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Home My WebLink AboutMiscellaneous - 371 SUMMER STREET 4/30/2018.... ....... .... .... 6 cn C) m m North AndDver Board of Assessors Pub'liz Acc6ss t pO RT/l t ,SSACHU Click Seal To Return Search for Parcels Search for Sales Summary Residence Detached Structure Condo Commercial Page 1 of 1 North Andover 'fiea:l 4 Assessors, _ _, . oF Talk NPrnnerty Record Card Location: 371 SUMMER STREET Owner Name: HOGAN, PATRICK BOE, MICHELLE Owner Address: 371 SUMMER STREET City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 6 - 6 Land Area: 1.02 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 2610 s ft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 483,600 502,000 Building Value: 276,500 294,900 Land Value: 207,100 207,100 Market Land Value: 207,100 Chapter Land Value: http://csc-ma.us/PROPAPP/display.do?linkId=1708519&town=NandoverPubAcc 3/30/2011 .2, ! I NO :o it i IN f 1 �` 4 I ofOIX'w `y I I i0 f �(T) m_lca aiC2 W� }U C U U !C In a3a�m F' �.W o { � cr CL } � I o LL W.. 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U!cn ==. �M fn w ao o R ooiE"w:5= = co p 0 m co (a dlV E �if�0 lin ug Io `0� F- in 'LL j2 �W m ,Y W ! m N `Q 1 J+O mI Z' 3: 1 UNlmLL' Ue _:(Dr;Z' E_ w 5,'�,U! d i I�,R, _� '�IIojo{Jf- NIZ'D�ttnI71 o >,g m'� aai fa�i��la� Y oVx o in vi �Ix LLI 12t LL, MIL LL IU o ai to oy � PUBLIC HEALTH DEPARTMENT Town of North Andover Community and Economic Development Division CERTIFICATE OF COMPLIANCE As of: March 20, 2017 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: D -Box Repair of an On -Site Sewage Disposal System By: David Chandler — Sewer Works At: 371 Summer Street Map 107.A Lot 0166 North Andover, MA 01845 of this ce ific t of be Aonstrued as a guarantee that the system will function satisfactorily. Michele Grant Public Health Agent 120 Main St., North Andover, Massachusetts 01845 Phone 978.688.9540 fax 978.688.9542 Web www.northandoverma.gov III Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Commonwealth of Massachusetts Title 5 Official Inspection_ Foran Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 371 Summer St Property Address Michelle and Patrick Hogan Owner's Name N Andover Ma 01845 2/8/2017 City/Town State Zip Code Dae speotion 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: David Chandler Name of Inspector Sewer Works Company Name 26 Hillside Ave. Company Address Westford City/Town 978-692-4410 Telephone Number B. Certification MA State S137 License Number 01886 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 ewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of y e310 CMR 15.000). The system: < � Passes. ® Conditionally Passes ❑ Fails F � �yCt`� ❑ Needs Further Evaluation by the Local Approving Authority O ,r h 2/8/2017 Inspector's Signa r 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 Summer St Property Address Michelle and Patrick H Owner's Name N Andover Cityrrown B. Certification (cont.) Ma 01845 State Zip Code 2/8/2017 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: On this date the septic system for this property was inspected and evaluated. Based on what was observed during the inspection it was determined this day that the septic system did not meet any failure criteria set forth by DEP, therefore the system passed Title 5 pending replacement of dbox. This report and this inspector make no judgement as to the future functioning or longevity of this septic system. B) System Conditionally Passes: ® One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. , The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 371 Summer St Property Address Michelle and Patrick Owner's Name N Andover Cityrrown B. Certification (cont.) Ma 01845 State Zip Code 2/8/2017 Date of Inspection ❑ 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 ❑ obstruction is removed ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 371 Summer St Property Address Michelle and Patrick Hogan Owner's Name N Andover Ma 01845 2/8/2017 City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® 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 • <L,� Commonwealth of Massachusetts Title 5 Official Inspection Form a a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 371 Summer St Property Address Michelle and Patrick Hogan Owner Owner's Name nform equine fo d fotii's every requireN Andover Ma 01845 2/8/2017 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 i ❑ ® 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 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 371 Summer St Property Address Michelle and Patrick Owner Owner's Name information is N Andover required for every page. City[Town C. Checklist n Ma 01845 State Zip Code 2/8/2017 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms):600 gpd t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts N Title 5 Official Inspection Fora a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 371 Summer St Property Address Michelle and Patrick Hogan Owner Owner's Name information is N Andover required for every page. Cityrrown D. System Information Description: Ma 01845 State Zip Code 2/8/2017 Date of Inspection Water meter readings, if available: t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Number of current residents: 4 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): 162.9 gpd Detail: Sump pump? ® Yes ❑ No Last date of occupancy: na Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 371 Summer St Property Address Michelle and Patrick Hogan Owner Owner's Name information is N Andover Ma 01845 2/8/2017 required for every page. Cityrrown 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 Sewer Works 978-6924410 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): 11 t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 371 Summer St Property Address Michelle and Patrick Hogan Owner Owner's Name information is required for every N Andover Ma 01845 2/8/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: constructed 1981 Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): 18" feet Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 12" feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 11'x5'x4' of liquid Sludge depth: 14" t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Farm a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M ' 371 Summer St Property Address Michelle and Patrick Hogan Owner Owner's Name information is N Andover Ma required for every page. City/Town State D. System Information (cont.) t5ins • 3113 01845 2/8/2017 Zip Code Date of Inspection 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 20" 3" 8° 14" How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): recommend pumping every two years, both baffles were intact, no signs of aany cracks o r leaks, liquid level at outlet invert, 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): Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 371 Summer St Property Address Michelle and Patrick Hogan Owner Owner's Name information is N required for every Andover Ma 01845 2/8/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass Dimensions: Capacity: Design Flow: Alarm present: Alarm level: gallons ❑ polyethylene ❑ other (explain): 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 371 Summer St Property Address Michelle and Patrick Hogan Owner Owner's Name information is required for every 'N Andover Ma 01845 page. City/Town State Zip Code D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" 2/8/2017 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.): observed slight uneven flow, Dbox has "rotted" and observed leaks; requires replacement, no solids observed in Dbox Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 371 Summer St Property Address Michelle and Patrick Hogan Owner Owner's Name information is required for every N Andover Ma 01845 2/8/2017 page. Cityrrown 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: 20'x45' ❑ 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 observed was clean septic sand, no signs of hydraulic failure, no damp soils, grass over leaching area 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Fi Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 371 Summer St Property Address Michelle and Patrick Hogan Owner Owner's Name information is required for every N Andover Ma 01845 2/8/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 371 Summer St Property Address Michelle and Patrick Hogan Owner's Name N Andover Ma 01845 2/8/2017 Cityrrown 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Commonwealth of Massachusetts u - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 371 Summer St Property Address Michelle and Patrick Hogan Owner Owner's Name information is required for every N Andover Ma 01845 2/8/2017 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated de th to hi h round water' 4' p g g feet Please indicate all methods used to determine the high ground water elevation: U 8 Obtained from system design plans on record If checked, date of design plan reviewed: Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: Checked with local excavators, installers - (attach documentation) Accessed USGS database - explain: You must describe how you established the high ground water elevation: Review of original plans prepared for property by Frank Gelines and Assoc. of N Andover indicates an established ground water elevation from deep test hole in April 1977 an elevation of 110.00'. Bottom of leachfield elevation of 114.00'. A 4' seoeration. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts Title 5 official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 371 Summer St Property Address Michelle and Patrick Hogan Owner Owner's Name information is N required for every Andover Ma 01845 2/8/2017 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 s q, I � q .h/ Of T1, 7770 Town of North Andover HEALTH DEPARTMENT ,S$ACHUstt CHECK #: DATE: a/ k24- cc/? LOCATION: 5-0(y) M H/O NAME: "J CONTRACTOR NAM E- Type of Permit or License: (Check box) 0 Animal $ 0 Body Art Establishment $ 0 Body Art Practitioner $ 0 Dumpster $ 0 Food Service - Type. 13 Funeral Directors $ 13 Massage Establishment $ 0 Massage Practice $ 0 Offal (Septic) Hauler $ 0 Recreational Camp $ 0 Sun tanning $ 0 Swimming Pool $ 0 Tobacco $ 0 Trash/Solid Waste Hauler 13 Well Construction $ SEPTIC Systems: 0 Septic - Soil Testing $ 0 Septic - Design Approval 0 Septic Disposal Works Construction (DW0 $ 13 Septic Disposal Works Installers (DW[) 0 Title 5 Inspector $ Title 5Report - 1fn15,, $ 0 Other (Indicate) $ He.Agent Initials White - Applicant Yellow - Health Pink - Treasurer iep�� I. Commonwealth of Massachusetts Map-Block-Lot �w° • 107.A0166 ----------------------- x BOARD OF HEALTH PermitNo 17- B North Andover HP -200333 BH -017---------- P.I. FEE �a�rant� F.I. DISPOSAL WORKS CONSTRUCTION PERMIT _S Permission is hereby granted i��)//_--,C� __ �t �r___4 to(Construct)an. Individual Sewage Disposal System. at No 371 SUMMER STREET ---------------------------------------------------------------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. BHP -2017-033 Dated --M-arch-0-6-,-2-0-1-7 ----- ------------------------------- --------------------------------- I ---------------------------------------------------------------- Issued On: Mar -06-2017 BOARD OF HEALTH ---------------------------------------------------------------------------------- Commonwealth of Massachusetts Map -Block -Lot '. 107.A0166 BOARD OF HEALTH North Andover CERTIFICATE OF MPLIANCE THIS IS TO That the Indiv' al Sewage Disposal System (Construct) by- - - -- - - -------------------------------------------------------------------------------- at No 371 -SUMMER -STREET --------------------------------------------------------------------------------------- -------------------------------�in ---------- has been installed in accordan with the provisions of TITLE 5 of the State Environmental o cribe applicationfor Disposal rks Construction Permit No. BHP -2017-033 Dated March 06 2017 ------------- ----------------------------------------------------------------- Printed On: Mar -06-2017 BOARD OF HEALTH Commonwealth of Massachusetts Map -Block -Lot �� may' • 107.A0166 ----------------------- BOARD OF HEALTH Permit No North Andover BHP -2017-0333 P.I. FEE ��R1r►��a4t F.I. DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted __---_----- to (Construct) an Individual Sewage Disposal System. at No 3-7-1-SUMMER STREET ----------------------------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. BHP -2017-033 Dated _-March-06,"2017- ------------------------ - - - - ----- ------- ---------------------------------------------------------- I ssued - ----------------------------------------------- Issued On: Mar -06-2017 BOARD OF HEALTH Commonwealth of Massachusetts BOARD OF HEALTH North Andover CERTIFICATE OF COMPLIANCE THIS IS TO CERTIFY, That the Individual Sewage Disposal System (Construct) by — --------------------------------------------------------------- Installer Map -Block -Lot 107.A0166 ----------------------- at No 3-71 -SUMMER---STR-EET ---------------------------------------------------------------------------------------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. BHP -2017-033 Dated ___ March_06,_2017 ------------------------------------- Printed On: Mar -06-2017 BOARD OF HEALTH 1 GG e' 3a �• °c a Town of North Andover '�'•�.; ;o �:•,' HEALTH DEPARTMENT ,SSACHU`E< CHECK #: /b DATE: 31(012-01 ''. LOCATION: 3") 5Y H/O NAME: E CONTRACTOR NA4 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 �QXs e,P� $ ❑ Septic - Design Approval 19 Septic Disposal Works Construction (DWC) ❑ Septic Disposal Works Installers (DWI) ❑ Title 5 Inspector ❑ Title 5 Report ❑ Other: (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer OF NORiH 9ti � A �y. �4SSA CN )SES Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Application for Septic Disposal System r 6U�I TODAY'S DATE Construction Permit -TOWN OF T014UN OF NORTiiANDOVER $35 l TFuIl i'Re�it�T NORTH ANDOVER, MA 01845 ��5.00 - omponent Application is hereby made for a permit to: ❑ Construct a new on-site sewage disposal system* ❑ Repair or replace an existing on-site sewage disposal system* Repair or replace an existing system component — What? 60Y, A. Facility Information Address or Lot # City/Town 2.- *TYPE OF SEPTI SYSTEM*: ➢ ❑ Pump ravity (choose one) ***If pump system, attach copy of electrical permit to application*** ❑ Conventional System (pipe and stone system) ➢ ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification ❑ Pressure Distribution S.A.S. (No D -Box) ➢ ❑ Pressure Dosed (D -Box Present) S.A.S. to install this type of system.) ➢ ❑ Does the system require an effluent filter? Yes No If yes, does plan specify make and model of filter? YES = (no further info. needed) NO = (installer must specify brand of filter before D WC issuance) What is the Make? 2. Owner Informatio Name What is the Model? 3-7/ . 9,� e4e4_- Addd s (if different from above) City/Town State Zip Code Email address 3. Installer Information Telephone Number Name Name of Company Aeo "�� 9�•-e_ Address k,-) Y-- t; r7 City/Town 4. Designer Information Name Address State Zip Code Telephone Number (Cell Phone # if possible please) Name of Company City/Town - State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 y r • bM° ti. Application for Septic Disposal System Construction Permit - TOWN OF NORTH ANDOVER, MA 01845 PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: Residential Dwelling or ❑Commercial B. Agreement TODAY'S DATE $350.00 - Full Repair $175.00 - Component The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover. 1 understand that until a final Certificate of Compliance has been issued by this Bard of Health, the installed system is not approved.. Name— — Date — . Application Approved By: (Board of Health Representative) Name Date Application Disapproved for the following reasons: For Office Use Only: 1. Fee AttachcdP Yes No 2. Project Manager Obligation Form Attached. Yes No 3. Pump Sys tem? If so, Attach gflp,E ofElectrical Permit Yes No Applicant received copy of "Electrical Inspection Notes for Septic Systems" Yes No Handout? 4. Reviewed approvalletter, all paperwork received? Yes No Missing; 5. Foundation As -Built? (new construction only): (Same scale as approved plan) Yes No 6. Floor Plans? (new construction only): Yes No Application for Disposal System Construction Permit • Page 2 of 2 North Andover Health Department Community and Economic Development Division ^KlLftITC \A/A@TC\A/ATCn L%VC%TCIIA f%r%k1L%TC%1lf+TIP1wl AIf1TCC LOCATION INFORMATION ADDRESS: 371 Summer Street MAP: 107.A LOT: 0166 INSTALLER: David Chandler —Sewer Works 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: SITE CONDITIONS - ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port A ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION -BOX ❑ Installed on stable stone base ® H-20 D -Box ❑ Inlet tee (if pumped or >0.08'/foot) ❑ Hydraulic cement around inlet & outlets ® Observed even distribution ® Speed levelers provided (not required) ❑ Schedule 40 PVC Pipe Comments: Did not view the pipes or stone. Spoke to David Chandler and asked him to read the local Regulations, as well as leaving the hole open so the Health Inspector can view. SOIL ABSORPTION SYSTEM (General) ❑ Bottom of SAS excavated down to C soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 40 Mil HDPE barrier installed ❑ Laterals installed and ends connected to header (and vented if impervious material above) ❑ Elevations of laterals and chambers installed as on approved plan ❑ Retaining wall (boulder/ concrete / timber/ block) ❑ Final cover as per plan Comments: SOIL ABSORPTION SYSTEM (Gravel -less Chambers) ❑ Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ❑ Number of chambers per, row: ❑ Number of rows (trenches). Comments: Total Chambers = 1 .1 Comments: PUMP CHAMBER Comments: CONTROL PANEL Comments: DISTRIBUTION -BOX ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement ❑ Installed on stable stone base H-20 D -Box [, Inlet tee (if pumped or >0.08'/foot) Hydraulic cement around inlet & outlets Observed even distribution Speed levelers provided (not required) ❑ Schedule 40 PVC Pipe Comments: 0 5T h� North Andover Health Department (ommunity and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 371 Summer Street MAP: 107.A LOT: 0166 INSTALLER: David Chandler —Sewer Works DESIGNER: PLAN DATE: .5k -Q_ 1,oa- e, %� �' Zak 41,7 /011V1 BOH APPROVAL DATE ON PLAN: //�� INSPECTIONS I�Vzlalcv_lovelz; /-).0 �0;16 00651�-�Iai� TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS Comments: SEPTIC TANK ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port e , SOIL ABSORPTION SYSTEM (General) ❑ Bottom of SAS excavated down to C soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 40 Mil HDPE barrier installed ❑ Laterals installed and ends connected to header (and vented if impervious material above) ❑ Elevations of laterals and chambers installed as on approved plan ❑ Retaining wall (boulder / concrete / timber/ block) ❑ Final cover as per plan Comments: SOIL ABSORPTION SYSTEM (Gravel -less Chambers) ❑ Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ❑ Number of chambers per row: ❑ Number of rows (trenches): Comments: Total Chambers = , 6-1a , DelleChiaie, Pamela From: DelleChiaie, Pamela Sent: Wednesday, March 30, 2011 9:43 AM To: 'RJ Inspections' Subject: FW: I.R. - Septic - Title 5 - 371 Summer Street Attachments: 20110317134515463 Importance: High Here you go........:) r Pamela DelleChiaie Departmental Assistant I Community Development I Health Department Town of North Andover 1600 Osgood Street I Bldg 20 1 Suite 2-36 North Andover, MA o1845 9 Office - 978-688-9540 Fax -978-688-8476 O Email - pdellechiaieotownofnorthandover.com "F5 Website httpJ/www.townofnorthandover.com/Pages/index "We can never see the path of our life if we are too busy focusing on the pebbles under our feet. "--Anonymous From: DelleChiaie, Pamela Sent: Thursday, March 17, 2011 1:56 PM To: 'chris.papineau@nemoves.com' Subject: I.R. - Septic - Title 5 - 371 Summer Street Importance: High Reference: 978.8 86.4472 Chris Papineau Dear Chris, Attached is a scanned copy of the most recent Title 5 Report for 371 Summer Street as you requested. Please call again if you have any questions. coat ReP46 a, Pamela DelleChiaie Departmental Assistant I Community Development I Health Department Town of North Andover 1600 Osgood Street I Bldg 20 1 Suite 2-36 North Andover, MA o1845 2 Office - 978-688-9540 ( Fax - 978-688-8476 Email = pdellechiaieotownofnorthandover.com '25 Website http://www.townofnorthandover.com/Pages/index "We can never see the path of our life if we are too busy focusing on the pebbles under our feet. "--Anonymous `'1DelleChiaie, Pamela From: DelleChiaie, Pamela Sent: Thursday, March 17, 2011 1:56 PM To: 'chris.papineau@nemoves.com' Subject: I.R. - Septic - Title 5 - 371 Summer Street Attachments: 20110317134515463 Importance: High Follow Up Flag: Follow up Flag Status: Flagged Reference: 978.886.4472 Chris Papineau Dear Chris, Attached is a scanned copy of the most recent Title 5 Report for 371 Summer Street as you requested. Please call again if you have any questions. 9W Reqd*4, Pamela DelleChiaie Departmental Assistant I Community Development I Health Department Town of North Andover 1600 Osgood Street I Bldg 20 Suite 2-36 North Andover, MA 01845 2 Office - 978-688-9540 Fax -978-688-8476 Email - pdellechiaiePtownofnorthandover.com SLI Website http//www.townofnorthandover.com/Pages/index "We can never see the path of our life if we are too busy focusing on the pebbles under our feet. "--Anonymous 1 F0= •` Y` L9 Town of North Andover `*.'• :: HEALTH DEPARTMENT �SSACHU`+Et CHECK #: DATE: LOCATION: L -f7.4 H/O NAME: CONTRACTOR N (Check box) 5407 ❑ 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 5 In pector 5 Report $ $ �� e ❑ Other: (Indicate) $ Health Agent Initials:;, White - Applicant Yellow - Health Pink - Treasurer',.,. Commonwealth of Massachusetts M Title 5 Official Inspection Foran Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r� 371 Summer Street ` Property Address Patrick Hogan Owner Owner's Name information is required for every N. Andover MA 01845 3/31/11 page. City/Town 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: When filling out forms A. General Information on the computer, use only the tab 1. Inspector: 41P 1 key to move your cursor - do not James Wright [ 1 use the return TOWN OF NORTH ANDOVER key. Name of Inspector t. H DEPARTMENT Aspen Environmental Services LLC % Company Name 270 Lawrence St Company Address Methuen MA 01844 City/Town State Zip Code 978-681-5023 2035 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system::: ❑ PassesP, Conditionally Passes ❑ Fails Needs Further Evaluation by the Local Approving Authority Insp or's S' 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 addresshow the system will pe under the same or different conditions of use. t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 go t Owner information is required for every page. 15ins • 09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 371 Summer Street Property Address Patrick Hogan Owner's Name N. Andover City/Town B. Certification (cont.) MA 01845 3/31/11 State Zip Code Date of Inspection Inspection Summary: Check A, BAD 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): Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Owner information is required for every page. t5ins • 09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 371 Summer Street Property Address Patrick Hogan Owner's Name N. Andover Citylrown _ B. Certification (cont.) B) System Conditionally Passes (cont.): MA 01845 3/31/11 State Zip Code Date of Inspection ❑ 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 ❑��o�bstruction is removed 0- distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): 9-'�--❑ N ❑ ND (Explain below): FA ❑ 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 Requiredj)f 'the Board of Health: ❑ Conditions exist which requ' further evaluation by the Board of Health in order to determine if the system is failing to pr ect public health, safety or the environment. 1. System will pas nless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that a system is not functioning in a manner which will protect public health, safety and the vironment: ElCe pool 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 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. t5ins • 09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 371 Summer Street Property Address Patrick Hogan Owner's Name N. Andover Cityrrown B. Certification (cont.) MA 01845 State Zip Code 3/31/11 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 stem (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surfa water supply. ❑ The system has a septic tank and SAS and th SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS an the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the AS 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 analysi , performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failu 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 ❑ iz;n Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ❑ E:]Liquid 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 depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17 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 ollowing, in addition to the questions in Section D. Yes No ❑ ❑ the system is withi 0 feet of a surface drinking water supply ❑ ❑ the syste s within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the stem is located in a nitrogen sensitive area (Interim Wellhead Protection a — IWPA) or a mapped Zone II of a public water supply well If you have answe d "yes" to any question in Section E the system is considered a significant threat, or answered " " in Section D above the large system has failed. The owner or operator of any large system consi ered 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 • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 371 Summer Street Property Address Owner Patrick Hogan Owner's Name information is required for every N. Andover MA 01845 3/31/11 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: ❑ JM 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 ollowing, in addition to the questions in Section D. Yes No ❑ ❑ the system is withi 0 feet of a surface drinking water supply ❑ ❑ the syste s within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the stem is located in a nitrogen sensitive area (Interim Wellhead Protection a — IWPA) or a mapped Zone II of a public water supply well If you have answe d "yes" to any question in Section E the system is considered a significant threat, or answered " " in Section D above the large system has failed. The owner or operator of any large system consi ered 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 • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 371 Summer Street Property Address Patrick Hogan Owner Owner's Name information is required for every N. Andover MA 01845 3/31/11 page. CitylTown 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 2/ ❑ 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? 0 El as 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) �% L1 ❑ E ❑ 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? u ❑ 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? ❑ L? 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, aIan at the A 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): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): O el t5ins • 09/08 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 Summer Street Property Address Patrick Hogan Owner Owners Name information is required for every N. Andover MA 01845 3/31/11 page. City/Town 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? [if yes separate inspection required] Laundry system inspected? Seasonaluse? Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump?, ---v 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. .; etc.): Grease trap present? Industrial waste holding Non -sanitary waste present? to the Title 5 system? Water meter readi Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �< 371 Summer Street - .-F—Y _UU1Waa Patrick Hogan Owner Owner's Name information is required for every N. Andover MA 01845 3/31/11 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other (describe below): General Information Pumping Records: Source of information: C/ /� - ��/� / v Was system pumped as part of the inspection? ❑ Yes [�ICIo If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no), (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative tech 1 no ogy. 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 • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments s.• °y 371 Summer Street Property Address Patrick Hogan Owner information is Owner's Name required for every N. Andover MA 01845 3/31/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate f all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: Material of construction: cast iron [:140 PVC ❑ other (explain): ❑ Yes D- ' o feet Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: Material of construction: concrete ❑ metal If tank is metal, list age: ('C°6-�1 / -C�-- feet ❑ fiberglass ❑ polyethylene ❑ other (explain) years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1�2 x 5)1 X t� Sludge depth: 3 If t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 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 Summer Street rlupeny muuress Patrick Hogan Owner's Name N. Andover Cityrrown D. System Information (cont.) MA 01845 State Zip Code Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? 3/31/11 Date of Inspection CO f 1 Y Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): e j Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal fiberglass 9 ❑ polyethylene ❑ other (explain): Dimensions: Scum thickness Distance from top o scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins • 09/08 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 M ,•''r 371 Summer Street Patrick Ho an Owner information is owner's Name required for every N. Andover MA 01845 3/31/11 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene y El other (explain): Dimensions: Capacity: Design Flow: Alarm present: Alarm level: Date of last pui Comments (co, gallons gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No uate of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 09/08 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 371 Summer Street Property Address Patrick Hogan Owner's Name N. Andover MA 01845 CltyrFown State Zip Code D. System Information (cont.) 3/31/11 Date of Inspection Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 4% 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.): J Pump Chamber (locate on site plan): Pumps in working order: Alarms in working order: Comments (note condition of pump chamber ❑ Yes ❑ No ❑ Yes ❑ No of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 09/08 - ritle 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 = Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 371 Summer Street Property Address Owner Patrick Hogan information is Owner's Name required for every page. N. Andover MA Cityrrown 01845 3/31/11 State D. System Information (cont:) Zip Code Date of inspection Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches. number, length: leaching "e COY fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, vegetation, etc.): level of ponding, damp soil, condition of 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 cesspo Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 371 Summer Street Property Address Patrick Hogan Owner Owner's Name information is required for every N. Andover MA 01845 page. Cltyrro Am State Zip Code D. System Information (cont.) Comments (note condition of soil,.signs of hydraulic failure, level of po etc.): �- Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note etc.): 3/31 /11 Date of Inspection dition of vegetation, of soil, signs of hydraulic failure, level of ponding, condition of vegetation, t5ins - 09108 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 Summer Street Property Address Patrick Hogan Owner Owner's Name information is required for every N. Andover MA 01845 3/31/11 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: B d-sketch in the area below drawing attached separately t5ins • os/oa 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 M s•''r 371 Summer Street rroperry Haaress Patrick Hogan Owner information is Owner's Name required for every N. Andover MA 01845 page. Cltylrown State Zip Code D. System Information (cont.) Site Exam: VZ Check Slope 3/31/11 Date of Inspection ❑ Surface water Check cellar & ❑ Shallow wells Estimated depth to high ground water: Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins •09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 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 Summer Street Property Address Patrick Hogan Owner's Name N. Andover MA Citylrown State E. Report Completeness Checklist 01845 3/31/11 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 I�Sy em Information — Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 09/08 Title 5 Official Inspection Forth; Subsurface Sewage Disposal System • Page 17 of 17 "—' -"++ +�• • w 17I 00007) (j PAGE 01/01 Summary Red C"6er,Q clad ar aMQY 51 f !1:36:55 AN' by tis; Town 6f North Andover PeAe i Tac Map # 210-107.A-0166-0000.0 Parcel Id 17992 371 SUMMER STREET PATRICK HOGAN 371 SUMMER STREET NORTH ANDOVER, MA 0'1846 Class 101 Single f=amily Slze Total 1,02Acms Property Type-' 1 Re9idential FY 2011 UP Mailinla Index Nama/Address PATRICK HOGAN Type Loan Number Active/lriact. From 371 SUMMER STREET Owner Until NORTH ANDOVER, MA 01845 DOLAHER, DAVID previous Customer" 371 SUMMER STREET Inactive 511212005 N, ANDOVER, MA 01845 MICHELLE BOE Previous Customer 371 SUMMER STREET Inactive 5/31/2009 NORTH ANDOVER, MA 01345 KATHERINE NORTON Previous customer 371 SUMMER STREET Inactive 2/12/2905 NORTH ANDOVER, MA 01845 Ui;3__>a►GC0"' Maint Account No cycle Bldg Id, 14278.0 - 371 SUMMER STREET 2100274 02 Cycle 02 US Services Maint. Acooumt No. 2100274 Service Code MISCFEE ADMIN FEE WPR WATER UB Meter Maintenance Account No, 2100274 Serial No Status 29955895 a Active Date Reading 2/412011 459 11/112010 ,450 8(312010 432 0128/2010 430 5/4/2010 416 2/212010 357 11/2/2009 n4 814/2009 342 51412009 334 2/4/2009 320 11/5/2008 302 8/4/200B 282 5/2/2008 259 2/5/2008 242 11/2/2007 224 Occupant Name Activelinaeuve Last Billing Date 3/2/2811 Active Rate 0.63 518 Charge l: 7ultipllerlUsers 01 ALL METER SIZE 7.82 72.20 1 / 19 Location ERT HH Brand b Badger 9 Type Si2e YM Cons Code Consumption w Water 0.63 0.63 Posted Bate 710 a Actual a Actual 19 3115/2011 Variance a Actual 18 12/13/2010 0 260% f Final 2 14 9113/2010 6/28/2010 -78%% a Actual a Actual 29 6/9/2010 -20% a Actual 23 22 3/11/2010 270% 20% S Actual 8 12/11/2009 181% a Actual a Actual 14 9/11/2009 6/16/2009 -45°% a Actual 18 20 3/16/2009 12/10/2008 _240% ,8% a Actual a Actual 23 9/12/2008 -12% a Actual 17 611>3/2008 25% 3°/s a Actual 16 36 3114/200$ 1115/2008 -520% •25°% i"'�AS` :NORTy1 . Town ofNorth Andover `�,'•�,; ;; :. HEALTH DEPARTMENT ,SSACNU5�4 CHECK #: DATE: LOCATION: H/O NAME: CONTRACTOR NAME: Type of Permit or License: (Check box) 4 ❑ Animal r $ ❑ Body Art Establishment r $ 4 ❑ Body Art Practitioner $ ❑ Dumpster f ,. ❑ Food Service - Type.- 0 ype:❑ 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'I�ns�ector $ Tttle' 5 Report $�� ❑ Other. (Indicate) $ 2442 Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer :a a. a t O lu c w c V a L: d a 0 z u, � 3 3 I a� 0 O c w y V w J L: d a 0 3 I a� 0 O c w y z z z u, � 3 ► � N a C 0 CO) N ` d a o �.. ai m y O y w O J z z z U 3 3 V E d � C d1 N o 0co ► y �c N m O y z z z u, � 3 k m W o N ` o E m y a Gyi 3 3 C d1 N o 0co ► a +: 0 �L 0 ll 3 _ L o m O Ec to ami ioo a� a� G1 V y Cl) C9 O D FO- 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. VQ ietrdn 4r ! Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 371 Summer Street Property Address Patrick Hogan Owner's Name No. Andover City/Town MA 01845 5/21/2007 State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 1. Inspector: Beniamin C. Os000d Jr. Name of Inspector New England Engineering Services, Inc. Company Name 1600 Osgood Street Suite 2-64 Company Address No. Andover MA 01845 City/Town 978-686-1768 Telephone Number B. Certification State License Number 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 G� Inspe is Signature-- 6 ignature s'/ZZlo7 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. TITLE 5 FORM 2007. DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 15 a 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 Summer Street Property Address Patrick Hogan Owner's Name No. Andover MA 01845 5/21/2007 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: 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. 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 TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 15 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 Summer Street Property Address Patrick Hogan Owner's Name No. Andover MA 01845 5/21/2007 City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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: 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 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. TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 3 of 15 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 Summer Street Property Address Patrick Hogan Owner's Name No. Andover City/Town B. Certification (cont.) MA 01845 5/21/2007 State Zip Code Date of Inspection C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: TITLE 5 FORM 2007.DOC • 08/06 Yes No ❑ [4 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'/2 day flow ❑ [A Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ [9 Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Y Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. - Title 5 Official Inspection Form: Subsurface Sewage Disposal System •.Page 4 of 15 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 Summer Street Property Address Patrick Hogan Owner's Name No. Andover MA 01845 5/21/2007 City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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. ❑ Q 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.] ❑ N The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ [4 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 ❑ 14 the system is within 400 feet of a surface drinking water supply ❑ [Pg the system is within 200 feet of a tributary to a surface drinking water supply ❑M 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. TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 15 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 Summer Street Property Address Patrick Hogan Owner's Name No. Andover MA 01845 5/21/2007 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 P❑ 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) ❑ �(j Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? Q ❑ 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? IX ❑ 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: 1p, ❑ 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)] TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 15 Commonwealth of Massachusetts w Title 5 Official Insp Subsurface Sewage Disposal System Fo °M 371 Summer Street D. System Information Residential Flow Conditions: Number of bedrooms (design): R Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required] Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): 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: Last date of occupancy/use: Other (describe): ❑ Yes ection Form ❑ rm - Not for Voluntary Assessments [2 No ❑ Yes ® Property Address ❑ Yes ® Patrick Hogan Owner Owner's Name information is required for No. Andover MA 01845 5/21/2007 .every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): R Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required] Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): 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: Last date of occupancy/use: Other (describe): ❑ Yes ❑ No ❑ Yes [2 No ❑ Yes ® No ❑ Yes ® No ❑ Yes No C v r- r e. �T Date Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Date TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 371 Summer Street D. System Information (cont.) General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: 5/21/2007 Date of Inspection /v 12-5] 20 qy— P ER P.y -F-L gallons [� Property Address ❑ Patrick Hogan Owner Owner's Name information is required for No. Andover MA 01845 every page. City/Town State Zip Code D. System Information (cont.) General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: 5/21/2007 Date of Inspection /v 12-5] 20 qy— P ER P.y -F-L gallons [� Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes X No TITLE 5 FORM 2007.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System . Page 8 of 15 Owner information is required for every page. Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 371 Summer Street Property Address Patrick Hogan Owner's Name No. Andover City/Town D. System Information (cont.) Building Sewer (locate on site plan) State Zip Code 5/21/2007 Date of Inspection Depth below grade: feet- `( Material of construction: rN i cast iron ❑ 40 PVC Elother (explain): Distance from private water supply well or suction line: tQ- feet Comments (on condition of joints, venting, evidence of leakage, etc.): V,oIL.y Ctr&aD tN &mac. Septic Tank (locate on site plan) Depth below grade: feet Material of construction: �] concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness /.Syo C�-r�s.Lo a 5 �r m it .r Distance from top of scum to top of outlet tee or baffle rr Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? MEASa(LE 5I C4 TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 15 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 Summer Street Property Address Patrick Hogan Owner's Name No. Andover Cityrrown 01845 5/21/2007 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.): -FP+IV ` IA/ CO 0 E> cZN s>:77o/n.1 Or✓TLET PlIPE 1i X TCND 1.-/ 7ZD e'ca N c FL,E—/r ? G XTZT�u oi4:3, D ✓T"L E—f P/ PE / N 70 c D Nc 2E—R;�" ?ZF€ Grease Trap (locate on site plan): Aj I (} Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass feet ❑ polyethylene ❑ other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 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): iv 114 Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 15 (\, Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 371 Summer Street Owner information is required for every page. Property Address Patrick Hogan Owner's Name No. Andover City/Town MA 01845 5/21/2007 State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Desi n Fin— Z.1 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 Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert O „ 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.): 13&X t^j &-00 eDrJp (7)"ZI A G -P -"E p:ser-(BLM.',A L G?J AL, iaa;1 Lvt pIII! ,.3CE &F G -c Iti' n /t 12- C _PDLt ng G�}-/L/Zy oveiC Pump Chamber (locate on site plan): 1,,,1,4, Pumps in working order: ❑ Yes ❑ -No Alarms in working order: ❑ Yes ❑ No TITLE 5 FORM 2007.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 15 i0 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 371 Summer Street Owner information is required for every page. Property Address Patrick Hogan Owner's Name No. Andover Cityrrown D. System Information (cont.) State Zip Code 5/21/2007 Date of Inspection 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: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: NJ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: qc'� S•f-: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Ai2L%19 of:::: F�tC111 P L -C, o AA --X02.+-��9 L N� t1 v� pe. -/c o f- P0AJD1114 ()Ari -t!' .Sc'��L OR t�.�J..SrJ.�t JC -C -17)900N. TITLE 5 FORM 2007.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 15 Owner information is required for every page. Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 371 Summer Street Property Address Patrick Hogan Owner's Name No. Andover City/Town State Zip Code 5/21/2007 Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): nVj r,' 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): A-�,A Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): TITLE 5 FORM 2007.DOC • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments /e 371 Summer Street 9 1ST IRoX D. System Information (cont.) 01845 5/21/2007 Zip Code 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. ®15T-ApoCc3' Property Address 13' — 114 Patrick Hogan Owner Owner's Name information is No. Andover MA required for every page. City/Town State 9 1ST IRoX D. System Information (cont.) 01845 5/21/2007 Zip Code 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. ®15T-ApoCc3' A — -T" 1,, 13' — 114 P_TArvK L,5�1 _,5 A-- I13 TITLE 5 FORM 2007.DOC - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 15 w Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 371 Summer Street �w Property Address Patrick Hogan Owner Owner's Name information is required for No. Andover MA 01845 5/21/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: N Check Slope ❑ Surface water uoAfE ❑ Check cellar N o 50M? ❑ Shallow wells Aj,� AJ Estimated depth to ground water: feet ly Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date [� Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: srcwo j -- .1 cta04 -TY 14'r TITLE 5 FORM 2007.DOC - 08/06 A -D.! %}'C n1 j UAipC,i -j /V S> �v S. yr r' ? 1.1V -0 04-s G --',-Il ✓` Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 15 I < L--, Commonwealth of Massachusetts _m2ft City/Town of NORTH ANDOVER, MASSACHUSETTS � System Pumping Record Form 4 DEP has provided this form for use by local Boards of Heal tae�System Pumpin�Record must be submitted to the local Board of Health or other approvin autlR E,IVED A. Facility Information Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return kFey. 2 v o reuen System Location; System Owner: Name Address (if different from location) SEP 11 2007 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT OA State O ) WS— Zip Code City/Town State Zi Code Telephone Number B. Pumping Record . 1. Date of Pumping ) Quantity Pumped: Inon Date Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes `No 5. Condition of S C> If yes, was it cleaned? ❑ Yes ❑ No 6. Syst m Pumped By: (-C Nam Vehicle License Number �[C J� Co any 7. Location where conte is wer disposed: 7 S b Si ature'o Hauler. Date http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 ,TH OF MASSACHUSETTS OFFICE OF ENVIRONMENTAL AFFAIRS ARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 371 Summer Street _ FIVED _ North Andover_Owner's Name: David Dolaher 4 Owner's Address: 371 Summer Street 2005 _ North Andover, MA 01845_ Date of Inspection. 2/23/2005_ TU HEALTH DEPARTMENT WN OF NORTH ER Name of Inspector: Neil J. Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address: _111 Argilla Road_ _Andover, Ma. 01810_ Telephone Number: ( 978 ) 4754786 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: Inspector's Signature: _X Passes Conditionally Passes ry the Local Approving Authority Date: 2/23/2005 The system inspector shall submit a\ copy ddiis inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments: ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 371 Summer Street _ North Andover Owner: _Dolaher_ Date of Inspection: 2/23/2005_ Inspection Summary: Check A B,C,D or E / ALWAYS complete all of Section D A. System Passes: X 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. 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: Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 371 Summer Street_ _ North Andover — Owner: _Dolaher_ Date of Inspection: 2/23/2005 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 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance — "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria 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. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 371 Summer Street _ _ North Andover — Owner: _Dolaher_ Date of Inspection: 2/23/2005_ D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: _ No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool No Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _No_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _No Liquid depth in cesspool is less than 6" below invert or available volume is'/z day flow. _No Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _No_ Any portion of the SAS, cesspool or privy is below high ground water elevation. _No Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. —No Any portion of a cesspool or privy is within a Zone 1 of a public well. _ —No Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ _No_ 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.] _No_ (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 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 371 Summer Street _ North Andover — Owner: _Dolaher Date of Inspection: 2/23/2005 Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No Yes_ _ Pumping information was provided by the owner, occupant, or Board of Health No Were any of the system components pumped out in the previous two weeks ? Yes_ _ Has the system received normal flows in the previous two week period ? _No Have large volumes of water been introduced to the system recently or as part of this inspection ? Yes_ _ Were as built plans of the system obtained and examined? Yes_ _ Was the facility or dwelling inspected for signs of sewage back up ? Yes _ Was the site inspected for signs of break out ? Yes_ _ Were all system components, excluding the SAS, located on site ? _Yes_ _ 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 ? _Yes_ _ 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: Yes no _Yes_ _ Existing information. _Yes_ _ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 371 Summer Street _ North Andover – Owner: _Dolaher_ Date of Inspection: 2/23/2005_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): _4 Number of bedrooms (actual): 4_ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): _600_ Number of current residents: Does residence have a garbage grinder (yes or no): Yes_ Is laundry on a separate sewage system (yes or no): _ No Laundry system inspected (yes or no): r Seasonal use: (yes or no): No_ Water meter readings: Yes, 176194Ft3_ Sump pump (yes or no): Yes_ Last date of occupancy: _Current_ COMMERCIALANDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sgft,etc.): Grease trap present (yes or no): _ Industrial waste holding tank present (yes or no): — Non -sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: Pumped Sept. 1998, owner_ Was system pumped as part of the inspection (yes or no): Yes_ If yes, volume pumped: _1500_gallons -- How was quantity pumped determined? _Measured tank_ Reason for pumping: _Inspect tank TYPE OF SYSTEM Septic tank, distribution box, soil absorption system _ Single cesspool , Overflow cesspool Privy _ Shared system (yes or no) (if yes, attach previous inspection records, if any) _ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) _ Tight tank _ Attach a copy of the DEP approval Other (describe): _ Approximate age of all components, date installed (if known) and source of information: 24 years old, 11/9/1981, As built plan_ Were sewage odors detected when arriving at the site (yes or no): No Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 371 Summer Street_ _ North Andover— Owner: _Dolaher_ Date of Inspection: _2/23/2005 BUILDING SEWER _ X _ (locate on site plan) Depth below grade: _24" Materials of construction: _Xcast iron _X_40 PVC _other Distance from private water supply_ well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): no leaks visible. SEPTIC TANKS: X _ 4" Cast iron thru wall, 3" PVC in house, Depth below grade: _12"_ Material of construction: X concrete — metal _fiberglass _polyethylene _other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): — (attach a copy of certificate) Dimensions: 10' x 5' x 4' Sludge depth —6" _ Distance from top of sludge to bottom of outlet tee or baffle: 21"_ Scum thickness: _6" _ Distance from top of scum to top of outlet tee or baffle: _8" _ Distance from bottom of scum to bottom of outlet tee or bathe: _15" _ 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.)_ Pumped septic tank Inlet tee ok. Inlet baffle ok. Outlet tee ok Outlet baffle ok Depth of liquid at outlet invert. No evidence of leakage._ GREASE TRAP: (locate on site plan) Depth below grade: _ Material of construction: _concrete metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: 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 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _371 Summer Street- - North Andover— Owner: _Dolaher_ Date of Inspection: 2/23/2005_ 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 (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: X Depth of liquid level above outlet invert: _0 _ Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.):_ D -box level & distribution equal. No evidence of leakage. No evidence of solid carryover._ PUMP CHAMBER: , (locate on site plan) Pump in working order (yes or no): ____ Alarm in working order (yes or no): ____ Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): _ Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 371 Summer Street_ _ North Andover _ Owner: _Doiaher_ Date of Inspection: 2/23/2005_ SOIL ABSORPTION SYSTEM (SAS): X_ (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: _ leaching chambers, number: leaching galleries, number: leaching tranches, number, length: X leaching fields, number, dimensions: _1 field 20' x 451 _ 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 ponding to surface. No sign of hydraulic failure 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 sludge layer: _ Depth of scum layer: _ Dimensions of cesspool: Materials of construction: . Indication of groundwater inflow (yes or no): _ Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): _ PRIVY: (locate on site plan) 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 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 371 Summer Street _ North Andover — Owner: _Dolaher Date of Inspection: 2/23 /2005_ SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Ato1=19'9" Ato2=13'9" A to D -Bog = 26110" BtoI=5'10" B to 2 = 15'5" B to D -Bog = 29'7" D - Bog Water Meter House A Porch Deck B Septic Tank 2 1 45' 20' Driveway Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 371 Summer Street_ _ North Andover— Owner: _Dolaher_ Date of Inspection: _2/23/2005_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water _4'Deep _ Please indicate (check) all methods used to determine the high ground water elevation: X Obtained from system design plans on record - If checked, date of design plan reviewed: _4/30/1977_ 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: _ As per design plan_ Summary Record Card generated on 2/24/2005 10:07:42 AM by Lisa Warren Page 1 Town of North Andover Tax Map # 210-107.A-0166-0000.0 371 SUMMER STREET DOLAHER, DAVID 371 SUMMER STREET N. ANDOVER, MA 01845 Class 101 Single Family Size Total 1.02 Acres FY 2005 UB Mailing Index Name/Address Type Loan Number DOLAHER, DAVID Payor 371 SUMMER STREET N. ANDOVER, MA 01845 UB Account Maint. Property Type Active/Inact. From Account No Cycle Occupant Name Active/Inactive Bldg Id. 7694.0 - 371 SUMMER ST Last Billing Date 12/9/2004 2100274 02 Cycle 02 Active UB Services Maint. Service Code Rate Charge Multiplier/Users MISCFE5 ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 33.60 /1 UB Meter Maintenance . Serial No Status Location Brand Type Size 0027636122 a Active ENC L ? w Water 0.63 0.63 Date Reading Code Consumption Posted Date 2/14/2005 1760 a Actual 11 11/19/2004 1749 a Actual 12 12/17/2004 8/16/2004 1737 a Actual 12 9%20/2004 5/18/2004 1725 m Manual estimate 12 6/14/2004 2/17/2004 1713 a Actual 15 4/16/2004 i rteslaemidi Until YTD Cons 0 Variance 0% -5% 1% -10% 0% �'s'} CC -,> 4^ Ui .� W N I-= �3 � r.7 B'` R=_ wA W 'V '-�, e) � 1; •- -+NNNNNNNNNNNNNC3NN . 2NFieAWNi1I^sr^�G.YNw'+WNk1ri:W'V%� .,:�s�l"O � ONNNNNNNNNNNNNNNN^Ja� .:=ti,:l_C GOMtn WNCIiNWxUiW'Vv'G'', O ^J ATNQ Ntiti�OUlFjff� 6Q?NU^Mul NNNNNNNNNNNNNCII) NN� ^'@@@@@====@@@mm@@.c o ; `trS 14ac zwwww J Q •T C,C�Q umcr,C',0cr,0ululLn. o oa'S.wNs:rd��y:.@ OCO•�7G°tiw?WN-jI-i@Mn0 %WNj" ow+.r. g;V � �' •" �4'+.^W0.^^1NfAebah+�'�'tJl:l1U'94�NCt9@ i �'+] x" # '+a O N.µ. OND ZV9m u 7,4 N.*N0ND.4mMW..v@W@-mIz'. J!# H� IU WNW ra NNNW"VWt�,f-+•WWCvWN'*3NW�darA�r�� JV' � tri "'4 •'a ;w+}°t,, �t Jai.T�m@@@@@wm0rwmM)m@6'. is tll 7.4 " a a a v a 1Y1 .k Kw -7Leiw-, i1 U'1U9UiUlG°1Fal-`M}.+-@@,@@ A-,aNC2<c4r,Ln J1V9@6?{9@Cm@S9@ FZS ti WWW,iW'tJWNWWW,.",WWNW,�,A��O "�- y Y 3 3 ;, µs .N �n . r a A �'s'} CC -,> 4^ Ui .� W N I-= �3 � r.7 B'` R=_ wA W 'V '-�, e) � 1; •- -+NNNNNNNNNNNNNC3NN . 2NFieAWNi1I^sr^�G.YNw'+WNk1ri:W'V%� .,:�s�l"O � ONNNNNNNNNNNNNNNN^Ja� .:=ti,:l_C GOMtn WNCIiNWxUiW'Vv'G'', O ^J ATNQ Ntiti�OUlFjff� 6Q?NU^Mul NNNNNNNNNNNNNCII) NN� ^'@@@@@====@@@mm@@.c o ; `trS 14ac zwwww J Q •T C,C�Q umcr,C',0cr,0ululLn. o oa'S.wNs:rd��y:.@ OCO•�7G°tiw?WN-jI-i@Mn0 %WNj" ow+.r. g;V � �' •" �4'+.^W0.^^1NfAebah+�'�'tJl:l1U'94�NCt9@ i �'+] x" # '+a O N.µ. OND ZV9m u 7,4 N.*N0ND.4mMW..v@W@-mIz'. J!# H� IU WNW ra NNNW"VWt�,f-+•WWCvWN'*3NW�darA�r�� JV' � tri "'4 •'a ;w+}°t,, �t Jai.T�m@@@@@wm0rwmM)m@6'. is tll 7.4 " a a a v a 1Y1 .k Kw -7Leiw-, i1 U'1U9UiUlG°1Fal-`M}.+-@@,@@ A-,aNC2<c4r,Ln J1V9@6?{9@Cm@S9@ FZS ti WWW,iW'tJWNWWW,.",WWNW,�,A��O "�- Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 371 Summer Street, North Andover Owner: Dolaher Date of Inspection: 2/23/2005 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. Bateson Enterprises, Inc. • A WILLIAM F. WELD Governor ARGEO PAUL CELLUCCI Lt. Governor ,=2,1V COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 0 ONE WINTER STREET. BOSTON. NIA 02108 617-292=5500 TRUDY COXE h Secretary i_ DAVID B. STRUHS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECT ON'FORM Commissioner PART A A CE R ,TIFICATION Property Address: 11 / StjVuw�,r- S '• tJ(%A & IA'^ (Address of Owner: Data of Inspection' � -9 Of different) Name of Inspector: iVc, I S \ I am a DEPppr ved system insp ctor pursuant to Section 15.340 of Title 5 (310 CMR" 15.000) Company Name: c Mailing Address: 11% ' Telephone Number: 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: t/Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ F I s �y � Inspector's Signature: c �C�J'�'V Date: / c The System Inspector shall submit a copy of this inspection report to the Approving Authority within ihirty (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 6 tines shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the iystem owner and copies sent to the buyer, if applicable, and the approving authotiiy. INSPECTION SUMMARY: Check A, B, C, or d + A] SYSTEM tnot found any information which indicates that the system violates any of the faiiuie criteria as refined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Condition!! 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 pa's's. Indicate yes, no, or not determined (Y, N, or NO). Describe basis of determination in All instances. if not determined"; explain why not.. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Cettificate of Compliance (attached) indicating that the tank was installed 'within twenty (20) year's prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. ,- (revie*d 04/25/97) *694 S ei 16 DEP on the World Wide Web: h6Ji0MN.mAgnet.dtiite.nra.usldep >� Printed on Recyded Paper y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) d Property Address: Owner: Date of Inspection: q _ a y �C) BJ SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipes) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four times a year due to broken or obsti fitted pipe(s). The system will juts inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed CI 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 ii failing iC protea the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of i bordering vegetated Weiland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND OUBUC WATER SUppLIER, IF Ai'PROftjATE) DETERMlNE6 THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND WET* AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption System 60 and the SAS is Within f00 feet to a Surface wet& 3ii001y or tributary to a surface water supply. _ The system has a septic tank and 'soil ab4orp6on 'system and the SAS i3 within a Zone I of a public Water supply WOO. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water Supply well: _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for Coliform bacteria and volatile organic tompounds indircates that the well is free from pollution from that facility and the presence of amnioma fiitrogen and `nitfate nitr6g0h Is +Equal to or less than 5 ppm. Method used to determine distani (appoitrmation .not valid: 3) OTHER (reviiod 04/35/97) Yalta 2 ei ib P SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM f ` PART A CERTIFICATION (continued) Property Address: ( cj(��n�nVy�e�-- pX— Owner: �^, LI\ c ( � t� � )a K W Date of Inspection: , q - ,L4 DI SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR i SAW. the basis for this determination is identified below. The Board of Health should be contacted to determine what will be fiecessa y to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overbaded o'r 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 i/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed POWs). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool of privy is within 100 feet of asurfacewater 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 fess than 100 feet but greater than to feet from a private water 1 supply Will with ito acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well Water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. . El LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the fdllowing: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the 'system is a significaht thi+eat ib public health and safety and the environment because one or more of the following conditions exist: 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 (1nterirn Wellhead Protection Area = IWPA) or a ittapped ZoM *ll of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance With the groundwater treatrrtertt tirograrn requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the bepattrtieni for further ihforrhAtiofi. (revised 04/1S/97) pays ! 6i io 4 SUBSURFACE SEWAGE DISPOSAL 51tOEM MfttTiON FORM PA -RT I C14CKUst Property Address: SQ Mvrl Owner: Date of I nspection.K V)A&A ..q -� 4 - CI ir-1 Check if the following have been done: You most indicate either "Yes' or "No" As to each of the foll6Wing: Yes o mping information Was provided by the owner, occupant, or Board of Health. None of the system corn ponents have been pumped fo'r at least two i and the systirh hit bion" 4divIiIii n6fthal flow rates during that period. Large volurnk of )f *ater have not been int'rod'uced into the 06M recently or as part of this inspection. As built plant have been obtained and examined. Wi if they are h6i available With N/A. The facility or dwelling g was inspected for signs of se*agii back-up. The system does not receive non -sanitary or industrial %4*16 flow. The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, h-7ve- been located on the site. The septic tank manholes were uncovered; opened, And thii interior of the teptic.tank was Impeded for condition of baffles or tees, material of construction, dimensioris, d6oth, of liquid, depth of sludge, depth of kdfti. The size and location of the Soil Absorption System on the `site has been determined based on: The facility owner (and occupants; it different from owner) were provided with information on thik pirdoOt MgihtenAhL# of Sub -Sur . face Disposal System. Existing information. Ex. Plan at B.O.H. L Determined in the field (if any of the failure criteria related to Part C it at issue, approximation of distancii is unacceptable) 115.302(3)(b)] (:wised 04/2S/07). jaiii A U 10 ,c - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ,( SYSTEM INFORMATION Property Address: so Owner: Date of Inspection: C(_��_� FLOW CONDITIONS RESIDENTIAL: Design flow: .p/bedroom for S.A.S. Number of bedrooms: Number of current residents: Q Garbage grinder (yes or no):—y4—> 9% Laundry connected to syslem (yes or no):�S Seasonal use lyes or no): 1 D 3 r -_ t Water meter readings, if available (last two (2) year usage (gpd): ! ��' SQcrt,E.IS Sump Pump lyes or no):N es Last date of occupancy: COMMERC I.AUI NDUSTRIAL: Type of establishment: Design flow: gallons/day Grease trap present: lyes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non -sanitary waste discharged to the Title 5 system: (yes or ho) Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information I o -Rs p fu V�Q.t"' System pumped as part of inspection: (yes or no) If yes, volume pumped: ISMO allons 0 Reason for pumping: %Vs c , TYPE OF TEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection ie -cords, if any) VA Technology etc. Copy of up to date contract? Other APPROXI TE AGE of all components, date installed (if known) and source of information: Dy\ 1+ P I at,-, Sewage odors detected when arriving at the site: (yes or no) ID iv, - (revised 04/25/97) Oags 6 be 16 SUBSURFACE SEWAGE DISPOSAL SyStEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) PropertyAddress: 3 h i !�u t au-tf-- --s -V IV' AL `� Owner: R�, Date of Inspection: BUILDING SEWER: (Locate on site plan) zoiher Depth below grade:IainMaterial of construction: cast iron _ 40 PVC exp ) Distance from private water supply well or suction lire I (. Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:..// (locate on site plan) It Depth below grade: Material of construction: _1 concrete _metal _Fiberglass _Polyethylene _.other(explainj If tank is metal, list age _ Is age confirmed by Certificate of Compliance _ (Yes/No) Dimensions:©t t y- `{ ` I Sludge depth:cf.__ a t tt of outlet tee or baffle: Disfance from top of sludge to bottom Scum thickness: 'all $ t' Distance from top of scum to top of outlet tee or baffle: j I Distance from bottom of scum to bot;prn 0 outlet tee, or baffle: How dimensions were determined: 6= v-c��L— Comments: (recommendation for pumping, conditi unlet and outlet tees or ba es, hof liq}�id rev n ' 1ai' n outer intpority_ evidence of leakage, etc.) GREASE TRAP: r*10�*� (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene other(expiain) 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: . (recommendation for pumping, condition of inlet and oinlet tees o'r baffles, depth of litjuid level in Fetation to bullet invert, structural integrity, evidence of leakage, etc.) 0,. (revised 04/2S/97) Dag 6 e 10 C� I .y SUBSURFACE SEWAGE DiSPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: hj I 15UWgk Owner: ( (`)Ccv't Date of inspection: mat t_9t.7 TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or 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 level: Alarm in working order — Yes; _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) s DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: 49 PUMP CHAMBER: �'�`'( S� r (locate on site plan) V V Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenantes, etc.) (revised 04/25/97) OiLye 7 of 16 Ji - SUBSURFACE SEWAGE biSPOSAl. SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address : '�'11 V Vv& � w Owner: Date of Inspection: nl a�11�}I r SOIL ABSORPTION ``SYSTEM (SAS):`Ttl� (locate on site plan, if possible; excavation )not required, but may be approximated by non -intrusive meihods) If not determined to be present, explain: Type: leaching pits, number:, leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length:�_ ��e1� leaching fields, number, dimensions: aO X µl overflow cesspool, number: Alternative system: Name of Technology: Comments: (note con ition f soil, signs of by raulic failure, level of ponding, condition of vegetation, etc.) CESSPOOLS: J"A (locate on site plan) Number and configuration: Depth -top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: . . Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, eic.) PRIVY: IYA-6 (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.) IF - (revised 04/25/97) Pigs 8 ei 16 I ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection. SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmark's or benchmarks locate all wells within 100' (Locate where public water 'supply comes into house) K Q� Wt � e i t�ul d+ 3� tc � I A -lo 3 i �3)� it a� l( • f 155 (revised 04/25/97) Pigs 9 bi id Y ' . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C • • SYSTEM INFORMATION (continued) Property Address:- U w.-� ( . Owner: Date of Inspection.hc• � ," i cJ1e'(— �1� ��- � v� `"I"-cTL4- —c? t7 Depth to Groundwater L1 Feet Please indicate all the methods used to determine High Groundwater Elevation: y Obtained from Design Plans on record " Observation of Site (Abutting property, observation hole, basement sump etc.) 1, Determine it from local conditions LI—Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) (revised 04/25/97) Page 16 eL 16 TFL: (508) 475-1474 FAX: (508) 475-5451 BATESON ENTERPRISES, INC. Excavating - Water & Sewer Lines - Septic Systems & Pumping Service 111 Argilla Road r . Andover; Mass. 01810 Title 5 Inspection Report 31,11 SU yNA K, O -,q- s� . "l Property Address: ------------------ EM f . OwV1 '�- S'�q � q N'p f- Owner:----------------------------- Q- -au�a Date Of Inspection: ---------------- My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. J-1 Neil J. Bateson Bateson Enterprises Inc: 11 of 11 FORM 4 - SYSTEM PUNHILNG RECORD Conunonwealth of Massachusetts , Massachusetts ►ystem PumBeing Record •stem Owner � 65— Date n Date of Pumping 1c) �' � Quantity Pumped: Cesspool: No Yes ❑ gentir Tant-• X'- Yes System Pumped by.- License #. Contents transferred to: ' Date Inspector titMot L6 H Oofci or I'limplog: q - I ��---�� Coottilivol No I 8-C-4 (A ,Yklmo Pillopt(I by, CoMM1.4 It 01JObf tial It! - 001t: - vv, 1,001,