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Home My WebLink AboutMiscellaneous - 371 STEVENS STREET 4/30/2018PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 5/2/16 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Repair of D -Box By: Todd Bateson At: 371 Stevens Street Map 096.0 Lot 0066 North Andover, MA 01845 of tkis cer iAcate shalynot be construed as a guarantee that the system will function satisfactorily. Micliele GranT-'--,J Public Health Agent 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com •,�°F'. , Commonwealth of Massachusetts Map -Block -Lot 096.00066 BOARD OF HEALTH Permit No North Andover BHP -2016-0103 ______________________ FEE $175.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd Bateson to (Repair) an Individual Sewage Disposal System. at No 371 STEVENS STREET as .shown on the application for Disposal Works Construction Permit No. 1311P-20167010 Dated May -02-,-20-16 Issued On: May -02-2016 ------------------------- BOARD OF HEALTH y Application for Septic .,Disposal SVstem Construction Perrnit ' TOWN OF 1 NORTH ANDOVER, MA 01845 Important:. When filling out forms on the computer, use onlythe.tab key to mole your cursor -do not use the return key. OQ TODAY'S DATE $ 250:00.— Full Repair 1,4,5A4 -component Aaalication is hereby made for a Permit to: APH ❑ Construct a new on-site sewage disposal system' 272016 ❑ Repair or replace an existing. on-site sewage disposalsystem' TOWN 0': "�ORTyANdO (WRepair or replace an existing system component — What? St�'�, 7�FpARTM�� A. Facility Information Address or Lot # Cityrrown �q3o� 2: *TYPE OF SEPTIC SYSTEM*: ➢ ❑ Pump Bzravity (choose one) " if pump system, attach copy of electrical permit to application"' ➢ &.1ftnventional 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) ➢ ❑ Pressure Dosed (D -Box Present) S.A.S. ➢ ❑ Does the system require an effluent filter? Yes No If yes, does plan specify make and model of filter? YES = (no further info. needed) WO = (installer must specify brand of filter before DWC issuance) What is the Make? What is the ModW 2. Owner Information —�aHbb A., a-5 Name - Addres (if different from above) s AL,, Cityrrown 3. Installer Information IYI.f _ oi F4,5-- State Zip Code %W `7 Telephone Number Name p Name of Comp ' 111 ARG ILLA ROAD ANDOVER MA 01810 i Address L Cityrrown 4. Designer -Information Name Address Citylfown State Zip Code 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 TODAY'S DATE $:250.0 T Full Repair $125.001- component PAGE 2 OF 2 A. Facility; nformation continued.... S. Type- of Building: oResIdential. 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 T111e 5.of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place the system 1n operation until a Certificate of Compilance has been lssuedPg this Board of Heath. Name Date Appiic ppr ed: ( and o ealth Representative) 2 b Name Date Appttionsapproved, for the following reasons: For Office Use Only: 1 ' Fee Attached? Yes J , / No 2.. Projec ariager Obligation Forns Attached. Yes 1/ No A: BM12 vstem Ifso) Attach cQpy ofElectrrcal Pumrt`.. Yes No 4. Foundatro"s B. - (hew construction-ronly): Yes NO (Same scale as aroYed plan) A FloorMws? (hew consn• only); Yes_ No Appifcatlon fior- 00.9al 4ysterii:t;6nstrgctl0h Permit � Page 2 of 2 SEPTIC'S"Ygrm.DiVALUM-mika mmL .. MT-0i3LIGATTIONS As fi�*NqtfhAadomSmsedaiaa�fg f c septi eyatabso�t.the�toprxtyat: U. "j. 5 i4%usvcu ettepdc lyu1 .. �_.,.. --pry $m bS Re3stivd m theapp&xd� oaf' �-�- ��, i�•> Rduawf acme Abd dated Dated _ I n"Flia toad the foilovoLv Oligatdosns fat t gcmeat ofou pngect: I. As the iusmuetY I am .obligated iv cbtd& mff pe=ns acctBoatd of f3eaith approved plana pft to MpcdonWag any:wo* ca R e Y. Ast fbe istiltet;.I.tit say and afl'a�: I£2 :� with stay compimy Ptqrztma=grt, >at any othtrpa4cao�`=t e� as iosgae oa and t#zc aystua is =tnady, tkeo 4 Item6smsbilbe st l tble. 4 hm 111'#4 Wi•193 ad icil r aqt i ecdos� bat nothave tcb4pa! ai�t . b. - twat slat tip f+at �th% ar- bm o wiebriL OI�'(a� ell to � Inc must • •ba ttiittrxi•� xhc-Boti�d ofHeahiy ate: .` for•ia � ate, 'Iiasmlte= itmiist p>at fair tb�.hupedleim �itba : � �'aPQtk#�af be rely fable oa c. B�-fsst>ithc ti>>Qat inapeetiaa ath �t11 #s enr�?Pltte: Installer daes< not 4. Aa'tbe kodla Ieumd that aiiy l`Zt' Puflc"�i'tbaarnsn findl . • to eo>tsypieae tlia�nsl�Bstti�tt of thm s}ndd}_id� tlitsedippls`o� ttoa • ltni 'S.. �.b th`ainaoi}ie>S•i a�des�ts+aii . I . •oaf �•pce•of � " � . a Deet tnrst.sYtC}s per tkvad�a aft&e eieanv ontarr l�sv haep sseQcbedt b. Iaspetefa� arfthei►tad �eadsgg ebb Ae oseaL . �•Piaslfaapeo�osrbyBoatriat�STe�iltbtsAsB`'atao�ulfd� • . . d IatuffeidbA arms&, D-. ong ,ems, ��, pip her, ►aaGf other . d. Undmi pM bmud SqWc•bg.4&= 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. ILEI Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 371 Stevens Street Property Address Estate Of Donald Downes Owner's Name North Andover MA 01845 5/2/2016 Cityfrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information RECEIVED Inspector: MAY 17 2016 Neil J. Bateson TOWN OF NORTH ANDOVER Name of Inspector Bateson Enterorises Inc. Company Name 111 Argilla Road Company Address Andover City/Town 978-475-4786 Telephone Number B. Certification MA 01810 State Zip Code S115 License Number 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 ❑ -Neek Fu Signature ❑ Conditionally Passes ❑ Fails the Local Approving Authority 5/2/2016 Date The system inspector shall submit a copy of this inspection report to the Approving Authority. (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 371 Stevens Street Property Address Estate Of Donald Downes Owner's Name North Andover Cityrrown B. Certification (cont.) MA 01845 State Zip Code 5/2/2016 Date of Inspection 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: After permit from B.O.H., install new d -box with riser, inspection from B.O.H., septic system now passes Title 5 Inspection. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 F\ Commonwealth of Massachusetts Title 5 Official Inspection Form R4*%, t Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 41'y 371 Stevens Street TOwNOF 7Z��6 Property Address Ty �p gNOO � R Estate Of Donald Downes �RrMFN Owner Owner's Name information is required for North Andover MA 01845 4/15/2016 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer, use 1. Inspector: only the tab key to move your Neil J. Bateson cursor - do not Name of Inspector use the return key. Bateson Enterprises Inc. Company Name ffi 111 Argilla Road Company Address Andover MA 01810 Citylrown State Zip Code 978-475-4786 S115 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 151.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 4/15/201E Insp ct s ignature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 3113 Title 5 Official Inspection Forth: 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 Stevens Street Property Address Estate Of Donald Downes Owner's Name North Andover Citylrown B. Certification (cont.) MA 01845 4/15/2016 State Zip Code Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfIltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. Y ® N ❑ ND (Explain below): t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 371 Stevens Street Property Address Estate Of Donald Downes Owner's Name North Andover MA 01845 4/15/2016 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ® N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins • 3113 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 371 Stevens Street Property Address Estate Of Donald Downes Owner's Name North Andover MA 01845 4/15/2016 City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D -Box replacement with riser on top. 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 '/ day flow t5ins • 3/13 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 Stevens Street Property Address Estate Of Donald Downes Owner Owner's Name information is North Andover required for every page. Cityrrown MA 01845 4/15/2016 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 R - Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 371 Stevens Street Property Address Estate Of Donald Downes Owner's Name North Andover MA 01845 4/15/2016 Cityrrown C. Checklist State Zip Code Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ 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): N/A Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 9 tiro t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments "< 371 Stevens Street Property Address Estate Of Donald Downes Owner information is required for every page. Owner's Name North Andover MA 01845 4/15/2016 Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) Laundry system inspected? Seasonaluse? Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: E Yes ❑ No ❑ Yes ® No ❑ Yes ❑ No ❑ Yes ® No Yes ❑ Yes E No Two weeks ago Date Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Farm: 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 371 Stevens Street Property Address Estate Of Donald Downes Owner Owner's Name information is required for North Andover MA 01845 4/15/2016 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Date Pumped 2014, owner gallons ❑ Yes ® No 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Owner information is required for every page. t5ins • 3/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I 371 Stevens Street Property Address Estate Of Donald Owner's Name North Andover Cityrrown State 01845 4/15/2016 Zip Code Date of Inspection D. System Information (cont.) i Approximate ague of all components, date installed (if known) and source of information: 43 vears old. 12/1/1973. as built Dian Were sewage Building Sewi Depth below gl Material of con ® cast iron Distance from Comments (on 4" Ca ors detected when arriving at the site? (locate on site plan): Iron 3 feet ® 40 PVC ❑ other (explain): water supply well or suction line: feet ;ion of joints, venting, evidence of leakage, etc.): through wall. 3" PVC in house. no leaks visible Yes ® No j I Septic Tank (locate on site plan): Depth below grade: feet Material of construction: Z concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) I If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 6'x 4' Sludge depth: 2" ❑ Yes ❑ No Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 0,j 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 Stevens Street Property Address Estate Of Donald Downes Owner's Name North Andover MA 01845 4/15/2016 Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge, to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 31" 2" 8" 13" How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet baffle ok. Outlet tee oak. Depth of liquid at outlet invert. No evidence of leakage. Center cover has riser 4" deep. Grease Trap (locate on site Depth below grade: Material of construction: ❑ concrete ❑ met Dimensions: Scum thickness plan): ❑ fiberglass Distance from top of scum t top of outlet tee or baffle Distance from bottom of scu to bottom of outlet tee or baffle Date of last pumping: feet ❑ polyethylene [❑ other (explain): Date t5ins • 3113 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts IBM Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r< 371 Stevens Street Property Address Estate Of Donald Downes Owner Owners Name information is North Andover MA 01845 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 4/15/2016 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: Design Flow: Alarm present: Alarm level: gallons gallons per day ❑ Yes ❑ No 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Owner information is required for every page. Commonwealth of Massachusetts `title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1371 Stevens Street Property Address Estate Of Donald Downes Owner's Name North Andover Cityrrown D. System Information (cont.) MA 01845 state Zip Code Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 4/15/2016 Date of Inspection Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D -box cover broken, replaced it. Evidence of carryover. Evidence of leakage. D -box needs to be replaced, has corrosion holes. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form RoWk Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 371 Stevens Street Property Address Estate Of Donald Downes Owner information is required for every page. t5ins • 3/13 Owner's Name North Andover Citylrown D. System Information (cont.) Type: MA 01845 4/15/2016 State Zip Code Date of Inspection El leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields 1 field 15'x 50' 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.): Soil ok. Vegetation ok. No sign of ponding to surface. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 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 Stevens Street Property Address Estate Of Donald Downes Owner's Name North Andover MA 01845 4/15/2016 Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins - 3/13 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 14 of 17 Owner information is required for every page. t5ins • 3/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 371 Stevens Street Property Address Estate Of Donald Downes Owner's Name North Andover MA 01845 4/15/2016 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 El drawing attached separately Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Owner information is required for every page. Commonwealth of Massachusetts 'title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 371 Stevens Street Property Address Estate Of Donald Downes Owner's Name North Andover MA 01845 4/15/2016 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar Shallow wells Estimated depth to high ground water: 4 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: 7/15/1973 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: Design plan ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: As per test pit data on design plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 3113 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System • Page 16 of 11 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 Stevens Street Property Address Estate Of Donald Downes Owner's Name North Andover MA 01845 4/15/2016 Cityrrown State E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked Zip Code 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 ra t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 ' Surhmary Record Card generated on 4/5/2016 2:47:23 PM by Karen Hanlon Town of North Andover Tax Map # 210-096.0-0066-0000.0 Parcel Id 14153. 371 STEVENS STREET DOWNES, DONALD 371 STEVENS STREET N. ANDOVER, MA 01845 Page 1 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 0.69 Acres FY 2016 UB Mailinn Index Name/Address Type Loan Number Active/Inact. From Until DOVES; DONALD Payor 371 STEVENS STREET N. ANDOVER; MA 01845 UB Account':Maint. Account No.. Cycle Occupant Name Active/Inactive Bldg Id. 15963.0 - 371 STEVENS STREET Last Billing Date 1/6/2016 3160014 03 Cycle 03 Active UB Services:Maint._ Account No. 3160014 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 11.40 /1 US Meter Maintenance Account No. 3160014 Serial No Status Location Brand Type Size YTD Cons 32945197 a Active 00 b Badger w Water 0.63 0.63 202 Date Reading Code Consumption Posted Date Variance, 3/1/2016 261 aActual 4 38% 12/3/2015 257 aActual 3 1/20/2016 -41% 9/2/2015 254 a Actual 5 10/16/2015 25% 6/3/2015 249 a Actual 4 7/24/2015 30% 3/4/2015 245 a Actual 3 4/28/201.5 5% 12/5/20.1.4 242 aActual 3 1/15/2015 -50% 9/4/2014 239 a Actual 6 10/15/2014 48% 6/4/2014 233 a Actual 4 7/16/2014 33% 3/5/2014 229 a Actual 3 4/11/2014 -1% 12/4/2013 226 aActual 3 1/17/2014 -50% 9/5/2013 223 a Actual 6 10/15/2013 -30% 6/7/2013. 217 a Actual 9 7/24/2013 8% 3/5/2013 208 a Actual 8 4/22/2013 0% 12/5/2012 200 aActual 8 1/9/2013 -9% 9/6/2012 192 a Actual 9 10/15/2012 12% 6/6/2012 183 a Actual 8 7/16/2012 -29% 3/6/2012 175 a Actual 11 4/14/2012 85% 12/7/2011 164 aActual 6 1/17/2012 -20% 9/7/2011 158 a Actual 8 10/13/2011 6% 6/2/2011 150 a Actual 7 7/20/2011 -3% 3/4/2011 143 a Actual 7 4/13/2011 10% 12/7/2010 136 a Actual 7 1/12/2011 -52% 9/2/2010 129 a Actual 14 10/15/2010 98% 6/2/2010 115 a Actual 7 7/15/2010 -1% 3/3/2010 108 a Actual 7 4/14/2010 2% 12/3/2009 101 aActual 7 1/12/2010 17% 9/2/2009 94 a Actual 6 10/15/2009 -18% 6/2/2009 88 a Actual 7 7/20/2009 6% 3/6/2009 81 a Actual 7 4/29/2009 14% 2 �4F SCAM .040 v P I!�nrv+✓� k, MASS, y /7 ^F, C#OI/'z*S r000 TRMK a in JA/ ,Jar i 2 p 2 �• IJ wa G 41 16 M y"/ VF- Al T S-6 , S�cTro�v s.) 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Sr'Pr� If To ! �� itir /o "VP/N / -Z , M IAA i 0 PSolr c Y `� f✓��{ Fay g � 'E'A Ei+PF4%6��va�� /�,��' "e -,r S Ti.t00:Ir- C-.eAfklee - SN . 2 or ?- 1 � �-1 4 K1 � & N t L.LV I SW tZ„Q nv-:) Cll/f2L1S r So. 00 GT l ST rZ-F- �,T LOT /A� f r�� r- A,%niL, � � p t000 C,At�• Szj I PA Id, I ION AetA W40 1 � for b»xTw•.� r So. 00 GT l ST rZ-F- �,T > po\vf-4S - \-Z)7 A GT lave P 16 P064 L MEST" FiT TOP SOIL 5v 6,;* 1 L 4,s -PLb,) Gr- PIS:r1c r -r SATvr(-A-r4G-rj .G/Alij. lZm. q"ley/A /A 3 0 V, > P 16 P064 L MEST" FiT TOP SOIL 5v 6,;* 1 L 4,s -PLb,) Gr- PIS:r1c r -r SATvr(-A-r4G-rj .G/Alij. lZm. q"ley/A /A — ILK MIN rD?5q1L'C6oM -All e-tzvsliz4> pe-,oTOUE Vb"�N, -4' 'ItP 41l 5/5/7/1-3 717) J'L)'kJC- Z,1ci73 ' z~nsr ' � y COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION °D nri.E s OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: �� STCA4S t/ dst 0 i q Owner's Name 4cm,lNty PSCe��"".'. Owner's Address: 3AY+� Date of Inspection: Q —„-_4 f I f Name of Inspector: (please print) t l I -tic.f� --- -" Company Name: Mailing Address: J0.6 Z, Telephone Number:. 06'7 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of 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 Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signatur Date: �g ` d . The system inspector shall submit a copy of this inspe tion 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 2 A�,��,� ****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. Title 5 lnsnertinn Pe% , Al trinnn ,a .: Page 2 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address•f,_%Q�`tyv Owner: . 6 -SN` c.� Date of Inspection:, Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. 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. 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: R Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -PART A CERTIFICATION (continued) Property Address: r TetC% Owner:JAFC r s. Date of Inspection: — 2—%/ — �. C. Fu • r Evaluation is Required by the Board of Health: Conditio exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect blic health, safety or the environment. 1. System will pass Board of Health determines in accordance with 310 CMR 15 (1)(b) that the system is not funett ing in a manner which will protect public health, safety a the environment: _ Cesspool or privy is thin SO feet of a surface water _ Cesspool or privy is wi S0 feet of a bordering vegetated wet or a salt marsh 2. System will fail unless the Board of Health d Public Water Supplier, if any) determines that the system is functioning in a manner that protec he ublie,health, safety and environment: _ The system'has a septic tank ands absorption %with ) and the SAS is within 100 feet of a surface water supply or tributan to a urface water su _ The system has a septic /and SAS and the SAZone I of a public water supply. — The system has a sep stank and SAS and the SAS is within 50 of a private water supply well. _ The system has a optic tank and SAS and the SAS is less. than 100feet t 50 feet or more from a private water suppl well". Method.used to determine distance "This syste pazses if the well water analysis, performed ata DEP certified laboratory, for coliform bacteria apdvolatile organic compounds indicates that the well is free from pollution from that facility and the pre ince of ammonia nitrogen and nitrate nitrosen is equal to or less than 5 ppm, provided that no other fail a criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: cj - Owner: bL VJ ' v D� Qi✓\ Date of inspection: 2 s 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 '/-_ day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ Any portion of the SAS, cesspool or privy is below high ground water elevation. _ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. JS. Any portion of a cesspool or privy is within 50 feet of a private water supply well. -K— 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 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.l Ab(Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems:- To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either "yes" or "no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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. Page S of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: s]U_ l FX S� d�flsfiT�o eQ-c.4v Owner 3/j - - - Date of Inspection: Check if the followine have been done. You must indicate `yes" or "no" as to each of the followins: Yes No Ar _ Pumping information was provided by the owner, occupant, or Board of Health _ X 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 ? �jA-Wcre 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 ofZhe 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 m intenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (DSAS) on the site has been determined based on: Yes no *c Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Pan C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)) 5 Page 6 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:a 7/59— Owner: \-b 6W N -k -C. Date of Inspection: -2U RESIDENTIAL FLOW CONDITIONS Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): Number of current residents: e„ Does residence have a garbage grinder (yes or no): Is laundry on a separate sewage system (y s or no): f if yes separate inspection required) Laundry system inspected (yep or no): / Seasonal use: (yes or no). IV Water meter readings, if av ']able (last 2 years usage (gpd)): Sump pump (yes or no): Last date of occupancy: Lao� COMMERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): _ and Basis of design flow (seats/persons/sgfr.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): . Pumping Records GENERAL INFORMATION �,� Source of informatio,.n: / S(� Was system pumped as part of the inspection (yes or no): _ If yes, volume pumped: _gallons — How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Q- 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 _ Attach a copy of the DEP approval _Other (describe): Approximate age of all cor0,ponents, date installed(if known) and source of information: Were sewage odors detected when arriving at the site (yes or no): L\ Page 7 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4 1% W✓y tiy<S Owner: /V Date of Inspection:--- ch 3 BUILDING SEWER (locate on site plan) t Depth below grade: Materials of construction: _cast iron _40 PVC _other (explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): i,e k, r -TL- SEPTIC TANK: A (Iocate on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polyethylene — other(explain)-If tank is metal list age: _Is age confirmed by a certificate) Certificate of Fompl�iance (yes or no): _ (attach a copy of �i Dimensions: if Sludge depth: eL Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: �, s Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bonom of outlet tee or baffle: How were dimensions determined: _c--/a,� Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to putlleet,invert, evidence of leakage, etc.): i GREASE TRAP: _(locate on site plan) Depth below grade: _ Material of construction: _concrete metal fiberglass _polyethylene or (explain): _ — -- Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or -baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page 8 of l 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: v "Ove Date of Inspection: — TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass _polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present Lyes 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: 6L (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 6 Comments (note if box is level and distribution to outlets equal. anv evidence of solids carryover_ anv evidence of PUMP CHAMBER: (locate on site 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.): Page 9 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: j u _ Owner t~!lie's • . R`. �_ Date of Inspection: __ —► �� SOIL ABSORPTION SYSTEM (SAS): 6�_ (locate on site plan, excavation not required) If SAS not 1pcated explain why: Type leaching pits, number: _ leaching chambers, number - leaching galleries, number. r leaching trenches, -number, lenu:•o® leaching fields. number, dimensions: overflow cesspool, number: innovativeialternative system Type!name of technology: Comments (note condition of soil, signs of hydraulic failure, level of pondin-, damp soil. condition of veQetatinn 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 laver: Depth of scum laver: 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) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Page 10 of 11 M OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: sv,5 a Owner•" �c�S Date of Inspection: 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. IC A Cg�) 2)n i 4 �� Rage 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORIM PART C SYSTEM INFORMATION (continued) Property Address: /V Gy Owner. ^j Cs Date of Inspection: q=_0 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 00 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 propertyiobservation 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 mest describe hpw you eltablohed the high `3 >r �.,,�„wr��►' -.- -�. „�, - � �iM 1. �.� � <v *� a'. �, � :� r f ,.�.� 11 r �"'�. r � } ""'�^ :. f r, _�. � '� ..rr 5Y https:Hmail.google.com/mail/ca/u/0/#linbox/l546cc6e53adbgfe?projector=1 1/1 BOARD OF HEALTH No.Andover, Mass. T SUBSURFACE DISPOSAL DESIGN CMK LIST 371 LOT APPROVED DATE Provided: DISAPPROVED DATE ' - � - S 5,61 0 7 Reasonsi c-s-rE,�2 ob Iry 1 _ �NSv pct i 3� t=iu, nw FILL A,M1 1 8n�L� The submitted plan must show as a minJimim: Title V Reg 2.5 FAIL OK a) the lot to be served-area,dimensions lot #,abutters blocation and log deep observation hoes -distance to ties c location and results percolation tests -distance to ties d design calculations & calculations shoving required leaching area (e) location and dimensions of system -including reserve area f) existing and proposed contours (g) location any wet areas within 1001 of sewage disposal system or disclaimer -check wetlands mapping (h) surface and subsurface drains within 100' of sewage disposal system or disclaimer I(i) location any drainage easements within 1001 of sewage disposal systema or disclaimer -Planning Hoard files (j) known sources of water supply within 2001 of sewage disposal a system or disclaimer (k) location of any proposed well to serve lot -1001 from leaching facility (1) location of water lines on property -10 I from leaching facility (m) location of benchmark (n) driveways (o) garbage disposals (p) no PVC to be used in construction (q) profile of system -elevations of baseme it, plumb, pipe, septic tank, distribution box inlets and outletr cb stribution field piping and Other elevations (r) maximum ground water elevation in area s�_;age disposal system (s) plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Reg 6 Septic Tanks (a) capacities -150 of flow, water table, tees, depth of tees, access, pumping (b) cleanout (c) 101 from cellar wall or inground swimming pool (d) 25+ from subsurface drains Reg 10.2 Distribution Boxes I(a) slope greater 0.08 Reg 10.1 1 b) sung ,.... ��, � x�'. r— }-_ - - _ _ _.. gy I 1 b'�•� N /y �r;, � �� .�t :_,.�. `�=�: :. -�. u ` C\ 11 ,,,� O � 1 � �� \ V �� .- �� s' PLAN OF L�Nla - /1/o.q TN 4 NDOVE12' ✓UI- Y /_9_7_3 �/��RLfJ CYP • j _-.✓ v1:11, r. Cl Al. 0 F � CNARGEs ao � y r 0N ,Lor B o - � e � AQEA .3 0 030 ' u 3 y Q6 W V 200.00 I t o � LOT A ? Q d 0 No rE RL14NN/NG t6o.4R® .4,"ROV,94 A n/07- RCQU/o 2. o COQ oh m �C ti 3� _-.✓ v1:11, r. Cl Al. 0 North )-idover, Mass. Street No Lot No Loc/Siibdiv. Pland Owner kAj Nd In-,,;163tiga r - Observer SOIL PROFILE DATES p I-E.ev 2.Elev-. 3. El ev C,0 tWK 1,1'14.,El ev vl� 0 0 0 2 5 6 7 8 9 10 DATF-S 2-1 3 4 6 7 8 9 I - I'Dcation on Datum PFRCOT AnIOT 'I"ESTS I 2 3 5 6 7 8 9 10 Ti -e3 to Tes Pits ---Pit-NUl,,) ber 2 Start, Saturation-- �,a —k- T,F -3 -.- D -,-,op of 5"--TiTre Dro of-6"-Till-je Drop 2, on - ------- -----