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.IProperty Record Card
Location: 371 PLEASANT STREET
Owner Name: JONES, ERNEST L
MCALOON, EILEEN
Owner Address: 371 PLEASANT STREET
City: NORTH ANDOVER State: MA Zip: 01845
Neighborhood: 5 - 5 Land Area: 0.90 acres
Use Code: 101-SNGL-FAM-RES Total Finished Area: 2651 sqft
ASSESSMENTS
;al Value:
ilding Value:
id Value:
rket Land Value:
apter Land Value:
CURRENT YEAR
471,100
275,300
195,800
PREVIOUS YEAR
489,600
293,800
195,800
http://csc-ma.us/PROPAPP/display.do?linkId=1705780&town=NandoverPubAcc 6/29/20 )
North Andover Health Department
Community Development Division
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES -
LOCATION INFORMATIQN-
ADDRESS:
INSTALLER:
DESIGNER:
PLAN DATE:
BOH APPROVAL DATE ON PLAN:
INSPECTIONS " ��/
TANK INSPECTION:
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION:
MAP: LOT:
SITE CONDITIONS
Comments:
dl �
❑ Contractor reports any changes to design plan
❑ Existing septic tank properly abandoned
❑ Internal plumbing all to one building sewer
❑ Topography not appreciably altered
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
l gallon tank has been installed
loading
�❑ Monolithic tank construction
-z5
Water tightness of tank has been achieved by
��ySSv testing
❑ Inlet tee installed, centered under access port
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Qt NORTH qy 1 5 5 6
• Town of North Andover
��,'•o;,;;::`,` HEALTH DEPARTMENT
,SSACH�Stt
CHECK #: Jd� TE: D �%
LOCATION: ���"''�l`i
H/0 NAME:
CONTRACTOR NAME:
Type
of Permit or License: (Check box)
❑
Animal
$
❑
Body Art Establishment
$
❑
Body Art Practitioner
$
❑
Dumpster
$
❑
Food Service - Type:
$
❑
Funeral Directors
$
❑
Massage Establishment
$
❑
Massage Practice
$
❑
Offal (Septic) Hauler
$
❑
Recreational Camp
$
❑
Sun tanning
$
❑
Swimming Pool
$
❑
Tobacco
$
❑
Trash/Solid Waste Hauler
$
❑
Well Construction
$
SEPTIC Sustems:
❑ Septic - Soil Testing $
❑ Septic - Design Approval $
Septic Disposal Works Construction (DWC) $�
❑ Septic Disposal Works Installers (DWI) $
❑ Title 5 Inspector $
❑ Title 5 Report $
❑ Other. (Indicate) $
A//.
ealth Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
Address
1-azvv� Z2..( -t 1 Gc,
City/Town
4. Designer Information
Name
Address
City/Town
M �
�a1�3s
State Zip Code
Gi"1 9 3c.6 7-j S 9%
Telephone Number (Cell Phone # if possible please)
Name of Company
State
Zip Code
Telephone Number (Best # to Reach)
Application for Disposal System Construction Permit • Page 1 of 2
¢ N°RTh Application for Septic Disposal System
3: •`'' ` °c
-Construction Permit -TOWN OF
TODAY'S DATE
'''�' • �' ORTH ANDOVERMA 01845
$ 250.00 — Full Repair
,
�ss�cHuss
$125.00 - Component
Important: Application is hereby made for a permit to:
When filling out ❑ Construct a new on-site sewage disposal system*
forms on the
computer, use ❑ Repair or replace an existing on-site sewage disposal system*
only the tab key
[Repair
to move your or replace an existing system component — What?
cursor - do not
use the return
key. A. Facility Information
3) 1 R
x/01_
1�1
Address or Lot #
City/Town
Q
,f 1
2.- *TYPE OF EPTIC SYSTEM*:
���%/S
❑ Pump El Gravity (choose one)
MOWN OF NORTH ANDOVE
***If pump system, attach copy of electrical permit to application
* HEAt.TH DEPARTMENT
❑ Conventional System (pipe and stone system)
❑ 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
4 _j 0'V
Name
Address (if different from above)
City/Town State
Zip -Code
Telephone Number
3. Installer Information
' S
� ► 5t .,.sem^ -..j � ko,.,s.c% 0°,4
Name Name of Company
Address
1-azvv� Z2..( -t 1 Gc,
City/Town
4. Designer Information
Name
Address
City/Town
M �
�a1�3s
State Zip Code
Gi"1 9 3c.6 7-j S 9%
Telephone Number (Cell Phone # if possible please)
Name of Company
State
Zip Code
Telephone Number (Best # to Reach)
Application for Disposal System Construction Permit • Page 1 of 2
1.
Lw
Application for Septic Disposal System
�r��•,..�� Construction Permit -TOWN OF TODAY'S DATE
ORTH ANDOVER, MA 01845 $ 250.00 - Full Repair
' °••�• ; ;" $125.00 -Component
,S -
PAGE 2OF2
A. Facility Information continued....
5. Type of Building: E] esidential 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 Aq#dyer, and not to place the system in operation until a Certificate of Compliance has
been issued by this Board of Health.
Name
Applic#t'on Aiproved By:
Name
forth
For Office Use Only:
1. Fee Attached.
Date
of Health Representative)
Date
reasons:
2. Project Manager Obligation Form Attached?
3. Pump S sy tem? If so, Attach cQRK of Electrical Permit
4. Foundadon As -Built? (new construction ronly):
(Same scale as approved plan)
5. Floor Plans? (new construction only):
Yes No
Yes n/ No
Yes No
Yes No
Yes No
Application for Disposal System Construction Permit • Page 2 of 2
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.
Q
h,/7
nnen /�
a
Commonwealth of Massachusetts KV3111,41001VIAL
Title 5 Official Inspection Form AN = I hill
Subsurface Sewage Disposal System Form - Not for Voluntary Assessme s
371 Pleasant St.
Property Address
Jones
Owner's Name
North Andover
City[Town
MA 01845
State Zip Code
TOWN OR NORTH ANDOVER
7/2/2011
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:
Chad Jablonski
Name of Inspector
Jablonski & Sons, Inc.
Company Name
167 Willow Ave.
Company Address
Haverhill
LU
City/Town State
978-360-9358 4574
Telephone Number
B. Certification
License Number
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. 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
❑ Needs Further E-qluation by the Local Approving Authority
-1/'31 1"a
Date
The sy Inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Heffllb 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 371 Pleasant St.
Property Address
Jones
Owner Owner's Name
information is
required for every North Andover MA 01845 7/2/2011
page. 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:
SAS and all components in good working order. Septic and distribution box were replaced 7/22/2011/
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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 371 Pleasant St.
Property Address
Jones
Owner Owner's Name
information is
required for every North Andover MA 01845 7/2/2011
page. City/Town 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 ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17
MAN
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
371 Pleasant St.
Property Address
Jones
Owner Owner's Name
information is
required for every North Andover MA 01845
page. City/Town State Zip Code
B. Certification (cont.)
7/2/2011
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:
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/i day flow
t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
371 Pleasant St.
Property Address
Jones
Owner Owner's Name
information is North Andover MA 01845 7/2/2011
required for every
page. Citylrown 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.
E]® 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.
t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 371 Pleasant St.
Property Address
Jones
Owner Owner's Name
information is
required for every North Andover MA 01845 7/2/2011
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): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 600 gpd
t5ins -11/10 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
M e'' 371 Pleasant St.
Property Address
Jones
Owner Owner's Name
information is
required for every North Andover MA 01845 7/2/2011
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents:
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 ears usage d Attached
9 ( Y 9 (9p ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Occupied
Date
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
❑ Yes ❑ No
❑ Yes ❑ No
t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° 371 Pleasant St.
M
Property Address
Jones
Owner Owner's Name
information is
required for every North Andover MA 01845
page. City/Town State Zip Code
D. System Information (cont.)
Last date of occupancy/use: Date
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:
Hasn't never been Pum
na
gallons
na
na
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
7/2/2011
Date of Inspection
❑ Yes ® No
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from 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 • 11/10 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 371 Pleasant St.
Property Address
Jones
Owner Owner's Name
information is
required for every North Andover MA 01845 7/2/2011
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:
Plan dated 12/10/1980
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer (locate on site plan):
Depth below grade: 40" below top foundation
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.):
Watertiqht at foundation
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
® concrete ❑ metal
15"
feet
❑ fiberglass ❑ polyethylene ❑ other (explain)
If tank is metal, list age: na
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 10.5'x 5.5'x 5.5'
Sludge depth: na
t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 371 Pleasant St.
Property Address
Jones
Owner Owner's Name
information is
required for every North Andover MA 01845 7/2/2011
page. City/Town 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 na
Scum thickness na
Distance from top of scum to top of outlet tee or baffle na
Distance from bottom of scum to bottom of outlet tee or baffle na
How were dimensions determined? na
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank was replaced with a 1500 gallon tank
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain):
t5ins • 11/10
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
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 Form - Not for Voluntary Assessments
371 Pleasant St.
Property Address
Jones
Owner Owner's Name
information is North Andover
required for every
page. Citylrown
State
01845
Zip Code
7/2/2011
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
Desi n Flow
g 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
t5ins - 11/10 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
371 Pleasant St.
Property Address
Jones
Owner Owner's Name
information is North Andover
required for every
page. Citylrown
D. System Information (cont.)
MA 01845
State Zip Code
7/2/2011
Date of Inspection
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert na
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.):
Box was replaced with H2O distribution box
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.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 371 Pleasant St.
Property Address
Jones
Owner Owner's Name
information is North Andover
required for every
page. Cityrrown
D. System Information (cont.)
Type:
MA 01845 7/2/2011
State Zip Code Date of Inspection
❑
leaching pits
number:
❑
leaching chambers
number:
❑
leaching galleries
number:
❑
leaching trenches
number, length:
®
leaching fields
1-32'x30'
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.):
No sign
of hydraulic failure or ponding
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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17
1�wrmjjil
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
371 Pleasant St.
Property Address
Jones
Owner Owner's Name
information is
required for every North Andover MA 01845 7/2/2011
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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
371 Pleasant St.
Property Address
Jones
Owner Owner's Name
information is
required for every North Andover MA 01845 7/2/2011
page. 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
t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
371 Pleasant St.
Property Address
Jones
Owner Owner's Name
information is North Andover
required for every
page. Citylrown
D. System Information (cont.)
Site Exam:
®
Check Slope
®
Surface water
®
Check cellar
®
Shallow wells
h d t
MA 01845
State Zip Code
7/2/2011
Date of Inspection
4' below stone
OW a up o g groun wa er. feet
Please indicate all methods used to determine the high ground water elevation:
E t; t d d fl,t h'i
15
01
Obtained from system design plans on record
If h k d d t f desi n Ian reviewed•
12/10/1980
c ec e, a e o g p 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:
Soils test performe 6/6/1980 by Scott Gives and witnessed by Tom Murphy
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17
LLIfula-mil,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
371 Pleasant St.
Property Address
Jones
Owner Owner's Name
information is
required for every North Andover MA 01845
page. City/Town State Zip Code
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
7/2/2011
Date of Inspection
® 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17
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• Town of North Andover
`�'•�;, o �. �' HEALTH DEPARTMENT
,SSACHUsf't
CHECK #: ATE: IdiP/%
LOCATION:
H/ O NAME:
CONTRACT(
01
Type
of Permit or License: (Check box)
❑
Animal
$
❑
Body Art Establishment
$
❑
Body Art Practitioner
$
❑
Dumpster
$
❑
Food Service - Type:
$
❑
Funeral Directors
$
❑
Massage Establishment
$
❑
Massage Practice
$
❑
Offal (Septic) Hauler
$
❑
Recreational Camp
$
❑
Sun tanning
$
❑
Swimming Pool
$
❑
Tobacco
$
❑
Trash/Solid Waste Hauler
$
❑
Well Construction
$
SEPTIC Systems:
❑
Septic - Soil Testing
$
❑
Septic - Design Approval
$
❑
Septic Disposal Works Construction (DWC)
$
❑
Septic Disposal Works Installers (DWI)
$
❑ Title Inspector
g Title 5 Report /
$�
G/
$�
❑ Other. (Indicate) $
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
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.
W5
I.
Commonwealth of Massachusetts
Title 5 Official Inspection Flo
Subsurface Sewage Disposal System Form - Not for Voluntary
371 Pleasant St.
Property Address
Jones
Owner's Name
North Andover
City/Town
MA _ 01845
State Zip Code
V
7sessments
JUL
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT 'I YY
7/2/2011
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
Inspector:
Chad Jablonski
Name of Inspector
Jablonski & Sons, Inc.
Company Name
167 Willow Ave.
Company Address
Haverhill
City/Town
978-360-9358
telephone Number
t3. certification
MA
State
4574
License Number
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. 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
❑ Needs Further Evaluation by the Local Approving Authority
716 /Z-//
Date
The syst mi pector shall submit a copy of this inspection report to the Approving Authority (Board
of Healt 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 • 11/10 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
371 Pleasant St. _
Property Address
Jones
Owner's Name
North Andover MA 01845 7/2/2011
Citylrown 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:
❑ 1 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):
Liquid level was 2' below outlet invert.
t5ins • 11/10 Tide 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17
• Commonwealth of Massachusetts
Title 5 official Inspection Form
' sl Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
371 Pleasant St.
Property Address
Jones
Owner Owner's Name
information is
required for every North Andover MA 01845 7/2/2011
page. City/Town 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 ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
® distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below):
Box is cracked and needs to be reolaced
❑ 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17
Owner
information is
required for every
page.
t5ins • 11/10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
371 Pleasant St.
Property Address
Jones
uwnerrs Name
North Andover _MA 01845 7/2/2011
CitylTown 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
® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/z day flow
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17
Commonwealth of Massachusetts
Title 5
Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
371 Pleasant St.
Property Address
Jones
Owner Owner's Name
information is
required for every North Andover
MA 01845 7/2/2011
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 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 • 11/10 Title 5 official Inspection Form: 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
371 Pleasant St.
Property Address
Jones
Owner Owner's Name
information is
required for every North Andover MA 01845 7/2/2011
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.-
n:Existing
Existinginformation. 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 bedroomsn desi : 4 --- - 3
( g) Number of bedrooms {actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 600 gpd
t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17
Commonwealth of Massachusetts
r Title 5 official Inspection Form
jR Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
371 Pleasant St.
Property Address
Jones
Owner Owner's Name
information is
required for every North Andover
page. City/Town
D. System Information
Description:
MA 01845
State Zip Code
7/2/2011
Date of Inspection
Number of current residents: 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 igpd))� Attached
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Occupied
Date
Commercial/Industrial Flow Conditions:
Type of Establishment: ----- - ____
Design flow (based on 310 CMR 15.203):
Gallons per day (9Pd)
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 the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins • 11/10 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
°M _F 371 Pleasant St.
Property Address
Jones
Owner Owner's Name
information is
required for every North Andover
page. City/Town
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
MA 01845 7/2/2011
State Zip Code Date of Inspection
Date
General Information
Pumping Records:
Source of information: Hasn't never been pumped
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: na
gallons
How was quantity pumped determined? na _
Reason for pumping: na
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):
t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
s
371 Pleasant St.
Property Address
Jones
Owner Owner's Name
information is
required for every North Andover MA 01845 7/2/2011
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:
Plan dated 12/10/1980
Were sewage odors detected when arriving at the site?
❑ Yes ® No
Building Sewer (locate on site plan):
Depth below grade:
40" below top
foundation
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.):
Watertight at foundation
Septic Tank (locate on site plan):
Depth below grade:
15"
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene
El other (explain)
If tank is metal, list age:
na
years
Is age confirmed by a Certificate of Compliance? (attach a copy
of certificate)
❑ Yes ❑ No
Dimensions:
11' x 5'x 6'
Sludge depth:
no way to determine
t5ins • 11/10 Tale 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
�M 371 Pleasant St.
r-tuptirty muctress
Jones
Owner Owner's Name
information is
required for every North Andover
page. City/Town
t5ins • 11/10
D. System Information (cont.)
MA_ 01845
State Zip Code
7/2/2011
Date of Inspection
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle no way to determine
Scum thickness no way to determine
Distance from top of scum to top of outlet tee or baffle no way to determine
Distance from bottom of scum to bottom of outlet tee or baffle no way to determine
How were dimensions determined? no way to determine
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank needs to be replaced _
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:
feet
❑ polyethylene ❑ other (explain):
nate
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
�• 371 Pleasant St.
Property Address
Jones
Owner Owner's Name —
information is North Andover
required for every MA 01845 7/2/2011
page. Citylfown State Zip Code Date of Inspection
u. 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
El other (explain):
Dimensions:
Capacity:
gallons
Design Flow: _.._
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level. -- — Alarm in working order:
Date of last pumping:
Date
Comments (condition of alarm and float switches, etc.):
❑ Yes ❑ No
Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins • 11/10
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 371 Pleasant St.
rroperty Aaaress
Jones
Owner Owner's Name
information is
required for every North Andover MA _ 01845 7/2/2011
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 na
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.):
Box is cracked and needs to be
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.):
Soil Absorption System (SAS) (locate on site plan, excavation not required).-
If
equired):If SAS not located, explain why:
t5ms - 11/10 Tale 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�1i -
�= Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
'�.. 371 Pleasant St.
Property Address
Jones
Owner Owner's Name
information is
required for every North Andover MA _ 01845 7/2/2011
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits
number:
❑ leaching chambers
number:
❑ leaching galleries
number:
❑ leaching trenches
number, length:
® leaching fields
number, dimensions: 1- 32'x 30'
❑ 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.):
No sign of hydraulic failure or ponding
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 • 11110 Tale 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17
Commonwealth of Massachusetts
_ Tale 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
371 Pleasant St.
r-ruperty muoress
Jones
Owner Owner's Name
information is y _North Andover
required for ever MA 01845 7/2/2011
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 - 11/10
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 17
Owner
information is
required for every
page.
t5mS - 11/10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
371 Pleasant St.
Property Address
Jones
owner's Name
North Andover MA 01845 7/2/2011
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
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
-' 371 Pleasant St.
Property Address
Jones
Owner Owner's Name
information is
equired for every North Andover MA 01845
page. City/Town State Zip Code
u. System Information (cont.)
Site Exam:
®
Check Slope
®
Surface water
®
Check cellar
®
Shallow wells
7/2/2011
Date of Inspection
Estimated depth to high ground water: 4' below stone
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: 12/10/1980
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:
Soils test performe 6/6/1980 by Scott Gives and witnessed by Tom Murphy
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins • 11110
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
371 Pleasant St.
rroperly Haaress
Jones
Owner Owner's Name
information is
required for every North Andover MA
page. City/Town State
E. Report Completeness Checklist
01845 7/2/2011
Zip Code Date of Inspection
® 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 - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17
Summary Record Card generated on 7/1/2011 92436 AM by Lisa Evans Page 1
Town of North Andover
Tax Map # 210-095.0-0010-0000.0
Parcel Id 14101
371 PLEASANT STREET
JONES,ERNEST
371 PLEASANT STREET
N. ANDOVER, MA
01845
Class 101 Single Family Property Type 1 Residential
Size Total 0.9 Acres
FY 2011
UB Mailina Index
Name/Address Type Loan Number Active/Inact. From Until
JONES, ERNEST Payor
371 PLEASANT STREET
N. ANDOVER, MA
01845
UB Account Maint.
Account No
Cycle
Occupant Name
Active/Inactive
Bldg Id. 16216.0 - 371 PLEASANT
STREET
Last Billing Date 4/6/2011
3150304
03 Cycle 03
Active
UB Services Maint.
Account No. 3150304
Service Code
Rate
Charge
Multiplier/Users
MISCFEE ADMIN FEE
0.635/8
7.82
1/
WTR WATER
01 ALL METER SIZE 19.00
/1
UB Meter Maintenance
Account No. 3150304
Serial No Status
Location
Brand
Type Size
YTD Cons
16336602 a Active
ERT HH
METE METE
w Water 0.63 0.63
126
Date
Reading
Code
Consumption
Posted Date
Variance
6/1/2011
719
a Actual
g
74%
3/1/2011
710
a Actual
5
4/13/2011
-53%
12/2/2010
705
a Actual
11
1/12/2011
10%
9/1/2010
694
a Actual
10
10/15/2010
-30%
6/1/2010
684
a Actual
14
7/15/2010
57%
3/3/2010
670
a Actual
9
4/14/2010
-10%
12/2/2009
661
a Actual
10
1/12/2010
-8%
9/2/2009
651
a Actual
11
10/15/2009
8%
6/2/2009
640
a Actual
10
7/20/2009
2%
3/4/2009
630
a Actual
10
4/29/2009
-11%
12/2/2008
620
a Actual
11
1/20/2009
-19%
9/3/2008
609
a Actual
14
10/10/2008
23%
6/2/2008
595
a Actual
11
7/16/2008
24%
3/4/2008
584
a Actual
9
4/11/2008
-13%
12/4/2007
575
a Actual
10
1/22/2008
-6%
9/7/2007
565
a Actual
11
10/12/2007
-6%
6/8/2007
554
a Actual
12
7/20/2007
13%
3/7/2007
542
a Actual
11
4/16/2007
-10%
12/1/2006
531
a Actual
11
1/19/2007
5%
9/6/2006
520
a Actual
11
10/20/2006
-44%
6/8/2006
509
a Actual
21
7/10/2006
84%
3/3/2006
488
a Actual
10
4/17/2006
-32%
12/8/2005
478
a Actual
16
1/17/2006
-25%
9/6/2005
462
a Actual
22
10/14/2005
-7%
6/2/2005
440
a Actual
21
7/15/2005
-9%
3/9/2005
419
a Actual
26
4/5/2005
-22%
i
TOWN OF NORTH ANDOVER
PERMITTED SEPTIC
INSTALLERS - RENEWED
FOR 2010
Contact SORTED BY TOWN
BOSTON, MA 02110
Doing Business As
Mailing Phone
Cit
1
John T. Shaw III
(978) 474-8088
ANDOVER, MA 01810
2
Joseph Watson
(978) 475-8581
ANDOVER, MA 01810
3
Michael W. Reilly
(978) 375-48.1.1
ANDOVER, MA 01810
4
Todd Bateson
(978) 815-2703
ANDOVER, MA 01810
5
Philip A. Busby, Jr.
(603) 362-6015
ATKINSON, NH 03811
6
Robert L. Innis
(978) 663-6006
BILLERICA, MA 01821
i
1L.,dviu n. unarea
(9 /8) 265-7641
BOSTON, MA 02110
8
Charles Zaher
(978) 804-7786
CHELMSFORD, MA 01824
9
James Hartigan
(978) 766-0087
DANVERS, MA 01923
10
David V. Zaloga, Jr.
(603) 765-9296
EXETER, NH 03833
11
Daniel R. Briscoe
(978) 372-2200
GROVELAND, MA 01834
12
Timothy Quinlan
(978) 457-0528
HAVERHILL, MA 01830
13
Bruce Hoehn
(978) 697-3490
HAVERHILL, MA 01832
14
John L. DiVincenzo
(978) 372-7471
HAVERHILL, MA 01835
15
John B. Hayes
(207) 439-1989
Kittery, ME 03904
16
Serge R. Beaulieu
(603) 893-9189
LONDONDERRY, NH 03053
17
James Kellett
(781) 953-7146
LYNNFIELD, MA 01940
18
Arthur F. Hutton
(978) 685-2667
METHUEN, MA 01844
19
Bill Hall
(978) 689-3711
METHUEN, MA 01844
20
Stephen lacozzi
(978) 479-4407
METHUEN, MA 01844
21
James H. Currier
(978) 774-6685
MIDDLETON, MA 01949
22
Daniel A. Giard
(978) 686-7653
NORTH ANDOVER, MA 01845
23
Peter Breen
(978) 265-7580
NORTH ANDOVER, MA 01845
24
William (Tom) Sawyer
(978) 360-7832
NORTH ANDOVER, MA
25
Angelo Petrosino
(978) 664-2030
NORTH READING, MA 01864
26
Craig Waelty
(978) 664-2126
NORTH READING, MA 01864
27
Warren Pearce, Jr.
(978) 664-5264
NORTH READING, MA 01864
28
Kevin Coyle
(603) 944-8501
PLAISTOW, NH 03865
29
Charles Beshara
(603) 893-2229
SALEM, NH 03079
30 John
J. Soucy
(603) 216-7175 SALEM,
NH 03079
31 Joseph
Surianello
(978) 458-9117 TEWKSBURY,
MA 01876
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Ba. -..rd of Health
Flor-th Andover, %s s
1
APPROVED DAT$
Provided:
SJBSIMPACE DUPOSAL DEUGN CHECK LIST
.r�.r.� LOT A2j_L U:.,iC`✓li
() p�
DISAPPROVED DATE
Reasons:
Title o �An 410
Reg 2.5 submitted plan mwt shoir as a nizimumi
he lot to be served-area.Umens'ions lot ,#,abutters
ocation and log deep observation hoes -distance to ties
ocation and results percolation tests -distance to ties
esign calculations & calculations showing required leaching area
location and dimensions of system -including reserve area
existing and proposed contours
g) location any tit areas Athin 2001 of sewage disposal system or
disclaimer -check wetlands mapping
uvwface and subsurface drains witidn 1001 of sewage disposal
aystcm or disclaimer
(I location any drainage easements t1thin 1001 of singe dizgijsal
GyGtcqa or disclaimer -Planning Board files
_ (j),-kf,,tn rources of rater supply within 2001 of
uvstcn. or disclaimer
7'vcgtion of €.n7, proposed tell to serve lot -1001 from l.cacbing f.•aci i _qty
.. �_ (1 loc.aUon of inter lines on property -10 from leaci xg facility
? oration of b:�rie k
firlvel-ays
garbage di.spos-k.ls
no PVC to be used in construction
q) profile of system -elevations of basement, plumb, pipe, so, tic t.nr k,
distribution box inlets and outlets, distribution field piping and
Mer elevations
r) mute ground water elevation in area sewage disposal system
s plan mst be prepared by a Professional. Engineer or other
professional authorized by l.avr to prepare such plans
Reg 6 S - tic- tic Tanks
�9_
c t es- 50% of flow, water table, tees, depth of tees,. s, pupping
out
101 from cellar wall or inground swi=dng pool
d) 251 fyrov.. subsurface drains
Reg 10.2
Reg 10.4
tion Boxes
0.08
I
0
tisurface g3:iM Check List Page 2
' I FAIL I OR
Reg 11.2
11.4
11.10
11.n
Reg 15.1
15.4
15.8
3.7
Reg 14.1
14.3
14.4
14.6
14.7
1!0.10
Reg 9.1
9.6
Leaching -Pits
Leaching pits a preferred where the installation is possible
a) calculation ' leaching area -m nineem 500 sq ft
b) spacing
c)surface a 21
d) cover terial
'e) 2 ' x2 t n splash pad
f) tee Xt elbow
g) no bends in pipe from d -box to pipe
X" Leaching Fields
a) no greater than 20 mutes/inch
by area -rd nimin 900 sq ft
c c struction of field
€ arface drainage 2 %
e) 201 from cellar vmn or inground evinmIng pool
Leachin Trenches
a) cllo
of leaching area -gain 500 sq ft
b) spacing-4/ft min 6 ft with reserve between
c) dimensions
d) cows action
0) s
f) =r ace drainage 2%
W s ®p e x = _to be shoim)
b) y/x X 150 = (to be shoe)
EUMS
a) approval
b) stand-by power
Board'of Health BEMC SYSTEK
North An42ver _xMaas. INSTALLATION CH3CK LIST LOT
M
40
5.
Distribution Box
1.
Distance Tot
Wetlands
b. All Lines Flowing Equal Amounts
a,.
6*.
teach Field or Trench
b. Drains
b. Stone Depth
c. Well
d: Clem DoubleWashedStone'
2.
Water Line Location
a*ions
b* =rDepth
c lash Pads
3-
No PVC Pipe
0 C Cement Pipe to Pit Both Sides
Cement
Septic Tank
8.
a. --Tess r. -Length & To Clean 'Dat Covers
9.
_71nal, Grading Inspection
3.0.
b. Cement Pi -pe to Tank .- on Both Sides of Tank
40
5.
Distribution Box
a. Covers & Box - No Cracks
b. All Lines Flowing Equal Amounts
c. No Back Flow
6*.
teach Field or Trench
a. Dimensions
b. Stone Depth
a, Capped Ends
d: Clem DoubleWashedStone'
7.
Leach Piti/
a*ions
b* =rDepth
c lash Pads
d. Tees
0 C Cement Pipe to Pit Both Sides
Cement
f. Clean Double Washed Stone
8.
No Garbage Disposal
9.
_71nal, Grading Inspection
3.0.
Barricading Covered System
3.1.
As Built Subndtted-
a. Lot Location
b. Dimensions of System
c. Location vith Regard -to Perc Test
d. :Elevations
e.' 'Water Table
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