HomeMy WebLinkAboutMiscellaneous - 374 SHARPNERS POND ROAD 4/30/2018N 4
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Commonwealth of Massachusetts
H City/Town of NORTH ANDOVER ~�
a System Pumping Record 2014
C'
Form 4 'i I
M Spey`'
to','JIf L.J.�f}
DEP has provided this form for use by local Boards of Health. Other forms may be ised,'but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must he submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important: When
filling out forms
1. System Location:
on the computer,
use only the tab
374 SHARPNERS POND ROAD
key to move your
Address
cursor - do not
NORTH ANDOVER
use the return
City/Town
key.
VQ 2. System Owner:
JAMES FARO
Name
redrn
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
10/13/14
Date
MA
State
State
Telephone Number
2. Quantity Pumped:
3. Component: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No
5. Observed condition of component pumped:
GOOD CONDITION
6. System Pumped By:
JAMES H CURRIER II
Name
X SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD
01845
Zip Code
Zip Code
1500
Gallons
❑ Grease Trap
If yes, was it cleaned? ❑ Yes ❑ No
H79 406
Vehicle License Number
10/13/14
Signature Hauler Date
Signature of Receiving Facility (or attach facility receipt) Date
t5form4.doc• 11/12 System Pumping Record • Page 1 of 1
�L\ Commonwealth of Massachusetts
N
City/Town of NO. ANDOVER RECEIVED
a System Pumping Record
Form 4 2013
G7 6yey`v
DEP has provided this form for use by local Boards of Health. Other forms T
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer, use 374 SHARPNERS POND RD.
only the tab key Address
to move your NO. ANDOVER MA 01845
cursor - do not City/Town
use the returnState Zip Code
key. 2. System Owner:
QJAMES FARO
Name
Address (if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 1/8/13
p g Date 2. Quantity Pumped:
3. Type of system: ❑ cesspool(s) ® Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ® No
5. Condition of System:
1500
Gallons
❑ Grease Trap
If yes, was it cleaned? ❑ Yes ❑ No
6. System Pumped By:
JAMES H. CURRIER
H79 406
Name
Vehicle License Number
J's SEPTIC & DRAIN
Company
7. Location where contents were disposed:
GLSD Az
118/13
Signaturel6f Hauler .
Date
Signature of Receiving Facility
Date
t5form4.doc• 03/06
System Pumping Record • Page 1 of 1
MORTN 5 0 1 6
Fj •. • Cp
Town of North Andover
�+�'•>,;,,o:: HEALTH DEPARTMENT
,s•SACNUSt�
CHECK #: % DATE: �02/
LOCATION:'
H/O NAME:
CONTRA NAM
Type
of Permit or License: (Check box)
❑
Animal
$
❑
Body Art Establishment
$
❑
Body Art Practitioner
$
❑
Dumpster
$
❑
Food Service - Type:
$
❑
Funeral Directors
$
❑
Massage Establishment
$
❑
Massage Practice
$
❑
Offal (Septic) Hauler
$
❑
Recreational Camp
$
❑
Sun tanning
$
❑
Swimming Pool
$
❑
Tobacco
$
❑
Trash/Solid Waste Hauler
$
❑
Well Construction
$
SEPTIC Sustems:
❑ Septic - Soil Testing $
❑ Septic - Design Approval $
❑ Septic Disposal Works Construction (DWC) $
❑ Septic Disposal Works Installers (DWI) $
❑Z5it'le
Inspector $
Report
❑ Other: (Indicate) $
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
N__`=
140
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System.F07rrh- Not for Voluntary Assessments
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
VQ
a�
4---"4 -
State Zip Code Date
MAY 2 1 Z,g10
OF NO MbOVgg
Inspection results must be submitted on this form. Inspection forms may not be altered in an
way. Please see completeness checklist at the end of the form. A
A. General Information
6�!C' F kA � cl
Tele one Num er License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
[� Passes ❑ Conditionally Passes ❑ Fails
`❑ Needs Further Evaluation by the Local Approving Authority
I
I nspkctgr`s'Signature/ Date
The sysTem-irispector 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 • 09/08 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 1 of 17
Property F
Owner
Owner's N
information is
required for
every page.
City/Town
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
VQ
a�
4---"4 -
State Zip Code Date
MAY 2 1 Z,g10
OF NO MbOVgg
Inspection results must be submitted on this form. Inspection forms may not be altered in an
way. Please see completeness checklist at the end of the form. A
A. General Information
6�!C' F kA � cl
Tele one Num er License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
[� Passes ❑ Conditionally Passes ❑ Fails
`❑ Needs Further Evaluation by the Local Approving Authority
I
I nspkctgr`s'Signature/ Date
The sysTem-irispector 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 • 09/08 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form.- Not for Voluntary Assessments
Owner Owner'4 N
information is
required for
every page. City/Town
B. Certification (cont.)
State Zip Code Date of
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes:
I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Seepage Disposal System Form - Not for Voluntary Assessments
Owner Own am
information is Al.
required for A OT
every page. City/ I own
B. Certification (cont.)
X0 B) System Conditionally Passes (cont.):
Stale Zip Code Date
❑ 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
❑ Y ❑ N ❑ ND (Explain below):
❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if (with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17
wo
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property
city/ To* - '
B. Certification (cont.)
State Zip Code Date
�V1h
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 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 • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Add ess
Owner Owner'
nformation is
required for
every page. CitylTown *StatZip Code Date of Ip pe ion
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
e
E] 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.
El Any portion of a cesspool or privy is within 50 feet of a private water supply w
❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 fee
from a private water supply well with no acceptable water quality analysis. [Th
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 analys
and chain of custody must be attached to this form.]
E] 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
E] E] 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 • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17
i
II.
t
is
is
❑ ❑ 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 • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal Syst9q Form - Not for Voluntary Assessments
City/Town
C. Checklist
State Zip Code Date of
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?
1:11 Have large volumes of water been introduced to the system recently or as part of
this inspection?
V' ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
P ❑ Was the facility or dwelling inspected for signs of sewage back up?
Ej-?'�❑ Was the site inspected for signs of break out?
U+' ❑ 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?
�-r, Was the facility owner (and occupants if different from owner) provided with
J�'/ E] 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.
❑ 2/-' 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)]
� -14-0">
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):
t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 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
, 4.., di
Property Address
Owner's Name
City/Town Sta a Zip Code Date of In pec on
D. System Information
Description:
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ;?f No
Is laundry on a separate sewage system? [if yes separate inspection required] 0 Yes ❑ No
Laundry system inspected? 0 Yes ❑ No
Seasonal use? /10 ❑ Yes No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump?
Last date of occupancy:
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present?
Industrial waste holding tank present?
Non -sanitary waste discharged to the Title 5 system?
Water meter readings, if available:
❑ Yes 2 -IN
Date
Gallons per day (gpd)
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Dispgsal System Form I Not for Voluntary Assessments
Property Address
Owner's Name
City/Town t4tate Zip Code Date ofVpEWtion
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? ❑ Yes � No
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
gallons
Type of System:
Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other (describe):
t5ins • 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
D. System Information (cont.)
Zip Code Date of
Approximateageof 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:
PIC'ast iron ❑ 40 PVC ❑ other (explain):
Distance from private water supply well or suction line'
❑ Yes [/ No
feet
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
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)
Dimensions:
Sludge depth:
❑ Yes ❑ No
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17
Property AddreMI `
azo
Owner
Owner's Nam
information is
required for
every page.
City/Town
D. System Information (cont.)
Zip Code Date of
Approximateageof 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:
PIC'ast iron ❑ 40 PVC ❑ other (explain):
Distance from private water supply well or suction line'
❑ Yes [/ No
feet
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
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)
Dimensions:
Sludge depth:
❑ Yes ❑ No
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 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
Property
D. System Information (cont.)
Septic Tank (cont.) !
Distance from top of sludge to bottom of outlet tee or baffle �---�—
Scum thickness
!/
Distance from top of scum to top of outlet tee or baffle �'�
Distance from bottom of scum to bottom of outlet tee or baffle ~ 6Q� 14A�r"
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
•s
OGrease Trap (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal
Dimensions:
Scum thickness
feet
❑ fiberglass ❑ polyethylene ❑ other (explain):
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for oluntary Assessments
Property Addre n
Owner Owner's N
information is
required for
every page. City/Town
Zip Code Date of
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.):
fight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
I
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain):
Dimensions:
Capacity:
Design Flow:
gallons
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins - 09/08 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not foyVoluntary Assessments
Property E
Owner Owner's �
information is
required for
every page. City/Town
l5ins - 09/08
D. System Information (cont.)
State Zip Code Date
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert '
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.):
Opump Chamber (locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not
why:
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17
Commonwealth of Massachusetts
- W Title 5 Official Inspection Form
Subsurface Sewage Dispo al System Form - Not for Voluntary Assessments
' M
Property Ad esy/'\
Owner
information is
required for
every page.
t5ins - 09/08
Owner's
City/Town State
D. System Information (cont.)
Type:
Date of I
•v
❑
leaching pits
number:
❑
leaching chambers
number:
❑
leaching galleries
number:
leaching trenches
length: e
number,
❑
leaching fields
number, dimensions:
❑
overflow cesspool
number:
❑
innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure,
level of ponding, damp soil, condition of
vegetation,
etc.):
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth — top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17
t,.
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal Systefn Form - Not for Voluntary Assessments
Zip Code Date
D. System Information (cont.)
?d
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 - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 17
iF
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage pisposal System Form - Not for Voluntary Assessments
OwnQf's Na e 1
City/Town
D. System Information (cont.)
Zip Code Date
CJ
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:
F— hand -sketch in the area below
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property
Owner's
City/Town
D. System Information (cont.)
Site Exam:
heck Slope
urface water
Zip Code Date of
heck tlar
Shallow wells
Estimated depth to high ground water: �1. l
feet
Please indicate all methods used to determine the high ground water elevation:
Obtained from system design plans on record
If checked, date of design plan reviewed: 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
nd 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
Property Address
Owner's Name/
CitylTown AtateZip Code Date of InAictiqK
E. Report Completeness Checklist
nspection Summary: A, B, C, D, or E checked
spection Summary D (System Failure Criteria Applicable to All Systems) completed
❑ System Information — Estimated depth to high groundwater
etch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17
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North Andover Board of Assessors Public Access
Click Seal To Return
Search for Parcels
Search for Sales
Summary
Residence
Detached Structure
Condo
Commercial
111 W-0111211 11, 11�1112 =1*1 n-41
Parcel ID :210/090.B-0049-0000.0 FY:2010
SKETCH
Click on Sketch to Enlarge
Page 1 of 2
77 1
IPropert3
Community :1`
PHOTO
Click on Photo to
374 SHARPNERS POND ROAD
http:Hcsc-ma.us/PROPAPP/display.do?linkld=1521104&town=NandoverPubAcc 4/27/2010
Location: 374 SHARPNERS POND ROAD
Owner Name: FARO, JAMES W
MARIE A FARO
Owner Address: 374 SHARPNERS POND ROAD
City: NORTH ANDOVER State: MA Zir
Neighborhood: 5 - 5 Land Area:
1.
Use Code: 101-SNGL-FAM-RES Total Finished Area: 2,
ASSESSMENTS CURRENT YEAR
PREVIO
Total Value: 453,800
5W
Building Value: 255,800
30 0)
Land Value: 198,000
1%
Market Land Value: 198,000
Chapter Land Value:
LATESTSALE
Sale Price: 265,000 Sale Date:
09/16/1986
Arms Length Sale Code: Y -YES -VALID Grantor:
FARR BET
HOMES Il\
http:Hcsc-ma.us/PROPAPP/display.do?linkld=1521104&town=NandoverPubAcc 4/27/2010
a n .
end Septic dd t0®ns
Systems
Why do 1 need this approval?: The Health
Department must approve all applications for
additions to houses served by a septic system
before the Building Department will issue any
permit. This is because there are several things
that the Health Department must check, namely:
• Does the addition meet setback
requirements?
Is the septic system working now?
• Where exactly is the septic system?
• Will there be more flow to the system?
• Does the system currently comply with
relevant regulations?
• Is the system large enough to handle any
extra flow?
• Is there room enough on the lot for a new
system and a reserve?
All these questions address the problem of
whether the septic system is or can be made
large enough for the maximum number of
people the house could hold. An addition of any
kind when there is a septic system on the site is
considered "new construction".
What do 1 need?: You will need to submit floor
plans for the proposed addition along with a
complete floor plan of all floors of the house as it
currently exists. The two plans should be in the
same scale. You will also need a certified plot
plan showing the outline of the existing house,
the proposed addition, the location of the septic
system, and any wells or pools on the site. These
Should all be to scale. It is also recommended
that you have your septic system inspected by a
certified Septic System Inspector. It is important
that your inspector checks on the size of your
septic system as well as how well it is working.
Who do I see? See the Health Department if
You cannot locate the septic system; there may
be a plan on file. See the Zoning Officer to find
out if your lot and the proposed addition meet
# HD -03
Zoning requirements. Check with the
Conservation Department to discover whether
wetlands will be a factor in your project. Then
submit your entire package to the Health
Department for a decision on your septic
system's fate. A Civil Engineer could help you
With this process.
How do I do this?: To start the process you must
first go to the Building Department and apply for
a permit for an addition. You will pay a fee and
receive some paperwork. You will probably have
to go through the Conservation Commission
process if there are any wetlands anywhere near
your project site. If your site is located in tho kake
Cochiewick watershed, then you should check
with the Planning Department to see if you need
a special permit. If you have submitted your
application to the Board of Health, staff can be
reviewing it while you are going through other
departmental processes. A final approval and
permission for a building permit will depend on
the approval of all pertinent departments.
Other References:
• 310 CMR 15.000 Title 5 (You can
download a copy of Title 5 at
w vvw.state.ma.us de br wwrn t5 ubs.
tm)
• Town of North Andover Requirements for
the Subsurface Disposal of Sewage
• . List of properties in the Watershed (in the
Community Development and Services
office at 27 Charles Street)
Town of North Andover Health Department - Community Development & Services Division
This brochure is intended nor educational purposes only. It does not cover al1Jurisdictions or scenarios that o
permit application maybe subject to. Permit applications are site specific. y ur
ow
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107 Forest St. N FORM 4 - SYSTEM PnIPI G RECORD
Middleton, MA 01949
(508) 774-2772
Commonwealth of Massachusetts
Massachusetts
w
System P n2th- E Record
Location
Date of Pumping: ` Quantity Pumped: lei% all
r € •ns
Cesspool: No ❑ Yes ❑ Septic Tank: No ❑ Yes
System Pumped by:
License #:
Contents transferred to:
Date
Inspector
0 THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY 0
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: J---�hAa
SI'STE.,N1 OWNER & ADDRESS
D:vTE' OF PUMPING:
CI SSPOOL; NO YES
SYSTEM LOCATION
(example: left front of house)
QUANTITY PUMPED 15D-� GALLONS
SEPTIC TANK: NO YES
N,aTURE OF SERVICE: ROUTINE - EMERGENCY
UI3S1,'R%'AT10NS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
.1)YSTI7.,N1 PUMPED BY:
coM.'1'1ENTS:
(:UN"1'I��.N"1'S T}ZANSFERRLll "1'U:
FULL `hO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
TOWN OF NORTH ANDOVERof ,►ORTN 7
/ Office of COMMUNITY DEVELOPMENT AND SERVICES `,�.o
�.: d . o
HEALTH DEPARTMENT
400 OSGOOD STREET
NORTH ANDOVER, MASSACHUSETTS 01845
Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone
978.688.9542 —FAX
Public Health Director E-MAIL: healthdept a townofnorthandover.com
WEBSITE: http://www.townofnorthandover.com
April 11, 2005
To all Sharpeners Pond Road Residents:
Please note that it has come to the attention of the Health Department that many residents are
leaving their trash barrels and trash bags out at the curbside for days, or weeks at a time.
Empty trash barrels blowing about in the road are a safety hazard, and trash and debris along the
roadway is a health hazard. Please be mindful of this, as the Health Department will conduct
periodic inspections of the area to determine who is in violation, and fines will be issued if
protocol is not followed.
The Board of Health follows the State Sanitary Code regarding Human Habitation,
105.CMR.410, Section 1:
410.600
(A): Garbage or mixed garbage and rubbish shall be stored in watertight receptacles with tight-
fitting covers. Said receptacles and covers shall be of metal or other durable, rodent -proof
material. Rubbish shall be stored in receptacles of metal or other durable, rodent -proof material.
Garbage and rubbish shall be put out for collection no earlier than the day of collection.
(B): Plastic bags shall be used to store garbage or mixed rubbish and garbage only if used as a
liner in watertight receptacles with tight -fitting covers as required in 105 CMR 410.600(A),
provided that the plastic bags may be put out for collection except in those places where such
practice is prohibited by local rule or ordinance or except in those cases where the Department of
Public Health determines that such practice constitutes a health problem. For purposes of the
preceding sentence in making its determination the Department shall consider, among other
things, evidence of strewn garbage, torn garbage bags, or evidence of rodents.
410.602
(A) Land. The owner of any parcel of land, vacant or otherwise, shall be responsible for
maintaining such parcel of land in a clean and sanitary condition and free from garbage, rubbish
or other refuse. The owner of such parcel of land shall correct any condition caused by or on
such parcel or its appurtenance which affects the health or safety, and well-being of the
occupants of any dwelling or of the general public.
(D) Common Areas. The owner of any dwelling abutting a private passageway or right-of-way
owned or used in common with other dwellings or which the owner or occupants under his
control have the right to use or are in fact using shall be responsible for maintaining in a clean
and sanitary condition free of garbage, rubbish, other filth or causes of sickness that part of the
passageway or right-of-way which abuts his property and which he or the occupants under his
control have the right to use, or are in fact using, or which he owns.
Residents should know the following:
.y
• The Town has a mandatory paper and cardboard recycling ordinance that requires
residents to separate these items from their household trash. Paper and cardboard are
collected every other week on the same day as the household's normal trash. Residents
can call the DPW at 978.685.0950 to get their recycling schedule.
• Residents are responsible for picking up loose trash left at the curb after collection.
Banned Items and Recycling Requirements:
Please refer to the DPW website for a complete list of all the recycling requirements:
hitp://www.northandoverrecycles.com.
Please contact the Health Department if you have any additional questions. Thank you.
l
Sawyer, REHS/RS
Public Health Director
File
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FML APPROVAL
/V �530,q
' BOARD OF HEALTH
j Town of North Andover,Mass.
Permit # Ir� � Y
APPLICATION FOR WELL & PUMP PERMIT
Application is hereby made for permit to drill a well (). Application'is
made to install (_) a pump system-. _
Location: Address /� �y /-1� (_47 -W -Lot ## :7... .
�6Y�� �CC1�Y Address
Owner ���eZ1etl , k, Tel. gZ-
Well Contractor �� ke)1_11k5 Address
/JC� � Tel.---
Pump ContractortAddress Tela
WELL CONTRACTOR (To be completed at time of pump test)
Type of Well
Well used for
Diameter of Well
Size of Casing
Depth of Bed Rock
r
Depth casing into Bed Rock
Was Seal Tested? Yes (_) No (_)
Date of Testing
Depth of Well
Well Ended in What Material
Depth to Water
Delivers Gals.Per Min. for 4 hours
Drawdown feet after pumping
hours at GPM
Date of Completion
Signature Well Contractor
PUMP INSTALLER (To be filled in before
installation)
Size & Name Pump
Pump Type Used
Water Pump Delivers GPM
Size of Tank
Pipe Material Used in Well: Cast Iron
(_) Galvanized ( ) Plastic ( )
Well Pit (_) or Pitless Adapter ( )
Was sleeve used to protect pipe? Yes
(_) NO(_) Type or Name Well Seal
Date
Date Water analysis report submitted
to Board of Health
Date release given tD owner of record
& Bldg. Insp
Health Inspector
BOARD OF HEALTH
No.Andover, �iass.
SUBSURFACE DISPOSAL DEMON CHECK LIST
7 r_A
LOT #SH�I«N�yTZS ,YO�D
APPROVED DATE S- I
Provided:
DISAPPROVED DATE
Reasons:
Title V
Reg 2.5
Reg 6
Reg 10.2
Reg 10.1
FAIL
The submitted plan must show as a minimum:
a) the lot to be served -area, dimensions lot #,abutters
b location and log deep observation Mes-distance to ties
c location and results percolation tests -distance to ties
d design calculations & calculations showing required leaching area
(e) location and dimensions of system -including reserve area
f) existing and proposed contours
(g) location any wet areas within 100' of sewage disposal system or
disclaimer -check wetlands mapping
(h) surface and subsurface drains within 1001 of sewage disposal
system or disclaimer
(i) location any drainage easements within 1001 of sewage disposal
system or disclaimer -Planning Board files
(j) know sources of water supply within 2001 of sewage disposal a
system or disclaimer
(k) location of any proposed well to serve lot -1001 from leaching facility
(1) location of water lines on property -101 from leaching facility
(m) location of benchmark
(n) driveways
(o) garbage disposals
(p) no PVC to be used in construction
(q) profile of system -elevations of basement, plumb, pipe, septic tank,
distribution box inlets and outlets, distribution field piping and
Other elevations
(r) maximum ground water elevation in area sewage disposal system
(s) plan must be prepared by a Professional Engineer or other
professional authorized by law to prepare such plans
Septic Tanks
(a) capcapac tties-150$ of flow, water table, tees, depth of tees,
access, pumping
(b) cleanout
(c) 101 from cellar wall or inground swI a mi ng pool
(d) 251 from subsurface drains
Distribution Boxes
(a) slope gra—te-F-ENE 0.08
b) su p