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HomeMy WebLinkAboutMiscellaneous - 353 PLEASANT STREET 4/30/2018 (2)o ^� e� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 353 Pleasant street Property Address Tnni VAntn Owner Owners Name information is North Andover MA 01845 August 20,2013 required for every State Zip Code Date of Inspection page. City/Town Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. ®I� 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: John DiVincenzo Name of Inspector Stewarts Septic Serive Company Name A Sni ith Kimhall street Company Address Bradford Cit crown 978-372-7471 Telephone Number B. Certification MA State S113386 License Number 5E;' Z'-' b 2313 01835 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 ❑ Neids, Further FAluation bathe Local Approving Authority Date Y The system inspectors IIs mit a copy of this inspection report to the Approving Authority (Board of Health or DEP) wit days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Commonwealth of Massachusetts UtTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 353 Pleasant St Property Address Toni B Vento Owner Owner's Name information is North Andover MA 01845 8/20/2013 required for every North state Zip Code Date of Inspection page. 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. EIVED Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. A. General Information/ Inspector: John DiVincenzo AUG 2 9 2013 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Name of Inspector J and S Development Corp dba Stewart's Septic Service, Andover Septic Company Name 58 South Kimball st Company Address Bradford Ma 01835 City/Town state Zip Code 978-372-7471 s113386 Telephone Number License Number B. Certification 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 16,340 of Title 6 (310 CMR 16.000). The system: ❑ Passes Z Conditionally Passes ❑ Fails ❑ Needs Fujher)9pluationjtq the local Approving Authority 8-20-2013 Date The system inspector sKallsellim' it 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. thine - W3 Title 5 Official Inspection Form: Subsurface Sew ne Disposal System a Pepe 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 353 Pleasant St Property Address Toni B Vento Owner's Name North Andover Cityrrown B. Certification (cont.) MA 01845 State Zip Code 8/20/2013 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: 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 Oficial Inspection Form: Su¢surface Sewage Disposal System - Fuge 2 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 353 Pleasant St Property Address Toni B Vento Owner's Name North Andover MA 01845 8/20/2013 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced [] Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced Z Y ❑ N ❑ ND (Explain below): Dist Box needs to be replaced, coroaded around outlets ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 353 Pleasant St Property Address Toni B Vento Owners Name North Andover MA 01845 8/20/2013 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ N Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 N Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 353 Pleasant St Property Address Toni B Vento Owner Owner's Name information is required for every North Andover MA 01845 8/20/2013 page. cityrrown 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 li 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 • 3l13 ?ill: 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 353 Pleasant St Property Address Toni B Vento Owner's Name North Andover City/Town C. Checklist MA 01845 8/20/2013 State Zip Code Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No 0 ❑ 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): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): A ':T&LTN-lfl t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 353 Pleasant St Property Address Toni B Vento Owner owner's Name information is required for every North Andover page. City/Town D. System Information Description: MA 01845 8/20/2013 State Zip Code Date of Inspection 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 Occupied Date ❑ Yes ❑ No ❑ Number of current residents: ❑ 3 ❑ Yes Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) 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 Occupied Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 353 Pleasant St Property Address Toni B Vento Owner— -- Owner's Name information is required for every North Andover page. Cityrrown D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: MA 01845 8/20/2013 State Zip Code Date of Inspection Date General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping - Type of System: Stewarts Se 1500 Gallon gallons Site_guage on truck Inspect flank ® Yes ❑ No 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 DiWossl System • Page 8 of 17 Septic tank, distribution box, soil absorption system (� Single cesspool ❑ Overflow cesspool ® Yes ❑ No 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 DiWossl System • Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 353 Pleasant St Property Address Toni B Vento Owner Owner's Name information is required for every North Andover MA 01845 8/20/2013 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: 6-8-1981 Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: 40" feet Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): — Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 6" BTG feet ❑ Yes ® No ❑ 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: Sludge depth: ❑ Yes ❑ No t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 353 Pleasant St Property Address Toni B Vento Owner Owner's Name information is required for every North Andover page. City/Town D. System Information (cont.) Septic Tank (cont.) MA 01845 State Zip Code 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 28 1" 5" 14" 8/20/2013 Date of Inspection How were dimensions determined? Tape Measure, Sluge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Both baffles good, No leakage, Liquid levels good Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: t5ins • 3/13 Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System f=orm - Not for Voluntary Assessments M 6 353 Pleasant St Property Address Toni B Vento Owner Owner's Name information is required for every North Andover NIA 01845 8/20/2013 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: Ej concrete 1-1 metal Q fiberglass Dimensions: Capacity: gallons Design Flow: gallons per Alarm present: 0 Yes Alarm level: El polyethylene F -I other (explain): • Alarm in working order: 0 Yes © No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ® No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sawage Disposal System • Page 11 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 353 Pleasant St Property Address Toni B Vento Owner's Name North Andover MA 01845 8/20/2013 CityTrown 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.): Dist box level concrete around outlet inverts very closee to breaching box, needs replacing, No solids carry over, No leakage, concrete is paper thin Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 353 Pleasant St D. System Information (cont.) Type: Property Address ❑ Toni B Vento Owner Owner's Name information is required for every North Andover page. City/Town D. System Information (cont.) Type: ❑ leaching pits ❑ leaching chambers ❑ leaching galleries ❑ leaching trenches ® leaching fields ❑ overflow cesspool ❑ innovative/alternative system 8/20/2013 Date of Inspection number: number: number: number, length: number, dimensions: number: 1-30x32 Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No hydraulic failure, No ponding, No damp soils Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ® No t5ins + 3113 Title 5 Official Inspection Form: Subsurface Sewpge Disposal System - Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 353 Pleasant St Property Address Toni B Vento Owner Owner's Name information is North Andover MA 01845 8/20/2013 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.): t5ins • 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 Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 353 Pleasant St Property Address Toni B Vento Owner's Name North Andover MA 01845 8/20/2013 City/Town 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 15ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 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 353 Pleasant St Property Address Toni B Vento Owner's Name North Andover MA 01845 8/20/2013 City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 8' feet Please indicate all methods used to determine the high ground water elevation: z Obtained from system design plans on record If checked, date of design plan reviewed. 8-8-81 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) z Checked with local Board of Health - explain: Pulled files Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Water @ elevation 141.0 bottom of bed @ 145.0 system 4° above water table plans by Frank Gelinas & Associates INC Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 3f13 Title 5 Official Inspection Form: subsurface sewage Disposal system • Page 16 of 1 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 353 Pleasant St Property Address Toni B Vento Owner's Name North Andover MA 01845 8/20/2013 Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist E inspection Summary: A, B, C, D, or E checked E Inspection Summary D (System Failure Criteria Applicable to All Systems) completed E System Information — Estimated depth to high groundwater E 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 Commonwealth of Massachusetts:�1 W City/Town of No Andover a W� System Pumping Record F�R� � 2 2013 Form 4 �M OrNORTH ANDOVER TH DEPARTMENT Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. HEAL DEP has provided this form for use by local Boards of Health. Oth s may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information 1. System Location: No Andover Ma Citylrown State Zip Code 2. System Owne �7n,n4-n Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping --6)?-�� +o 3. Type of system: ❑ Cesspool(s) ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes 5. Condition of System: 6. yst . Pu ped By Name Stewart's Seotic Service Company State Telephone Number 2. Quantity Pumped: Septic Tank ❑ Tight Tank Zip Code Gallons ❑ Grease Trap No If yes, was it cleaned? ❑ Yes No Vehic a License Number 7. Location ;�he ere disposed: Stewart'sre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Date Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 • S�TTLED'I • • MCOPY PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 8/29/2013 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Complete Repair of D -Box By: John DiVincenzo At: 353 Pleasant Street Map 095 Lot 0020 North Andover, MA 01845 of thisificate shall not be construed as a guarantee that the system will function satisfactorily. Public Hefalth Agent 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com North Andover Health Department Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 353 Pleasant Street MAP: 0095 INSTALLER: John Divencenzo DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS DISTRIBUTION BOX: TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: LOT: 0020 SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing . . 0. Comments: PUMP CHAMBER Comments: CONTROLPANEL Comments: DISTRIBUTION -BOX Comments: ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Installed on stable stone base [� H-20 D -Box [v]� Inlet tee (if pumped or >0.08'/foot) Q� Hydraulic cement around inlet & outlets Observed even distribution Speed levelers provided (not required) • Commonwealth of Massachusetts Map -Block -Lot 095.00020 g BOARD OF HEALTH PenmtNo North Andover - BHP -2013-0877 ---------------- -- ---- FEE $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted John DiVincenzo Rnrc)Dy to (Repair) an Individual Sewage Disposal System. I fyj 91 at No 353 PLEASANT STREET ---------------------------------------------------------------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. BHP -2013-087 Dated August -2-8,-2-01-3 ----------------------------------------------------------- Issued On: Aug -28-2013 BOARD OF HEALTH ---------------------------------------------------------------------------------- � H af,HonrH � = Town of North Andover �'••,,,,, .: HEALTH DEPARTMENT 1gSACHU`+tt CHECK #: LOCATION: H/O NAME: CONTRACTI 6514 Type of Permit or License: (Check box) 0 Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ Septic Disposal Works Construction $� ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ 4YN Title 5 Report $ ❑ Other: (Indicate) $ ( "p) Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Application for Septic Disposal System 8 Construction Permit - TOWN OF TODAY'S DAV ORTH ANDOVER, MA 01845 $ 250.00 — Full Repair $125.00 - Component Application is hereby made for a permit to: ❑ Construct a new on-site sewage disposal system* Repair or replace an existing on-site sewage disposal system* -6 Repair or replace an existing system component — What?-OL57 A. Facility Information Address or Lot # .` - A City/Town 2.- *TYPE OFOEPTIC SYSTEM*: AUG 2 8 2013 ❑ Pump [t}/Gravity (choose one) ***If pump system, attach copy of electrical permit to application*** TOWN OF NORTH ANDOVER conventional System (pipe and stone system) #EALTH DEPARTMENT ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D -Box Present) S.A.S. 2. Owner Information 1Ao P 1-6 -e.-- Address (if different from a ove) City/Town State Telephone Number Installer Information Zip Code Name _ � , i � � Name of Company Addre 1� City/Town State Zip Code Telephone Number (Cell Phone # if possible please) 4. Designer Information Name Address City/Town Name of Company State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 IJ .ee ' a .--,- NORTH Application for Septic Disposal System Construction Permit — TOWN OF To AYSD E ORTH ANDOVER MA 01845 $ 25.00 - Component PAGE 2 OF 2 A. Facility Information continued.... 5. Type of Building: residential Dwelling or ❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place the s stem in operation until a Certificate of Compliance has been issued by this Board of Hepit —TL LJAN - t� ?14 eZ3 Name Date Application Approved : (Board of Health Representative G' Name Date Application Di /pproveifor the following reasons: For Office Use Only: 1. Fee Attacbed.? Yes No 2. Project Manager Obligation Form AttacbedP Yes No 3. Pump Svstem? If so, Attach copy ofElecttical Permit Yes No 4. Foundation As -Built? (new construction ronly): (Same scale as approved plan) Yes No 5. Floor Plans? (new construction only): Yes No Application for Disposal System Construction Permit • Page 2 of 2 I F- I WV. PIPE OUT OF HISIE. 12 I Ki v Plpa.. I 1,qTo -FA-h41L it,A Pi9F-OUTOFTA-xhlV- INV PIPE INTO Qe?QX LNLV P, PP: NV E: N1 Q. OP - .A. u I L -T ID SY�T EM IrJ T N O'C T'If A L Ty u -T C6" - a -C m , �9 P\ c-_- t14 C---31 t1l E_ e 15 CER EJ ' SEPTIC & DRAIN SERVICE 107 FOREST STREET; MIDDLETON, MA 01949 (978) 774-2772 FORM 4 - SYSTEM PUMPING RECORD coM O EALTH OF MASSACHUSETTS 7Cf0 V , MASSACHUSETTS SYSTEM PUMPING RECORD SYSTEM OWNER: ve� 4 &l SYSTEM LOCATION: bo c 79 </ - 069- �a DATE OF PUMPING: 7 _'�p 2 - CESSPOOL: NO.' F-] YES 6/ /l QUANTITY PUMPED: / 57��. - GALLONS SEPTIC TANK: NO YES SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE CONTENTS TRANSFERRED TO: DATE: 7- -;2- 5? - / % INSPECTOR: �� ✓� 7C'vVNWF N'0RCH u,7. BOARD OF ',:E,-•LiH Se N I i i - ., G -T `A -E,11E ti s ' �z � PL `7 . � �. Tv_'N �L i, i JL�1.�.i'-z C-T._.'i • .. Y�.J.���J'�T"'i '�7 3 7� _ C --1 N.� T L.E. \/AT i 0 P4 A,$. 1NY__ PIPE OUT DF HSE IZ4 L) 5,C)� '-A -4 J � u I L INV PiPE nrrn ou. i 5e 1 -S 1 V PIP DUTOF TI-61my I L} (, 2 1 ' INV_PiPEINTODE3QX S.31 , G •J V�_JV�rr�EI��SPd�L"' c iLi%. INV. Pi ps= 01)T D psnX (1,- l it -IV E nl D or- Pi P;,E� "-4 NoR T � ANDOVF� �E,ALTY T�:UST ATE, SvNE 7_�98� � k G�7EL.tN,f�g AS`�vGl/�TES =uL, rfij 1 E N i til E E 2 g ARL: -1 (TSC T' S /-OT Board'of Health North An(�o4eriHass. SCP R�RED DATE DISAPPROVED Reamast 1 d BEMC SISM INSTALLATICK CHECK LIST 13 OK 1. Distance Tot a. Wetlands b. Drains c. Well LOT/ `7�G1 ✓'� AVATZON Ob FAIL 2. Water Line Location 3. No PVC Pipe $• Septic Tank - - /� a. _Tees --Length & To Clean Out Covers. b. Cement Pipe to Tank.- Oa Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Lines Flowing Lqual Amoimts c. No Back Flow 6e. Leach Field or Trench a. Dimensions b. Stone Depth r c. Capped ids d. Clean Double Washed Stone' ?• Leach Pits, a. Dimensi s b. Stone epth f C. Spl sh Pads d. T s e. anent Pipe to Pit - Both Sides / f. Clean Double Washed Stone �. No Garbage Disposal �9• Final Grading Inspection 10. Barricading Covered System 11._ As Built Submitted- - -- a. Lot Location b. Dimensions of System c. Location with Regard -to Pere Test d. Elevations e: Water Table Yl}�Wfkndovor,F'lass SUEMPACE DISPOSAL DESIGN CHECK LIST LOT APPROVED DATE DISAPPROVED DATE�,w Provided: Reasons: Title v F Reg 2.5 submA .ted plan must shot as a Wmimum: jcL.-Idesign he lot to be served-area,dimensions lot #, abutters log deep hoes to ties ocation and observation -distance ocation and results percolation tests -distance to ties calculations & calculations showing required leaching area cation and dimensions of system -including reserve area xisting and proposed contours g) location any vat areas ethin 1001 of sewage disposal system or disclaimer -check wetlands crapping h),surface and subsurface drains-,d.thin 1001 of sewage disposal system or disclaimer (i) location any drainage easements within 1001 of serge disposal systea or disclaimer -Planning board Piles �J�)D= sources of tinter supply within 2001 of sewage disposal tem or disclaimer ocation of proposed well. to serve lot -1001 from leacbing facility _ � ocation of voter lines on propcxty-101 frog: leaching facility ocation of be..nchmark Iddrivairays bage di gosals o PITC to ba uF ed in construction �.. _ ro_i.le o£ �y to Ael.o if ons: of ba: 1 t, plumb, pipe, septic tank, W.str buti.on box inlets and outlets., distribution field piping and a tvicr elevations ground water elevation in area sewage disposal system s) plan t,st be prepared by a Professional Engineer or other professional authorized by lata to prepare such plans Reg 6 St tic _Tanks (a) capTacit'ies-750% of flow, water table, tees, depth of tees, access, purping cleanout 1 from cellar val or inground md=i .ng pool (d) 251 from subsurface drains Reg 10.2 Distribution Boxes Reg 10.1 ['b} sunp 0.08 r Sebe—.mace 13-a "ign Chcck List Pale 2 FAIL OK Reg 15.1 15.4 15.8 3.7 Reg 311.1 lh.3 14.1.E 11x.6 111.7 11;.10 Reg 9.1 9.6 Leaching Pits Leaching pits/are preferred where the installation is possible t) calculatio of leaching area -minimum 500 sq ft �) spacing surface a 2% i cover terial :) RI x4o splash pad P) at elbow' ;) o bends in pipe from d -box to pipe ,.,.-Leaching Fields no greater than 20 minutes/inch area -minimum 900 sq ft construction of field surface drainage 2 % 9) 201 from cellar wall or inground s-dimrAng pool t)c cM orisleaching area -min 500 aq ft �) spacing-4,pt min 6 ft with reserve bet -,den ;) dizensioAb drainage 2% � Do x,.11 to e soge g x = to be shown) �) y/x X 50 = to be shown) PuTs/ I) ra;d val )) -bar power i SEP — 7 J00k Sysl TOWNe�TN OEPAR MENT R Type: Emergency Routine Cesspool: No Yes Date of Pumping: LA -0y System Pumped By: Wind kvw EnwronmenW, LLC Contents transferred to: Contents Disposed at: Date: )/ f b l V 4 Pumper Signature: :alth of Massachusetss Massachusetts Location Dep Approved Form - 12/07/95 Form 4 - OSystem Pumping Record Septic tank: w =Yes Quantity Pumped: Gallons Permit #: � Commonwealth of Massachusetts City/Town of NORTH ANDOVER, MASSACHUSETTS - System Pumping Record _ A Form 4 '.4 DEP has provided this form for use by local Boards of Health. The System Pumping Record must be submitted to the local Board of Health or other approving authority. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. 1.-0 iehm ' A. Facility Information System Location: Address City/Town 2. System Owner: _ V i° i✓� Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ NOV 0 2 2007 TOVIN O :,C State Zip Code State Zip Code Telephone Number C'�- // Date 2. Quantity Pumped Cesspool(s) peptic Tank Gallon Q C0 ❑ Tight Tank ❑ Other (describe): --- 4. Effluent Tee Filter present? ❑ Yes �Olf yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: � n 6. System Pumped By: ©sem_ rf Name Vehicle License Number c,t-J Company 7. Location where contents were disposed: SignaIur o Haule Date http://www.mass.gov/dep/w�a-ler/aWovals/t5forms.htm#inspect t5form4.doc• 06/03 1 System Pumping Record • Page 1 of 1 <C\ Commonwealth of Massachusetts ,EP '13 2N City/Town of TOWN OF NORTH ANDO% System Pumping Record NORTH ANDOVER HEALTHoEpARTMEN Form 4 h DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. 1[ 1. System Location: -57 Address Kov-bn Ancl_ov V City/Town 2. System Owner: —i_ c3O i Ve4d-- Name Address (if different from location) City/Town B. Pumping Record State Zip Code -- ---- ---- State Zip Code 978-794-.0L9.3 --- Telephone Number � �, o /5-00 --- -- 1. Date of Pumping pate 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s)U✓ Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe):-�---------- ---- ---- -_------------- 4. Effluent Tee Filter present? ❑ Yes Do/No If yes, was it cleaned? ❑ Yes &?"'No 5. Condition of 6. System Pumped By: , tin GQ L ICA n --- -- - Name Company 7. Location where contents were disposed: G.L.S. Signature of Hauler Signature of Receiving Facility 76678 ---- Vehicle License Number MA. Date Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1