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HomeMy WebLinkAboutMiscellaneous - 380 FOREST STREET 4/30/2018IL Commonwealth of Massachusetts City/Town of a W° System Pumping Record RECEIVE® Form 4 0�,j 19 LU I DEP has provided this form for use by local Boards of Health. Other orms may be used, but t e information must be substantially the same as that provided here. B with your local Board of Health to determine the form they use. The System P §D& s bmitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left front of house, right front of house, left side of house, right side of house, Left rear of hous rlg t rear of houses eft side of building, right rear of building, under deck. © �jd__(. City/Town 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ State Zip Code Stat'- ^ "t ^ Telephone Number Date 2. Quantity Pumped: Gallons Cesspools)Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes L''f'No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of„Sys$em: - V\ �4zf;r 6. System Pumped By Neil J. Bateson Name Bateson Enterprises Inc. Company 7. Location where contents were disposed: G.L.S.D�LQweJ�l taste Water^ �— d � , Signature of F5821 Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts R 111vb C ity/Town ofAPR 20 Q a W° 11 System Pumping Record Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System -Loc ti�t Left front of house, right front of house, left side of house, right side of house Left/ �.rirar of house right rear of house, left side of building, right rear of building, under deck. City/Town State Zip Code 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ Date Cesspool(s) Sta _Zip Code Telephone Number — 2. Quantity Pumped: 2-'ge'ptic Tank Gallons ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ . Yes 0No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System- I� (rzv 6. System Pumped By: Neil J. Bateson Name Bateson Enterprises Inc. Company 7. Locatio where contents were disposed: J L.S.D. ell Wa to Water, t5form4.doc• 06/03 F5821 Vehicle License Number Date System Pumping Record • Page 1 of 1 t. Dellehiaie, Pamela From: Sawyer, Susan Sent: Tuesday, May 11, 2010 1:28 PM To: DelleChiaie, Pamela; Grant, Michele Subject: 380 forest Title V FYI The Title V for this property had to attach a water test. .It was missing the results for "ammonia nitrogen" I checked with Linda Hmurciak for advice and then called the lab. The lab says they were not asked to do the test. I called Neil Bateson and he will be contacting the realtor to do a test. I left a message for Ryan Flanagan with Salem V to call me back and if he does you can give him the information. Once received, the Health Dept. will give the ok if the level is under recommended amounts. I am giving Pam back the paperwork to hang on to it. Thx S 5 1a a0 i0 Cin rn 4a-+ ha-- L-� '�e. (��x_ P50� a(n mom �cc� {� Cr�o�, C Delle;hiaie, Pamela From: Sawyer, Susan Sent: ay 2010 10:20 AM To: C:De:lleehiaie,PameSubject: orest If the realtor, Ryan Flanagan, calls about 380's Title V, please tell him that I will be reviewing it this afternoon and should have a handle on it after 3:30. He called, but I am holding of returning his call until I have an answer to a question I have. thx 1 Of ANO oily , _0 51 1 ♦ 09 Town of North Andover HEALTH DEPARTMENT Ssemus° CHECK #: DATE: LOCATION: H/O NAME: CONTRACTOR NAMEt 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 _ $ ❑ I Trash/Solid Waste Hauler $ O Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ;T*t' T*tl Inspector $ Title 5 Report $ ❑ Other. (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer i 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. Comn nv4ealth � )f MassacKusetts Title 5 Of'icialllnsection For p 7AMW0M6VVgg1Fat Subsurface Sewage Disposal System Form - Not for Voluntary Ass ssme N 380 Forest Street WOM, Fri Property Address EAL17�1 � W Frank Letizia DEPAR Owner's Name North Andover MA 01845 4/10/2010 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. A. General Information 1. Inspector: Neil J. Bateson Name of Inspector Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover City/Town 9784754786 Telephone Number. B. Certification. Ma 01810 State Zip Code SI15 License Number I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes ❑ Fails ® Nee s Further Evaluation by the Local Approving Authority 4/10/2010 In pectol° Signa 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 - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 1 of 17 M Owner information is required for every page. t5ins • 09/08 i• Commonwealth of Massacftusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 380 Forest Street Property Address Frank Letizia Owner's Name North Andover MA 01845 4/10/2010 City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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 11 Commonwealth of Massachusetts a Title 5 Official Inspe Subsurface Sewage Disposal System Form - 380 Forest Street Property Address Frank Letizia Owner Owner's Name nformequine fo tiis North Andover required for every page. Cityrrown B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ 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 I' ❑ 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 ction Form Not for Voluntary Assessments MA 01845 4/10/2010 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 ❑ 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 I' ❑ 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 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 380 Forest Street Property Address Frank Letizia Owner's Name North Andover MA 01845 4/10/2010 Cityrrown 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: tape measure ** 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 '/2 day flow t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts W . Title 5 Official Insp Subsurface Sewage Disposal System Form 380 Forest Street Property Address Frank Letizia Owner Owner's Name nformation is required for North Andover every page. CityrFown B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or ection Form ❑ ® - Not for Voluntary Assessments ❑ ® 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 i laboratory, for fecal coliform bacteria indicates absent and the presence MA 01845 4/10/2010 provided that no other failure criteria are triggered. A copy of the analysis State Zip Code Date of Inspection ❑ ® 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- 1 0,000g pd. ❑ ® 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 • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts N r Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 380 Forest Street Owner information is required for every page. Property Address Frank Letizia Owner's Name North Andover City town C. Checklist MA State 01845 4/10/2010 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No I I Pumping information was provided by the owner, occupant, or Board of Health Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Existing information. For example; a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): N/A Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): N/A t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17 Commonwealth of Massachusetts G Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 380 Forest Street Property Address Frank Letizia Owner Owner's Name information is required for North Andover MA 01845 4/10/2010 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 9 ( Y 9 (gP ))� On well water Detail: Tank 55' to well, D -box 75' to well Sump pump? ❑ Yes ® No Last date of occupancy: Current 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 - 09/08 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts a W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 380 Forest Street Property Address Frank Letizia Owner Owner's Name information is required for North Andover MA 01845 4/10/2010 every page. City/Town 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: Unknown Date Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: gallons ® 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 �M 380 Forest Street Property Address Frank Letizia Owner information is required for every page. Owner's Name North Andover Cityrrown D. System Information (cont.) MA 01845 State Zip Code 4/10/2010 Date of Inspection Approximate age of all components, date installed (if known) and source of information: Tank installed 1999, d -box & trenches original, info at B.O.H. Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 1 feet ❑ Yes ® No ❑ 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: 10'x5'x4' Sludge depth: 1" ❑ Yes ❑ No t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 M 380 Forest Street Owner information is required for every page. t5ins • 09/08 Property Address Frank Letizia Owner's Name North Andover CityrFown 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 26" 1„ 8" 14" 4/10/2010 Date of Inspection How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage Grease Trap (locate on site plan): Depth below grade: feet 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: Date 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 380 Forest Street Property Address Frank Letizia Owner Owner's Name information is required for North Andover MA 01845 4/10/2010 every 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 ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: 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 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 380 Forest Street Property Address Frank Letizia Owner's Name North Andover MA 01845 4/10/2010 Citylrown State Zip Code Date of Inspection D. System. Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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. Evidence of light carryover. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required):, If SAS not located, explain why: t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 380 Forest Street Owner information is required for every page. t5ins • 09/08 Property Address Frank Letizia Owner's Name North Andover Cityrrown State D. System Information (cont.) leaching pits leaching chambers leaching galleries leaching trenches leaching fields overflow cesspool 01845 4/10/2010 Zip Code Date of Inspection number: — number: number: number, length: number, dimensions: number: 5 trenches 30' long ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetation ok. No sign of ponding to surface. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth – top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts N v u Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 380 Forest Street Owner information is required for every page. Property Address Frank Letizia Owner's Name North Andover Cityrrown State 01845 4/10/2010 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 • 09/08 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 14 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 380 Forest Street Property Address Frank Letizia Owner's Name North Andover MA 01845 4/10/2010 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 kpt(( o-� = t — A_0 Ci AQ,-" 7 0 ` -l-v A-u,'�—_ = -box— q© r D-) 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 380 Forest Street Property Address Frank Letizia Owner's Name North Andover Cityrrown D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water MA 01845 State Zip Code >6 4/10/2010 Date of Inspection 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: Essex County Soil Map You must describe how you established the high ground water elevation: Essex County Soil Map, Sheet # 36, Canton Soil, Water > 6' deep. 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. t5ins - 09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 380 Forest Street Property Address Frank Letizia Owner's Name North Andover RAA Cityrrown State E. Report Completeness Checklist 01845 Zip Code 4/10/2010 Date of Inspection ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 110 ry f NEW ENGLAND RADON, LTD. 603-893-4260 Fax: 603-893-8163 11A Industrial Way Email: despinal@newenglandradon.com Salem, New Hampshire 03079 Website: www.newenglandradon.com ER WATER ANALYSIS RESULTS DATE: 29 Mar 2010 KEVIN BORERI 44 PARK ST ANDOVER, MA 01810 LAB#:t 62948 Date & time Sampled: 03/27/2010, 1000 Date Received: -------------------------------------------------------------------------- 03/27/2010 RJ INSP TEST SITE: 380 FORREST STREET, NO ANDOVER, MA (538609) PARAMETERS RESULTS REQUIREMENTS ANALYTICAL DATE OF MCL/SMCL METHOD ANALYSIS HARDNESS *# <5.0 75 mg/1 SM2340C 03/29/2010 IRON * <0.1 0.3 mg/1 EPA 200.8 03/29/2010 MANGANESE *# <0.05 0.05 mg/1 EPA 200.8 03/29/2010 pH *# 7.7 6.5 - 8.5 EPA 150.1 03/27/2010 CHLORIDE *# 170.4 250 mg/1 EPA 300.0 03/29/2010 SODIUM *# 138.1 250 mg/1 EPA 200.8 03/29/2010 NITRATES **# 0.7 10 mg/1 EPA 300.0 03/29%2010 COLIFORM **# A ABSENCE/100 ml P/A COLISURE 03/27/2010 E -COLI **# A ABSENCE/100 ml P/A COLISURE 03/27/2010 THIS SAMPLE MEETS EPA PRIMARY STANDARDS FOR THE PARAMETERS TESTED. A = Absent; P = Present ** EPA Primary standards are standards that are related to health issues. mcl.html#mcls) * EPA Secondary standards are aesthethic in quality and should not affect healthy individuals. (www.epa.gov/safewater/mcl.html#mcls) Authorized by: Julia Espinal for NER, LTD MCL: Maximum Contamint Level. SMCL: Secondary Maximum Contaminant Level. NOTE: These results r late only to the sample as submitted to the Lab. # - NELAC accredited analysis. TIME OF ANALYSIS 0931 0931 1710 0945 1053 0945 1630 1630 (www.epa.gov/safewater/ DelleChiaie, Pamela From: Sawyer, Susan Sent: Tuesday, May 11, 2010 4:38 PM To: DelleChiaie, Pamela Subject: FW: 380 Forest When this comes in give it to Michele. If she finds the level to be ok to the standard, then we should be all set with the Title V and Neil can be called to tell him it is ok. Just in case I am not here. S -----Original Message ----- From: Kevin Boreri [mailto:kevinboreri@yahoo.com] Sent: Tuesday, May 11, 2010 3:23 PM To: Sawyer, Susan Subject: Re: 380 Forest Getting sample tomorrow. Kb Kevin Boreri REMAX Partners 44 Park Street Andover Ma 01810 Cell 978 289 2993 On May 11, 2010, at 2:02 PM, "Sawyer, Susan" <ssM r@townofnorthandover.com> wrote: I am sure this can get done in time. S -----Original Message ----- From: Kevin Boreri [mailto:kevinboreri@yahoo.com] Sent: Tuesday, May 11, 2010 2:03 PM To: Sawyer, Susan Cc: Jim Bampos Subject: Re: 380 Forest Thank u. Kb Kevin Boreri REMAX Partners 44 Park Street Andover Ma 01810 Cell 978 289 2993 WN Commonwealth of Massachusetts Title 5 Official Inspection Fo Subs isposal System Form - Not for Voluntary E 380 Forest Street.- Frank treet. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. MA 01845 State Zip Code Y 25 2010 5/19/2010 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Neil J. Bateson Name of Inspector Bateson Enterpri Company Name 111 Argilla Road Company Address Andover Cityrrown 978-475-4786 Telephone Number B. Certification Inc. Ma State SI15 License Number 01810 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 Furter Evaluation by the Local Approving Authority 5/19/2010 Inspector's gn ure 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 • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Frank Letizia Owner Owner's Name information is required for North Andover 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. MA 01845 State Zip Code Y 25 2010 5/19/2010 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Neil J. Bateson Name of Inspector Bateson Enterpri Company Name 111 Argilla Road Company Address Andover Cityrrown 978-475-4786 Telephone Number B. Certification Inc. Ma State SI15 License Number 01810 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 Furter Evaluation by the Local Approving Authority 5/19/2010 Inspector's gn ure 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 • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 At Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments 380 Forest Street Property Address Frank Letizia Owner Owner's Name nformation is required for North Andover MA 01845 5/19/2 every page. Cityrrown State Zip Code Date of B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D t5ins - 09/08 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: After water analysis found no problem with well water, septic system now passes Title 5 Inspection B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17 i 010 Inspection t5ins - 09/08 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: After water analysis found no problem with well water, septic system now passes Title 5 Inspection B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17 From:RE/MAX Partners N ashoba 9784703040 ical, LLC Tel: 979-391-4428 Fax: 978-391-4643 3 2A Willow Road, Ayer MA 01432 Website: http:iAvvww.NavhobaAnaiydcal.con CUent ReMax Partners Kevin Boreri 44 Park St Andover, MA 01810 380 Forest Street, North Andover MA Parameter Method - Kitchen Sink Sampled' 6/122010 8:46.'00 AM by K Boned Ammonle, MG/L SM 45WNH3-D Certificate of Analysis 05/19/2010 16:59 #336 P.002 LabNumber: 113770 Use this number with all c ragwndence ReportDate: 5/18/2010 Result MCL Mn Date of Analysis Anatyst ND Not Spec 0.1 SM712010 M-MAI118 MCL=Maximum Contaminant Level (EPA Umlt), MRL - Minimum Reporting Level Sodium GuldeUnes- Mass 20, EPA 250, # = Result Exceeds Unit or Guideline ND i None Detected (<MRL), • = Background Bacteria Noted Massachusetts Certified Laboratory#MA1118 David L. Knowlton Laboratory Director Page 1 of 1 �ys� '"� 3's� Nashoba Analytical, LLC Tel: 978-391-4428 Fax: 978-391-4643 LabNumber: 113770 31A Willow Road, Ayer MA 01432 Website: http://www.NashobaAnalytical.com Use this number with all correspondence Client: ReMax Partners Kevin Bored 44 Park St Andover, MA 01810 ReportDate: 5/18/2010 Certificate of Analysis 380 Forest Street, North Andover MA Param Result MCL MRL Date of Analysis Analyst - Kitchen Sink Sampled: 5/12/2010 8:45:00 AM by K Bored Ammonia, MG/L SM 4500-NH3-D ND MCL=Maximum Contaminant Level (EPA Limit), MRL = Minimum Reporting Level Sodium Guidelines- Mass 20, EPA 250, # = Result Exceeds Limit or Guideline ND = None Detected (<MRL), . = Background Bacteria Noted Not Spec 0.1 5/17/2010 M-MA1118 Massachusetts Certified David L. Knowlton Laboratory #MA1118 Laboratory Director Page 1 of 1 On May 11, 2010, at 1:55 PM, "Sawyer, Susan" <ssawyergtownofnorthandover.com> wrote: Hello Kevin, Please find attached the recently submitted information and a copy of the 1999 water test. See the ** on the second page for a list of the tests. They list the ammonia nitrogen. Susan Sawyer Health Director <SKMBT_60010051109040.pdf> <SKMBT 60010051108580.pdf> —�C\' Commonwealth of Massachusetts �6 . j City/Town of System Pumping Record Form 4 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. YQ DEP has provided this form for use by local Boards of Healtl information must be substantially the same as that provided 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. A. Facility Information 1. System Location- - Address `�:'5 V v City/Town 2. System Owner: Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): I I i v v k-ouz--e- -,j- State Zip Code a ` p Code St t7J ,( 0 3 Telephone Number 7 Date 2. Quantity Pumped Cesspool(s) c Septic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes do If yes, was it cleaned? ❑ Yes ❑ No 5. Conditio�stem: Leti-V � 6. System, P&AV6a\'- url $y:� Name v Vehicle License Number Company 7. Location were contents c Signature Date t5form4.doc^ 06/03 System Pumping Record . Page 1 of 1 I WO a a ❑ N ._ ❑ w i o w Z CO .10 t;,El w U a OZ o a z w '< 3a oI o w IN ¢Uwa Um e� z OLL O w z a, wQ�, W a_OZW- Mw20 NIN Ivllli M be:ubMl�tetl to the.local Boarc A Fac111tYInforrt10"n ruLn ,•J;TWr 41Alung.out' ;1;>; System Location;'' r, Lim only the tab key Address to move your a ,.ausar,•do not usi the rotum :%='• CIty I Own System OwnAr,, kCHUSETTS alth. The System Pumping Record mus: Ing authority, lft State • , :,� ',ti ! , •� ,Ir.,: Name ,; Ma ,.Addrsss (If different from locatlon) Ck/Towrti, State Zl p Code .r %��� Telephone Number �,'':,: 'v �'�• ord '.;:.4s:�r,'i.i::;.l•;r:...i/,±[u!•..vliC�l��ill.tri.+;'�,! .. .,` •'1 Dte of Pumpingl �� aDate 61 2, Quantity Pumped: b Type pf system; : [] Cesspools) ;,.'. eptic Tank ❑ Tight Tank 1f.Other (dascrfbe Effie ant Tea Flite� present? Yes .[] o If yes, was It cleaned? ❑Yes ❑ No :4 Cor>ditlori o(:S8 ,x111/ L 1'1 'I• •!r'rr '• :. , T.Pumped BT., • . GAA •��=:1,:•�''�i��•. �1 � „Cv�r,7;il��l. �,. ,h•f .f,�';.%y ,,; ,,,' I :�'r'•' ��'; jr'•�f/hI� �.1�1f S� Ucen�e Number f�!1'� .II:X` .. ��� •;l' • . //��;V,,e�hlGe TJJ�/7 �n � , ••, ,�'F L J T. v�M1, /, r'��`,'• ' "'��;j `(F'�: • �! '1r ..(I��l�IJI! I' 1'•7,• ' , uit / ' sed;oonteritsµere dlopo '1_• .i'. .;r �l:'/l'4.1 ),�Yr•. 5;i}' :1, '�' •''i'� 1i :•�•:',rii•,F, �' ;��.,, v•i:;t..�+carr;: �:�„>F / {. ;.,: �;.>'>~'r,•. ,: ;sbnature of Hauler;, ,. •;,..• wi�i;;,N':.a,,.',.,.,:.1',.' — L'— . .. ,�• : hUPj/wwM.a' pprova)s/t5forms,htm#Inspec Dela .sYs_godep.Wataa Sy:tam Pumping Record Page I cl i V,� 6, 1 IdP %V•9 No v TOWN W'NOR-1-11 U -A I POMPINQ JYMM 9 UA ct ADDRESS 77s -14 TITY ','t s s POO L, N, y NA rvx6 op 3byY)CE: I t,,K u l' -N a001) V F,VLL K4AYY QUA33 17�j 8AyylBa KOM.: 8XCUMB SOLIDS SOL ID OA RA Y9 Y� ,- un rvNo ry.,�tonx&bp rt c �.e i TOWN pF`NO$TH ANDOVER c��.o�¢�" �' SYSTEM PUMPING} RECORD DATE Y - SYS TEM OWNER & ADDRESS NO - G rvC�ove ma. SYSTEM LOCATION TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: SYSTEM OWNER & ADDRESS a�r�' 4 V v SYSTEM LOCATION (example: left front of house) DATE OF PUMPING: Dom-- QUANTITY PUMPED GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES^ NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYS TEM PV MP L`D BY: COMMENTS: CONTENTS TRANSFERRED TO: _. FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) FROM : RandXonvStoreFAX PHONE NO. : 617 628 7209 1, r Feb. 26 1999 02:20PM Pi I : MLT Y�N)"r-T C -03E: --iE-2 F. i'N I z*K=ft baw% i%jg ff IcIr -6 EAST MAIN MCrT. A,0. YCLEPHONE. W,1) 281-0222 FAX, (978) 263-33% MA URTIFICOR Of URLYSIS Mr. Yonng Yung 380 Forest She, N. Ardover, MA 01#45 hS ? . "�� 8 43 33774 P,01 810MARINE ID: 902f4 2124199 E6 L DES, W L DESCRIPTION: in -use, well. -30 years oicand 4T f0el in de;th, [Uated • 43'tt"h"p"above adiress. SAMPLE INFORMATION: Samples taken by Tcry Giordano on February 16, i4q.q. FINDINGS: I l ii 0 I rn fu CL io I4 W C 0. W 421 �L fu 0 cu ' E ro CL Q) 0 Cm C L•: C d V) N E E d C: 0 P ro 5 y n a 0 T _a L J Q u 3 0 E 3 U 1 C 3 3 f V m C _o V O 0 Q m 0 L .� ICU, E C O E 6 m O oca - 4 i i C Gl F" G � V Q I � 7 I c V 0 0 c, 0 Z cu ' E ro CL Q) 0 Cm C L•: C d V) N E E d C: 0 P ro 5 y n a 0 T _a L J Q u 3 0 E 3 U 1 C 3 3 FROM : RandDConyStoreFAX PHONE NO. : 617 628 7209 Feb. 26 1999 02:21PM P2 2/26/49 CQ 1:57 PM CERTIFICATE OF ANALYSIS Mr. Yonng Yung 610MARNE ID: 90266 Ko Folod Sweet 2124(99 N, Andover, MA 01645 ta WRLDESCRIPTION: In -use Al, -30 years old and 400 feet in depth, located al the 3 e MS. SAMPLE NFORMATION: Samples taken by Tony Ootdam oil February is. 1999 FINOLSIGS: YUN(. PAGE- I OF 2 SIOMARINE Q 90266 71241.9fi ()1/2 :t 44. V� J1 lotal coldom i3adella/100 ml 0 0 - 5 92222 2116/99 - 300.0 218199 Nitrate N]VoW 2TT�(-mlylll Ammonia Nitropm Content (,T, �oi) 0.01 4500 NH3 B&C 202199 I UR Benzene ND ND - 5.0 5.0 7.0 6. 0.5 524.2 0.5 524.2 2172199 0 . .5 uY 524.2 2122/99 Car bon Teir achloridj 1. 1 -Dichlorciethylene 1, 2-Dirhioroethaije ND 5.0 0.5- 524.22.!22199 para -Dichlorobenzene ND ND's' 5.0 5-0 0.5 524.2 222/99 * 524.2 2/72J99 Tricliforoethylene ND 200,0 1.1,14richlotoethane -0-F, 0.5 524,2 Z/22/99 Vinyl Chloride 2,0 100.0 -0.5 524.2 2/22199 0.5 -5T4 F- 2(22'99 Monochloobenzene o-Dichlorobeinzone ND 600.00.5 524.2 2122(99 trans-1,2-dichloroethylene 1000 0.5 524.2 2122/99 dc -1, 2-01flilofoethylem 0 70 524,2 1.2-DichlorWopane ND 50 0-5 524.2 2/22199 Phylbenzene -ND 0 0.5 524.2 Stpene -j-000 2.122199 Letlac l0rcdhYlenc ND- 5.0 524,2 2122/89 Toluene ND - 1000,0 --05 0.5 524,2 212,2/99 Xylem (total) -0000.0-- 524.2 M 222/99 Dichloromethane ND 5.0 0.5 524.2 21'22199 f .2,4,Ti lchlorobenzone ND 70.0 0.5 524.2 2!22j99 "2--rdoloroethano ND 5.0 05. 524.2 2,122199 (Norobrm LL - I- 219 .�54,� )2itL 2_0 YUN(. PAGE- I OF 2 SIOMARINE Q 90266 71241.9fi ()1/2 FEB -25-1999 14:28 BIOMARINE INC. 978 283 3374 P.01 �fit0 ?p/ Fox ate Hyen Bio army 16 EAST MAIN STREET, P.O. BOX 1153, GLOUCESTER, MA 01931.11 �1e�+•`- --�--�„_- TELEPHONE. (978) 281.0222 FAX: (978) M-3374 — �_ ---- CERTIFICHTE Of AIIALYSiS-----___ Mr. Young Yung SIaMARINE f0: 90266 N. Andover, MA 01845 2/24/99 FELL MDESCWMPTIOMMln-use fflwe1I,-:Wi0yaWr-soidZW-4iiuMr��•,.c.�•,Mau M..ru � in depth, located at the above address. SAMPLE INFORMATION: Samples taken by Tony Giordano on February 16, 1999. FINDINGS: 2/16/99 2/18/99 2/22/99 �*,iitav ,3r 2/22/99 2/22/99 2/22/99 2/22/99 2/22/99 2/22/99 2/22/99 2/22/99 2/22/99 2/22/99 2/22/99 2/22/99 2/22/99 2/22/99 2/22/99 2/22/99 2/22/99 2/22/99 2/22/99 2/22/99 2/22/99 2/22/99 PAGE I OF 2 FEE -25-1999 14:29 BIOMARINE INC. .:ERomarine YUNG 978 283 3374 P.02 BIOMARINE 10: 90266 2/24/99 --- r-..-.. -Jw " QQ0 f-cl MMU Iavvraiones #MAU26, 123, M-NH003. PAGE 2 OF 2 TOTAL P.©2 7'RIOX COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET; BOSTON MA 02108 (617) 292-5500 TRUDY CORE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: �3 FC?S �P `:�-�--� Name of ow,',6(,. v ` .•� V /� Il l cJ<- -vti\ > c1 Q c" Address of Owner: (Date of I mpeetion: - ci q - �>rj i Name of haspector: fPhmwe Print) l2_ t I am a D system pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: , E V �`�, . `3 VBG . fklailling Addiress: mac, Hct. c:).l F_v o TAep(wne Number: C4 t — — 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: _ Passes _ Conditio Ily Passes eeds urther Evaluation By the Local Approving Authority _ F � u J �11� ci c� 7 -- �j h►spector's Signature: Date= The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty 130) 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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS A .r revised 9/2/98 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A � 11 CERTIFICATION Itmrtt wed) Property Addresstjs C� �Ut`p �s�r �S C • I Vi✓K`' !` t^�� �('� ).R` Owner: Date of Inspection: INSPECTION SUMMARY: Check A, B, C, o/ D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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. Indicate yes, no, or not determined (Y, N, or ND). 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 Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years 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 complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four 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 revised 9/2/98 Page2oril 4 Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:.3�61cxa�'Jti`p?2�C— Owner: Date of Inspection: C. FURTHEREVALUATION 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES 1N ACCORDANCE WITH 310 CMR 15.303 (1)(b) 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 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 NI A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. 1---' 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 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. Method used to determine distancee- (approximation not id). a 3) OTHER 1 i�4-WP `tO �C7X r V"'' ,.!►'r 1 � Rl (ate �i civoh►- � eA om-' Vv�. Q-- v" VOT VL. revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (cwdlt>ved) Property Address: 31F Owner: 7� _JV \ j pQ Date of Inspection: D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary 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 overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any.portion of a cesspool or privy is within a Zone I of a public well. 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: 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: The system serves a facility with a design flow of 1'0,000 gpd or greater (Large Systeml and the system is a significant threat to 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 (Interim Wellhead Protection Area = IWPA) or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412►. Please consult the local regional office of the Department for further infognation. revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST 4 Property Address: Owner: Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes by Board Health. Pumping information was provided the owner, occupant, or of None of the system components have been pumped for at least two weeks and the system has been -receiving non, now rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. i The facility or dwelling was inspected for signs of sewage back-up. "receive The system does not non -sanitary or industrial waste flow. The site was inspected for signs of breakout. L-/ All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: Existing information. For example, Plan at B.O.H. the Determined in field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) 115.302(3)(b)) [. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SubSurface Disposal Systems. ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: Date of Inspection: 1 aqs FLOW CONDITIONS RESIDENTIAL: Design flow: IJ/A- g.p.d./bedroom. Number of bedrooms (design)NJA (design)NJNumber of bedrooms (actuai):_q Total DESIGN flow W-4 Number of current residents: Garbage grinder (yes or no):_�� Laundry (separate system) (yes or no): LE! if yes, seperate.inspection required Laundry system Inspected Lyes or no) Seasonal use (yes or no):_ xb Water meter readings, if gvpilable (last two year's usage (gpd): c" UjQ- `� Quol ` Sump Pump (yes or no): NO Last date of occupancy: UV4 Q COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gpd ( Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or nol_ Non -sanitary waste discharged to the Title 5 system: (yes or no) Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Uvv � u)U 0 - System System pumped as part of inspection: (yes or no)_ 4� If yes, volume pumped: gallons Reason for pumping: TYPE OF YSTEIN Septic tank/distribution box/soil absorption system Single cesspool o Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records. If any) IIA Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed (if known) and source of information: CK N,,- \, VV& , " 0&Q-. � ' t)S c. — fO lu v� e .� Sewage odors detected when arriving at the site: (yes or no) revised 9/2/98 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (confiwedl Property Address:'�Q Owner: '�la'v1C'i ®ate of Inspection.. ` BUILDING SEWER --- (Locate on site plan) )t Depth below grade: y Material of construction: cast iron E- PVC ,r o er (explain) `,✓� Vv Com`; o Vy� �. Distance from private water Diameter _!: t k Comments: (popdition,of joie SEPTIC TANK: &- - (locate on site plan) or Auction line venting, eviden a of leakage, etas ^' �•— �. � t� Depth below grade: ka..r Material of construction: _concrete _metal ._Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance IYes/No) Dimensions: XJ A Ll X 7•. t:x�__ V Seo, Sludge depth: p p Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 0 Distance from top of scum to top of outlet tee or baffle: l 3 n Distance from bottom of scum to bottom of putlet tee or baffle: How dimensions were determined: .5uc �c c� �`r�-r1 `3�c1 (�. CAe_P`TA-`V-W Comments: !recommendation for pumping, ponditiQn�o_f�'nlet and outie tees or baffles, depth o liquid avid@1nc'a of leak�ss etc.) "�'� y �{'_ . O L , ho •-hY �/._ . X11 1� �A,V\� I f -, A c- r3 41" OQ GREASE TRAP•�� (locate on site plnl)-' - 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: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) revised 9/2/98 page !ofit SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C rSYSTEM INFORMATION ((continued) Property AddresSt �jQ2,a'Y <�`7 • U� ` ` /�'Y�` =C 11D/C' Owner: Date of Inspection: (a_ (4, �J TIGHT OR HOLDING TANK V1eT (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 present Alarm level: Alarm in working order: Yes _ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_✓ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if iqv aq distribution is equal, evidence of soli carrywver, vi nce of leakage into or out of box etc.) � •.l u <� ����' C C G� ��kC l—, C- A 1 _MC -Q, e -7A- \J I P_-li QVVez- :'Z:�h C., C- F) PUMP CHAMBER:('_—�U (locate on site plan) J cv\ Pumps in working order: (Yes or No) " Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C �^ c� SYSTE,.,M, `INFORMATION JamtIrwed) Property Address:�C� Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):_✓ (locate on site plan, if possible; excavation not required, location may be approximated by non -intrusive methods) If not located, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: C.'^ leaching trenches, number, length: G��A7)iC�X. leaching fields, number, dimensions: 11 overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil; condition of vegetation, etc.) CESSPOOLS: (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: mote condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: 1,01LAC , (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: inote condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C µ SYSTEM WFORMATION Imo) Property Address: .� Ores-- #JCi t• 4JA_ 4�-- ( J UQ-4�- Date of inspection: ' SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) X11 wc� C-,0 u, -Q _3j711 revised 9/2/98 Page 10 of 11 n K e(c- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C T SYSTEM` INFORMATION ti�(conKu4 Property Addresik: eG t��C�P_� 3: �i� (AA,, A,'Q1� Owner: Date of Inspection: L`i-cle) NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater �16 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions CLIDehecked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers L, ---Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) e 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: Owner: Date of Inspection: i �'` 3'9 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. Neil J. Bateson Bateson Enterprises, Inc. Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES WILLIAM J. SCOTT Director (978)688-9531 January 22, 1999 Young K. Jung 380 Forest Street North Andover, MA 01845 27 Charles Street North Andover, Massachusetts 01845 RE: Title 5 Inspection Report — 380 Forest Street Dear Homeowner: Fax(978)688-9542 The North Andover Health Department has received and reviewed the Title 5 Inspection Report that was generated from the inspection of your septic system on December 29, 1998. Your inspector has determined that your septic system requires further evaluation in order to determine if it is protecting public health and the environment according to Title 5 of the State Sanitary Code. You are hereby required to perform a well water analysis at a water testing laboratory licensed to test for drinking water standards. The well water analysis must test for coliform bacteria, volatile organic compounds, ammonia and nitrate nitrogen. In addition, the pipe leading from the septic tank to the D -box requires replacement, and any trees which have grown up over the leach area must be cut down. The Board thanks you for your willingness to help protect the environment, the ground water and public health. Please do not hesitate to call the Health Department office at the number below if you have any questions. Sincerely, Sandra Starr, R.S. Health Administrator Cc: File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 zW c o Z O .0 Z E .� LL `y �' J W O '• \ O N J a W O `O Z rlo U �o N ' nw.. N ` N rz j . U m f— U v a p 2 Q w a a� w ce v a °0LL- c O O Q U N u O Z N N (V rz a`o E Q) L � Z I � s N ,*,Ft»*; C N O ft `� t oA hE rO hMpy a Q _ **» N CL N LL AKUtU PAUL LtLLMU Lt. Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART A CERTIFICATION F x. Property Address: Address of .Owner: Date of Inspection: '" • O " :` (If different) Name of Inspector: I am a DEP pproved syste inspector pursuant to Section, 15.340 of Title 5 (310 CMR 15.000) Company Name:�T Se /�c. ✓`�' �'� �!� Mailing Address:( L Telephone Number: % 7 DAVID B. S'TRUHS Commissioner 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 d' posal systems. The system: asses , Conditional l y . Passes _ .Needs F rther Evaluation B ,.the Local Approving Authority F ils Inspector's Signature:f- Date: The System tnspecto shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the s stem is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or. D: A] SYSTEM P. S: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303: Any failure criteria not'evaluated are indicated below. 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. Indicate yes, no, oir not determined (Y, N, or ND). 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 Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years 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. (revised 04/2S/97) Pago 1 of 10 DEP on the World Wide Web: http:lh~. magnet. state. me. us(dep 0 Printed on Recycied Paper e �� .,r, a �.wd! t• .. tom: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A } ] CERTIFICATION (continu ) AW I :i Property Ajd ss: Owner: .,J 0" i" Date of Inspectio 3� �l B) SYSTEM CONDITIONALLY PASSES (continued) y Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obs tructed 4 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 pipe(s) are replaced obstruction is removed f distribution box is levelled or replaced Fr i ;a- -' The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health) broken=. i 3 gt Ft, P pe(s) ife replacec'f =' t. 51 obstruction is removed i' 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 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 a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. . _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. 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 - -Privatewater supply ,well; unless a vvel.l water.analysis for Eoliformbacter,a 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. Method used to determine distance (approximation nonvalid). 3) OTHER i ` (revised 04/25/97) Paque 2 of 30 r „i' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Lj Property Address: r Owner: ►) t tr Date of Inspec o : ”. 0 _ y� D] SYSTEM FAILS: r 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 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No . ywf Backup. of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool s.. Static liiauid level in the distribution box above' outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ Any portion of a cesspool or privy is within a Zone I of a 'public well. 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. If the well has been analyzed to.be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: ,. .,The following criteria apply to large systems in addition to the criteria above: Thesystemserves a faciairy,,wrth_a,design.:ffow.of.;l0 00Qygpd:or<.greater.•{Larg.Sysem) aid, tf�esystem s -is ,> significant threatao -- r . 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 (Interim Wellhead Protection Area, IWPA) or a mapped Zone 11 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 treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.' (revised 04/25/97) Page 3 of 10 T, (revimad 04/2S/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST '•,� I/(/ Property A ress: t Owner: Date of Inspec io :f Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: YesNo' fi- Pumping information was provided by the owner, occupant, or Board of Health. A_ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection'. ��i�L// As built plans have been obtained and examined. Note if they are not available with N/A. .f The facility or dwelling was inspected for signs of sewage back-up. f; The system does not receive non -sanitary or industrial waste flow. The site was inspected for signs of breakout. ,,✓' _ All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank,was inspected for condition.of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. '- The size and location of the Soil Absorption System on the site has been determined based on: _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of tY P P P Pe Sub -Surface Disposal System: Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)J (revimad 04/2S/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Propert Ad ess:9 �- AJO dL•�G/r Owner�j Date of Inspe& bn: FLOW CONDITIONS Design flow:¢room for S.A.S APP Number,of bedrooms: Number of current residents: §' Garbage grir•;der (yes or no): Ald xr Laundry connected to system (yes or no):kZ5` Seasonal use (yes or no): Water meter readings, if?Vailalllast two (2) year usage (gpd): Sump Pump (yes or no);( Last date of occupancy. F f " COMMERCI.AUINDUSTRIAL: Type of establishment: Design flow:.. aallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: Ives or no)_ Non -sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of,.oc•cupancy: ;. OTHER: (Describe) Last date of occupancy,: GENERAL INFORMATION PUMPING RECORDS andf nformation: System pumped as part of inspection: (yes or- o) ' If yes, volume pumped: ¢al Ions ;. Reason for pumping TYPE OF SAff M ,.. Septic tank/distnbuutjo on_)/s6il absorptiori systern s Single cesspool Overflow cesspool Privy Shared System (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other XI TE AGE of all components, date installed (if known) and source of information: �44r' t Sewage odors detected when arriving at the site: (yes or no)' (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property_6ddress:SOU xv Owner: Date of Inspe BUILDING SEWER: (Locate on site. plan) Depth below grade-./ Material of construction: --dstiron 40 PVC other (explain) Distance from - rate water supply well or suction 11ric e Diameter SEPTIC TANK: (locate on site plan) Depth below grade' Material of construction: crete __,_metal _Fiberglass _Polyethylene —Other(explain) If tank is metal, list age Is age confirmed by Certificate of Compliance (Yes/No) Dimensions: 23 X 141 Sludge depth: Distance ffofftop of sludge to bottom of outlet tee or baffle: .Scum thickness: Distance from top of scum to top of outlet tee or baffle: 16 Distance from bottom of scum to bottom of outlet tee or baffle: 65 How dimensions.were determined:AML�lz T -40V-. Comments: (recommendation for pumping, condition of inlet and outlet t baffles, depth of liquid level i elation to outlet invert, structural 0 integrity, evidence of leakage, etc.) GREASE TRAP: (locate,on site plan). Depth below grade: Material of construction: —concrete —metal _Fiberglass _Polyethylene —other(exp lain) - 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: (recdmmenclation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidL ince of leakage, etc.) 7 (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C E' SYSTEM INFORMATION (continued) fv f'ropertress: Owner:it x Date of Inspe 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: igallons fi ' Desi n'flow allons/da� Alarm level. 'Alarm in working order _ Yes; _ No Date of previous pumping: Comments: (condition of. inlet tee, condition of alarm and float switches, etc.) .,. DISTRIBUTION BOX: �✓ (locate on site plan) Depth of liquid level above outlet invert: t Comments: (note f level and dist,�ibution is equ evidence of solids carryover, evidence of leakage into or out of box, etc.) `604 l 4 - L5 O'er Ct rs J4— 1�1 a dl PUMP CHAMBER: (locate on site plan) I , s• f t h r r Pumps in working or. er: (Yes or No) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) k± (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C �. SYSTEM INFORMATION (continued) 70 Prope Add „ " ress:43 5 ✓ « _Tj Owne rV Date of InspG SOIL ABSORPTION SYSTEM (SAS): j,�•''' (locate on site plan, if possible; excavation not required,. but may be approximated by non -intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number: * leaching galleries, number leaching trenches, number length: .iia r leaching fields?;nurribgi, dimension¢: overflow cesspool, number: Alternative system: '* Name of Technology: Comments: (note condition of oil, signs of hydraulic failure, lev f pon.ing, co ition of vegetation, etc.) P o a A ��. a .. CESSPOOLS: — (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: x inflow (cesspool must be pumped as part of inspection) its ,> Comment's: , # I (note condition of soil, signs of hydraulic failure, level of pondmg,•condition of vegetation, etc,) q, 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.) i (reviaad 04/25/97) 1 Paye 8 of 10 1- 1. ( i r i ♦ �.i ..-e�.4-�'4v,...:d, r+h41 ?- 4" .y-..'�`'u -a1-Z'}r t.'F SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propertgess:. l 57- ?� Owner:�N 'Date of Inspe 1h* �' 3 -/may/ `► �' SKETCH OF SEWAGE DISPOSAL SYSTEM: ` include ties to at least two permanent references landmarks or benchmarks r: locate all wells within 100' (Locate where public water supply comes into house) p (revimad 04/25/97) Page 9 of 10 (revimad 04/25/97) Page 9 of 10 Town of North Andover, Massachusetts Form No. 3 NORTH BOARD OF HEALTH {p- A DISPOSAL WORKS CONSTRUCTION PERMIT 9SSACHUS�t Applicant Y /1j, NAME ADDRESS TELEPHONE Site Location _ 3 P -2O WVLES-77: S?". ac1971 c- �/jA)k1 " Permission is hereby granted to Construct ( ) or Repair (yI) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. Fee (J� CHAIRMAN, BOARD OF ITFEALTH D.W.C. No. i0 � ST3"T I S SEPTIC TANK SERVICE 47 RAIIROAD STREET BRADFORD, MA 01835 Wmovl Lie- 1S/-0614 978-372-7471 InS-%G 11 Li r - MONTH OF C, b I ace td66 / M Lo. d6do /xo / . d4e) Sq.lern 5f, 110 Fvre-sY-sl- 65 8r i cl (e- 6 e-13 -1 X75 Win -L-rsJ: J Yf p .-L .5 Lr r) St .5 -`tee I ace td66 / M Lo. d6do /xo / . d4e) ci �� z a n rt 0 n 0 n 0 a � a 0 D D '0 Q' 3 V) I (D O Q O --n o m rb � O C I tD � r3r 3 3 � m � 2 (D O rt i ca 3 n 3 C O > S v► m '0ti1 3 � Ov i' n C rt D c aj � � J 3 1 3 �D i ci �� NORTIy O ti�eo y°1�0 H p ,SSACMUSE� Town of North Andover, Massachusetts BOARD OF HEALTH mob. /p 19 Form No. 3 APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: CURRENT INSTALLER'S LICENSE# LOCATION: LICENSED INSTALL R: SIGNATURE: TELEPHONE#��- CHECK ONE: REPAIR: L, --- NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. Administrative Use Only $75.00 Fee Attached? Yes ✓ No Foundation As -Built? Yes No �--' Floor Plans? Yes No Approval ..�' ell- Date: a %