HomeMy WebLinkAboutMiscellaneous - 400 SHARPNERS POND ROAD 4/30/2018 (2) 400 SHARPNERS POND ROAD d Road
210/090.6-0047-0000.0
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PUBLIC HEALTH DEPARTMENT
Town of North Andover
Cormnunity Development Division
CERTIFICATE OF
COMPLIANCE
As of: 6/16/2016
This is to certify that the individual subsurface disposal system received a
SATISFACTORY INSPECTION of the:
Repair of Baffle, Riser and D-Box
By: John DiVincenzo
At:
400 Sharpners Pond Road
Map 090.B Lot 0047
;, - North Andover, MMA 01845
The Issuance of this ce ate shalJ not belconstrued as a guarantee that the system will function satisfactorily.
U l
Mi bele Grant
+
Public Health Agent
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
• S�,T'TCED"j�d •
I -
TED
North Andover Health Department
fommunity and Economic Development Division
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: 400 Sharpners Pond Rd. MAP: 090.13 LOT: 0047
INSTALLER: John DiVincenzo
DESIGNER:
PLAN DATE:
BOH APPROVAL DATE ON PLAN:
INSPECTIONS
Baffle and riser and d-box INSPECTION: 6/16/16
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
❑ Contractor reports any changes to design plan
❑ Existing septic tank properly abandoned]
❑ Internal plumbing all to one building sewer
❑ Topography not appreciably altered
Comments:
SEPTIC TANK
Building sewer in continuous rade on
❑ 9 grade,
compacted firm base
❑ Cleanouts per plan
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ 1500 gallon tank has been installed
H-10 loading
- ❑ Monolithic tank construction
❑ Water tightness of tank has been achieved by
visual testing
❑ Inlet tee installed, centered under access port
tlet tee inst lied, centered under access port
Was baffle1e4uent filter)
inch cov within 6" of finish grade
'--� a over one access port
❑ Hydraulic cement around inlet & outlet
Comments:
PUMP CHAMBER
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ 1500 gallon Pump Chamber installed
❑ H-10 loading
❑ Monolithic tank construction
❑ Inlet tee installed, centered under access port
❑ Pump(s) installed on stable base
❑ Alarm float working
❑ Pump On/Off floats working
❑ Separate on/off floats
❑ Drain hole in pressure line
❑ cover at final grade installed over pump
access port
❑ Water tightness of tank has been achieved by
testing
❑ Hydraulic cement around inlet & outlet
Comments:
CONTROLPANEL
❑ Alarm & Pump are on separate circuits
❑ Alarm sounds when float is tripped
❑ Location of control panel: basement
❑ Alarm signal located inside: basement
Comments:
DISTRIBUTION-BOX
IE YInstalled on stable stone base
1 H-20 D-Box
Inlet tee (if pumped or >0.08'/foot)
Hydraulic cement around inlet & outlets
Observed even distribution
[� Speed levelers provided (not required)
Schedule 40 PVC Pipe
Comments: ( L� Q� �S ury b ,
•,'t,'(KLED Tipya, . Commonwealth of Massachusetts Map-Block-Lot
090.80047
-----------------------
BOARD OF HEALTH Permit No
BHP-2016-0203
North Andover -----------------------
fi� a ti P.I. FEE
� n yah F.I. $175.00
-----------------------
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted John DiVincenzo ,
------ ----------- ----- --�--p------
- ------------------------------------------- ----
to(Repair)an Individual Sewage Disposal System. LE, a
at No 400 SHARPNERS POND ROAD
as shown on the application for Disposal Works Construction Permit No. BHP-2.016_-020-r bated, xJ.une_1,3.,2016
------------- -----------------------------------------------
I ssued On:Jun-13-2016 BOARD OF HEALTH
r
Application for Septic Disposal System
�"+ `• TODAY'S DATE
tw „
Construction Permit — TOWN OF
$350.00-Full Repair
NORTH ANDOVER, MA 01845 $175.00-Component
Important: Application is hereby made for a permit to:
When filling out ❑Construct a new on-site sewage disposal system*
forms on the
computer,use ❑ 5erair or replace an existing on-site sewage disposal system* /
only the tab key
to move your Repair or replace an existing system component—What? � _AG IV
cursor-do not �� o-
use the return A. Facility Informatiop
key. p� � �r
(/ ', G P
Address or Lot# if V1 �J
Q RECEIVED
City/Town
'B0m' 2.-*TYPE OF SEPTIC SYSTEM*: JUN 13 2016
➢ ❑ Pum ravity(choose one)
***If pump sly, m, attach copy of electrical permit to application*** TOWN OF NORTH ANDOVER
➢ onventional System (pipe and stone system) HEALTH DEPARTMENT
➢ ❑ Infiltrator or Biodiff user(Gravel-Less)(Attach a copy of your certification to install this type of system.)
➢ ❑ Pressure Distribution S.A.S.(No D-Box)
➢ ❑ Pressure Dosed(D-Box Present)S.A.S.
➢ ❑ Does the system require an effluent filter? Yes No
If yes, does plan specify make and model of filter? YES =(no further info. needed)
NO=(installer must specify brand of filter before DWC issuance)
What is the Make? What is the Model.
2. Owner Information
lzekz '4'y _
Na?/,�
® v 4',*. ez
Address/(ifdifferent frof�'abov
/ d AP G1
City/Town State ) r—&
Email address Tele one Number
3. Installer Information
Name
Name of Company
Address "_ r / / _ \
City/Town State Zip Code
Telephone Number(Cell Phone#if possible please)
4. Designer Information
Name Name of Company
Address
City/Town State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
° Application for Septic Disposal System
TODAY'S DATE
Construction Permit - TOWN OF
$350.00-Full Repair
NORTH ANDOVER, MA 01845 $175.00-Component
PAGE 2OF2
A. Facility Informati n continued....
5. Type of Building: 4Residential Dwelling or❑Commercial
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the afore-described
on-site sewage disposal§ystern in accordance with the provisions of Title 5 of the
Envir n ental 94e, aell as the Local Subsurface Disposal Regulations for the Town of
No do er. I nd stand that until a final Certificate of Compliance has been issued by
thi B rd f I h, installed system is not approved.
00 9 13 �6
e Date
I p1ij�ati Approve yand of ealth Representative)
G
ame Date
Application Disapproved for the following reasons:
For Office Use Only:
1. Fee Attached? Yes_ / No
2. Project Manager Obligation Form Attached. Yes t! No
3. Pump Sys tem? If so,Attach copV ofElectricalPe t Yes No
Applicant received copy of
"Electrical Inspection Notes for Septic Systems" s No
Handout?
4. Reviewed approval letter, all paperworkreceivedP . Yes No
Missing:
5. Foundation As-Built?(new construction only): Yes No
(Same scale as approved plan)
6. Floor Pians?(new construction only): Yes No
Application for Disposal System Construction Permit•Page 2 of 2
SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North A over licensed installer for the nstruction r the septic system for the property at:
zall
(Address of septic system) For plans by
(Engineer)
Relative to the application of (�L�ijaJ j ] ccw�
(Installer's name) And dated
(Original ate
Dated )X�
o ay s date7 With revisions dated
(Last revised date)
I understand the following obligations for management of this project:
1. As the installer, I am obligated to obtain all permits and Board of Health approved plans p1lior to
performing any work on a site. I must have the approT ved 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 manager, 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 Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against me and/or
MY cQMpan�L-
a. Bottom of Bed—Generally, this is the first (1'� inspection unless there is a retaining wall,which
should be done first. The installer must request the inspection but does not have to be present.
b. Final Construction Inspection—Engineer must first do their inspection for elevations, ties, etc.
As-built of verbal OK (or e-mail to: healthdept&townofnorthandover.com) from the engineer must
be submitted to the Board of Health, after which installer calls for an inspection time. Installer must
be present for this inspection. With a 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. Installer does not
have to be on-site.
4. As the installer, I understand that only I may perform the work (other thanimple excavation)and I am required
to complete the installation of the system identified in the attached application for installation. I further
understand that work done 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 ofHealth 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 121ans. No instructions by the home ner neral contractor, or any other persons shall absolve
me of this obligation.
i
Undersigned Licensed Septic Installer: T s D
lJ ►✓)/J c �` a l `
(Name—Print) affie—Signe7
Commonwealth of Massachusetts
Title 5 Official Inspection Form RECEIVED
H - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments JUN 14 2016
400 Shar ner pond road TOHEALTH DEPARTMENT
WN OF NORTH ANDOVER
Property Address �I o_��
Helen Yang J
Owner Owner's Name
information is
required for every North Andover Ma 01886 May 24,2016
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not John DiVincenzo
use the return Name of Inspector
key.
Stewarts Septic Serive
Company Name
58 South Kimball street
Company Address
Bradford MA 01835
City/Town State Zip Code
978-372-7471 S113386
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. 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
❑ Ne s Further EvaAation by th Local Approving Authority
� •ati • le
In ctor's Signature Date
T te
system inspector a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
400 Sharpner pond road
Property Address
Helen Yang
Owner Owner's Name
information is North Andover Ma 01886 May 24,2016
required for every Y
page. 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):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 400 Sharpner pond road
Property Address
Helen Yang
Owner Owner's Name
information is North Andover Ma 01886 May 24,2016
required for every Y
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
® Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
outlet baffle needs replacing.
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
400 Sharpner pond road
Property Address
Helen Yang
Owner Owner's Name
information is North Andover Ma 01886 May 24 2016
required for every y
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or "No" to each of the following for all inspections:
—
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters
❑ ® due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/ day flow
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
U Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
400 Sharpner pond road
Property Address
Helen Yang
Owner Owner's Name
information is North Andover Ma 01886 May 24,2016
required for every Y
page. City/Town State Zip Code Date of Inspection
B. Certification cont.
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
El 0 The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
j ❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
'w a 400 Sharpner pond road
Property Address
Helen Yang
Owner Owner's Name
information is North Andover Ma 01886 May 24,2016
required for every y
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes No
® ❑ 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?
i
® ❑ 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
j approximation of distance is unacceptable) [310 CMR 15.302(5)]
I
j D. System Information
j Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
j DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 600
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 400 Sharpner pond road
Property Address
Helen Yang
Owner Owner's Name
information is North Andover Ma 01886 May 24 2016
required for every Y
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
i
Last date of occupancy: Occupied
Date
Commercial/Industrial Flow Conditions:
I
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
j Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
u 1: Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
400 Sharpner pond road
Property Address
Helen Yang
Owner Owner's Name
information is North Andover Ma 01886 May 24,2016
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Stewarts
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1500
gallons
How was quantity pumped determined? Site Guage on Truck
Reason for pumping: Inspect Tank
Type of System:
®
Septic tank, distribution box, soil absorption stem
p p Y
❑ 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•3/13 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
400 Sharpner pond road
Property Address
Helen Yang
Owner Owner's Name
information is North Andover Ma 01886 May 24,2016
required for every Y
page. Cit /Town Y State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1998
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 24"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: 12"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 400 Sharpner pond road
Property Address
Helen Yang
Owner Owner's Name
information is North Andover Ma 01886 May 24,2016
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
29"
Scum thickness 0
Distance from top of scum to top of outlet tee or baffle 0
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? Tape Measure & Sludge judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Outlet baffle needs replacing top of baffle was coroaded inlet pipe ok.
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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
_ v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
400 Sharpner pond road
Property Address
Helen Yang
Owner Owner's Name
information is North Andover Ma 01886 May 24,2016
required for every y
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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w, 400 Sharpner pond road
Property Address
Helen Yang
Owner Owner's Name
information is North Andover Ma 01886 May 24,2016
required for every y
page. City/Town 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.):
Equal dist very little solids carryover no leakage.
I
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
1 Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
I
i
I
I
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
400 Sharpner pond road
Property Address
Helen Yang
Owner Owner's Name
information is North Andover Ma 01886 May 24,2016
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length:
3-45
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
No hydraulic Failure no ponding no damp soils.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
400 Sharpner pond road
Property Address
Helen Yang
Owner Owner's Name
information is North Andover Ma 01886 May 24 2016
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
400 Sharpner pond road
Property Address
Helen Yang
Owner Owner's Name
information is North Andover Ma 01886 May 24,2016
required for every Y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w, 400 Sharpner pond road
Property Address
Helen Yang
Owner Owner's Name
information is North Andover Ma 01886 May 24,2016
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
❑ Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: 8.5
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: 1998
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
pulled file
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Taken From design plan on record bottom of bed at elevation. 111.50 water at elevation 107.50 4'
above water table.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w, 400 Sharpner pond road
Property Address
Helen Yang
Owner Owner's Name
information is North Andover Ma 01886 May 24,2016
required for every y
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
LOT
7f VAM
IF R
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Sawyer, Susan
From: Sawyer,Susan
Sent: Tuesday, March 11, 2014 6:01 PM
To: 'Jian Helen Yang'; construction
Cc: Grant, Michele; Blackburn, Lisa
Subject: RE: Layout of 400 Sharpners Pond Rd, North Andover
Good Evening,
I have reviewed the file for 400 Sharpners Pond Road in relation to the existing home and the proposal of the addition of
two rooms and a bathroom.The addition is the completion of an attic space.
As it was proposed to me;
1) There is no increase in the footprint of the building, hence a title V septic inspection will not be required
2) The submitted drawing could be conservatively be called a 9 room home and the file shows the septic system
was designed for 600 gallons per day,which translates to an 11 room maximum home
With this information, it has been determined that the plan the contractor proposed to me can be approved.
You may bring down the application to the Health Department and we will be able to sign the form if the application has
notchanged.
Thank you
Susan
Susan Sawyer
Public Health Director
Town of North Andover
1600 Osgood Street
Suite 2035
North Andover,MA 01845
Phone 978.688.9540
Fax 978.688.8476
Email mailto:ssawver@townofnorthandover.com
Web www.TownofNorthAndover.com
From: Jian Helen Yang [mailto:Jianheleny0a gmail.com]
Sent: Monday, March 10, 2014 2:26 PM
To: Sawyer, Susan; construction
Subject: Layout of 400 Sharpners Pond Rd, North Andover
Dear Susan,
It was very nice talking to you. As requested, please find attached the layout of my house at 400 Sharpners Pond
Rd.
1
Thanks for your kind consideration. Just to let you know that the proposed 1/2 bath on the attic is optional. It
will be for occasional use only when children use the playroom. I am also ok if the proposed storage/office
should be limited to storage only, or if the attic should not be partitioned at all. There has been a lot of heat loss
from the attic this winter and one of the considerations is to insulate the attic space.
Please let me know if you have further questions.
Best,
Helen
Please note the Massachusetts Secretary of State's office has determined that most emaiis to and from municipal offices and officials are public records.For more
information please refer to:hftp://www.sec.state.ma.us/pre/preidx.htm.
Please consider the environment before printing this email.
2
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FORM U - LOT RRTFASE FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant0A,0,L2,.
fills out this section******4*******+****
APPLICANT: �Ln P L::, - Phone
LOCATION: Assessor' s Map Number Parcel
Subdivision lot Is)
Street St. Nunber 4nQ
************************Official Use Only************************
RECOMMENDATIONS OF TOWN AGENTS:
G Date Approved
Ccnservatlon Administrator Date Rejected
Coi=ents
Date Approved
Town Planner Date Rejected
Coents
r ,
n
Date Approve
mood Inspecto-- :ealth Date Rejected
Date Approved
Sepzlc Inspector-Health Date Rejected
Commen-_S
Public Works - sewer/water connections _
- drlvewav permit
Fire Derartment
Received by Building Inspector Date
2CARD of fbn�)y
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BOARD OF HEA=TH
No .Andover, Mass .
SUBSURFACE DISPOSAL DESIGN CHECK LI5r
LOT # S+�J� St9N`J
•r
APPROVED DATE -I SS DISAPPROVED DATE
Proviyded: Reasons:
Title V FAIL Ob
Reg 2.5 The submitted plan must show as a minimum:
a) the lot to be served-area,dimensions lot #,abutters
b location and log deep observation Mes-distance to ties
c location and results percolation tests-distance to ties
d design calculations & calculations showing required leaching area
(e) location and dimensions of system-including reserve area
f) existing and proposed contours
(g) location any vet areas within 100' of sewage disposal system or
disclaimer-check wetlands mapping
(h) surface and subsurface drains within 100' of sewage disposal
system or disclaimer
(i) location any drainage easements within 100' of sewage disposal
system or disclaimer-Planning Board files
(3) know= sources of water supply within 2001 of sewage disposal a
system or disclaimer
(k) location of any proposed well to serve lot-1001 from leaching facility
(1) location of water lines on property-3.01 from leaching facility
(m) location of benchmark
(n) driveways
(o) garbage disposals
(p) no PVC to be used in construction
(q) profile of system-elevations of basement, plumb, pipe, septic tank,
distribution box inlets and outlets, distribution field piping and
ather' elevations
(r) maximum ground water elevation in area sewage disposal system
(s) plan must be prepared by a Professional Engineer or other
professional authorized by law to prepare such plans
Reg 6 Septic Tanks
(a) capac t es- 50�6 of flow, water table, tees, depth of tees,
access, pumping
(b) cleanout
(c) 10, from cellar wall or inground swimming pool
(d) 251 from subsurface drains
Reg 10.2 Distribution Boxes
(a)
Rope greater 0.08
Reg 10.4 (b} sung
4.
COMMONWEALTH OF MASSACHUSETTS — ¢
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500
R
nz,
T UDY CORE f.
.•. }. seCretBTy �7qr
ARGo enwPAUL. CELLUCCI DAVID B.STRUHS ;
Commissioner {yr
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Y lltddnrse.
A1,0 ° ark;ers'Fond i
Name of Owner
N.Ada Address of Owner:
Name Please��,
I pq "tor- PrirrU
1 »DEP approved inspector pure T Section 15.340 of Title 5(310 CMR 15.000)
Company NL�! f Pa'✓,` i �—hC,
•;iMaig.Addrwglsq �Fi ,4h o1.e.�,�rriA oi��d
To' Ntrrnber - V <,i,
{ 5`CERTJRCAT10f11 JI MENT
t .
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-sitesewagedisposal systems. The system:
yL.. Passes d
Conditionally Passes
Need Further Evaluation By the Local Approving Authority
Fail
Date:The System Inspector submit a co of thi nspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
completing this.)nspectio . If the syate 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 n
r a copies sent n to
Y the-buyer,er if I'
P applicable,� Y PP a,and the approving authority.
NOTES AND COMMENTS:
`l
/.t
.
26
1
t� revised 9/2/98 x . Page Ioru
��� PrinlPd nn Rrm. !rff P,nP
,4v
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION 1continued)
--14roperty Addrses:. Hoo,$ha rpm e rs Fend)t i4 n
, Al, olo v e r I n A o1v q
} �'. h Cordejl .
Does of wapacoon: 9 L6/00
3F �9
p� MSPEC7<ION SUMMARY: Chock8
� , C,
v `r
A. S STEM PASSES:
1 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.
4r f'.pYM9MTS _
i
%,,I, SYSTEM CONDRIONALLY PASSES:
a e
One.or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon F
completion of the replacement or repair,as approved by the Board of Health, will pass.
Indicate yes,no,or not determined IY,N,or NO). Describe basis of determination in all instances. If"not determined",explain why not.
_ The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a 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
4
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year duo to broken or obstructed pipe(s). The system will pass
Inspection if(with approval of the Board of Health):
i
broken pipe(s)are replaced
obstruction is removed
t
X.
y J�4
i S
tr'
*Note: :THE'TITLE 5 INSPECTION IS NOT'A GUARANM/WARRANTY OF THE FUrM FUNCTION OF THE
SEPTIC SYSTEM.
revised,9/.2,/ 8 Pssezof11
R
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
s CERTIFICATION(continued)
Property Address: 1/00 Shc� Pond, �� f�� �}n o(0�c YI kn,4 0!Y,l b
Owner.
X06 h rdt
C. FURTHER EVALUATION IS REOUMED 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 he",safety and 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 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.
y
dc.
Z4
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 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.
Thesystem 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.
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 Y and volatile e or
9ani
c compounds nds indi
ca
to
s 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 not valid).
PP a4d).
Aqla
r
- - / lli .
{.
[ i 4
revised .9/2`/98
Page 3 or it z,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM :
PART A
CERTIFICATION(continued)
ae
l , Prop.nr�►ddreas: HbD �ha.rp n ars >POr►�l Ylof. N. f�n�ld�ci; �'�1 &T yo
' owner �seph • rolrao-:
i D. '- SYSTEM FAILS.
YOU must Indicate either r"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 b
Yes.
e necessary to correct the failure.
-',les
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
y
cesspool.
r t '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 V 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($).
Number of times pumped
r-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. x;;
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
T-- Any portion of a cesspool or privy is lose-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.
ft
a.,
E` LARGE SYST 3A 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 sones 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:
Yes NO
00. `
the system is within 400 feet of a surface drinking water supply M,
the system is within 200 feet of a tributary to a surface drinking water supply ,j`;,;
the system Is located in a nitrogen sensitive area(interim Wellhead Protection Area-rIWPA)or a mapped "r
water supply wall) pp d tons 11 of a public t
TM Owner Or
operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information. ,
i � ' t.r t rs 4..•
4f;
revised' 9/2/98 Pbge4of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
\..ter,- { •,`
Prevwty Addrea� yoocShi+.rpnsnd (. N, And over; h�i A o s tie :''�f>
Ow.m. ird e UeL ,
rl� °yr oaa� 1912610 ' ,' II
Check N the following have been done:You must indicate either"Yes" or"No" as to each of the following:
rthk. •`�Q {`+'} Pumping Information-was provided by the owner,occupant,or Board of Health.
✓ 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.
As built plans have been obtained and examined. Note if they are not available with N/A.
✓ , -. The facility.or dwelling was inspected.for signs of sewage back-up. �(+
✓' The system does not receive non-sanitaryfr
or industrial waste flow.
qt,
The site was inspected for signs of breakout. ?
rs
.' r ft u
All system components,excluding the Sal 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 x„wl
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.
Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) x
11 5.302(3)(b)) V.<
S The facility owner land occupants,If different from owner)were provided with information on the proper maintenance.of•
SubSurface Disposal Systems.
h
71
1 1�
, Il
tI tr .'•J - - ' - r?” f µti
F,
Yf
revised 9/2/98
Page seru
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C x
SYSTEM INFORMATION
f
—PiopertyAddnss: Noo.Sha.rpners land.lei(. lU. Ano(o✓c, Vhf orgy5 W�:
owner. LTosh 0_$rotell
s' a_
paof Insp.coon. 9125100
fi RESIDBIITIAL FLOW CONDITIONS q l
s Deslgn,flow .p.d./bedrooms 1.
r Number of bedrooms(design): Number of bedrooms(actual):
Total DESIGN flow y
r ,Number of current nsitleMs;,, A
Garbage grinder Ives or no):.Jgo a
Laundry(separate system) . (yes or no): b;, 11 yes,separate inspection required
Laundry system inspected..(yes or no)
Seasonal wo(Yes or no): i?
Water meter readings,if available(last two year's usage(gpd):
Sump Pump(yes or no): el,Q :'
Last date.of occupancy:C c u.kT,ti•.7��
t, z
COMMERCIALANDUSTRIAL
':Type.of establishrnont: . Y/O
Design flow:_ and (Based on 15.203) t:
Basis of design flow
Greasa trap present:(yes or no)_
Industrial Waste Holding Tank present:lyes or nom„
Non-sanitary waste discharged to the Title 6 system:(yes or no)_
Water meter readings,if available:
Last date of occupancyc ,, dt
OTHER.IQescribel
,.cat data of occupancy:
GENERAL INFORMATION
PUMPING RE<:QRDS and source of information:` nn
System pumped as part of Inson:Ikes o no) '
If yes,volume pumped: gallons �"
Reason for pumping: 4S inn :74-j-01 1W.
r 41; F
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system lye$or no) (if yes,attach previous Inspection records,if any)
UA Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other , ,
APPRO)GMATE AGE of all components,date installed(if known)and source of information: '{
y r Sauvage odors detected when arriving at the site:lyes or no)
cFs.
R
M -
tt y.
, ,revised "9/2/:98 Page 6of11
t��
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,.
PART C
SYSTEM INFORMATION continued
• l
)
Phapaftr Addleas: �/G 0 /IA.YIa'9 ! 0110 SGC.. N,
A ndevu, 1'1'l A o is v� ,� •
Owrwmph res(c f 1 Q
."o of Illepwdwc 9/zst D o s x
BUILDING$EWER
14ocate on site plan)
r •,. /� s
a i Depth below grade..LZ..0
Material of construction:Zest iron 40 PVC,other(explain) :`
Distance from�private water supply well or suction line /✓ ��`
Diameter 1tr
_ CotrMrnnts:(condition of jo)nu;venting,evidence of leakage,etc.)
SEPTIC TANK:
,(locote,on site plan) }q
,` Depth below geode
Motorial of construction:�oncrste_,,,metal_Fiberglass —Polyethylene_other(explain)
If tank is metal,list age_ Is age confirmed by Certificate of Compliance_,(Yes/No) sr
Dirrwtnsions.
:r•�
�yF Distance from top of Vudgs to bottom of outlet tee or baffler
}+ Scum:thickness: mai
G -Distance from top of scum to top of outlet tee or baffle: '/
Distance from bottom of scum to bottom of ot or baffler
How dimensions were,detarmined: a "rpcll
\''*"'•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.) fs='.
TRAP:
GREASE a r
on to ::b 4
Qcete si . , P,
Depth:below grade ; t
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 baffler'
Dote of but pumping: ,# .
A
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.) egr ,
Ya'P
,-AArc
:dl's!'.:
revised. 9/2/98 e
Pa¢ 7of11
i +s;
J]' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C Ali
SYST13A INFORMATION(continued)
It
I, , Property.Address;,y�•o Sharpnersonce l2�Q, lll /�vto(ov�.�^ YYli4 Ul�tis : ���'`
owner
D1roe of harpectiaer. 91 z.7 o O Y�,
TOOK OR HOLDWG_TANK:,4 ink must be pumped prior to, or at time of,inspection) 'fig,
r
(locate on site plan) �r
a^� Depth below
Material of construction:_concrete_metal Fiberglass_Polyethylene_other(explain)
Dimensions: � .
Capacity:,_„_,_,_,_gallons W
�i
Design.flow:-_�gallons/day
Alarm presets
Alarm level:,_Alarm in working order:Yes No 5
,,..Date of previous pumping:
condieipn Qf inipt,taat condition of alarm and float switches,etc.)
�fy.
W$TRIB(ITION BOX. r
lhnate on alta plan)
of liquid level above outlet Invert: .� y
' (nate if IwN and distribution Is equal,evidence of solids carryover,evidence of leakage into or out of box, etc.) CO
+ PtW MMS:
(locate on alto plan)
Pumps in working order:(Yes or No) 1
,l Alarms in working order(Yes or No �f x
� .
'` • Commenw
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
ti
f
n
5
s•
}
v yy
revised .9/2/98 ' Page seru
•: �r
' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r
PART C
i�
SYSTEM INFORMATION(caromed)
Address- yve Shct,•-priers mond 12oC, �•Andr�v�r� MA OtTyS
Owner: 77
CTo3ePh Cord c 11 et.
� Di�of� .91.a�loo.
SOY.ABSORP'TM SYSTEM(SAS):,
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
,e
a�, .51f riot located.#xPlalr<. %_,,�
Type:
.leaching pits,number:
.. caching cherrlbem,number:_
leaching gelled**,number:
leaching trenches,number,length:I�- --�� �
Isaehing fields,number,dimensions:
i overflow cesspool.numbers f`
Alternative system: V.
r Nims of Technology:' t yiy
N t
Commsnu ;:
i+=a (note condition.of soil,signs of hydraulic failure,level of ponding,damp:soil,condition of vegetation, etc.) `
Yf
i CIMSPOOL.S:
y llolaate Pn sits plan} �_
t
i f,5
h
b ':Number and configuration.
Depth-top of.Uquid to inlst invert:
�,Dspth of solids.lalyar: F.
Depth of,sewn layer:
r t Dimensions of cesspool:' J _:
Materials of construction.•
r;
- � Indicsaon Of groundwater'
'3 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.) '
R
t �4.
rn}tt! R.-
pocate.on plan}
Materials of construction:
Dimensions: ,
Depth of solids:_
F4 '
Corrurients ... n.
{ ,!.(note condition of*oil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) `
L
revised 9/2/98
Page 9er11 :
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C r=
SYSTEM INFORMATION(contirared)
`,�--'r►�rtX�` ��D,c�' harpnus 1�Gnd.l�d� N, f}'nc�or�r l?1f� OlSY6 s�")� ��
Inrp�aarr. T, !
c�t ,rt t S+�a t t*�+�!tfyHt Se(•�����OO,, ::,¢' � '.t �'r: Ali
n SKETCH OF EWAGE,MS►POSAI SYSTEM.
inawoo.as$to at least two permanent reference landmarks or benchmarks
' Water suppi come:into house) S A
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i'
V�f./, °;h ✓ r Y r'i � `MK- *. .fir ' ��, ��} t �;.
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f fft�tt^,�i{jt`•F FF}{{A"n•j.irl'}1t r p y 3 • '—,�.�'-—�.........- ....,,,. , r, F
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y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property kOdn
as--4406 15ha✓pner3 Pon4YlcQ., lu,�}ndav�-,
owner:'.'' :cTaepM eo.rol'.t llcL I
rh rj= :NRCS Report name ¢
Soil Type_
Typical depth to groundwater
US¢S Date website visited
'Observation Wells checked
Groundwater.depth: Shallow Moderate Deep
SITE EXAM s Slope
Surface water
Check Cellar
;;,;Shallow wells
Estimated Depth to Groundwater Feet
a Plssso cstesll the methods used to determine High Groundwater Elevation: H
y Obtained from Design Plans an record
Y.
.Observed$Ito(Abutting property,observation hole,basement sum_ p etc.)
D tarmined'ftam local.conditions
},,Checked with Ioca1 Board of health ,
Chackod FEMA Maps
Checked
pumping records
Checked local excavators,installers
t Used USES Data
Describe`how you established the High Groundwater Elevation. (Must be completed)
i4co di""pvo
1-4
is OV C> tq� -
Pakf
t:
-4,
reyjsed ' 9/2/98 rageuotu
1
LDT
20
1
t�
F-6
.3¢r
13C,86
SCA LE • "-40'
>�
160,9Z
MURPHY �
F No. 708 i
33'
t
1