HomeMy WebLinkAboutMiscellaneous - 35 SHANNON LANE 4/30/2018 (2)N
North Andover Board of Assessors Public Access Page 1 of 1
gORTI{ �lorth Andover Board..... of Assessors
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roperty Record Card
Parcel ID :210/107.A-0230-0000.0 FY:2012 Community: North Andover
Click on Sketch to Enlarge
Click on Photo to Enlarge
Location: 35 SHANNON LANE
Owner Name: TREBBE, JAMES D
DINA F TREBBE
Owner Address: 35 SHANNON LANE
City: NORTH ANDOVER State: MA Zip: 01845
Neighborhood: 7 - 7 Land Area: 1.01 acres
Use Code: 101-SNGL-FAM-RES Total Finished Area: 3419 s ft
Total Value: 643,100 643,100
Building Value: 417,400 417,400
Land Value: 225,700 225,700
Market Land Value: 225,700
Chapter Land Value:
Price: 409,000 Sale Date: 08/29/1995
s Length Sale Code: Y -YES -VALID Grantor: MARINO, DANIEL
Doc: Book: 04326 Page: 0190
http://csc-ma.us/PROPAPP/display.do?linkld=1896220&town=NandoverPubAcc 6/25/2012
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Owner
information is
required for
every page.
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key
ISI
ISI
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
35 Shannon Lane
Property Address
Victor Capozzi
Owner's Name
North Andover
Cityrrown
MA 01845
State Zip Code
5/13/2016
Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. General Information
1. Inspector:
RECIE tl E®
MAY 2 4 2016
Neil J. Bateson T
Name of Inspector HEALTH ji"v7 AMENTER
Bateson Enterprises Inc.
Company Name
111 Argilla Road
Company Address
Andover
Cityrrown
978475-4786
Telephone Number
B. Certification
MA
State
S115
License Number
01810
Zip Code
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ N ads iFurther Evaluation by the Local Approving Authority
5/13/2016
Insp cto s Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
35 Shannon Lane
Property Address
Victor Capozzi
Owner's Name
North Andover
Cityrrown
B. Certification (cont.)
MA 01845
State Zip Code
5/13/2016
Date of Inspection
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
After permit from electrical department Hall Pump installed new electrical junction box for pump
controls, electical inspector inspected same, now septic system passes Title 5 Inspection
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not
determined," please explain.
The septic tank is metal and over 20 years old" or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17
Owner
information is
required for every
page.
Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
4:1 1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
35 Shannon Lane
Property Address
Victor Capozzi
Owner's Name
North Andover
MA 01845 4/22/2016
U10Vf
APR 2 6 2016
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. General Information
1. Inspector:
Neil J. Bateson
Name of Inspector
Bateson Enterpri
Company Name
111 Argilla Road
Company Address
Andover
City/Town
978-475-4786
Telephone Number
B. Certification
Inc.
MA
State
S115
License Number
01810
Zip Code
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
❑ Passes ® Conditionally Passes ❑ Fails
ElNee7s:urthaluationer Evby the Local Approving Authority
4/22/2016
Inspecto nature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
""This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
35 Shannon Lane
Property Address
Victor Capozzi
Owner's Name
North Andover MA 01845 4/22/2016
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
® One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5lns - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
35 Shannon Lane
4/22/2016
Date of Inspection
a kation (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are. repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pi�e(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if (with approval of Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
❑ Y ® N ❑ ND (Explain below):
❑ Y ® N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ® N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if (with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ® N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins • 3113
Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 3 of 17
Property Address
Victor Capozii
Owner
owner's Name
information is
required for every
North Andover MA 01845
page.
Cityrrown State Zip Code
B C
4/22/2016
Date of Inspection
a kation (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are. repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pi�e(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if (with approval of Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
❑ Y ® N ❑ ND (Explain below):
❑ Y ® N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ® N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if (with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ® N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins • 3113
Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 3 of 17
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
35 Shannon Lane
Property Address
Victor Capozzi
Owner's Name
North Andover
City/Town
B. Certification (cont.)
MA 01845 4/22/2016
State Zip Code Date of Inspection
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
Junction box hanging by wires in pump tank needs to be replaced.
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes
No
❑
®
Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑
®
Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑
®
Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑
®
Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/z day flow
t5ina' 3(13
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10, 000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area — IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins • 3113 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System •Page 5 of 17
Commonwealth of Massachusetts
Title 5
Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
35 Shannon Lane
Property Address
Victor Capozzi
Owner
Owner's Name
information is
required for every
North Andover
MA 01845 4/22/2016
page.
City/Town
State Zip Code Date of Inspection
B. Certification (cont.)
Yes
No
❑
® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑
® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑
® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑
® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑
® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑
® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10, 000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area — IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins • 3113 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System •Page 5 of 17
Commonwealth of Massachusetts
A -Title 5 Official Inspection Form
's Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
_ t
" 35 Shannon Lane
Property Address
Victor Capozzi
Owner owner's Name
information is
required for every North Andover MA 01845 4/22/2016
page, City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
® ❑
Pumping information was provided by the owner, occupant, or Board of Health
❑ ®
Were any of the system components pumped out in the,previous two weeks?
® ❑
Has the system received normal flows in the previous two week period?
❑ ®
Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑
Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑
Was the facility or dwelling inspected for signs of sewage back up?
® ❑
Was the site inspected for signs of break out? ,
® ❑
Were all system components, excluding the SAS, located on site?
® ❑
Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑
Was the facility owner (and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑
Existing information. For example, a plan at the Board of Health.
® ❑
Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 600
t5ins • 3113 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System •Pape 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
35 Shannon Lane
Property Address
Victor Capozzi
Owner Owner's Name
information is
required for every North Andover MA 01845 4/22/2016
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)): Yes
Detail:
Sump pump?
❑ Yes ® No
Last date of occupancy:
Current
Date
Commercial/Industrial Flow Conditions:
Number of current residents:
4
Gallons per day (gpd)
Does residence have a garbage grinder?
❑
Yes
® No
Is laundry on a separate sewage system? (Include laundry system inspection
information in this report.)
❑
Yes
® No
Laundry system inspected?
❑
Yes
❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)): Yes
Detail:
Sump pump?
❑ Yes ® No
Last date of occupancy:
Current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Gallons per day (gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present?
❑ Yes ❑ No
Industrial waste holding tank present?
❑ Yes ❑ No
Non -sanitary waste discharged to thetTitle 5 system?
❑ Yes ❑ No
Water meter readings, if available:
t5ins - 3/13 Title 5 Official Inspection form: Subsurface Sewage Disposal System - Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
35 Shannon Lane
Property Address
Victor CapoZzi
Owner Owner's Name
information is
required for every North Andover MA 01845 4/22/2016
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Type of System:
Date
Pumped 2015, owner
1500
gallons
Measure tank
Inspect tank & tees
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
® Yes ❑ No
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other (describe):
t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Pape 8 of 17
Commonwealth of Massachusetts
- Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
35 Shannon Lane
Property Address
Victor Capozzi
Owner Owner's Name
information is North Andover MA 01845 4/22/2016
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
29 years old, 4/30/1987, as built plan
Were sewage odors detected when arriving at the site?
Building Sewer (locate on site plan):
Depth below grade:
Material of construction:
® cast iron ® 40 PVC ❑ other (explain):
❑ Yes ® No
4
feet
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
4" cast iron through wall, 3" PVC in house, no leaks visible.
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
® concrete ❑ metal
3
feet
❑ fiberglass ❑ polyethylene ❑ other (explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate)
Dimensions: 10' x 5'x4'
Sludge depth:
4"
❑ Yes ❑ No
t5ins • 3/13 Tide 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
35 Shannon Lane
Property Address
Victor Capozzi
Owner Owner's Name
information is
required for North Andover MA 01845 4/22/2016
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
29"
Scum thickness 2.1
Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom of outlet tee or baffle
13"
How were dimensions determined?
Tape Measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. Pumped septic
tank. Center cover has riser 8" deep.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17
Commonwealth of Massachusetts
-
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Y
35 Shannon Lane
Property Address
Victor Capozzi
Owner Owner's Name
information is North Andover MA 01845 4/22/2016
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass
Dimensions:
Capacity:
Design Flow:
Alarm present:
Alarm level:
Date of last pumping:
gallons
❑ polyethylene ❑ other (explain):
gallons per day
❑ Yes ❑ No
Alarm in working order:
Date
Comments (condition of alarm and float switches, etc.):
❑ Yes ❑ No
* Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins • 3113 Title 5 Official Inspection form: Subsurface Sewage Disposal System • Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
35 Shannon Lane
Property Address
Victor Capozzi
Owner Owner's Name
information is North Andover MA 01845 4/22/2016
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0 for both boxes
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D -box 1 level. No evidence of leakage. No evidence of
carryover. Vent pipe is out of d -box 1. D -box 2 level & distribution equal. No evidence of leakage. No
evidence of carryover.
Pump Chamber (locate on site plan):
Pumps in working order:
®
Yes
❑
No*
Alarms in working order:
®
Yes
❑
No`
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Pump ok. Alarm ok. Junction box is hanging by the wires, this needs to be replaced. Alarm
has both audible & visual.
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17
Commonwealth of Massachusetts
"I'itle 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
35 Shannon Lane
D. System Information (cont.)
Type:
El
leaching pits
leaching chambers
leaching galleries
leaching trenches
leaching fields
overflow cesspool
innovative/alternative system
MA 01845
State Zip Code
4/22/2016
Date of Inspection
number:
number:
number:
number, length:
number, dimensions:
number:
3 trenches 55'
long
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soil ok. Vegetation ok. No sign of ponding to surface.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth — top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow
t5ins • 3/13
❑ Yes ❑ No
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17
Property Address
Victor Capozzi
Owner
Owner'sName
information is
required for
North Andover
every page.
City/Town
D. System Information (cont.)
Type:
El
leaching pits
leaching chambers
leaching galleries
leaching trenches
leaching fields
overflow cesspool
innovative/alternative system
MA 01845
State Zip Code
4/22/2016
Date of Inspection
number:
number:
number:
number, length:
number, dimensions:
number:
3 trenches 55'
long
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soil ok. Vegetation ok. No sign of ponding to surface.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth — top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow
t5ins • 3/13
❑ Yes ❑ No
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17
Commonwealth of Massachusetts
Title' 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
35 Shannon Lane
Property Address
Victor Capozzi
Owner Owner's Name
information is
required for every North Andover MA 01845 4/22/2016
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
!sins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17
Owner
information is
required for every
page.
Commonwealth of Massachusetts
`Citle 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
35 Shannon Lane
Property Address
Victor Capozzi
Owner's Name
North Andover
City/Town
D. System Information (cont.)
MA 01845
State Zip Code
4/22/2016
Date of Inspection
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand -sketch in the area below
❑ drawing attached separately
_ '5`
�avrE- -136tr
D
VQ44-
0
vvc�_ bc�up_
F`Attkja-rJ
t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17
r
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
35 Shannon Lane
Property Address
Victor Capozzi
Owner's Name
North Andover
Cityrrown
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water:
MA 01845
State Zip Code
4
4/22/2016
Date of Inspection
feet
Please indicate all methods used to determine the high ground water elevation:
FG -51
❑M
/1
■❑
Obtained from system design plans on record
If checked, date of design plan reviewed:
4/5/1985
Date
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health - explain:
Design plan
Checked with local excavators, installers - (attach documentation)
Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
As per test pit data on design plan.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins - 3/13 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
35 Shannon Lane
Property Address
Victor Capozzi
Owner owner's Name
information is
required for every North Andover MA 01845 4/22/2016
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System information — Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17
Summary Record Card generated on 4/25/2016 11:48:11 AM by Karen Hanlon Page 1
. Town of North Andover
Tax Map # 210-107.A-0230-0000.0
Parcel Id 18055
35 SHANNON LANE
VICTOR CAPOZZI
35 SHANNON LANE
NORTH ANDOVER MA 01845
Class 101 Single Family
Zoning2 1 Residential
Size Total 1.01 Acres
FY 2016
Property Type
Zoning3
1 Residential
1 Residential
UB Mailing Index
Name/Address
Type
Loan Number
Active/Inact.
From
Until
VICTOR CAPOZZI
Owner
35 SHANNON LANE.
NORTH ANDOVER MA 01845
TREBBE, JAMES D. & DINA F
Previous
Customer
Inactive
8/16/2012
35 SHANNON LANE
N. ANDOVER, MA
01845
UB Account Maint.
Account No Cycle
Occupant Name
Active/Inactive
Bldg Id. 14222.0 - 35 SHANNON LANE
Last Billing Date 3/14/2016
2100218 02 Cycle 02
Active
UB Services Maint.
Account No. 2100218
Service Code
Rate
Charge
Multiplier/Users
MISCFEE ADMIN FEE
0.635/8
7.82
1/
WTR WATER
01 ALL METER SIZE 30.40
/1
UB Meter Maintenance
Account No. 2100218
Serial No Status
Location
Brand
Type
Size
YTD Cons
16465210 a Active
ERT
METE METE
w Water
0.63 0.63
1692
Date Reading
Code
Consumption
Posted Date
Variance
2/2/2016 2930
a Actual
8
3/28/2016
-22%
11/2/2015 2922
aActual
10
12/30/2015
-98%
8/4/2015 2912
a Actual
584
9/14/2015
14500%
5/5/2015 2328
a Actual
4
6/22/2015
1 %
2/3/2015 2324
a Actual
4
3/20/2015
-92%
11/3/2014 2320
aActual
54
12/15/2014
-10%
8/1/2014 2266
a Actual
56
9/11/2014
1332%
5/5/2014 2210
a Actual
4
6/12/2014
7%
2/4/2014 2206
a Actual
4
3/17/2014
-95%
10/31/2013 2202
aActual
76
12/20/2013
5%
8/1/2013 2126
aActual
73
9/18/2013
1546%
5/1/2013 2053
aActual
4
6/18/2013
-4%
2/7/2013 2049
a Actual
5
3/13/2013
28%
10/30/2012 2044
a Actual
3
12/13/2012
-97%
8/14/2012 2041
f Final Bill
127
8/14/2012
511%
5/2/2012 1914
a Actual
18
6/20/2012
210%
2/2/2012 1896
a Actual
6
3/14/2012
-85%
11/1/2011 1890
aActual
39
12/15/2011
-39%
8/2/2011 1851
a Actual
65
9/14/2011
668%
5/2/2011 1786
a Actual
8
6/13/2011
-13%
2/4/2011 1778
a Actual
10
3/15/2011
-86%
11/1/2010 1768
aActual
68
12/13/2010
-41%
8/3/2010 1700
a Actual
118
9/13/2010
431%
5/3/2010 1582
a Actual
22
6/9/2010
37%
2/1/2010 1560
aActual
16
3/11/2010
-63%
11/2/2009 1544
aActual
43
12/11/2009
-35%
Commonwealth .of Massachusetts
City/Town of .
System Pumping. Record
Form 4
DEP has;'provided this form for use -by local Boards of Health. Other forms maybe •used, but the
information, must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted.to
the local Board of Health or other approving authority.
A. Facility. Inforrrmitlon
1. System Location: Left / Right front of house, Left ight rear nous , eft / right side of house, Left /
Right side of building, Left / Right front of building, a Ig uild'mg, Under deck
Address
5 n
Citylrown state Zip Code
2. System Owner.
Name'
Address (if different from location)
City/rown State- _ Zip Code
`7/
Telephone Number;.
.B. Pumping Record
1. Date of Pumping Date 2 Quantity Pumped: Gallons —�
3. Type -of system: ❑ Cesspool(s) eptic Tank ❑ .Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yeas 0-90 If yes, was it cleaned? ❑ Yes ❑ Na
5. Condition of stern:
6: System Pumped By.-
Nell
y:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Location where contents- were disposed:
Water
F5821
Vehicle License Number
3
Date
0orrn4.doo- 06/03 System Pumping Record • Page 1 of 1
Owner
information is
required for
every page.
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
Commonwealth of Massachusetts
Title '5 Official inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
35 Shannon Lane
Property Address
Dina Trebbe
Owner's Name
North Andover MA 01845
City/Town State Zip Code
614-42
Date of Inspection
14�
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. General Information
1. Inspector:
Benjamin C. Osgood, Jr.
Name of Inspector
none
Company Name
16 Hillside Ave
Company Address
Amesbury
Citylrown
978-834-6585
Telephone Number
B. Certification
Unit 3
MA
State
870
License Number
JUL 16 2012
TOWN OF NORTH ANDOVER
01913
Zip Code
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
/3, � a 2 6-28-12
Inspectg s Signature zz Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
35 Shannon Lane
Property Address
Dina Trebbe
Owner's Name 6--2V'12
North Andover MA 01845 .644-+2
Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
35 Shannon Lane
Property Address
Dina Trebbe
Owner's Name 6 2S -/ 2
North Andover MA 01845 -6-44-42
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if (with approval of Board of Health):
❑
❑
❑
broken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
❑ Y
❑ Y
❑ Y
❑ N
❑ N
❑ N
❑
❑
❑
ND (Explain below):
ND (Explain below):
ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if (with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
11
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
35 Shannon Lane
Property Address
Dina Trebbe
Owner Owner's Name
information is -2-8- z
required for North Andover MA 01845 &44-42
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
35 Shannon Lane
Property Address
Dina Trebbe
Owner Owners Name
information is
required for North Andover MA 01845 644,12
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
El® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
El® Any portion of the SAS, cesspool or privy is below high ground water elevation.
1:1® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
El® Any portion of a cesspool or privy is within a Zone 1 of a public well.
El® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
El® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ® the system is within 400 feet of a surface drinking water supply
❑ ® the system is within 200 feet of a tributary to a surface drinking water supply
❑ ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area — IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
I
• Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,�•�''v 35 Shannon Lane
Property Address
Dina Trebbe
Owner
information is
required for
every page.
Owners Name
North Andover
CityrFown
C. Checklist
RAA AA nAc
z,9 -tZ
44442
Date of Inspection
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
® ❑
Pumping information was provided by the owner, occupant, or Board of Health
❑ ®
Were any of the system components pumped out in the previous two weeks?
® ❑
Has the system received normal flows in the previous two week period?
❑ ®
Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑
Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑
Was the facility or dwelling inspected for signs of sewage back up?
® ❑
Was the site inspected for signs of break out?
® ❑
Were all system components, excluding the SAS, located on site?
® ❑
Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑
Was the facility owner (and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑
Existing information. For example, a plan at the Board of Health.
® ❑
Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,.' 35 Shannon Lane
Owner
information is
required for
every page.
Property Address
Dina Trebbe
Owners Name 6 -2,S 1 Z
North Andover MA 01845 644-42
City/Town State Zip Code Date of Inspection
D. System Information
Description:
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump?
Last date of occupancy:
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present?
Industrial waste holding tank present?
Non -sanitary waste discharged to the Title 5 system?
Water meter readings, if available:
Gallons per day (gpd)
❑ Yes ® No
current
Date
❑
Yes
❑
No
❑
Yes
❑
No
❑
Yes
Number of current residents:
No
2
Does residence have a garbage grinder?
❑
Yes
®
No
Is laundry on a separate sewage system? [if yes separate inspection required]
❑
Yes
®
No
Laundry system inspected?
❑
Yes
®
No
Seasonal use?
❑
Yes
®
No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump?
Last date of occupancy:
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present?
Industrial waste holding tank present?
Non -sanitary waste discharged to the Title 5 system?
Water meter readings, if available:
Gallons per day (gpd)
❑ Yes ® No
current
Date
❑
Yes
❑
No
❑
Yes
❑
No
❑
Yes
❑
No
Commonwealth of Massachusetts
UV1; Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
35 Shannon Lane
Owner
information is
required for
every page.
Property Address
Dina Trebbe
Owner's Name 6-2-S-12-
North
-2-S-12,North Andover MA 01845 6-+#=t2
City(rown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other (describe below):
General Information
Pumping Records:
Source of information: unknown, no record
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
gallons
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) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
® Other (describe):
PUMP
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 35 Shannon Lane
Property Address
Dina Trebbe
Owner Owner's Name
information is
required for North Andover MA 01845
every page. Cityrrown State Zip Code
D. System Information (cont.)
6 z8—l2
Date of Inspection
Approximate age of all components, date installed (if known) and source of information:
Approximately 20 years
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer (locate on site plan):
Depth below grade: 4
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other (explain):
Distance from private water supply well or suction line: N/A
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Pipe looks good in basement
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
® concrete ❑ metal
2.5'
feet
❑ fiberglass ❑ polyethylene ❑ other (explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 gallons
Sludge depth:
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
35 Shannon Lane
Property Address
Dina Trebbe
Owner Owner's Name
information is 2S'!2
required for North Andover MA 01845 64442
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
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
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
ould not open tank, covers cemented shut. Recommend opening and pumping tank
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal
❑ fiberglass
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
feet
❑ polyethylene ❑ other (explain):
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 35 Shannon Lane
Property Address
Dina Trebbe
Owner Owner's Name
information is 6 -Z.� l2
required for North Andover MA 01845 6-14-42
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
5. 35 Shannon Lane
Property Address
Dina Trebbe
Owner Owner's Name 6 Z,9 Z
information is North Andover MA 01845 6-44-Q
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Distribution box in OK condition. Distribution normal. No evidence of leakage in or out. No solids
Pump Chamber (locate on site plan):
Pumps in working order:
®
Yes
❑
No
Alarms in working order:
®
Yes
❑
No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Pump and pump chamber appear to be in good working order
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
35 Shannon Lane
Property Address
Dina Trebbe
Owner
Owner's Name
information is
required for
North Andover MA
every page.
Cityrrown State
❑
D. System Information (cont.)
Type:
-,,-&!2
01845 6-1442
Date of Inspection
❑
leaching pits
number:
❑
leaching chambers
number:
❑
leaching galleries
number:
®
leaching trenches
number, length: 3 trenches
❑
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.):
Area of field is
grass and looks normal. No evidence of
ponding, damp soil, or unusual vegetation
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth - top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes
❑ No
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
35 Shannon Lane
Property Address
Dina Trebbe
Owner Owner's Name —( 2
information is North Andover MA 01845 6-44-42
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
35 Shannon Lane
Property Address
Dina Trebbe
Owner Owners Name 2S ^-)
information is
required for North Andover MA 01845 6.9442
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand -sketch in the area below
❑ drawing attached separately
Di.S i AoC_Cs
D—gLx Ar"V,
+� I
�j TaNr1,
1%i
-- Pin. P
13`
0-P_'
22l
Pomp
z,'rs4,vIA.
A- 13
f
l
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
35 Shannon Lane
Property Address
Dina Trebbe
Owner
Owner's Name
information is
North Andover MA
required for
every page.
City/Town State
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
6 -2-.:?-12-
01845
2_01845 6 -1* -+2
Zip Code Date of Inspection
4
Estimated depth toig groun wa er. feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health - explain:
❑ Checked with local excavators, installers - (attach documentation)
® Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
USGS maps indicate ater at 6'. System 2' below grade. System on a hill.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
35 Shannon Lane
Property Address
Dina Trebbe
Owner's Name 6 -2 -9 -12 -
North
•-Z9/2North Andover MA 01845 6-14-4-2
Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information - Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
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: 35 Shannon Lane No. Andover, MA 01845
Owner's Name: Dina Trebbe
Owner's Address: 35 Shannon Lane No. Andover, MA 01845
Date of Inspection: June 6, 2005
Name of Inspector: (please print) Benjamin C. Osgood, Jr. Certified Title 5 Inspector
Company Name: New England Engineering Services Inc.
Mailing Address: 60 Beechwood Drive North Andover, MA 01845
Telephone Number: 978-686-1768
RECEIVED
DEC 12 2005
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
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:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: 5,-. / �2-1 Date: / -
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.
2 ofl l
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 35 Shannon Lane No. Andover, MA 01845
Owner's Name: Dina Trebbe
Date of Inspection: June 6, 2005
Inspection Summary: Check A, B, C, D or E/ALWAYS complete all of Section D
A. System Passes:
`3 r5 I have not found any information which indicates that any of the failure criteria described in 310 CMR 15303 or in 310 CMR
15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
Al o 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:
3 of'11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
35 Shannon Lane No. Andover, MA 01845
Owner's Name:
Dina Trebbe
Date of Inspection:
June 6, 2005
C. Further Evaluation is Required by the Board of Health:
NO Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect
public health, safety or the environment
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is
not functioning in a manner which will protect public health, safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health ( and Public Water Supplier, if any) determines that the system is
functioning in a manner that protects the public health, safety and environment:
The system has a septic tank and (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:
4 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 35 Shannon Lane No. Andover, MA 01845
Owner's Name: Dina Trebbe
Date of Inspection: June 6, 2005
D. System Criteria applicable to all systems:
You must indicate "yes or No" to each of the following for all inspections:
Yes No
y 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 %s day flow
✓ Required pumping more than 4 tunes 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.
C-1 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.)
/V 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:
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 follom4pg criteria apply to large systems in addition to the criteria above)
Yes No
The system !,& thm 400 feet of a surface ater supply
The system is within feet of utary to a surface drinking water supply
The system is 1 m a nitro sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II
of a publ�-iter supply well
If you answered'"y&' to any question in Section E the system is nsidered a significant threat, or answered `yes" in Section D above
the large system has failed The owner or operator of any large sy considered a significant threat under Section E or failed under
Section D shall upgrade the system in accordance with 310 CMR 15.3 . 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: 35 Shannon Lane No. Andover, MA 01845
Owner's Name: Dina Trebbe
Date of Inspection: June 6, 2005
Check if the following have been done. You must indicate "Yes" or "no" as to each of the following:
Yes No
V/' 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_?
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 ?
Was the site inspected for sign of break out?
Were all system components, excluding the SAS, located on site?
V1 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
__NZ 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)]
6 of l l -
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 35 Shannon Lane No. Andover, MA 01845
Owner's Name: Dina Trebbe
Date of Inspection: June 6, 2005
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design)_ Number of bedrooms (actual): i J
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): /\X
.
Is laundry on a separate sewage system (yes or no): NQ [if yes separate inspection required]
Laundry system inspected ( yes or no): —
Seasonal use: (yes or no): /V D -
Water meter readings, if available (last 2 years usage (gpd):
Sump Pump (yes or no):A.' 0 ..
Last date of occupancy ( c (- r;�
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:y N V, tj o "/ &/ z o r3 D V 2 cco �2�5
Was system pumped as part of the inspection (yes or no): n 0
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): 5 Ft'�1 [ r A ti K y L, /vi P C Lt,+-aA P) 1 R O X ES r
Sore t4} 0 1S _ 1'T l 0,Aj S�s inn?
Approximate age of all components, date installed (if known) and source of information:
Were sewage odors detected wen arriving at the site (yes or no): n/ 0 .
7of11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 35 Shannon Lane No. Andover, MA 01845
Owner's Name: Dina Trebbe
Date of Inspection: June 6, 2005
BUELDING SEWER (locate on site plan)
a
Depth below grade: H f?
Materials of construction: 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.):
1-ioUs. C-1?0
SEPTIC TANK: (locate on site plan)
Depth below grade: 30
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: ),5 -co G ►�� �� r fs
Sludge depth: 12
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: t, '
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined: 'Vl CA s L' [2- s -7 �< V -
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet
invert, evidence of leakage, etc.):
7�i�1NIL- tn.a IT\0/J lonC2�MP.���
GREASE TRAP:' X1 14 1(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:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition structural integrity, liquid levels as related to outlet
invert, evidence of leakage, etc.
8 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 35 Shannon Lane No. Andover, MA 01845
Owner's Name: Dina Trebbe
Date of Inspection: June 6, 2005
TIGHT OR HOLDING TANK -__ k (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)
Depth of liquid level above outlet invert: 0
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.):
13-x
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PUMP CHAMBER: { S (locate on sire plan)
Pumps in working order (yes or no) y F 5
Alarms in working order (yes or no)cc
Comments (note condition of pump cumber, condition of pumps and appurtenances, etc.):
1p�-i 1A P C �ZPrB;F 12, &?FC--RF,s -7b, .fir wa 1214tN Cs- OIL, .
' 9Ohl
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 35 Shannon Lane No. Andover, MA 01845
Owner's Name: Dina Trebbe
Date of Inspection: June 6, 2005
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 tranches, number in length Z FP_CN c f-( c= S
leaching elds, 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)
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CESSPOOLS: N_ (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: A) a (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.
10of11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 35 Shannon Lane No. Andover, MA 01845
Owner's Name: Dina Trebbe
Date of Inspection: June 6, 2005
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.
p"A'r
It of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 35 Shannon Lane No. Andover, MA 01845
Owner's Name: Dina Trebbe
Date of Inspection: June 6, 2005
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
I
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:
_ 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:
,.zas r^n yV5c, ti's y 49,-0 au- L--)
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address of property3,j v`�ctr1✓ob:1 �,a�e� .tip {��,c' C -�:2 Mc-
Owner's name Shi&Lci a
Date of Inspection
PART A
CHECKLIST
I
Check if the following have been done:
Pumping information was requested of the owner, occupant, and 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.-
As built plans have been obtained and examined. Note if they are not
available with N/A.
�f
The facility or dwelling was inspected for signs of sewage back-up.
The site was inspected for signs of breakout.
/ All system components, excluding the SAS, 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 SAS on the site has been determined based
on existing information or approximated by non -intrusive methods.
% The facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance of SSDS.
' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
F;
FLOW CONDITIONS
If residential
_! number of bedrooms
number of current residents
_ �_ garbage grinder, yes or no
y laundry connected to system, yes or no
ti seasonal use, yes or no
If nonresidential, calculated flow:
Water meter readings, if available:
Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information:
e-
�z System pumped as part of inspection, yes or no
if yes, volume pumped Dov 6a/ T�nLt t Z�C` G�x! ��"'%' �'{�u.r►�ar•2
Reason for pumping:
111 '"2Ec7- J&Vy' ���.� 7a cr.cf1�t/ �Kr9�tit�ic2
Type of system
AZSeptic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection
records, if any)
Other (explain)
Approximate age of all components. Date installed, if known. Source of
information:
Sewage odors detected when arriving at the site, yes or no
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
.SYSTEM INFORMATION continued
,DTIC TA,N'K:
11
.;locate on site plan)
'depth below grade: 2
material of construction: ✓concrete metal ,____FRP other(explain)
dimensions: v �'
s-' sludge depth
?y' distance from top of sludge to bottom of outlet tee or baffle
_ scum thickness
(o" distance from top of scum to top of outlet tee or baffle
o bottom of outlet tee or baffle
distance from bottom of scum t
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,
depth of liquid level in relation to outlet invert, stru.t1__:.1 integrity,
evidence of leakage, recommendations for repairs, etc.) �s'
��Ne V e- s R rz ro
ADS'
y.
T i
DISTRIBUTION BOX:
(locate on 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, recommendation for repairs, etc.)
s
PUMP CHAMBER:____
(locate on site plan)
pumps in working order es or no
comments:and appurtenances,
(note condition of pump chamber, condition of pumps P PP
recommendations for maintenance or repairs,et'•) .11'AN�t'l� �� w
%Jcn
l c i
1 V
aS - 39
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
.•JIL 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 and number
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
.leaching fields, number, dimensions
overflow cesspool, number
,
Corrrents :
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc.)
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
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, recommendations for maintenance or repairs,etc.)
PRIVY: .
(locate on site plan)
materials of construction
dimensions
depth of solids
Comments:
(note condition of soil, signs of hydraulic failure, -level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc.)
Cl
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
'SKETCH OF SEWAGE DISPOSAL SYSTEM;
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
nv--mij TO r-,PnTTKn1
depth to groundwater
5q.,5
PUMP
met' -hod of determination or approximation:
5- k Cr 4-1 11 I-eli-I &
12
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
;indicate yes, no, or not determined (Y, N, or ND). Describe basis of
=`'determination in all instances. If "not determined", explain why not)
_/V Backup of sewage into facility?
Discharge or ponding of effluent to the surface of the ground or
surface waters?
/V -'Static liquid level in the distribution box above outlet invert?
Liquid depth in cesspool <611 below invert or available volume< 1/2 day
flow?
Required pumping 4 times or more in the last year?
number of times pumped 0
A/ Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
Is .any portion of the SAS, cesspool or privy:
below the high groundwater elevation?
within 50 feet of a surface water?
within.100 feet of a surface water supply or tributary to a surface
water supply?
V within a Zone I of a public well?
within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, not the SAS)?
-441 within 50 feet of a private water supply well?
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.
,3 C't
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
'rName of Inspector C, �
Company Name /kjc, 14.,,Y C �•�', yCti ' + $
Company Address�/
Certification Statement
I certify that I have personally inspected the sewage disposal system at
this .address and that the information reported is true, accurate and
complete as of the time of inspection. The inspection was performed and
any recommendations regarding upgrade, maintenance and repair are
consistent with my training and experience in the proper function and
manitenance of on-site sewage disposal systems.
Check one:
I have not found any information which Indicates that the system fails
to adequately protect public health or the environment as defined in
310 CMR 15.303. Any failure criteria not evaluated are as stated in
the FAILURE CRITERIA section of this form.
I have determined that the system fails to protect public health and
the environment as defined in 310 CMR 15.303. The basis for this
determination is provided in the FAILURE CRITERIA section of this
form.
Inspector's Signature
Date -?/ / �
,Original to system owner
Copies to:
Buyer (if applicable)
Approving authority
2URD OF'
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ENVIRONMENTAL
i
February 7, 2006
Wind River Environmental
163 Western Ave.
Gloucester, MA 01930
Board of Health Administrator,
577 Main Street, Suite 110, Hudson, Massachusetts 01749( E -Mail:
Telephone 978.562.4500 Facsimile 978.562.7255 wrenvironmental.com
This package contains the dump slips for the Board of Health from the field office
located in Gloucester, MA. This is the work we have completed.
If you have any questions, please feel free to contact our Branch Manager, David Martin
at 978-282-7315.
Thank you,
?issillian
NEW ENGLAND ENGINEERING SERVICES
lk INC
January 3, 2006
Ms. Susan Sawyer
North Andover Board of Health
400 Osgood Street
North Andover, MA 01845
RECEIVED
JAN 0 6 2005
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
RE: REVISED TITLE V REPORT: 35 Shannon Lane No Andover, MA
Dear Ms. Sawyer:
Enclosed is the Revised Title 5 Report for the above referenced property. The only
change is the inspection date which was erroneously listed as June 6, 2005 on the previous
report.
If there are any questions please call me at my office, 686-1768.
Sincerely,
Benjamin C. Osgood, Jr.
Certified Title 5 Inspector
60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099
I
{
NEW ENGLAND ENGINEERING SERVICES
lk INC
(-R-EC -El VED7
December 9, 2005
Ms. Susan Sawyer
North Andover Board of Health
400 Osgood Street
North Andover, MA 01845
DEC 12 2005
TOHEALLTH 0 PARTM TER
RE: TITLE V REPORT: RE: 35 Shannon Lane No. Andover, MA
Dear Ms. Sawyer:
Enclosed is a Title 5 Report for the above referenced property. The system Passes the
Title 5 inspection.
If there are any questions please call me at my office, 686-1768.
Sincerely,
Benjamin C. Osgood, r.
Certified Title 5 Inspector
60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099
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