North Andover HEALTH DEPARTMENT ,S$ACMUStt CHECK #: D�$ DATE: // 7 l/ LOCATION: �l�i ���G���� �ce XO - H/O NAME: $ CONTRACTOR NAME: $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Sustems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Tittle 5 Inspector $ ❑/Title 5 Report $ �y ❑ Other. (Indicate) $ 2297 Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer I of 11 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 347 Hillside Road, North Andover, MA 01845 Owner's Name: Anthony Accolla Owner's Address: 347 Hillside Road, North Andover, MA 01845 Date of Inspection: I/2 -20-CL- Name of Inspector: (please print) Benjamin C. Osgood, Jr. Certified Title 5 Inspector Company Name: New England Engineering Services Inc. Mailing Address: 1600 Osgood Street Building 20 Suite 2-64, North Andover, MA 01845 Telephone Number: 978-686-1768 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 the on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15340 of Title 5 (3 10 CMR 15.000). The system: _JZPasses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: � Q, ( G ' �y, Date: % 2 Za 2Ad 6 The system inspection 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. 2of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 347 Hillside Road, North Andover, MA 01845 Owner's Name: Anthony Accolla Date of Inspection: JZ�Z0�11� 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 304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: _OIL One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. 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: 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: 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: 3of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 347 Hillside Road, North Andover, MA 01845 Owner's Name: Anthony Accolla Date of Inspection: /,Z#0/0(F C. Further Evaluation is Required by the Board of Health: AkConditions 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 (SAS) Soil Absorption System and the (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 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 organize 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 5ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 4of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 347 Hillside Road, North Andover, MA 01845 Owner's Name: Anthony Accolla Date of Inspection: D. System 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 overload or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overload 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 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. i/ Any portion of a cesspool or privy is within 50 feet of a private water supply well. v' 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 nitrogen is equal to or less than 5ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) �10 (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: j 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 ei er "yes" or "no" to each of the following: (The following criteria a lyly to large systems in addition to the criteria above)_-,-' Yes No The system is within 400 -feet of a surfacearinking water supply The system is within 200 feet 9f'atrkutary to a surface drinking water supply The system is located i a nitrogen sensitive ea (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public watersupply well If you answered "yes" to ayiy'question in Section E the system is considere ignificant threat, or answered "yes" in Section D above the large system has ed. The owner or operator of any large system considere significant threat under Section E or failed under Section D shall -up -grade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the'Department. 5of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 347 Hillside Road, North Andover, MA 01845 Owner's Name: Anthony Accolla Date of Inspection: 12_12,61t,& 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 V, Were any of the system components pumped out in the previous two weeks_? t/ 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 an 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 ? V / Was the site inspected for sign of break out? L' Were all system components, excluding the SAS, located on site? Were all 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 difference from owner) provided with information on the proper maintenance of the subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes / No Existing information. For example, a plan at the Board of Health. v� 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(3)(b)] 6of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 347 Hillside Road, North Andover, MA 01845 Owner's Name: Anthony Accolla Date of Inspection: /Z/2C,/0,& FLOW CONDITIONS RESIDENTIAL \� Number of bedrooms (design) ' Number of bedrooms (actual). DESIGN flow based in 310 CMR 15.203 ( for example: 110 gpd x # of bedrooms) Number of current residents: -- -Z:l Does residence have a garbage grinder (yes or no): Is laundry on a separate sewage system (yes or no): &C [if yes separate inspection required] Laundry system inspected yes or no): _— Seasonal use: (yes or no): 0 �� Water meter readings, if available (last 2 years usage (gpd): Sump Pump (yes or no):� Last date of occupancy u COMMERCIAL/INDUS TRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sqft, 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: )2boz aza-1 DC r r 2� Was system pumped as part o the inspection (ye. or no):} f> If yes, volume pumped: gallons — How was quantity pumped determined? Reason for pumping: M/0 F SYSTEM Septic tank, distribution box, soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) Tight tank Attached a copy of the DEP approval Other (describe): Approximate age of all components, date installed (if known) and source of information: Ab :� -VS v � /l Air zea �e �, Were sewage odors detected wen arriving at the site (yes or no): ' o 7of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 347 Hillside Road, North Andover, MA 01845 Owner's Name: Anthony Accolla Date of Inspection: BUILDING SEWER (locate on site plan) i� Depth below grade: Materials of construction: X cast iron 40 PVC_other (explain) Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): -2 enuvlj- SEPTIC TANK: / (locate on site plan) e� Depth below grade: Material of construction: ,l" 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: 1-5-06) Ct /1019 5 Sludge depth: G/ Distance from top of sludge to bottom of outlet tee or baffler Scum thickness: Z / Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bolt m of outlet tee or baffle How were dimensions determined: k(a51ugr' `-'fig/C- Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): /�rr lC iii C/cuc! roll? 3/ 0�2 GREASE TRAP: !J T- (locate on site plan) Depth below grade Materials 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 sludge to bottom of outlet tee or baffle: Date of last pumping: Continents (on pumping recommendations, inlet and outlet tee or baffle condition structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc. 8of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 347 Hillside Road, North Andover, MA 01845 Owner's Name: Anthony Accolla Date of Inspection: 12-12 61 0 TIGHT OR HOLDING TANK: 4!6 (tank must be pumped at time of inspection)(locate on site plan) Depth below grade Materials 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: (if present must be opened)(locate on site plan) �r Depth of liquid level above outlet invert: Comments ( note if box is level and distribution to outlets equal, any evidnence of solids carryover, any evidence of leakage into or out of box, etc.): ,fax /rl o�� Cin �><-��r - �ve� �a�d �h a. SL/��fia✓� • %3�x c�earu a� C4 PUMP CHAMBER: AJ r4 (locate on sire 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.): 9of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 347 Hillside Road, North Andover, MA 01845 Owner's Name: Anthony Accolla Date of Inspection: /7 %b SOIL ABSORPTION SYSTEM (SAS): (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 in length leaching fields, number, dimensions: overflow cesspool, number: innovative/alternative system Type/name of technology: Comments ( note condition of soil, signs of hydraulic failure. Level of ponding, damp soil, condition of vegetation, etc) /ire n- - _lel /©� 5 rro�r�� 1. it/a-eLIjCle,i0cc �f , rPdli7cI / / aA70 V / 0K Zugus [�La-a CESSPOOLS: /1�` �4 (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): Comi ents(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: �% (locate on site plan) Material of construction: Dimensions: Depth of solids: Comments (note condition of soil signs of hydraulic failure, level of ponding, condition of vegetation, etc. 10 of 11 • OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 347 Hillside Road, North Andover, MA 01845 Owner's Name: Anthony Accolla Date of Inspection: /Z/?p/0(G 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. 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 347 Hillside Road, North Andover, MA 01845 Owner's Name: Anthony Accolla Date of Inspection: /Z/Zo/O(,, SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water �` feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record — If checked, date of design plan reviewed: 1. Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health — explain: Checked with local excavator, installers — (attach documentation) Accessed USGS database -explain: You must describe how you established the high ground water elevation: c710 leaC`I -�je 14 Z1 fz* Feet 1rol�dl ; Jan 05 07 08:59a Rnthon!j Rccolla 978-975-1087 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 347 Hillside Road, North Andover, MA 01845 Owner's Name: Anthony Accolla Owner's Address: 347 Hillside Road, North Andover, MA 01845 Date of Inspection: 12 -2o-C6- Name 20-ctr Name of Inspector: (please print) Benjamin C. Osgood, Jr. Certified Title 5 Inspector Company Name: New England Engineering Services Inc. Mailing Address: 1600 Osgood Street Building 20 Suite 2-64, North Andover, MA 01845 Telephone Number: 978-686-1768 P. 1 k--,- 51 / 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 the on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15340 of Title 5 (310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: The system inspection 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. Jan 05 07 08:59a Rnthon�j Accolla 978-975-1087 p.2 2of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 347 Hillside Road, North Andover, MA 01845 Owner's Name: Anthony Accolla Date of Inspection: /2-17010& Inspection Summary: Check A, B, C, D or E/ALWAYS complete all of Section D A. System Passes: 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR q.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N10 One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. 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: 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: 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_ Jan 05 07 08:59a Anthony Rccolla 978-975-1087 p.3 3of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 347 Hillside Road, North Andover, MA 01845 Owner's Name: Anthony Accolla Date of Inspection: /-2po/h- C. Further Evaluation is Required by the Board of Health: —k -IL 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(i)(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 (SAS) Soil Absorption System and the (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 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 organize 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 5ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Jan 05 07 09:00a Anthony Accolla 978-975-1087 p.4 4of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 347 Hillside Road, North Andover, MA 01845 Owner's Name: Anthony Accolla Date of Inspection: /-ZA0/0(0 D. System 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 overload or clogged SAS or cesspool. _ Static liquid level in the distribution box above outlet invert due to an overload or clogged SAS or cesspool r/ Liquid depth in cesspool is Iess than 6" below invert or available volume is less than % day flow Required pumping more than 4 times in the last year NOT due to clog ed 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 _f 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. r/ 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 nitrogen is equal to or less than 5ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) �j 1 !`% 0 (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. barge Systems: To be considered a large system the system must serve a facility with a design flow You must indicate et er "yes" or "no" to each of the following: (The following criteria a 1 to large systems in addition to the criteria above) Yes No The system is within The system is within 200 feet of a surfap d inking water supply to a surface drinking water supply gpd to 15,000 gpd. The system is located ' a nitrogen sensitive a (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a public water pp well If you answered "yes" to question in Section E the system is considere ignificant threat, or answered "yes" in Section D above the large system has - ed. The owner or operator of any large system considere signif cant threat under Section E or failed under Section D shall grade the System in accordatice with 310 CMR 15.304. The system owner should contact the appropriate regional office of apartment. Jan 05 07 09:00a Anthony Accolla 978-975-1087 p.5 5of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 347 Hillside Road, North Andover, MA 01845 Owner's Name: Anthony Accolla Date of Inspection: IZ/j_y f0(�. Check if the following have been done. You must indicate " es" 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 ? V Has the system received tjn��l fl�lyyl� jp th� f 7 _, �ICYI�II� iF�O I�CC��CI10� Have large volumes of water been introduced to the system recently or as part of an 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'? V Was the site inspected for sign of break out? / Were all system components, excluding the SAS, located on site? Were all 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 difference from owner) provided with information on the proper maintenance of the subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Ye;,,/No 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) [3 10 CMR 15.302(3)(b)] Jan 05 07 09:00a Anthony Accolla 978-975-1087 p.6 6of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 347 Hillside Road, North Andover, MA 01845 Owner's Name: Anthony Accolla Date of Inspection: /Z1Zp/Q to FLOW CONDITIONS RESIDENTIAL 7 Number of bedrooms (design) — Number of bedrooms (actual)- ` DESIGN flow based in 310 CMR 15.203 ( for example: 110 gpd x # of bedrooms) Number of current residents: Does residence have a garbage grinder (yes or no): Is laundry on a separate sewage system (yes or no): [if yes separate inspection required] Laundry system inspected es or no): - Seasonal use: (yes or no): NO Water meter readings, if available (last 2 years usage (gpd): Sump Pump (yes or no): Last date of occupancy U COMMERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sqft, 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: ) yl (1,e .&X ✓ (vz- . Was system pumped as part of the inspection (ye or no): A Yc) - If yes, volume pumped: gallons - How was quantity pumped determined? Reason for pumping: TYPE,OF SYSTEM Septic tank, distribution box, soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) Tight tank Attached a copy of the DEP approval Other (describe): Approximate age of all components, date installed (if known) and source of information: «L�.,L o /1-1 ,/- 701�1 z1 17 Were sewage odors detected wen arriving at the site (yes or no): " G Jan 05 07 09:01a Anthony Accolla 978-975-1087 p.7 7of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 347 Hillside Road, North Andover, MA 01 845 Owner's Name: Anthony Accolla Date of Inspection: ?? j!z/o(, BUILDING SEWER (locate on site plan) Depth below grade: 1 Materials of construction: X cast iron40PVC_other (explain) Distance from private water supply well or suction line: Continents (on condition of joints, venting, evidence of leakage, etc.): ?^ 2 Dk in -,Tx? R e&u_lit SEPTIC TANK: (locate on site plan) 1/ Depth below grade:—k—--- Material of construction: l� 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: D Q 11dr? Sludge depth: L% Distance from top of sludge to bottom of outlet tee or baffle:__ Scum thickness: L L Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottg�y,of outlet tee or baffle How were dimensions determined: +amu 15IAel- S fib k -- Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): GREASE TRAP: (locate on site plan) Depth below grade: Materials of construction: concrete metal fiberglass polyethylenc other (explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of sludge 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. Jan 05 07 09:02a Anthony Accolla 978-975-1087 p.1 8of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 347 Hillside Road, North Andover, MA 01845 Owner's Name: Anthony Accolla Date of Inspection: 12-12610((, TIGHT OR HOLDING TANK: (tom must be pumped at time of ins ecti / 1 p on)(locate on site plan) Depth below grade:1� Materials of construction: concrete eta] (explain) mfiberglass polyethylene other Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: --Alm in workingorder Date of last pumping: (Yes or no): Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX ---(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: e fr Comments ( note if box is level and distribution -to equal, any evidnence of solids carryover, any evidence of leakage into or out of box, etc.): 14 D!- Cv.�c>/ifior, - anteK ;h S cfiorr �ox c�Qd a.�v9 PUMP CHAMBER: ! r4 (locate on sire 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.): Jan 05 07 09:02a Anthony Accolla 978-975-1087 p.2 9oft] OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 347 Hillside Road, North Andover, MA 01845 Owner's Name: Ant ony ccolla 2 /o 1 Date of Inspection: 12 k SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required If SAS not located explain why TYPE leaching pits number leaching chambers, number leaching galleries number beaching trenches, number in length 1/ leaching fields, number, dimensions: fielO 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) Are& or9 -& W fooLS 17,.or al. lila -ev(dewce of /�rwdl'7c/ mski /. OK Anus ILO -1 11wbaa fior)61 J CESSPOOLS: /11 (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: l% (locate on site plan) Material of construction: Dimensions: Depth of solids: Comments (note condition of soil signs of hydraulic failure, level of ponding, condition of vegetation, etc. Jan 05 07 09:02a Anthony Accolla 978-975-1087 p.3 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 347 Hillside Road, North Andover, MA 01845 Owner's Name: Anthony Accolla Date of inspection: t2- 12--CVO(- 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. Jan 05 07 09:02a Rnthony Rccolla 978-975-1087 p.4 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 347 Hillside Road, North Andover, MA 01845 Owner's Name: Anthony Accolla Date of Inspection: /Z/ZO/O fp SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record - If checked, date of design plan reviewed: lr Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: Checked with local excavator, installers - (attach documentation) Accessed USGS database -explain: You must describe how you established the high ground water elevation: Sk Cf leac61_�jc IcyiS q h, r eel- Ajhel'- R COMMONIWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS Cf) DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON. MA 02108 617-292-5500 WILLIAM+ F. WELD TRUDY CORE Govemo- Sccmtar}, ARGEO PAUL CELLUCCI DAVID B. STRUHS Lt. Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner ` PART A ERTIFICATION Property Address: Address of Owner: Date of Inspection: ; J(If different) Name of Inspector: 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: A)o O,D 412' !L. SC -P !jl a 6ML,S Mailing Address: 2 4) '+," 12..00 4 T- Telephone Number:y" &te&2 V-7 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-sitesewage disposal systems. The system: �Pas/se's _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails _ g Inspector's Signature: Date: `�� ` The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: AI SYSTEM PASSES: _ ' 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: BI SYSTEM CONDITIONALLY PASSES: Jif'_ 4. 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) ears_ prior to the date of the inspection; or the septic tank, whether oPnot metal, is cracked, structurally unsound, shows ub'k@1 _1 g1 w xf It ajt, tank failure is imminent. The system will pass inspection if the existing septic tank is replacWAM :onforFtfirfg�tic tank as approved by the Board of Health. � ;C (revised 04/25/97) Page 1 of 10 MAY 1 1 1999 DEP on the World Wide Web httpJtwww.magnet.state.ma.us/dep 0 Printed on Recycled Paper p Property Address: Owner: Date of Inspection: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A • . CERTIFICATION (continued) /ZJ ,./ 14AI>d�i P34 �` _5 r B) SYSTEM CONDITIONALLY PASSES (continued) P 4 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 pipe(s) are replaced t' obstruttion is removed _� S C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: yl 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 4 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.` 4f 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 aseptic 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 p(3llution 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 04/25/97) Page 2 of 10 • Property Address: Owner: Date of Inspection: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A • . CERTIFICATION (continued) /ZJ ,./ 14AI>d�i P34 �` _5 r B) SYSTEM CONDITIONALLY PASSES (continued) P 4 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 pipe(s) are replaced t' obstruttion is removed _� S C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: yl 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 4 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.` 4f 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 aseptic 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 p(3llution 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 04/25/97) Page 2 of 10 43 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM � M ,. PART A CERTIFICATION (continued) Property Address: tle' Owner: / W 10 Date of Inspection. D] SYSTEM FAILS: You must indicate eit er " e " 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 Ieve'r in the distribution box above duet 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: g 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'll 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 04/35/97) Page 3 of 10 '3 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:" Owner: Date of Inspection: 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. t _ 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. As buileplans 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: 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)] (reviaad 01/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM • PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grader Material of construction: _ cast iron _40 PVC _ other (explain) Distance from private water supply well or suction lirf- Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:Q 7 (locate on site In) Depth below grade:(.?,, rade:(., Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _ (Yes/No) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle3 Scum thickness: I /, rr 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/W How dimensions were determined: ,O±Z S/ ?/< 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.) s f,� Q o r> C O> /D/ ,T/. a / -- L / G o. n G t' F^+'i 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: (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 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 3T 7 fi/�S'i e Gf . Owner: Date of Inspection: 9/-014- e-l FLOW CONDITIONS RESIDENTIAL: Design flow: e.P.d./bedroom for S.A.S. Number of bedrooms: Number of current residents: Garbage gnr:der (yes or no): N Laundry connected to system (yes or no):Xfs Seasonal use (yes or no):4b Water meter readings, if available (last two (2) year usage (gpd): Sump Pump (yes or no): Last date of 1occupancy: C k COMMERCIAL/INDUSTRIAL: 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 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy OTHER: (Describe) _ Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or If yes, volume pumped: �'G�gallons Reason for pumping TYPE OF SYSTEM �' ieptic tank/distribution box/soil absorption system_. Single cesspool "tp . ` 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: ! V 6/ Sewage odors detected when arriving at the site: (yes or no)' f -I b (revised 04/45/97) Page S of 10 P,yF • ' t • a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM + PART C SYSTEM INFORMATION (continued) Property Address:'T % /�,��/�� ��-'" { r,►fTiCG�Ci d Owner: Date of Inspection:] TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Yt4 Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions: Capacity: gallons Design flow:_ gallons/day ' 4 f Alarm level: Alarm in working order _ Yes; _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOXV6 (locate 'on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER:_ (locate on site plan) 1 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.) (revised 04/75/97) 0 Page 7 of 10 ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) ,Property Address: J Y7 1j' 151,0 r— 12-1 Owner: Date of Inspection: , /G p-� --5'' ce' 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) (revised 04/25/97) Paga 9 of 10 #A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) �Property Address: C/+ Owner: Date of Inspection:�1 Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) �termine it from local conditions Check with local Board of hdalth.5 ✓ Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) (revised 04/75/97) Page 10 of 10 A &A ASM FT rWt :. •. .. r i Lor unix_ GrjEc$�, R6,060 M -13U Lt OTC r-_ ! � E5 u I l,"T 5uALE Y4►T ENI 1►�I PoQ F Q,e.►•� tiC. G C31t.i..�..� a,S } � bst�Clr:r�'b •� •,�� a,N c cP4 skm 4err tet,... A.P.4 cep w4c . PUBLIC HEALTH DEPARTMENT Community Development Division Date: December 11, 2006 Address: 347 Hillside Road Re: Application for sunroom and deck Dear Mr. Accolla: Your application for a deck at has been reviewed by the Health Department. The application was denied on December 11,2006 for the following reasons: 1. x Missing information 2. x Passing Title 5 inspection of septic system required 3. ❑ Location of structure not acceptable 4. ❑ Undersized septic system To address the oroblem(s): If #1 is checked, please supply: 1/V a. Floor plan of existing and proposed addition — all rooms b. Certified plot plan showing house, septic system and proposed project in scale If #2 is checked: a. Have the septic system inspected by a State certified and locally licensed Title 5 b ci inspector to determine the size of the system and whether it is operating properly: OR b. Tie-in to municipal sewer NOTE: Our records indicate there is a well on this property, however it was not located on any plan. The septic system inspector must locate this in his report. If #3 is checked: a. Relocate the project If #4 is checked: ' a. Provide additional information proving that the existing septic system meets current capacity requirements. Please consult an engineer to determine the flow capacity of the septic system. 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com f- A •eb �y � T-/yO COCN[NC d�A°Awr�o y� K�Mp y1\J �r• i��/ PUBLIC HEALTH DEPARTMENT Community Development Division Date: December 11, 2006 Address: 347 Hillside Road Re: Application for sunroom and deck Dear Mr. Accolla: Your application for a deck at has been reviewed by the Health Department. The application was denied on December 11,2006 for the following reasons: 1. x Missing information 2. x Passing Title 5 inspection of septic system required 3. ❑ Location of structure not acceptable 4. ❑ Undersized septic system To address the oroblem(s): If #1 is checked, please supply: 1/V a. Floor plan of existing and proposed addition — all rooms b. Certified plot plan showing house, septic system and proposed project in scale If #2 is checked: a. Have the septic system inspected by a State certified and locally licensed Title 5 b ci inspector to determine the size of the system and whether it is operating properly: OR b. Tie-in to municipal sewer NOTE: Our records indicate there is a well on this property, however it was not located on any plan. The septic system inspector must locate this in his report. If #3 is checked: a. Relocate the project If #4 is checked: ' a. Provide additional information proving that the existing septic system meets current capacity requirements. Please consult an engineer to determine the flow capacity of the septic system. 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com It is recommended that you submit the floor plan as soon as possible. A full review of the project will be completed once the floor plan has been submitted. If it is determined that the septic system is undersized, you may be facing additional choices. Please feel free to call the Health Office at 978-688-9540 with any questions you may have. Sincerely, Su an ,S wyer, REHS/RS Health Director Encl. 2006 -Licensed Septic System Inspector List Cc: Building Department File 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com L,_ (OT tvwOT4&rl weza 5 Vim- 3 V �l.�.o►c� �: �. � `OY'4T 1 EIVbINC " ULM ,6 --- ". 74/ f tvwOT4&rl weza 5 Vim- 3 V �l.�.o►c� �: �. � `OY'4T 1 EIVbINC " ULM ,6 --- ". 74/ MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION Two Center Plaza Boston, Massachusetts 02108-1904 (617) 723-3800, Ma Only (800) 392-6108, Fax (617) 557-5675 09/18/02 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws, Ch. 139, Sec.313 _.' 2 7 2002 NORTH ANDOVER HEALTH DEPT. NORTH ANDOVER TOWN HALL NORTH ANDOVER MA 01845 - - Re: Insured: ANTHONY J & SANDRA N ACCOLLA Property Address: 347 HILLSIDE ROAD, NORTH ANDOVER, MA 01845 Policy Number: 0654826 Type Loss: Loss by Other Than a Pollution Hazard Date of Loss: 09/09/02 Claim Number: 193761 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Massachusetts General Laws, Chapter 143 Section 6 to be applicable. If any notice under Massachusetts General Laws chapter 139 Section 3 B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. MPIUA Claims Division CMA00021 •.. RT1-" hNVE. TOWN OF`NOX,TH ANDOVER r`so°°F_ ogF ��`. SYSTEM PUMPING RECORD DATE —Gi � D FEB SYSTEM OWNER & ADDRESS SYSTEM LOCATION, DATE OF PUMPING QUANTITYPUMPED CESSPOOL NO YsS SEPTIC TANK NO YES V/ NATURE OF SERVICE;;.RQIyTINE ' EMERGENCY OBSERVATIONS: GOOD CONDITION....FULL TO COVER HSV GREASE _ �BAFFLES IN LACE LEACHFIELD RUNBACK EXCESSIVE SOLIDS ___'FLOODED SOLID CARRYOVER OTHER EXPLAIN SYSTEM PUMPED BY FORM 4 - SYSTEM PUMPLNG RECORD Commonwealth of Massachusetts 6V00)f� , Massachusetts System Pumping Record Svstem Owner System Location :qui 5PC 01) fcl`6,F IA --el (20vr)-, /0�� Type: Emergency ❑ Routine ❑ Cesspool: No ❑ Yes ❑ S(-ptic Tar -Lk: No ❑ Yes F� Date of Pumping: /� � _� of QuantIry Pumped: %� _ gallons S\ stem Pumped by (Company): Rol 'An -,11 npf I' Q- Permit Contents transferred to: Contents disposed at: Date IJ -.0001 Pumper Signature ,,,,, Condition of systerrvother comments: 2001 DEP APPROVED FOP -%I - 1:/07/95 r A;�'DD ER BOARD OF HEALTH DISAPPROVED DATE TIME REASON ?ROVED, D4TE PROVIDED Titl 5 - Reg. 2.5 Fail OK The stibmitted plan must show as a minumum: the lot to be served (area, dimensions, lot //,abutters) (Planning Board -files) (b location and log of deep observation holes -distance to ties (c location and results of percolation tests -distance to ties design calculations (d)& calculations showing required leaching area location and dimensions sf system (including reserve area)- ?f-� existing and proposed contours 4 location of any wet areas within 100' of the sewage disposal system 01- disclaimer (check wetlands mapping 7(('hn . surface and subsurface drains within 100' of sewage disposal system or disclaimer (i) location of any drainage easements within 100' of sewage disposal system or disclaimer (planning board files) (') known- sources_ of_water supply within- 200' of sex. -,,age - disposal= -System_ o -r= ,disclaimer. - ( - location- of any -proposed well to serve the lot (100' from leaching facility) (1 location of water lines on property (10' from.leachin facilities) location of benchmark driveways )� garbage disposers no PVC is to be used in construction q) a profile of the system (elevations of basement, plum pipe septic tank, distribution box inlets and outle'-s distribution_ -field piping and any other elevations) maximum ground water elevation in area of sewage disc .system. (s) plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Septic Tanks Reg, 6 ) Capacities - 150% of flow, water table, tees, depth of tees, access, pumping, • b Cleanout 10' from cellar wall or inground swimming pool (d 25' from subsurface drains SOIL PROFILE & PERCOLATION TEST DATA North AndoverNo &Street --q L'oc./Subdiv. Plan Owner Investigator Observer 21�4_ SOIL PROFILES -DATE 3' Elev. 2. Elev. 3. Elev. 0 -79 0 0 0 1 41 1 2 2 2 3 3 3 Benchmark Elevation 4 5 6 7 8 9 10 4 = 5 6 7 8 9 10 Location Datum Percolation Tests -Date t No. 4'Elev. - Pit Number 1 2 3 4 S Start Saturation Soak -Mins. Start Test -Time Drop of 311 -Time - "-Time-Dro Drop of 6" -Time Mins.lst3"Dro Mins.2nd 3"Dro Percolation Rate Notes &Sketches on Back PAGE II STEWART'S SEPTIC TANK SERVICE (CONT'D) 04-22-96 A 31 STONE CLEAVE ROAD 1,800 201 BRADFORD STREET 11000 04-23-96 585 BOXFORD STREET 1,500 HEAVY A 175 GREAT POND ROAD 2,000 04-24-96 1615 OSGOOD STREET 500 FLOODED .A 122 OLYMPIC LANE 1,500 A 1116 SALEM STREET 750 04-25-96 A 75 FORREST STREET 11000 04-26-96 550 BOSTON STREET 2,000 2-1,000 TANKS 04-27-96 A 1015 JOHNSON STREET 11000 175 FOREST STREET 11000 350 SHARPNER'S POND ROAD 1,500 04-29-96 A 18 STEVENS STREET 1,250 A 100 FOREST STREET 1,500 A - 82 PADDOCK LANE 1,500 04-30-96 A 133 SUMMER STREET 11000 A 347 HILLSIDE ROAD 11000 i� From: Kathy. Fax: +1(978)373.6611 To: NO ANDOVER BOH Fax: +1(978)688-9542 Page 2 of 2 Wednesday, July 19, 2000 7:29 PM MONTHLY PUMPINGIDUE.PORT HAUL LIC 151 -OOH INSTALL LIC # 128-0 North Andover Board of Health Town Hall Annex 120 Main Street No. Andover, MAO 1845 PHONE: 978-682-6483 978-688-9540 FAX: 978-688-9556 978-688-9542 Dear Sirs: Stewart's Septic Tank Service 47 Railroad Street Bradford, MA 01835 978-372-7471 This is our monthly report of tanks pumped in your town in compliance with Title V regs. Unless otherwise stated, what we pumped was a septic tank. Any comments will be included whether the system was flooded, solid, etc. If we did not pump, you will not get a report. if you have any questions, please call KATHY during business hours Mon -Sat 8-5pm Thank you. DATE ADDRESS GALLONS COMMENTS 06-03-00 347 HILLSIDE ROAD 1500 9 t'. r4 .3 t.., i. Y l •4 ... 1 11 1 ad1 ar.. l r 4 7 rk, A Mt , Y a, TO The North Andover The North, Andover is Building Department Board of Pub.l.i.c Health G, The.North And,ovor The ;Kor'th' Anddver N Planning Board. Highway Surveyor The North Andover LdT Conservation Commission a 1A FIR OM Alton c. Bailey �p 347 Hillside Road North Andover, MA , SU,BJ$WTt -S% rfaCe Water Draizaage About a year ana a nair ago i purcnaaea mfr .nouav•au, ,fit ni-L.La-4,uto is Roall. There were many defects in this house and property, Many of these ,I have cprreated at my ohm expanse. However, many lirobl�eins . have arisen since_ than, Listed below are some; of these prcobldms which concern me very much: 1. I have discovered that my artesian well was drilled on: . lot ."C n In of .An my lob x; 2. A` large Bunt of 'loam' was removed frog iq Iand' +� �cim the land of the, Trombly Bus Company without. the.'p°ern ,a�sio� of either: of us. I understand that this may al'sq have been against the will of the Conservation Commission. 3. The septic, tank and septic system for, lot,,. %11 has been installed .c'loser'. than 10 feet from the, ;lo fins iietwaan l-ot "C" and my lot "D" . The current.. owner and, buil der on l of "C" . ha bulgy t h ,s driveway higher than the level of my dz'ive+p* or .garage . floor. kAs` allows, no, a k:r-or the surrace" ter that, ;a6o4nul"s, +ss Fon my land,. This water. forms a., virt,41 la co on ;air ptoper y a. within a very 'short period of time.... F'o,r example, during a. shower on June'. 20th, the water backed up to the' very ,adge of .my garage door. During this past vinter., a major_: castaatrophe happened. As a resin- t of construction actjv ty conducted by tkae builder of lot "0111 wa.ter;backe4 up, t4rdugh an underground drain pipe into my,. house. Over 104 gallons, of water was pumped off from my. family room',. cant bar` a professional, .cloaning. service... has ; ausad a :gaciee , sie.rsl of , damage to;; shay nothiiag about the ost.'..px4f`easac�, .. '.1 have been told from the beg.iiriniAgthat I wo'u1c hariri e. 'as.in easement and an adequate drain systemrom:'my laAd aa�sros`e lot "C" and, to a brook which is adjacent to lot :.'rte". 6. .on Tune 5, 1981 at 5:05 P.M. a backhoe/loader o eratoi� braught three or four loads of mud and clay f on •tha arbla oftt'o.,tt cook. to' the upland, side of the driveway on' ,lot 4V1 and jame•ai, i6 the open drain hole into which my ;sufac® waiter ara teriad been pe ng, lie sad d than hee was doing this.on the order, ,of tbA +bu3ld�er i f -' the' �housd o�n lot, „COO. ��' yI �,,ater $�zk�d: shy ,t ,s ...,......-.....:.«'r'...+..:.+�.-...�......�_,..`.._.. .. ..--. ,=._.,- ...�..,...�.-,......�:... :......,...„.-.-_... ...-... .:. .. ...............ss.-...,e...-x.�.:..,.r.-... ... -..� .. ..e. -.-r .:4..��r w1._......+.,-...,-...-.._._,..rn.+.,,�....xha.Mrw.�W+'rcu..!.•.ai.xMy,bl+ ...,:r,'„a. ... r# IrYr20V ED FAM PAIaCN OK FAIL OK 1. Distance Tot- a. WetIands - b. Drains c. Well 2. Water Line Location - - 3• No PVC Pips - Septic a. Ve-s -_Length do To- Clean Out Cogs - _ b. Cement Pipe to Tank - On Both Sides of Tank Distribution Box _ - // a. Covers &_ Box - No Cracks ✓ b. All Lines Flo -wing Pgsal Amounts c. Pdo Back Flow Leach Field or Trench a. Dimensions b. Stone Depth_ c. Capped Mids .. d. Clean Double Washed Stone - =-_ 7. LeaXenr�m-ntiP - a. s_._ b. - C. d. e. to Pit - Both Suedes f. Clean Double Washed Stone 8. No Garbage Disposal 9. Anal, Grading Inspection - - - 10.- Barricading Cohered System _-- 11. As Built S`abmi.t ted . . a. Lot Location .. - - b. Dimensions of System - c. Location with Regard -to Perc Test d. Elevations e. Water Table -