HomeMy WebLinkAboutMiscellaneous - 381 SUMMER STREET 4/30/2018Commonwealth of Massachusetts RECEIVED
City/Town of
w° System Pumping Record �011
Form 4 TOWN OF NORTH ANDOVER
wM , •'•" 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
System Location: Left / Right front of housegj:2' Righ ear f ouse, ft / right side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear of-iuilding, Under deck
1 I V\--v►V-CS �--
Address
Citylrown State Zip Code
2. System Owner:
Name
Address (if different from location)
City/Town
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping—�— 2. Quantity Pumped
Date
3. Type of system: ❑ Cesspool(s) eptic Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ESJ/No
5. Condition of System:
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Location wire-soatents were disposed:
Waste Water
100C )
Gallons
❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No
-eu-e c
F5821
Vehicle License Number
rtJ - l -T - l I
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts �..
w " City/Town of NORTH ANDOVER MASSA
CHUSE` TS
o
System Pumping Record
Form 4
i M
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Board of Health or other approving authority.
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
ienm
A. Facility Information
1. System Location:
City/Town State
2. System Owner:
Name
muutess (ir alnerent TrOm location)
1 0—
City/Town
MAY 11 2006
TOWN OF NORTH ANDOVER
State
I elephone Number
Zip Code
Zip Code
B� Pum pinb-lki&bTd-
1. Date of Pumping 2. Quantity Pumped: 115LW
Gallons
> 3. Type of system: ❑ Cesspool(s) eeptic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes N p
5. Condition of System:
ignature of H r
http://www.mass.gov/dep/wat approvals/t5forms.htm#inspect
vehicle License Number
t5form4.doc- 06/03 System Pumping Record - Page 1 of 1
Ld
3 S nES'.bF, O. o
ri
/17
a - Z
fri
-IN op
CC
oJ` . o� . 40
a d
?� bre _ 0 - a
Cb
o
O
M D A 9 Fbl�-' 2 4%�O ..Db ..OD :Zo
' n
L
1719 yo, ' Cr o,S aoc 0++
tD
IT
9 pf 2 si voce 1
X11 - •, 3,• L � £ /=V ° r _ ` ~� ,� !� t " � �,
DI
s7 g
ti
_ may, `'e"... !��'J�/f �p-� � ,� ,s• t .,.�£' �,{ ,
N
i' At
SOIL PROFILE $c PERCOLATION TEST DATA
1
Town/Cit No.&Streety/ --r�,�,-� - Lot No.
Loc./Subdiv. Plan Owner 4,/ D
j Investigator C.�= i'lP06z% -Observer
� r
SOIL PROFILtSDATE
1. ?. 3. 4
E ev. Elev._ --- Elev. —.Elev.
0 0177 o 0 0
2 2 2 2
3 3 3 3
�4 4 s 4 4
S \0 5 5 S
6 6 6 _.
7. 7 ( 7� 7
J 0.. .. ..
o
9 9 9
0 10 10 10 _... ..
Benchmark Location
Elevation Datum
Percolate n.Tests-Date
¢ 3U 77
Fit Number 1 2 3 4 S
Mart Saturation
Soak -M -ins.
Start -Test -Time
Drop" ---of 3" -Time
Drop of 611 -Time,' -
Mins.lst'3"Dro
Mins.2nd 3"Dro
Nuzes bxetcnes on Back Frank C. Gelinas & Associates, North And.
ueparUILU11- .-. A- mQ ,nt r
wronmental Protection issued labor in`d'umping..:.:
an April 18 enforcement order
MRI to submit a
sorting through it.il
which requires
plan describing steps to ensure "
MRI officials also
sulfur dioxide limit s ve
they meet the sulfur dioxide lim-
been set at a higher I than
its in MRI's permit.
where it was set when the permit
"Failure to take adequate ac-
in to (the order)
was issued.
he expects',fhe ;
_ tion response
will result in serious legal ac-
tion," according to the cover let-
McIver said
state to approve the plan ultiI
developed, but if for
ter sent by Edward H. Macron-
DEP regional 'engineer for
mately
some reason it is not accepted,
step he is aware of
ald,
t
wase prevention.to
The- legal "Action could 'in
the only other
bring sulfur dioxide -levels
down is the installation of scrub-
elude up to a 2^ ,000 fine, a year
dors.
in jail, or both.
The plant operators agreed to
Hoperoft said most other in-
cinerators have higher allow-
keep sulfur dioxide limits to 0.27
per million biothermal
able sulfur dioxide limits in
but when the engi-
pounds
unit (Btu) when it was issued a
their permits,
neers who designed the plant for
permit by the federal Environ-
Wheelabrator told the DEP the
mental Protection Agency in
current limit could be met, the
1982.DEP
during three sets of
built the limit into the per-
However,
compliance tests since 1988, the
,mit.
Wheelabrator Technologies
ut allowed nearly twice the
w1 to-the EPA
would-have-
ed limit into the air_.—
ed
r :� __ od level of
j 0
C� G' 4 5
i�i�a�VOOPa e
e intention
Goy of t
eseSiPeJ°lf�e see e- Tea$ ns
a ctea coon s ie�a1 sons, ,
,�atse e fot vea
N O' w eev aia thot e
an a metabe�e S Sed the
a say cn�ttee tatea tw ater tO e as
19 mePctT1�oo �usTea engi=-
W oUia s9s�em `f0W a
c r°
tOW ale sP?`e -�-� `'�
s�eP*.
1. D.F.
CLARK
TITLE V
SEPTIC SYSTEM PROFESSIONALS
INC.Ak-
May 27, 2004
D.F. CLARK, INC.
Mrs. Sue Marino
c/o Nick Geranios
Prudential How
76 Main Street
Andover, MA 01810
tip uc ..�• ._. -
JUN 20
.-.�.�--
,. > '
RE: Subsurface Sewage Disposal System Inspection
381 Summer Street, North Andover, MA
Dear Nick:
Please find enclosed the Subsurface Sewage Disposal System Inspection Report for the
above referenced property.. As noted on Part A of the report, the system hasap ssed the
inspection criteria. The inspection is good for the next two (2) years; you may extend the
life of the inspection to three (3) years by having the septic tank pumped annually (before
anniversary date of inspection).
Thank you for allowing us to be of service on this project.
Please contact us if you have any questions regarding this matter.
Sincerely,
D.F. Clark, Inc.
AA�;t
George F. Norris
Inspector
Enclosure
cc: vlorth Andover Board of Health
D.F. Clark, Inc. file
PO Box 265 24A Mitchell Road Ipswich, MA 01938
978-356-5638 Fax 978-356-5500 Tull Free 888 -DF -CLARK
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 381 Summer Street
North Andover, MA 01845
Owner's Name: Sue Marino
Owner's Address: 381 Summer Street
North Andover, MA 01845
Date of Inspection: May 22, 2004
Name of Inspector: (please print) George F. Norris
Company Name: D.F. Clark, Inc.
Mailing Address: P.O. Box 265, Ipswich, MA 01938
Telephone Number: (978) 356-5638
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is
true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and
experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system
inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approval Authority
Fails r�+, r�
Inspector's Signature: / \ / , ! `0'v Date: 51 a / to —1
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.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that time. This
inspection does not address how the system will perform in the future under the same or different conditions of use.
Title 5 Inspection Form 6/15/00
page 1
Page 2 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 381 Summer Street
North Andover, MA 01845
Owner: Sue Marino
Date of Inspection: ME 22, 2004
Inspection Summary: Check A, B, C, D or E / ALWAYS complete all of Section D
A. System Passes:
X I have not found any information which indicates that any of the failure conditions described in
310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
COMMENTS:
B. System Conditionally Passes:
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The
system, upon completion of the replacement or repair, as approved by the Board of Health, will pass.
Answer yes, no or not determined (Y, N, ND) in the for the following statements. If "not determined" please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound,
exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing
tank is replaced with a complying septic tank as approved by the Board of Health.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s) are replaced
_ obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass
inspection if (with approval of the Board of Health):
ND explain:
broken pipe(s) are replaced
obstruction is removed
2
Page 3 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 381 Summer Street
North Andover, MA 01845
Owner: Sue Marino
Date of Inspection: May 22, 2004
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is
failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system
is not functioning in a manner which will protect public health, safety and the environment:
Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is
functioning in a manner that protects the public health, safety and environment:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface
water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private
water supply well". Method used to determine distance
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and
volatile organic compounds indicates that the well is free from pollution from that facility and the presence of
ammonia nitrogen and nitrate nitrogen is, equal to or- less than 5 ppm, provided that no other failure criteria are
triggered. A copy of the analysis must be attached to this form.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 381 Summer Street
North Andover, MA 01845
Owner: Sue Marino
Date of Inspection: May 22, 2004
D. System Failure Criteria applicable to all systems:
You must indicate either "yes" or "no" to each of the following for all inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
_ X Liquid depth in cesspool is less than 6" below invert or available volume is less than'/2 day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s)
Number of times pumped
X Any portion of the SAS, cesspool or privy is below the high ground water elevation
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply
X Any portion of a cesspool or privy is within a Zone 1 of a public well
X Any portion of a cesspool or privy is within 50 feet of a private water supply well
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates
that the well is free from pollution from the facility and the presence of ammonia nitrogen and nitrate
nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of
the analysis must be attached to this form.]
No (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in
310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to
determine what will be necessary to correct the failure.
E. Large Systems:
To be considered large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either `yes" or "no" to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped
Zone lI 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.
4
Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 381 Summer Street
North Andover, MA 01845
Owner: Sue Marino
Date of Inspection: May 22, 2004
Check if the following have been done: You must indicate `des" or "no" as to each of the following:
Yes No
X Pumping information was provided by the owner, occupant, or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
N/A Were as built plans of the system obtained and examined? (If they were not available note as N/A)
X Was the facility or dwelling inspected for signs of sewage back up?
X Was the site inspected for signs of break out?
X Were all system components, excluding the SAS, located on site?
X 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?
X _ Was the facility owner (and occupants, if different from owner) provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has been determined based on:
Yes No `
X Existing information. For example, a plan at the Board of Health.
X _ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [3 10 CMR 15.302(3)(b)]
Page 6 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 381 Summer Street
North Andover, MA 01845
Owner: Sue Marino
Date of Inspection: May 22, 2004
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440
Number of current residents: 4
Does residence have a garbage grinder (yes or no): No
Is laundry on a separate sewage system (yes or no): No ; [if yes, separate inspection required]
Laundry system inspected (yes or no):
Seasonal use: (yes or no): No
Water meter readings, if available (last 2 years usage (gpd)):
Sump Pump (yes or no): No
Last date of occupancy: Currently Occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow (based on 310 CMR 15.203): gpd
Basis of design flow (seats/persons/sgft, etc.):
Grease trap present (yes or no):
Industrial waste holding tank present (yes or no):
Non -sanitary waste discharged to the Title 5 system (yes or no):
Water meter reading, if available:
Last date of occupancy/use:
OTHER: (Describe)
GENERAL INFORMATION
Pumping Records
Source of information: System was last pumped in September 2003 according to owner
Was system pumped as part of inspection (yes or no): No
If yes, volume pumped: _gallons — How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
X Septic tank, distribution box, soil absorption system
Single cesspool
Overflow cesspool
Privy _-
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract
(to be obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other (describe):
Approximate age of all components, date installed (if known) and source of information:
System was installed in the late 1970's according to owner
Were sewage odors detected when arriving at the site (yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 381 Summer Street
North Andover, MA 01845
Owner: Sue Marino
Date of Inspection: May 22, 2004
BUILDING SEWER (locate on site plan)
Depth below grade: 15"
Material of construction: X cast iron _40 PVC _ other (explain):
Distance from private water supply well or suction line: 42'
Comments: (on condition of joints, venting, evidence of leakage, etc.):
Buildingsewer ewer pipe is in good condition no evidence of leakage.
SEPTIC TANK: Yes (locate on site plan)
Depth below grade: 7"
Material of construction: X concrete _metal _ fiberglass_polyethylene
other (explain)
If tank is metal list age _ Is age confirmed by a Certificate of Compliance (yes or no): (attach a copy of
certificate)
Dimensions: 4'/Z' W x 8'L x 50" D
Sludge depth: 6"
Distance from top of sludge to bottom of outlet tee or baffle: 25"
Scum thickness: 0"
Distance from top of scum to top of outlet tee or baffle: N/A
Distance from bottom of scum to bottom of outlet tee or baffle: N/A
How were dimensions determined: Measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Inlet and outlet baffles are in place liquid level is at outlet invertSec tank is in good condition and does not
require pumping at this time. _
GREASE TRAP: No (locate on site plan) -
Depth below grade:
Material of construction: concrete metal fiberglass _polyethylene _other
(explain): _
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments: (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related
to outlet invert, evidence of leakage, etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 381 Summer Street
North Andover, MA 01845
Owner: Sue Marino
Date of Inspection: ME 22, 2004
TIGHT or HOLDING TANK: No (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: izallons
Design flow: gallons/day
Alarm present (yes or no):
Alarm level: Alarm in working order (yes or no):
Date of last pumping:
Comments (condition of alarm and float switches, etc.):
DISTRIBUTION BOX: Yes (if present must be opened)(locate on site plan)
(Depth below grade = 14")
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.):
No sign of solids carryover, distribution is equal.
PUMP CHAMBER: No (locate on site plan)
Pumps in working order (yes or no):—.—
Alarms
o):._Alarms in working order (yes or no):
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc):
Page 9 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 381 Summer Street
North Andover, MA 01845
Owner: Sue Marino
Date of Inspection: May 22, 2004
SOIL ABSORPTION SYSTEM (SAS): Yes (locate on site plan, excavation not required)
If SAS not located explain why:
Type
_leaching pits, number:
_leaching chambers, number:
_leaching galleries, number:
leaching trenches, number, length:
X leaching fields, number, dimensions: 1 leach field — 20' W x 45' L
_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.):
SAS is under back yard no ponding or signs of hydraulic failure present. hisnected leach field with a video
inspection camera and found it working well.
CESSPOOLS: No (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 or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRIVY: No (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.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
. PART C
SYSTEM INFORMATION (continued)
Property Address: 381 Summer Street
North Andover, MA 01845
Owner: Sue Marino
Date of Inspection: May 22, 2004
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.
Locate all wells within 100 feet. Locate where public water supply enters the building.
Summer Street
Page 11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 381 Summer Street
North Andover, MA 01845
Owner: Sue Marino
Date of Inspection: May 22, 2004
SITE EXAM
Slope
Surface water
Check Cellar
Shallow wells
Estimated depth to ground water 6'8" feet
Please indicate (check) all methods used to determine the high ground water elevation:
X Obtained from system design plans on record — If checked, date of design plan reviewed:
Observed Site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health -explain:
Checked local excavators, installers — (attach documentation)
Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Bottom of SAS is 30" below grade. According to soil testing performed on April 30, 1777 by Datsum Corporation
groundwater was observed at 6'8".
11
p`r
j7
1
TO:
FROM:
NORTH ANDOVER, MASS
BOARD OF HEALTH
DESIGN ENGINEER
-5-12--5 19 79
Re: Soil Absorption Sewage
System Inspection
This is to certify that I have inspected the construction of the said disposal system at
/ Lt 1,0 04 eR North Andover, Mass.
SITE LOCATION
The grades and construction are as specified in my plans and specifications dated
19—
OF
� "9
s J0 x _=
wzfAeer/R(K (Sanitarian
o No.
qeq`,r
NORl1l ANDOVER .BOARD OF HEALTH
SUBSURFACE DISPOSAL SYSTEM CHECK LIST.
'ED PRS
leg. 2.5
Reg. 6.1
Reg. 6.7
Reg. 6.$
Reg. 6.9
Reg. 6.1'
Reg. 6.1E
leg 3.7
The submitted plan must show as a minimum:
DISAPPROVED
the -lot- to be served (area dimensions, lot #, abutters)
To—cation and dimensions of system (including reserve area)
.design calculations
calculations showing required leaching area
-existing and proposed contours
location and log of deep observation holes -distance to ties
location and results of percolation tests -distance to ties
location of any wet areas within 100' of the sewage disposal
system or disclaimer
-surface and subsurface drains within 100' of sewage disposal
system or disclaimer
location of any drainage easements within 100' of sewage
disposal system or disclaimer
-known sources of water supply within 200' of sewage disposal
system or disclaimer
location of any proposed well to serve the lot (100t from leaching, facilt
location of water lines on property (10t from leaching facilities)
T aximum ground water elevation in area of sewage disposal system
"location of benchmark
plan must be prepared by a Professional Engineer or other
professional authorized by law to prepare such plans
-driveways
garbage disposers
profile of the system (elevations of basement, plumbers pipe :
septic tank,,,distribution box inle;ts.atnd outlets, distribution
field piping and any other elevations)
no PVC. -s to be used in construction
Tanks
a) Capacities - 150% of, flow
b) Water table
( d. /Depth of tees
(e) Access
,(f) Pumping
(g) Cleanout
(h) 10' from cellar wall or inground swimming pool
(1) 25' from subsurface drains
I Pum s
deg. 9.1 a Approval
leg. 9.6� (b) Stand-by power
('ommonw alth of Massachusetts
Massachusetts
System Pumping Record
Systeiti Owner
PM -1 ko
System Location
-3,91 -SL*tn YUa,'r_
57 -
Date of Pumping: —3 _ Cc� -aOO- Quantity Pumped: ` � gallons
Cesspool: No 1 Yes Ll Septic Tank: No L._� Yes «�
System Pumped by: vctt`ed4r6 Sit&'Z taa License #
Contents transferrred to : Greater Lawrence Sanitary District
Date:
Inspector:
t
TOWN OF
SYSTEM PUMPING RECORD -gO qr�`
DATE: ]-M-0
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
J40 VW
� S
DATE OF PUMPING: t QUANTITY PUMPED: b GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE -7EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: ( -7-
System Owner
Connnonwealth fjf Massachusetts
a , Massachusetts
stem Putn
In Record
System Location
Date of Pumping: l C 1 '3,c� 6 Quantity Putnped: �� gAllotis