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HomeMy WebLinkAboutMiscellaneous - 366 FOREST STREET 4/30/20181 . .. 4 �: t �. w W F N W W Q: LL w m M fA �W U � �In $4 J W U nQ CC)a IL 7aC� �o mC2 vo 0 �O J w M 0 0 Y U 0 J m O a 03 M ao 00 0 c M M U N N M ooUOCU O o b o �+ O 'O 'O y e _. _ w hv�� �- ,J A � J �OOO O JJ � t Qip 7� TO U.-�a >�N mro �a O� gc m °2wUS r a ZNN Z, C O "�WO O p Ow — W U�0000 Q C O rad o f -W z �$�; i < < b W v GS 3 � .. ° c v¢QQ g LL -K M KN -. m O Q .- O r U oo L: "o N toO Q 2 QQQ zdc NN ��r3cn S 0� LLCo ZW it g y o m a' 00 Q �i' 79_ W 00 OD Co�� Q J avw jj U 0 £ V Wr-��- � mm (� H m m S M � .n 0o N Q W L Z m axe 00 0) O G1 jitIR .. O 1 YlONO(O0�� m Ue � E mf1U y, QLL V O LO OD OD c O M v U �ILW c'A'A'A �°-� O o N W O = V, VI vI ~ " m e a �adQj g z f� � N in 0- w U) U d .° SR '� o N N :.,% O O m N 4 A m®Nmc ao to v� r°n v� C7 m m O r. j 0 m Q N W W � Q Za CmfAl4� to N a MLLm WMU)Ua¢g i� 'a 1 m 0CL O OPMp Y7 �I* �� m C V P r e0-�QQ it E Q SAOi00 X ,MDlCM LL N W O �HF-r (,Dm Q m� m � IL C LL C Q C m m .. •- R M W Cha CLL } W� CUo .W a'D �C o L� m W ° U �D<:D Un d+ �� 0 e r.r -� U w�U' o 30/ zo = z WG toMv rr �" a Q g !� 6 w X .. Q7 � "e co; g iciL- UmLL m N W r O EZE= j 3t M Nm N O = O a0, gmmmOC�M C9U� L (O� p z y W O� 3 M-; a wv t H� to 4 J W W 12MLL=wto w coM< N 0 W HOo vn t�.1.=t9O v to Z rmi QO: to Z IL M Lu Q w i5 m sO ca to F �_ CQ W 3 m 6 wmu° =LL w j,�QMz wu)- U- 3 D NEW ENGLAND ENGINEERING SERVICES INC December 19, 2005 Ms. Susan Sawyer North Andover Board of Health 400 Osgood Street North Andover, MA 01845 RECEI E!! Q DEC 2 1 2005 TOWN OF" '"DOVER HEALTH C:ci=-, „ I (V,ENT RE: TITLE V REPORT: RE: 366 Forest Street North 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, B- a V- Benjan-fin C. Osgoo, Certified Title 5 Inspector 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 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: 366 Forest Street North Andover, MA 01845 Owner's Name: Lauren Day Owner's Address: 366 Forest Street North Andover, MA 01845 Date of Inspection: 12/09/05 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 21 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: Inspector's Signature: C Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails The system inspection shall submit a copy of this iiYspection 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 vi F_I.4- , 88, 'FRo n.1 L.e ercl-t &,P F A. w A--vq; Z P_ V >= TF{ IS REFo Jz i , ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 2of11, OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 366 Forest Street North Andover, MA 01845 Owner's Name: Lauren Day Date of Inspection: 12/09/05 Inspection Summary: Check A, B, C, D or E/ALWAYS complete all of Section D A. System Passes: E� 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: PO One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If `not determined" please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): Broken pipe(s) are replaced Obstruction is removed Distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): Broken pipe(s) are replaced Obstruction is removed ND explain_ 3of11• OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 366 Forest Street North Andover, MA 01845 Owner's Name: Lauren Day Date of Inspection: 12/09/05 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: 4of11- OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 366 Forest Street North Andover, MA 01845 Owner's Name: Lauren Day Date of Inspection: 12/09/05 D. System Criteria applicable to all systems: You must indicate "yes or No" to each of the following for all inspections: Yes No L/I Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool --6G 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 V^ Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow ✓" Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times Pumped y 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. L/ 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 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.) Al 0 (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a barge 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 `Sno" to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No The systems. thin 400 feet of a surface drinl inwater supply The system is within 200 a ibutary to a surface drinking water supply The system is it in a nitrogen sensitive ar terim Wellhead Protection Area — IWPA) or a mapped Zone lI of a water supply well If you 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. 5 of 11 - OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 366 Forest Street North Andover, MA 01845 Owner's Name: Lauren Day Date of Inspection: 12/09/05 Check if the followine have been done. You must indicate "Yes" or "no" as to each of the following• Yes No _�vl Pumping information was provided by the owner, occupant, or Board of Health Were any of the system components pumped out m the previous two weeks-? Has the system received normal flows in the previous two week period ? V Have large volumes of water been introduced to the system recently or as part of an inspection ? f Were as built plans of the system obtained and examined? (If they were not available note as N/A) f/ Was the facility or dwelling inspected for signs of sewage back up ? Was the site inspected for sign of break out? r� Were all system components, excluding the SAS, located on site? V Were all the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner ( and occupants if difference from owner) provided with information on the proper maintenance of the subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes No Existing information. For example, a plan at the Board of Health. +/ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 6 of 11 - OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 366 Forest Street North Andover, MA 01845 Owner's Name: Lauren Day Date of Inspection: 12/09/05 FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design)__::I_Number of bedrooms (actual): DESIGN flow based in 310 CMR 15.203 ( for example: 110 gpd x # ofbedrooms): —' Number of current residents:_ Does residence have a garbage grinder (yes or no):T; Is laundry on a separate sewage system (yes or no):[if yes separate inspection required] Laundry system inspected ( yes or no): -- Seasonal use: (yes or no): /V 0 . Water meter readings, if available (last 2 years usage (gpd): to E L_t _ Sump Pump (yes or no): A,' Last date of occupancy c .; E. ) T COMM ERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sgft, etc Grease trap present (yes or no): Industrial waste holding tank present (yes or no): Non -sanitary waste discharged to the Title 5 system (yes or no) Water meter readings, if available: Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: S_ 12 Q C— !� er,RS 2e2 If) cti/ A/ t=s. p Was system pumped as part of the inspection (yes or no): &, p If yes, volume pumped: Gallons — How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _ Septic tank, distribution box, soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) Tight tank Attached a copy of the DEP approval Other (describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected wen arriving at the site (yes or no): /10 . 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 366 Forest Street North Andover, MA 01845 Owner's Name: Lauren Day Date of Inspection: 12/09/05 BUILDING SEWER (locate on site plan) Depth below grade:_____ Materials of construction:--.�Z_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.): SEPTIC TANK: (locate on site plan) Depth below grade: 3 &' Material of construction: ✓ concrete metal fiberglass polyethylene Other (explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance (yes or no): (attach a copy of certificate) Dimensions: 1,5'y o C*,4L-CC � s Sludge depth: /- 2 Distance from top of sludge to bottom of outlet tee or baffle: 0 Scum thickness: L A Distance from top of scum to top of outlet tee or baffle: Q Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined: rv� f C'S o rL c- s r, Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): T A ti' ll. L tiI fl C -L- - k-? 0 A.) , GREASE TRAP: N 4' (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: 366 Forest Street North Andover, MA 01845 Owner's Name: Lauren Day Date of Inspection: 12/09/05 TIGHT OR HOLDING TANK: 11 ! (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.): WA p 1L l.)-- M41 FtU-C r tiJ p (Z 0 .JT PUMP CHAMBER:�(locate on sire plan) Pumps in working order (yes or no) Alarms in working order (yes or no) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): 9of11• OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 366 Forest Street North Andover, MA 01845 Owner's Name: Lauren Day Date of Inspection: 12/09/05 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required If SAS not located explain why TYPE leaching pits number leaching chambers, number leaching galleries number leaching trenches, number in length leaching fields, number, dimensions: et -17 )2- ' X 001 overflow cesspool, number: innovative/altemative system Type/name of technology: Comments ( note condition of soil, signs of hydraulic failure. Level of ponding, damp soil, condition of vegetation, etc) D 5— 0 CD0eJ2P17 CESSPOOLS: v' Al (cesspool must be pumped as part of inspection) (locate on site plan) Number and configuration: Depth — top of liquid to inlet invert Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of Construction Indication of groundwater inflow (yes or no) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: (locate on site plan) Material of construction: Dimensions: Depth of solids Comments (note condition of soil signs of hydraulic failure, level of ponding, condition of vegetation, etc. 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 366 Forest Street North Andover, MA 01845 Owner's Name: Lauren Day Date of Inspection: 12/09/05 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. �c fut,s-- 5;-rl _ P?12 yP'-0 --9 a e s 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 366 Forest Street North Andover, MA 01845 Owner's Name: Lauren Day Date of Inspection: 12/09/05 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record - If checked, date of design plan reviewed: _ 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: F�semtzr &, F,e. (o w c�Y'c.c51c w -'i K n.)o sun,,? ?0 r- F• f6Me,- t5 ekNtS(4vD i4K)D Ls vQ�zH 112� 2 -To E -A -&T rt t+' A -r = 2 Tic, 3 LE 6 r 3 r f}s C> rc a /AA '.., Cfl g� Z -flax F t—C- 0v P— F& Fc e. t- L< -'w -P i H S �izo i'F 9T, -j , y 66 LITTLETON ROAD, WESTFORD, MA 01886 Report Number: 97173 New England Engineering Serv. Tnc. 60'Beechwood jir N'. Andover MA 01845 VW -10 (978)692-8395 Report Date: 12/19/05 366 Forest St. N. Andover MA FAX (978) 692-0023 1 -800 -649 -TEST nate Sampled: 12/14/05 Sampled by: Client FPA 524.2 PARAMETER MCL RESULT PARAM1-TER MGL RESULT Bcj=uc 5.0 ND 1,1,2,2 -Tetrachloroethane - ND Carbon Tetrachloride S.0 ND 1,3-Dichloropropanc - ND 1,1-Dichloroethylene 7.0 ND Chloromethane — ND 1,2-llichl�rocthanu 5.0 ND Rromomethaue — ND p-DichloroBenmane ' 5.0 Nn 1,2,3-Trichloropropane NO Trichloroethylene 5.0 ND 1,1,1,2-Tctrachloroethanc _ Nn 1,1,1 -Trichloroethane 200. ND Chloroethane — ND Vinyl Chloride 2.0 Nn 2,2-vichlorbprupane ND Monochlorobenzeue 100. ND o-Chlorotoluene _ NT) ortho-Dichlorobenzene 600. ND p-C:hlorotoluene _ -- ND trans-1,2-Dichloroethylcne 100. Nn IBromobenzene ND cis-1,2-Dichloroethylene 70.0 ND 1,3-Dicldurupropene -- NT) 1,2-Dichloropropane 5.0 ND 1,2,4-Trimethylbennene — ND L'thylbenzene 700. ND 1,2,3-Trichlorobenzene• ND Styrene 100. Nn n-propylbenzene ND Tetrachloroethylene 5.0 ND n-Bulylhcrmnc -- ND Toluene 1000. ND Naphthalene ND Xylenes(Total) 10000. ND Hexachlorubutadicne - NA Dichlorcmrethane 5.0 ND 1,3,5-Trimcthylhenzene -- NI) 1,2,4=I'richlorobecuenc 70,0 ND p-lsopropyltoluene ND 1,1,2-Trichlornethaue S.0 ND lsopropylhenrenc -- NI) Chloroform Ni) t-Flutylbenzene ND Rromodichloromethane — ND sec-Bulylhcnzcnc -- ND C:hlorodibromornuthano ND FluoroTrichloromethaue ND Bromofonn - ND Dichlorudilluoromethane -- NI) m -Dichlorobenzene ND Rromochloromethane - ND Dibromomelhanc NI) *Mc1hy1TeriiaryBulylF.ther -- ND 1, 1 -DicbJoropropene N D 1,1-Dichloroethanc _ ND % Recovery of Internal Standards: 4=Bromol7uorobLnz.cne 1.07 1,2 -Dichlorobenzene -d 107 Detection Limit: 0.5 urrLi.. Subcontracted to Mass DFP Lab MA072, NI)==�None Detected MCL Maximum Contmmination Level Results are in up -/L *MTBE (Onticmal) i'( 4. Michael P. Carlson. for ?(-I Thomtensen Laboratory Inc. Z00/ 100'a OZZb# Namisun £ZOOZ69BL6 61:tl SOOZ-61'oaQ • • f 66 LITTLETON ROAD, WESTFORD, MA 01886 Report Number: 97173 Client: New l;ngland Engineering Scrv. Inc. 60 Beechwood Dr N. Andover MA 01815 Sampled by: Client 'fest Pan, motor Total Coliform (P) Fccal Culili�rm/ F..coli (P) Ammonia -N Nitrate-N'•(P) Nitrite -N (P) (978) 692-8895 FAX (978) 692.0023 1.800.649 -TEST Report Date: 12/15105 Sample Inforination: 366 Forest St. N. Andover MA Date Received: 1/14/05 Certificate of Analysis FI'A Limit Results Date Sampled: 12114/05 Units Legends: (P)—Primary F.PA Standard, (S)=Secondary EPA Standard, #--Fxceeds LPA Lunit, TNTC=Too Numerous to Count, *—Background Bacteria Noted Tbis water sample as submitted, meets FPA requirements for the pamme - listed above. Massachusetts Certification 11 MA048 Michael P. Carlslm, liar ela Thcmtensen Laboratory Inc. ZOO/ ZOO'd OZZ6# NESNSZSUGH1 £ZOOZ698L6 61:D1 S00Z'6Z'3dQ 0 0. perl0omf Not Spec. <0.03 mg/L 10 1.6 mg/I. 1 x:0.05 mg/L - Legends: (P)—Primary F.PA Standard, (S)=Secondary EPA Standard, #--Fxceeds LPA Lunit, TNTC=Too Numerous to Count, *—Background Bacteria Noted Tbis water sample as submitted, meets FPA requirements for the pamme - listed above. Massachusetts Certification 11 MA048 Michael P. Carlslm, liar ela Thcmtensen Laboratory Inc. ZOO/ ZOO'd OZZ6# NESNSZSUGH1 £ZOOZ698L6 61:D1 S00Z'6Z'3dQ co r W O � m U O O c-0 cry z , U � N O > " w LU c.f) D � �1 n O Q Q U- co � | § \) x § / kk � a § \j§ \\ x / ° ^ |k§ m# / m/< �\ � ) )}\(�`(}\\/ ILI \ x § / of 11 / OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 366 Forest Street North Andover, MA 01845 Owner's Name: Lauren Day Date of Inspection: 12/09/05 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. f.5 ��ce 5 vU .P j 1-I;2 pk 2�� Perm! Date I BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION . Date Received q IMPORTANT: Applicant must complete all items on this ease LOCATION 3 L Li�22ie s t �'tie�-f Print PROPERTY OWNER MAP NO: —HISTORIC DISTRICT >tl, :':•.gib TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building 'Mddition ❑ Alteration One family ❑ Two or more family No. of units: ❑ Industrial ❑ Commercial ❑ Repair, replacement ❑ Demolition ❑ Assessory Bldg ❑ Other ❑ Others: Public D - .Sewer :. Water 0 )=lood lain 5 VNetlan�d� ❑Watershed District OWNER: Name: Address: DESCRIPTION OF WORK TO BE PREFORMED: Identification Please ;t or Print Clearly) Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contracto o - Plans Submitted Plans Waived ❑ Certified Plot Plan THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING S DEVELOPMENT ❑ COMMENTS CONSERVATION COMMENTS 41�0— DATE REJECTED Stamped Plans ❑ DATE APPROVED C' DATE REJECTED DATE APPR TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Ant ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. Permanent Dumpster on Site ❑ Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Drivewav Permit Located at 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signatureldate COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. 3 Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine FILE#� A 101'Forest St. �P\C1 . Middleton, s (608) 774-2772 5 0a,Tr t JY3 1919 , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PROPERTY OWNER'S NAME:_C(29 /(J / PROPERTY ADDRESS OF OWNER: �Q ✓i/1 �.. (if different) DATE OF INSPECTION: „Q NAME OF INSPECTOR: / %%DiYJi�S 0 THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY 0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address:366 1pST 57—M Oxlover Address of Owner: Date of Inspection: c;o? 15&1K * (If different) Name of Inspector: Cxi Company Name, Address and Telepha Number: Currier Septic & Drain Service, Inc. 107 Forest Street, Middleton, MA 01949 (508) 774-2772 I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: as es nditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: 7�' Date: The System Inspector shall submit co of is ins inspection report to the Approving Authority within thirty 30 days of PY P P PP 9 tY Y( ) Y completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority INSPECTION SUMMARY: Check A (W C or D: A) S STEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B) STEM CONDITIONALLY PASSES: 1 One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of dtermination in all instances. If "not determined", explain not The septic tank is metal, cracked structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) FILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (conriHutd) B) SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution b x's I veiled or rep 3e The system required pumping more than four times a year due to brol�n 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 C) F RTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of a th in order to determine if thesystem is failing to protect the public health, safety and thq environ ent.'�y 1) SYSTEM'WILL PASS UNLESS rdOJ�kll` HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SA ETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply -well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D) S STEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to etermine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. (revised 8/15/95) 2 FILE#g2.2q(,fi SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) D) SYSTEM FAILS (continued) Static liquid level in the distribution box above oulet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year hM due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Na Any portion of a cesspool or privy is within 50 feet of a private water supply well. Q A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: T following criteria apply to large systems in addition to the cri rig above: The desi flow of system is 10,000 gpd or greater (La System) and the system is a significant threat to public health and s�fe`ty and the environment because o or more of the following conditions exist: The owner or treatment pro further infor6 (revised 8/15/95) the system ilm4ithin 400 f:ett of rface drinking water supply the system is within 0 f of a tributary to a surface drinking water supply the system is located in a ni ogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of ,public water supp ell) er for of any such system shall bring ke system and facility into full compliance with the groundwater (m requirements of 314 CMR 5.00 and 6,00. Please consult the local regional office of the Department for FILE# 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: iPumping 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 g normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. AAs built plans have been obtained and examined. Note if they are not available with N/A. N The facility or dwelling was inspected for signs of sewage back-up. P he system does not receive non -sanitary or industrial waste flow. The site was inspected for signs of breakout. /All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for P P condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of /The;*ize and location of the Soil Absorption System on the site has been determined based on existing in ormation or approximated by non -intrusive methods. _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SubSurface Disposal System. (revised 8/15/95) 4 FILE# 22% SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS Design flow: � O gallons Number of bedrooms:_ Number of current residents: Garbage grinder (yes or noQVL Laundry connected to system (yes or no):*, Seasonal use (yes or no):_tL5 �I Water meter readings, if available: Irmi SI Last date of occupancy: DesignNreadin ons/day Greasees or not) Industrig Tank pres : (yes or no) Non-sacharged he Title 5 system: (yes or no) Water 'f avi e: Last date of �ffescribe) of occupancy: PUMPING RECORDS information: GENERAL INFORMATION System pumped as part of inspection: (yes or o �vio If yes, volume pumped: 1 0OU gallons Reason for pumping: 53aaon1L11)P 1 AI I MLCV TYPE OF SYSTEM S 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) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: l / /2 — 2'q yrs Q() Sewage odors detected when arriving at the site: (yes or no)A0 (revised 8/15/95) 5 FILE# Z2,?6A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SEPTIC TANK:1 (locate on site an Depth below grade: N Material of construction: concrete Metal _FRP _other(explain) Dimensions: i,�' S' _ 16on ca/ �v►X. Sludge depth: _ Z" Distance from top of sludge to bottom of outlet tee or baffle:- Scum affle:Scum thickness: Distance from top of scum to top of outlet tee or baffler Distance from bottom of scum to bottom of outlet tee or baffle:_/,1L�� Comments: (recommendation for pumping, condition of inl�ejjand,outlej tee or baffles, structu5al integrity, gvidence o�akage,etc.)L/%Al„ GREASE TRAP: (locate o %itep an) Depth belde: Material of const taction: _concrete _metal _FRP er(explain) Dimensions: Scum thickness: Distance from top of scum top Distance from bottom of scu t tee or baffle: of outlet tee or baffle: Depth Below Outlet liquid bevel in relation to outlet i Depth Below Outlet Invert: Comments: (recommendation r pumping, con dit n of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural. inte evidence of leakage, tc.) (revised 8/15/95) 6 FILE* q2, 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) TIGHT ORLDING TANK: (locate on site Ian) Depth below grade: Material of constructio concrete�r ZFRer(explain) Dimensions: Capacity: allons Design flow:gallons Alarm level: (condi h of inlet tee, condition of alarm and floats 'tches, etc.) DISTRIBUTION BOX:iS (locate on site plan) Depth below grade: Depth of liquid level abovg outlet invert: 7 R© Dimensions of D-Box;C t3Depth of Sump: Comments: (note if level and distribution is a ual, evidence of sol'ds carryover, evidence of leakage into or out of box, etc.) B I r but o �� ,e k Ply rr, Ke/1 /,4U le nt 5 .o _ 1� - r PUMP CHAMBER:( (loca a on sitVchsamrbeor,) Depth be w Pumps inw6Comments: (note conditiodition of pumps and appurtenances, etc.) (revised 8/15/95) 7 r -• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM (SAS): ` (locate on site plan, if possible e a ion not required, but may be approximately by non -intrusive methods) Depth to bottom of SAS:4_ Ston or Pit) If not determined to be Type: leaching pits, number: leaching chambers, number: leaching galleries, number:_ i leaching trenches, number, length; -3 Q�Lh-j Z!/26 I U)0 or -e— � Dre- Lf;'IE I' %� �L, leaching fields, number, dimensions: t4 CESSPOPLS: (locate o site an) Depth belo grade: Number and configuration: Depth -top of liquid to inlet invert: Depth of solids Depth of scum' Dimensions of c Materials of cor Indication of gr( inflow ( be pumped as part of inspection) Comments: (note condition of soil, sigps of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate site plan) Materials of co truDimensions: Depth of solids: Comments:��O<ition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 8/15/95) 8 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate a1L.we1ls_within_100' _._ . _. HOr,!EST sT Two Z9 IL LeAA �pa•i co -rtanK 1 Fro"T walk,- Pc�L DEPTH OF GROUNDWATER I. Depth to groundwater: -T+) feet 11.1gpNV LCI FILE# 922 91 L ' 0rtue�le tael( A IDT( = t8' B }o TI A -Dt 26 s `" B PI q (revised 8/15/95) 9 TOWN OF NORTH ANDOVER 9�a5�g6 BOARD OF HEALTH CERTIFICATE OF COMPLIANCE This is to certify that the septic tank constructed O or repaired ( X) by I MIKE REILLY installer at 366 FOREST STREET has been installed in accordance with the provisions of TITLE 5 of the State Sanitary Code and with the North Andover Board of Health regulations. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY. Z -7 ) 07"m--� - Board .of Health Inspector BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 5 Town of North Andover NORTH' OFFICE OF o COMMUNITY DEVELOPMENT AND SERVICES 3? A 146 Main Street North Andover, Massachusetts 01845 �9 coq-TFO-^P t(/ TOWN OF NORTH ANDOVER 9�a5�g6 BOARD OF HEALTH CERTIFICATE OF COMPLIANCE This is to certify that the septic tank constructed O or repaired ( X) by I MIKE REILLY installer at 366 FOREST STREET has been installed in accordance with the provisions of TITLE 5 of the State Sanitary Code and with the North Andover Board of Health regulations. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY. Z -7 ) 07"m--� - Board .of Health Inspector BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 -N e6V - 3�7-7 - c;(o R -) APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT �� DATE: CURRENT INSTALLER'S LICENSE# LOCATION: 3 (OG(�p�4— A, . LICENSED INSTALLER: SIGNATURE: DdTELEPHONE# L4-) r7 CHECK ONE: REPAIR: NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. Administrative Use Only $75.00 Fee Attached? Yes No Foundation As -Built? Yes Approval . zj /j /moi, No Date: 9/Z/ j�j 4 �v Applicant_ NAME Site Location 1� Town of North Andover, Massachusetts Form No. 3 BOARD OF HEALTH _2AIaki ('_19 DISPOSAL WORKS CONSTRUCTION PERMIT AKNRESS 1 W Permission is hereby granted to Construct ( ) or Repair �n Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. Fee S CHAIRMAN, BOARD OF HEALTH D.W.C. No. R(o r Applicant_ NAME Site Location 1� Town of North Andover, Massachusetts Form No. 3 BOARD OF HEALTH _2AIaki ('_19 DISPOSAL WORKS CONSTRUCTION PERMIT AKNRESS 1 W Permission is hereby granted to Construct ( ) or Repair �n Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. Fee S CHAIRMAN, BOARD OF HEALTH D.W.C. No. R(o A LL «.- O N m G O Q � >v V � p 1 o H i Q f L a = E z n O� '0 C c L C n O E C O O O a. MDQ 2 C C U .s.+ � — F- C � � Q Q w O � O CO O U O O C, in m Z 1 TOWN OFN04TH ANDOVER SYSTEM KWING RECORD DATE O Y s 1 r,M U WNER & ADDRESS r- 3ko Fo_l-es'7- -Sr- SYSTEM LOCATION DATE OF PUMPIN///"p Qt1ANTITY PUMPED __a�20 CESSPOOL NO ST .SEPTIC TANK NO YES/ V NATURE OF SERVICE;;.RO[7TINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASEBAFFLES IN LACE ROOTST LEACHFIELD RUNBACK EXCESSIVE SOLIDS—.FLOODED SOLID CARRYOVER OTHER EXPLAIN SYSTEM PUMPED BY a Commonwealth of Massachusetts W City/Town of North Andover System Pumping Record Form 4 M 2012 u i TC,A,Nl of "ANCOV=R 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. t5form4.doc- 03/06 System Pumping Record - Page 1 of 1 A. Facility Information Important: When filling out forms on the computer, 1. System Location30c�) 1 use only the tab i key to move your Address cursor - do not use the return North Andover Ma 01845 key. City/Town State Zip Code 2. System Owner: I n return Name Address (if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping2. Datteo Quantity uany Pum ped' Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter ❑ Yes.�J No present? If yes, was it cleaned? ❑ Yes JZ/No 5. Condition of System: 6. m Pumped By: �]Qa e , Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Aewart's of au Date /0e / of Receiving Facility Date t5form4.doc- 03/06 System Pumping Record - Page 1 of 1 COMMONWEALTH OF MASSA CHUSET BOARD OF HEALTH SYSTEM PUMPING RECORD SYSTEM OWNER DATE OF PUMPING: � /7— QUANTITY 7— QUANTITY PUMPED: /9-60 gallons CESSPOOL: ❑ Yes J4'No SEPTIC TANK: )U, Yes ❑ No SYSTEM LOCATION � System Pumped by: ELECTRIC SEWER CLEANING CO.,INC. ��• License Number: �O Contents Transferred to: Wv6w Date: DEP Form 4 -System Pumping Record ocation of septage disposal facility