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Miscellaneous - 386 SHARPNERS POND ROAD 4/30/2018 (2)
In r J NORT11 O�tsUn° ,6's Z. O ti \T,/_O COC Ac K. 1' T 7a�A°9ATeC' PUBLIC HEALTH DEPARTMENT Community Development Division C1FRTj1FICA`TtF Off' CO_14,1DLIAXCE As of: ,duly 28, 2006 this is to cert that the individual su6surface disposal system was: Repaired- Septic 7ankQ� D -Box 12epCacement by: James Xeffett At: 386 Sharpners Pond (Foad North Andover, M,4 01845 The Issuance of this cert Rate shall not be construed as a guarantee that the system will function satisfactorily. Susan 7 Sawyer, RVISAU Public Ifealth Director 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fox 978.688.8476 Web www.townofnorthandover.com TOWN OF NORTH ANDOVER NORTh Office of COMMUNITY DEVELOPMENT AND SERVICES o °`'t��. •1�° HEALTH DEPARTMENT 400 OSGOOD STREET "."• • �. NORTH ANDOVER, MASSACHUSETTS 01845 'ss�cwuset 978.688.9540 — Phone Susan Y. Sawyer, REHS/RS 978.688.8476 — FAX Public Health Director E-MAIL: healthdept@_townofnorthandover.com WEBSITE: htip://www.townofnorthandover.com TOWN OF NORTH ANDOVER SEPTIC DISPOSAL SYSTEM - INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System ( ) constructed; �J repaired; (Print Name) located at 38('C' S -#y9�?PNjRS 'A�vo r?0h+2D (Installation Address) was installed in conformance with the North Andover Board of Health approved plan, originally dated !zx-71-6 S' and last Revised on , with a design flow of gallons per day. The materials used were in conformance with those • specified on the approved plan; the system was installed in accordance with the provisions of 310 CMR 15.000, Title 5 and local regulations, and the final grading agrees substantially 'th the approved plan. All work is accurately represented on the As -built which hasa F the Board of Health. ®ENJAMIN C. o OSGOOD, JR. ,*Bed inspection date: /Aqo C CIVIL Engirw6r Representative turej0.45881 7'HNK, 1>IsT1210 69 o le AV C> 7b T+tiKc KE.s owl c y, ;(i1AKf,itf oS ,�► Alm And - Print Name Final inspection date: Engineer Representative (Signature) And - Print Name And - Print Name Engineer: (Signature) Date: • f4jGYh;n �Ioa And -Print ane ,yJ TOWN OF NORTH ANDOVER NORTH Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 400 OSGOOD STREET NORTH ANDOVER, MASSACHUSETTS 01845 �'Ss„Cmu Susan Y. Sawyer, REHS/RS 978.688.9540 - Phone Public Health Director 978.688.8476 - FAX SEPTIC SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 386 Sharpners Pond Road MAP: LOT:_ INSTALLER: Tames Kellett 1-781-953-746 DESIGNER: Ben Osgood PLAN DATE: 11/29/2005 BOH APPROVAL DATE ON PLAN: 12/06/2005 INSPECTIONS D -Box & Tank Inspection: 1/6/06 - Frida DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SELECT SYSTEM TYPE 1. GRAVITY DISTRIBUTION... ❑ 2. PRESSURE DISTRIBUTION... ❑ 3. PRESSURE DOSING... ❑ 4. HOLDING TANK... ❑ 5. ADVANCED TREATMENT... ❑ 6. OTHER... ❑ FAST SYSTEM COMPONENT SUMMARY FROM PLAN 1. GALLON TANK = 1500 2. LOADING OF SEPTIC TANK = 3. GALLON PUMP CHAMBER = 4. LOADING OF PUMP CHAMBER = 5. TYPE OF SAS 6. DIMENSIONS AND DETAILS OF SAS: Comments: Page 1 of 4 TOWN OF NORTH ANDOVER t NCR*ti , Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT " x 400 OSGOOD STREET • �, ...;:.:.. 4 NORTH ANDOVER, MASSACHUSETTS 01845 "Ss"„CHU Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX SITE CONDITIONS 1. Existing septic tank properly abandoned... ❑ 2. Internal plumbing all to one building sewer... ❑ 3. Topography not appreciably altered... ❑ SEPTIC TANK 1. Bottom of tank hole has 6" stone base... ❑x 2. Weep hole plugged... ❑ 3. Tank has been installed (H-10) Tank Size: 1,500 - MONOLITHIC...0 4. Water tightness of tank has been achieved (Visual)... ❑x 5. Inlet tee installed, under access port... ❑x 6. Outlet tee (gas baffle or effluent filter) installed, under access port... El 7. Cover to within 6" of final grade installed over one access port, must be over outlet of tank if effluent filter is present - Inches of Tank... ❑ 8. Hydraulic cement around inlet & outlet... ❑ ****Comments: **** PUMP CHAMBER — n/a 1. Bottom of tank hole has 6" stone base... 2. Weep hole plugged... ❑ 3. Pump Chamber Installed _Combo tank Gallons; (1-1-20) (Monolithic) 4. Inlet tee installed, under access port... 5. Pump(s) installed on stable base... ❑ 6. Alarm Float Working... ❑ 7. Pump On/Off Float Working... ❑ 8. Total # of Floats... 9. Drain hole in pressure line... ❑ 10. Cover to within 6" of final grade installed over one access port... ❑ 11. Water tightness of tank has been achieved — Visual or Vacuum Test or Water held for 24 hours (circle) 12. Hydraulic cement around inlet & outlet... ❑ Comments: Page 2 of 4 TOWN OF NORTH ANDOVER cf NORTo, Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 400 OSGOOD STREET► + NORTH ANDOVER, MASSACHUSETTS 01845 CMuse� Susan Y. Sawyer, REHS/RS Public Health Director D -BOX 1. Installed on stable stone base... ❑D 2. Inlet tee (if pumped or >0.08'/foot)... 0 3. Hydraulic cement around inlet & outlets... EX -1 4. Observed even distribution... ❑x 5. Speed levelers provided (not required)... ❑x - Comments: PIPE NEEDS TO BE BEDDED PROPERLY 978.688.9540 — Phone 978.688.8476 — FAX SOIL ABSORPTION SYSTEM 1. Bottom of SAS excavated down to Soil Layer, as provided on plan... ❑ 2. Size of SAS excavated as per plan... ❑ 3. Title 5 sand installed, if specified on plan... ❑ 4. 3/4-1 1/2" double washed stone installed... ❑ 5. 1/8-1/2" (peastone) double washed stone installed 6. Laterals installed and ends connected to header (and vented if impervious material above) 7. Gravel -less disposal systems: type, number and location as per plan......... ❑ 8. Elevations of laterals installed as on approved.plan... ❑ 9. 40 Mil HDPE barriers installed... ❑ 10. Retaining wall (boulder / concrete / timber / block) ... ❑ 11. Final cover as per plan ... ❑ *****Comments: ***** CONTROL PANEL 1. Alarm & Pump are on separate circuits... ❑ 2. Alarm sounds when float is tripped...... ❑ 3. Location of control panel: 4. Rated for exterior if placed outside... ❑ Comments: Page 3 of 4 TOWN OF NORTH ANDOVER t NORTH Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT 400 OSGOOD STREET " 'T1 +O°�n° NORTH ANDOVER, MASSACHUSETTS 01845 9SswCHuset Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX SYSTEM ELEVATIONS 1. Benchmark: 2. Rod at Benchmark: 3. Height of Instrument: INVERT ON DESIGN INVERT PLAN ELEVATION Building Sewer OUT Septic Tank IN Septic Tank OUT Distribution Box IN D -Box OUT Manifold Lateral 1 HIGH Lateral 1 Inv Lateral 2 HIGH Lateral 2 Inv Lateral 3 HIGH Lateral 3 Inv Page 4 of 4 µO"7`' Commonwealth of Massachusetts Map-Block-Lot J 090.B- 0048 - Board of Health Permit No North Andover BHP-2005-0728 P.I. tr '+•..�. •''tea'? FEE �J$ACHUSta F.I. $125.00 i Disposal'Works Construction Permit y Permission is hereby granted ( JAMES KELLETT I------------------- ------ to (Construct) an Individual Sewage Disposal System. at No 386 SHARPNERS POND ROAD ` x -------------------------------- as shown on the application for Disposal Works Construction Permit No. BHP-2005-072 Dated December 22 2005 ---------------- --------------- Issued On: Dec-22-2005 L---------------- ----------------------------------- ----------------------------- Board of Health In u°HTN Application for Septic Disposal System IZ Z� oa " TODA 'S DA n,Construction Permit - TO`NN of Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. tab It If ienxn r $ 250.00 - Full Repair $125.00 - Component Application is hereby made for a permit to: ❑ Cons ruct a new on-site sewage disposal system* ❑ air or replace an existing on-site sewage disposal system* Repair or replace an existing system component/ A. FacilityInformation / 3 S-6 �� 94 Address or Lot # ff City/Town 2.- *TYPE OF EPTIC SYSTEM*: ❑ Pump ETGravity (choose one) 71f pump system, attach copy of electrical permit to application*** ER'Conventional System (pipe and stone system) ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D -Box Present) S.A.S. 4 a ,/- /447 �TQ Name Address (if different from above) City/Town State Telephone Number 3. Installer Information Name Name of Company A dreel ss f 1;w G Ci /Town 4. Designer Information Name Address City/Town Zip Code State Zip Code Telephone Number (Cell Phone # if possible please) Name of Company State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 µ°kT� Application for Septic Disposal System O`1..0 ^gtiA �'Construction Permit - TOVN OF TODAY'S DATE x;$ 250.00 -Full Repair NORTH ANDOVER, MA 01845 ;95 °• _ 4�{ $125.00 - Component PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: tResidential Dwelling or ❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place thesystem in operation until a Certificate of Compliance has been ted by this Board �":�, Ith iz lei, Na Date / /% Application. Approved By: board of Health Representative) Name/,'Date Applio2tion Disapproved for the following reasons: For Office Use Only: 1. Fee Attached? Yest/ No 2. Project Manager Obligation Form Attached? ! Yes V' No 3. Pump System? If so, Attach copy ofElectrical�PVrrrtit Yes_ No 4. Foundation As -Built? (new construction ronly): Yes_ No (Same scale as approved plan) 5. Floor Plans? (new construction only): Yes_ No Application for Disposal System Construction Permit - Page 2 of 2 INSTALLER PROJECT MANAGEMENT OBLIGATIONS i As the North Andover licensed installer for the construction of the septic system for the property at 3� �4 "p4er P"-/ %U relative to the application ofJM 11(e'11P( dated for plans by /i/£, S' and dated with revisions dated I understand the following obligations for management of this project: I . As the installer I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer I must call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system is not ready then item three shall be applicable. 3. As the installer I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Tile 5 and the Board of Health Regulations may result in a $50.00 fine being levied against my company. a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. b) Final inspection — Engineer must first do their inspection for elevations, ties, etc. As -built or verbal OK from engineer must be submitted to Board of Health, after which installer calls for inspection time. Installer must be present for this inspection. With pump system all electrical work must be ready and able to cause pump to work and alarm to function. c) Final Grade — Installer must request inspection when all grading is complete. Does not have to be on site. 4. As the installer I understand that only I may perform the work (other than simple excavation) required to complete the installation of the system identified in the attached application for installation. I further understand that work by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system, and/or revocation or suspension of my license to operate in the Town of North Andover; significant fines to all persons involved are also possible. 5. As the Installer I understand that I must be on site during the performance of the following construction steps: a) Determination that the proper elevation of the excavation has been reached. b) Inspection of the sand and stone to be used. c) Final inspection by Board of Health staff or consultant. d) Installation of tank, D -box, pipes, stone, vent, pump chamber, retaining wall and other components. 6. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Undersigned icensed Septic Installer Date: NEW ENGLAND ENGINEERING SERVICES INC November 30, 2005 Mrs. Susan Sawyer North Andover Board of Health 400 Osgood Street North Andover, MA 01845 RECEIVED NOV 3 0 2005 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Re: 386 Sharpners Pond Road, North Andover, MA Septic Tank and Distribution Box Replacement Design Plan Dear Mrs. Sawyer, The following plans for the above referenced property are being submitted for approval. The plan calls for replacement of the septic tank and distribution box. The existing leaching facility shall remain intact. Enclosed are three copies of this design plan. Please contact this office with any questions or concerns. Sincerely. -'41� Steven E. Pouliot Project Manager 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 C -?d -�5 _f r Town of North Andover 400 Osgood Street North Andover, MA 01845 978.688.9540 - Phone Web Site - www.townofnorthandover.com E -Mail - healthdeot(cDtownofnorthandover.com 978.688.8476 - Fax Due upon receipt Invoice No. 1/6/2006 Bill To Jim Kellett Address 400 Salem Street Lynnfield, MA 01940 Phone 781-953-7146 Fax E -Mail Deposit Received $0.00 Invoice Subtotal $50.00 Tax Rate Invoice Total $50.00 Total Amount Due $50.00 Amount Paid 386 SHARPNERS POND ROAD- Fine for not being ready, X1/6/2006, — _ _ for inspection by Health Director 1/6/06—.. _ ,. .� , _ . _—$50.00j _RrCE ED JAN -3 _l_ 2006_ -- TOWN OF"NORTH ANDOVER- HEALTH DEPARTMENT _ +_ Received by: _ — ,Signature, +Print Name: _ -- i Subtotal + _ — — — _ _$50.00 j r Tax, $0.00 I�yLJ Total= $50.00 Thanks for letting us serve you! NEW ENGLAND ENGINEERING SERVICES INC January 12, 2006 Ms. Susan Sawyer North Andover Board of Health 400 Osgood Street North Andover, MA 01845 Re: 386 Sharpners Pond Road North Andover As -Built Septic System Design Dear Ms. Sawyer, RECEIVED JAN 13 2005 TOWN OF NORTH ANDOVER HEALTH DEPTME NV The following As -Built Plans for the above referenced property are hereby submitted for your approval. Enclosed are the following: 1. One (1) Copy of the Form 3 Certificate of Compliance 2. Three (3) Copies of the As -Built Plan If you have any comments or questions please do not hesitate to contact this office. Sincerely, Benjamin C. Osgood,Jr. .E. President 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 00,< C_} TOWN OF NORTH ANDOVER pORTh Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT ' 400 OSGOOD STREET NORTH ANDOVER, MASSACHUSETTS 01845 'SSwCHUSet Susan V. Sawyer, REHS/RS Public Health Director April 11, 2005 To all Sharpeners Pond Road Residents: 978.688.9540 — Phone 978.688.9542 — FAX E-MAIL: healthdept@townofnorthandover.com WEBSITE: http://www.townofnorthandover.com Please note that it has come to the attention of the Health Department that many residents are leaving their trash barrels and trash bags out at the curbside for days, or weeks at a time. Empty trash barrels blowing about in the road are a safety hazard, and trash and debris along the roadway is a health hazard. Please be mindful of this, as the Health Department will conduct periodic inspections of the area to determine who is in violation, and fines will be issued if protocol is not followed. The Board of Health follows the State Sanitary Code regarding Human Habitation, 105.CMR.410, Section 1: 410.600 (A): Garbage or mixed garbage and rubbish shall be stored in watertight receptacles with tight- fitting covers. Said receptacles and covers shall be of metal or other durable, rodent -proof material. Rubbish shall be stored in receptacles of metal or other durable, rodent -proof material. Garbage and rubbish shall be put out for collection no earlier than the day of collection. (B): Plastic bags shall be used to store garbage or mixed rubbish and garbage only if used as a liner in watertight receptacles with tight -fitting covers as required in 105 CMR 410.600(A), provided that the plastic bags may be put out for collection except in those places where such practice is prohibited by local rule or ordinance or except in those cases where the Department of Public Health determines that such practice constitutes a health problem. For purposes of the preceding sentence in making its determination the Department shall consider, among other things, evidence of strewn garbage, torn garbage bags, or evidence of rodents. 410.602 (A) Land. The owner of any parcel of land, vacant or otherwise, shall be responsible for maintaining such parcel of land in a clean and sanitary condition and free from garbage, rubbish or other refuse. The owner of such parcel of land shall correct any condition caused by or on .such parcel or its appurtenance which affects the health or safety, and well-being of the occupants of any dwelling or of the general public. (D) Common Areas. The owner of any dwelling abutting a private passageway or right-of-way owned or used in common with other dwellings or which the owner or occupants under his control have the right to use or are in fact using shall be responsible for maintaining in a clean and sanitary condition free of garbage, rubbish, other filth or causes of sickness that part of the passageway or right-of-way which abuts his property and which he or the occupants under his control have the right to use, or are in fact using, or which he owns. Residents should know the following: The Town has a mandatory paper and cardboard recycling ordinance that requires residents to separate these items from their household trash. Paper and cardboard are collected every other week on the same day as the household's normal trash. Residents can call the DPW at 978.685.0950 to get their recycling schedule. • Residents are responsible for picking up loose trash left at the curb after collection. Banned Items and Recycling Requirements: Please refer to the DPW website for a complete list of all the recycling requirements: http://www.northandoverrecycles.com. Please contact the Health Department if you have any additional questions. Thank you. S incere Sawyer, REHS/RS Public Health Director File NEw IENGLAND IENGINEIEMG SERVICES, INC. 1600 Osgood Street Building 20 Suite 2-64 North Andover, MA 01845 mel: (978) 686-1768 • Fax: (978) 327-6138 Ms. Susan Sawyer North Andover Board of Health 400 Osgood Street North Andover, MA 01845 May 3, 2006 RECEIVED MAY S 2006 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT RE: TITLE V REPORT: 386 Sharpners Pond Road, No. Andover MA Dear Ms. Sawyer: Enclosed is the Title 5 Report for the above referenced property. The system PASSES the inspection. If there are any questions please call me at my office, 686-1768. Sincerely, BenXmin C. O od, Jr. Certified Title 5 Inspector I 'of 11 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 386 Sharpners Pond Road No. Andover, MA 01845 Owner's Name: Allison Naftal Owner's Address: 386 Sharpners Pond Road No. Andover, MA 01845 Date of Inspection: April 27, 2006 Name of Inspector: (please print) Benjamin C. Osgood, Jr. Certified Title 5 Inspector Company Name: New England Engineering Services Inc. Mailing Address: 1600 Osgood Street Building 20 Suite 2-64, North Andover, MA 01845 Telephone Number: 978-686-1768 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 m the proper function and maintenance of the on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15340 of Title 5 (3 10 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails em Inspector's Signature: F �.--� Com_... �/ Dater The system inspection 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. w 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 386 Sharpners Pond Road No. Andover, MA 01845 Owner's Name: Allison Naftal Date of Inspection: April 27, 2006 Inspection Summary: Check A, B, C, D or E/ALWAYS complete all of Section D A. System Passes: 'Aa 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: lir0 One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): Broken pipe(s) are replaced Obstruction is removed Distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): Broken pipe(s) are replaced Obstruction is removed ND explain_ s- 3 'of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 386 Sharpners Pond Road No. Andover, MA 01845 Owner's Name: Allison Naftal Date of Inspection: April 27, 2006 C. Further Evaluation is Required by the Board of Health: 4/0 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 (SAS) Soil Absorption System and the (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 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 organize 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 5ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 46f 11 / OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 386 Sharpners Pond Road No. Andover, MA 01845 Owner's Name: Allison Naftal Date of Inspection: April 27, 2006 D. System 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 k o Discharge or ponding of effluent to the surface of the ground or surface waters due to an overload or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overload or clogged SAS or cesspool ✓� Liquid depth in cesspool is less than 6" below invert or available volume is less than % day flow v 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrogen is equal to or less than 5ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) Nt) (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either "yes" or "no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes T The sylmm is�Wldt of a surface drinking water supply The system isof a tributary to a drinking water supply The system is located in a of a public water supper area (Interim Wellhead Protection Area —1WPA) or a mapped Zone II If you answered "yes" y question in Section E the system is considered a ' cant threat, or answered "yes" in Section D above the large system failed. The owner or operator of any large system considereda ' cant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system o ould contact the appropriate regional office of the Department. 5of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 386 Sharpners Pond Road No. Andover, MA 01845 Owner's Name: Allison Naftal Date of Inspection: April 27, 2006 Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ✓ Pumping information was provided by the owner, occupant, or Board of Health ✓ Were any of the system components pumped out in the previous two weeks_? ✓ Has the system received normal flows in the previous two week period ? f Have large volumes of water been introduced to the system recently or as part of an 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 sign of break out? Were all system components, excluding the SAS, located on site? �C Were all 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 difference from owner) provided with information on the proper maintenance of the subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes No ✓ 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) [3 10 CMR 15.302(3)(b)] 6of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 386 Sharpners Pond Road No. Andover, MA 01845 Owner's Name: Allison Naftal Date of Inspection: April 27, 2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design) � Number of bedrooms (actual):_ DESIGN flow based in 310 CMR 15.203 ( for example: 110 gpd x # of bedrooms) -- Number of current residents:_ Does residence have a garbage grinder (yes or no): NO Is laundry on a separate sewage system (yes or no): [if yes separate inspection required] Laundry system inspected ( yes or no): Seasonal use: (yes or no): N 0 Water meter readings, if available (last 2 years usage (gpd):vy c c Sump Pump (yes or no): lVy Last date of occupancy—z ! re COMIKERCIALANDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sgft, etc Grease trap present (yes or no): Industrial waste holding tank present (yes or no): Non -sanitary waste discharged to the Title 5 system (yes or no) Water meter readings, if available: Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: ft, nm rt p # ^/ gce e &I gE- (L Zo o- Was system pumped as part of the inspection (yes or no): N o If yes, volume pumped: gallons – How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _ Septic tank, distribution box, soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) Tight tank Attached a copy of the DEP approval Other (describe Approximate age of all components, date installed (if known) and source of information: 1-4, t7 J;..', I.: 15 � �-, Were sewage odors detected wen arriving at the site (yes or no): N 0 7of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 386 Sharpners Pond Road No. Andover, MA 01845 Owner's Name: Allison Naftal Date of Inspection: April 27, 2006 BUILDING SEWER (locate on site plan) Depth below grade: P Materials of construction: cast iron_Z% 40 PVC other (explain) Distance from private water supply well or suction line: /..- Comments (on condition of joints, venting, evidence of leakage, etc.): ��1'L' )5 C.cisT iRDni TH1Z-0JC-11 waLi-. I�JG i=IZG=�1 > ��js�PC wAI-�- 7-AwA. 41,i Jill &C -C,6 SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene Other (explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance (yes or no): (attach a copy of certificate) Dimensions: 6-4d . 0 Sludge depth: L ) Distance from top of sludge to bottom of outlet tee or baffle: a Scum thickness: :L4 Distance from top of scum to top of outlet tee or baffle: y Distance from bottom of scum to bottom of outlet tee or baffle /3 " How were dimensions determined: nt Elms %j 9 a- 5-n c i4 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): "r04AJ 1'1- "E w- , /tj A EY Z� e b-, GREASE TRAP: (locate on site plan) Depth below grade: Materials 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 sludge 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. 8of11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 386 Sharpners Pond Road No. Andover, MA 01845 Owner's Name: Allison Naftal Date of Inspection: April 27, 2006 TIGHT OR HOLDING TANK IA_(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Materials of construction: concrete metal fiberglass polyethylene other Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: (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 evidnence of solids carryover, any evidence of leakage into or out of box, etc.): -& 4 (ise- i. ..r i,- L A Avy A A H ZC c> Ls r LJ w i—e le . e 2S i ,j s'i Al,(,E D, PUMP CHAMBER: VT(locate on sire plan) Pumps in working order (yes or no) Alarms in working order (yes or no) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 386 Sharpners Pond Road No. Andover, MA 01845 Owner's Name: Allison Naftal Date of Inspection: April 27, 2006 w ELS SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locat all wells within 100 feet. Locate where public water supply enters the building. � I 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 386 Sharpners Pond Road No. Andover, MA 01845 Owner's Name: Allison Naftal Date of Inspection: April 27, 2006 SITE EXAM Slope z "K. Surface water e:7 Check cellar ,�,,p r a(t� Shallow wells N�r•E Estimated depth to ground water feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record — If checked, date of design plan reviewed: Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health — explain: Checked with local excavator, installers — (attach documentation) Accessed USGS database -explain: You must describe how you established the high ground water elevation: _0KC-6 0,FSysT2M !S� f�B'D�+F 14'dT E.�t �-✓C / 4R NO 1 William F. Weld Governor Argeo Paul Celluccl U. Governor r a V'I r Commonwealth of Massachusetts Coy Executive Office of Environmental Affairs Department of Environmental Protection Trudy Coxe ' Secretary David B. Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ^� C CERTIFICATION 60,,erProperty Address 3 c �� �Q'�'s P(�I�� �AA..t Date of Inspection: 4 — a3 — 9�p (If different) Name of Inspector. p� � Company Name, Address and �eiephone Numbs13ATESON ENTERPRISES, INC. TEL: (508) 475-1474 Excavating - Water & Sewer Lines - Septic Systems & Pumping Se vice FAX: (508) 475-5451 Sj(� _ r/� v��� 1 1 1 Argilla Road a Andover, Mass. 01810 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 bn my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _ Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority .FNsub Inspector's Signature: Date: . - & The System Inspector shaacojfthis inspection report to the Approving Authority within thirty (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 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] SY=have nd 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. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. 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, 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 Fonforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 One Winter Street a Boston, Massachusetts 02108 i FAX (617) 556-1049 A • `? Pnnied on Recycled Paper 1�1 e Telephone (617) 292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Prepo"y Addv"si, A8CO6�6A A2,CS Owner. r' q T '^ Date of Inspection: �— S Crow h I r - a -2, Bl SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health): 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 Cl 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 it 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 13 FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or, tributary to a surface water supply. I. ,. . , 7 The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.. The system has a septic tank and soil absorption system and 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. 3)' ' OTHER (revised 11/03/95) 2 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 3e)(0?=R'aa, V2�Cj V1294\�A Owner. Owne Date of Inspection: D) SYSTEM FAILS: 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. 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 cdmpounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 13 of a public water supply well) The owner or operator of any such system shall bring the system and facility into firll 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 11/03/95) 3 �r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: C S�Ik0."�' TO.'A PA V. ai UazC w Oner.� Date of Inspection: ekv Check if the following have been done L_ P mping information was requested of the owner, occupant, and Board of Health. one 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. N/t plans have been obtained and examined. Note if they are not available with N/A. ty, or dwelling was inspected for signs of sewage back-up. �,�7e m does not receive non -sanitary or industrial waste flow e si was inspected for signs of broakaut. components, excluding the Soil Absorption System, have been located on the site. e septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, rial 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 or _�app ted by non -intrusive methods. y owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 MI t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Addrerss: �S( � QkS Owner- Date wner`�0� G 0 � ����n t� Date of Inspection: L4- a3 --4� FLAW CONDITIONS RESIDENTIAL Designflow �_H O gallons Number of bedrooms: Number of current residents:TI Garbage grinder (yes or no): 1v v F Laundry connected to system (yes or no):Yes Seasonal use (yes or noW0 Rater meter readings, if available: W�l� Lest date of occupancy: 6,3 CC COMM ERC IAL /INDUSTRIAL: Type of establishment: Design flow:----.gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non -sanitary waste discharged to the Title 5 system: (yes or no)_, Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: AT\)-, ` 9, System pumped as part of inspection: (yes or no7 If yes, volume pumped: 1, 7)O lony 1 r t Reason for pumping: 1V�S�2i�gVl�lrl.'CQQS TYPE O STEM 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) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: P -U'S lA--©whQ,,r- Sewage odors detected when arriving at the site: (yes or no) / 0 (revised 11/03/95) 5 1 _1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM_ INFORMATION (continued) Property AddressiQ S �p�S P 1" , AUar Owner. Q� 6-'U:k�\ v\SN\TQ- `A Date of Inspection: SEPTIC TANK:_ (locate on site plan) i t V1,�� 2'r- Co u.� Cc�us 3 Depth below grade._ Material of construction: �crete ._metal _FRP other(explain) Dimensions: 'AS • -5z- Ohg. Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:_ it Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pur evidence of leakazv., etc. ) G12WE TRAP j0, �..e (locate on site plan) Depth below grade condition of inlet and outlet tees Material of construction: _concrete _metal _FRP _other(explain Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: t Distance from bottom of scum to bottom of outlet tee or baffle: in relation to outlet 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.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (oo�nu ) PropertyAddreeet �318G- : -S�U Owner. (`--�( ��©coe 1V\, !�;k44!!,,� Date of Inspection: TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Capacity: Rallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX- V (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if le 1d distribution is ual, evidence of solids ver, vidence of le ge into or t of etc.)�,4A VII PUMP CHAMBERo4'-,(2V\4e-- j�Ol,V\g�g (locate on site plan) v Pumps in working order:(ges or no) Comments: ",; (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SM M I `v yoam= N (continued N) Property Address: c (�� • V��_ Owner. . 0 B— - �a,0 S wv c 1 Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods) If not determined to be present, explain leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: �`E/" `PS SO' 11 GCj leaching fields, number, dimensions: �l overflow cesspool, number: Comments: �te condition of soil, siigns of hydrau©failure 1 of,pondi g, conditigp pf vei tion etc.) CESSPOOLS: Y (locate on site plan) Number and configuration: ) Depth -top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: - inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: V v✓�� r (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.) (revised 11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 1 SYSTEM INNFFO�RMA/TION (continued) Property Addrese: � 6G SVk& S` Y14(, -1-4S `1 C ►`�' ' VG Owner. Date of Inspection: Lf SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' VQ- C6Se- 0 �C-. VikAk�r A'-�Osl — Vo Sa 32k, a'' 53 =36' u1, 0 _ 4 (o '6 r DEPTH TO GROUNDWATER .. 1...1_ _._,n D gD7, 1 a 5th (revised 11/03/95) 9 Y ' - p irk Yee i:^F ul auis l�lt�, iv I, TOWN OF NORTH ANDOVER R SYSTEM PUMPING RECORD 4 t DATE' 'f�f�4i 1�ZI� �� lY ii ;11 ,. 1':.. -..' :,:' .• � �� SYSTEM OWNER &ADDRESS SYSTEM LOCATION h p ` k4- (example: left front of house) y;,r Iwr,�,�n ri'n�"1 ���: `t't,'' .,1'1, i w°. ._��:��1�,•,: .. � �. © � h�V j� �� .. PS) 1 i:fir C t • �. G , I..DATE,OFPUMPING: QUANTITY PUMPED _ GALLONS jy�ls,Ufi�}��ti�tyyi,i�sf'R-ai�r�! CESSPOOL: NO YES _ ' 'SEPTIC TANK: NO YES �1 NATURE 0�.�.. F SERVICE: ROUTINE H'MF.Rf_'Tavry 1 ... '�r•'.�i£� ak�4' lac �•� i t a bt r�lkr 1,� E z - . _ ... .... .. � 1�SERVATIONS• GOOD CONDITION t FULL TO COVER HEAVY GREASE BAFFLES IN PLACE t ROOTS _ LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPi.AnvI a 6�r XSTEM PUMPEDD BY ignCif bile. A { _ -t' '� G"�y 1,•1� '�y•E=f - QMNENTS. t F, 1 ��r kF�pt 9t r 3tET�sjJ��`'''{''•��ijs� v i 5 p 1 Y IN -,,6 2001 E r ! �i*rli jn �' )' a.11►'M'S T A�TSFERRED TO. TENT R. ljtiiA�.T#ix �p.. 7 i DU 1t ii! M lry 0��,/ ''.. g�, �� 11 :v,J J; �j� l tit a b , t t i ,w�•�' 7 t.�P�j Wl 1��y��iN a•i1i¢r't E;'��4,i-r��:�,ff �{ ��}re.rr u ,'f t ., .., ' �