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Miscellaneous - 41 CEDAR LANE 4/30/2018 (3)
r-JID C7 • SF,'TTL'ED j6g6' � PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 10/30/2014 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Complete Repair of a D-Box By: James Boraczek At: 41 Cedar Lane Map 106.A Lot 0146 NprthAndover, MA 01845 Tdi since of this certi i at sh4l not be Anstrued as a guarantee that the system will function satisfactorily. c 1V�ichele Grant Public Health Agent 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com � Sy,'S5G"ED 76g6' � North Andover Health Department (ommunity Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 41 Cedar Lane MAP: 106.A LOT: 0146 INSTALLER: James Borachek DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS D-Box INSPECTION: 10/28/14 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 grade, on 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 ❑ Watertightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port *r. r ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed 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 ❑ Icover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ 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 Installed on stable stone base 2D , O �] H-20 D-Box ❑ Inlet tee (if pumped or >0.087foot) ❑ Hydraulic cement around inlet & outletsu ,❑ Observed even distribution ❑ Speed levelers provided (not required) Schedule 40 PVC Pipe Comments: `{� — � � �– ( ,I/l �k � � rS ti�•r�,f Commonwealth of Massachusetts 106.AOoek-Lot 9 06.A0146 -------------- BOARD OF HEALTH • Permit No North Andover BHP-2014-1278 -- -------- -- P.I. FEE s F.I. $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted James-Boraczek to(Repair)an Individual Sewage Disposal System. at No -4-1--CE-DAR-LANE as shown on thea application for Disposal Works Construction Permit No. BHP-2014-127 Daled,,.,,,October,27,2014 PP p f - --- ----------------------------------------------------------------- Issued On: Oct-27-2014 BOARD OF HEALTH Application for Septic Disposal System TODkY'd 15ATE w Construction Permit - TOWN OF $,25040--Full Repair NORTH ANDOVER, MA 01845 $1 . Component Important: Application is hereby made for a permit to: When filling out ❑Construct a new on-site sewage disposal system* forms on the computer, use ❑ Repair or replace an existing on-site sewage disposal system* only the tab key *epair or replace an existing system component—What? to move your cursor-do not use the return A. Facility Information key. 6V Address or Lot# tab City/Town y+--4nrt')2v,1,r I l 2.-*TYPE OF SEPTIC SYSTEM*: ➢ ❑ Pump PS.Qravity(choose one) ***If pump system, attach copy of electrical permit to application*** i ➢ ❑ Conventional System (pipe and stone system) ➢ ❑ Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system.) ➢ ❑ Pressure Distribution S.A.S. (No D-Box) ➢ ❑ Pressure Dosed(D-Box Present)S.A.S. ➢ ❑ Does the system require an effluent filter? Yes No If yes, does plan specify make and model of filter? YES =(no further info. needed) NO =(installer must specify brand of filter before DWC issuance) r What is the Make? ghat is the Model. 1 2. Owner Information PMMA 1/ Name V/ C���C Address(if different from above) A1AN9oVV' � City/Town State Zip Code 9?g- Telephone Number 3. Installer Information Name Name of Company V #g2t/ D/ AddIV// 03$y/ City/Town State Zip Code y?y-s-z 3& 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 NORTH ANDOVER, MA 01845 $125.00 Component PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: �tesidential 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. 1 understand that until a final Certificate of Compliance has been issued by this Board of Health, the installed system is not approved. Name Date Applica n Approved : (Board of Health Representative) r N e Dat p ication Diapp oved for the following reasons: For Office Use Only: f 1. Fee Attached.? Yes v No 2. Project Manager Obligation Form Attached? Yes No 3. Pump S sy tem? If so,Attach copy of Electrical Permit Yes No 4. Reviewed approval letter, all paperwork received? Yes No MISSing:' S. 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 M v As the North Andover licensed installer for the construction for the septic system for the property at: (Address of septic system) For plans by (Engineer) Relative to the application of aG1hCS A1Yc2 ex (Installer's name) And dated rigina ate Dated /(f 2_7// o ay s ate 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 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 manager, or any s 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 company. a. Bottom of Bed—Generally, this is the first (1S) inspection unless there is a retaining wall,which should be done first. The installer must request the in 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: healthdel2tQtoNvnofnorthandover.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 than simple 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 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 Licensed Septic Installer: (Today's Date) 1G/271t%t �glMtd �arl C2- ame— 'rmt am — e Commonwealth of Massachusetts / Title 5 Official Inspection Form J Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °~ L/1 Gdca( Liv PropertAddress �MM�. Ow ner Owner's Name information is required for every AI-41,v�vve( A2 Z✓_,i� page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection form not be altered in any way. Please see completeness checklist at the end of the form. �\ , `. anpoWhen outf orA. General Information filling out fms A'U� 20 14 on the computer, h, L'A 7 use only the tab 1 Inspector. key to move your TOWN OF NORTH ANDOVER cursor-do not IM-PJ ©(0CIC4 HFAL ra Dt_P ;'•1�FA.ry use the return key. Naft of Inspector . / olnc-%61s S(nA_( I b/zi"v r4/L a/flLe II Corpany Name Cornp�a//ny Address /AM DS f 117,j ,�/t .03a Y/ City/Town I State Zip Code / 600S Sj�Jo� 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: I� Passes El Conditionally Passes ❑ Fails /❑\Needs Further Evaluation by the Local Approving Authority pector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. `This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5i,u•3113 Title 5Offidel Inspection FarR subsurface Sevege Disposal System-Pagel of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Proprty Address VAIA l/ Ow ner Owner's Name information is p �] required for every H 4410 r page. aty/Town Sta a 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 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any .-e:idence of leakage into or out of box, etc.): / J't/' (Al Q t' UX Ci �N���iyl ZohF�/y. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * 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: t&ns-3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 c Commonwealth of Massachusetts -- Title v official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address ... ��9 l�►ll Ow ner Ov ner's Name information is n required for every page. Qtyrrown 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. Ynpooutf ms A. General Information filling out forms on the computer, use only the tab 1. Inspector. key to move your .►-... cursor-do not ` Afyl o 1,/)C2-r- use the return Name of Inspector key. f3 o y ( ,j 1 Company Na1T1e Co any Address �„' w►off rad /Ulf d 3' l City/Town State Zip Code 6gl- :329- 6c�os" S 3 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 X Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority ector's Signature Date The system inspector shall submit a copy of this Inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system Is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. a s-313 TIUe5Official hlspeceoiForm Subsurface So mge Disposal System-Pape t of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments cr44r LV Property Address 1JaUMrf+ YJ/ ON ner Owner's Name Infornlation is /0 b required for every. page. aty/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: ❑ 1 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, NO) 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 ❑ NO (Explain below): lv-(-fd S D-Pox Ens-3/13 Tilla 6Official Iris peckn Farm Subsurface Sewage Disposal SAtom-Page 2 of 17 i Commonwealth of Massachusetts =- Title 5 Official Inspection Form r Sub/ l..surface�Ssewage Disposal System Form -Not for Voluntary Assessments '// 46(r- IV Property Address Ow ner Owner's Name Information is required f or every AI 4AI00VP ©ISIS f0�2�"y page, Oty/Town State Zip Code Date of Inspection B. Certification (cant.) ❑ .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 Cq Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ .Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t51rs 3113 Tide 5OfOdafIspectloiFoimSubsurface SewigeDlsposalSystem•Page Sof17 Commonwealth of Massachusetts Title 5 official Inspection Form -" == Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �-1� Property Address Dy V�nra A,it Ow ner On/ner's Name information is required for every N—,+Vp0Ve( 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 ❑ '13— 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 t5im•3113 T105 Of ficid Ins pecaai F a in Subsurface Se Naga Disps:l 5 ystani•Pay a 4 0117 Commonwealth of Massachusetts Title 5 Official Inspection Form Sub/surface Sewage Disposal System Form Not for Voluntary Assessments r7 Property Address �!'MAIl Cw ner Ow ner's Nan-is information is .! required for every A/ dyP page. Qty/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ e;Ej� Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ IfT 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. ❑ ,E!f" Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ,LJ 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 analyst s and chain of custody must be attached to this form.] ❑ Zr The system is a cesspool serving a facility with a design flow of 2000gpd- 10,00 0g pd. ❑ �' The system JjILV. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered 'yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t9ns•3113 Tlde50fgcid ins pecUmForm Subsurface Sovagaoisposal sAte m•Pape 5of 17 Commonwealth of Massachusetts -- Tit 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments FroP�rty aaa�s�a� �M of ,'1 -- Cw ner Owner's Name Information is N� UC� �fj pJgys ©^2J-ly required for every 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? (ZJ ❑ Was the site Inspected for signs of break out? ❑ Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with ❑ information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: C/ Number of bedrooms (design): —�-- Number of bedrooms (actual): 1 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bed rooms): t-9,s,X1 T11a50ffidd InspecticnForm Sulsurfwe SevageDieposd SAjom•Papa 6 o 17 Commonwealth of Massachusetts '"° _ - Title 5 OffidaU Inspection Form Subsurface Sewage Disposal System-Foam"=Not"for Voluntary`Assessments`-,m' " Property Address Owner ON ner s Name Information is required for every page. City/Town State Zip Code Date.of hsps tion D. System Information a. b .• Description 1'}} Number of current residents: 2' 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 Last date of occupancy: Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM R 15.203):' Gallons per qay(gpd) Basis of design flow(seats/persons/sq.ft., etc:): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: 15lrr•3M 3 TJU 5 OfBdal Ins pecdon Form Subsurface SewQe Dlsposel Sletem•Page 7017 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal,System Form -Not for Voluntary Assessments . ��� Cedgf Civ . Rope Address I O„ _VIVA I�r! ner Information is Cwner's .q,v�VP( ,,/� 01$<�� AQ-7/=1y required for every r � !i page. aty/Town State Zip Code Date of Inspection D. System Information (cont.) • a Last date of occupancy/use: Date Other(describe below): General information Pumping Records: Source of information: Was system pumped as part of the Inspection? Yes ❑ No If yes, volume pumped: gallons: How was quantity �St , q y pumped determined? Reason for pumping: 111AIyN,y iacc Type of System: Septic tank, distribution box, soil absorption system . K C3 Single cesspool ❑ Overflow cesspool' ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous Inspection records, if any) ❑ Innovative/Altemative 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): lum-3113 Title60fficld InspecbonForm Subsurface Semp Olsposd SAtem•Page 8of 17 Commonwealth of Massachusetts Title 5 Official lnspection- Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments W CF�g� &A-1 Prop Address tY T3 ') l Ow ner Owner's Name information Is /0 required for every � f'r page. Oty/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes J No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: (cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: �S / feet Comments (on condition ofjoints, venting, evidence of leakage, etc.): rl /-hitt f'r'iC-V ' 06414, I4 Stc. Septic Tank (locate on site plan): Depth below grade: 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-3113 Tite5of8dal Ins pecticnFanx Subsurface Senega Disposal SWtem-Page Bof 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - LI1 CeAtr �v Roper Address VMS N.11 Ow ner Owner's Name Information is A/�/d e( /�. Ol$11S ��•2�^/y required for every ,� .�2.__ / • 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 Scum thickness Z Distance from top of scum to top of outlet tee or baffle /2 Distance from bottom of scum to bottom of outlet tee or baffle ee �'I PaJv/t�f• How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): is dlrrl Y��l� �Je hyk,Pe ymrb Iru/ �4, / Grc j ti � 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 tSlns-3'13 TItle6016dd InspectlonForm Subsurface SevogeDlsposd SAtem•Pape 10 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9/ CeAr �v Prope ty Address b�NMA Ow ner Owner's Name information is /�,—Pyy Dvcr PO 0AVS- /0-2/-1y required for every /V fY V /�{'/ / 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 worWng 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 TIOe5Df6dal Ins pecdon Form Subsurface SaHegeDisposd System-papa 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments LII CfAr &v RoperAddress t OMMA Iat N Ow ner ON ner's Name information is Q �SA)- required for every page. Qty/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 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.): i� Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No' Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc,): ` 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: t9ns•V13 Tile bMasi Ins pec don FanT..Subswtace sevbgoDisposal system-Page 12 d 17 i . Commonwealth of Massachusetts a Tale 5 Official Inspection Form4 Subsurface Sewage DisposalSystem'"Form rNot for VoIUntary'Assessmenfs' Property Address Owner's Name Information Is -2 }� s required for every--.-. page. Oty/Town •• State Zip Code Date of Inspection _...... • . ...D. System Information ,(cont) Type: , ••,,, , .. .., .. .. :� .. r ' ' leaching pits. .... ., number ....:, .. _ _... . .. . leaching chambers ..... . .... . ... number..,.............,...•.. ..... _.._ ❑.. ,. . .. ... leaching galleries number: ....._._. ......_.... ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: { ' ❑ innovative/alternative system Type/name of technology: i ';Comments (note condition of soil, signs of hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.): I 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 turfs-3113 Tide 5Official Ins pectlonForm Subsurface SevepeDisposal S)ctem•Pape 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3 ill Ceatau Jif!/ tv Property.Address �J Ow ner Owner's Name Information is required /0-?-Li for every /V iINfjoue( page. Qty/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.): r 6iru•3/13 Tile 6OfWEI Iris pection Form Subsurface SewageDlsposal System-Papa 14 of 17 Commonwealth of Massachusetts Tale 5 Official inspection Fora T" Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Lll CcdGf A,Ir tw Property Address DONVM[t //Id 9w ner Owner's Name information is required for every page. Cityfrown Stale 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: ❑ nd-sketch in the area below drawing attached separately t5ns•3/13 Title 5011104 6u pec Ual Forrrt Su bsirf ace Senapa Disposd S)5tem-Page 15d 17 'i r=Y CEDAR LANE } Sy c v WELL f. 1st ( F" } yt{ Ft t 4SY _t �fe �+i, aYa 4:. 5tv 4 fl.�{rSf /r�vA'1C 9 )MRSSSW J}r 1 4 ' �� ,�� . , s #. d } Y J '� rr� s.r i{i �+�%'✓ ,v v, y '�3ti / �, r . 1 4' va �r+ i Sr pix�,•j � s'r±1 r4f �- rvii ,�t1 S4)> _ Y: � ,.� v sd .4h2 ���1 �✓�A "7i'�,•,,iS.�(a�C S� � kYY re v71 '`1. 41 `CEDAR LANE t 4 r r 4a All: C 98 {a Pale 30 of 11 `i { 'r j. , Commonwealth of Massachusetts - Title 5 Official Inspection:,,Form Subsurface Sewage Disposal System Form.-Not for Voluntary.Assessments •:,. �l1 &JAr LAI Property Address - ow ner Cw ner's Name M U Information is required for every A/ -4ND9ytC /"r4 d/%y,S page. Qtyfrown 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: t eet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database- explain: You must describe how you established the high ground water elevation: Loo Before filing this Inspection Report, please see Report Completeness Checklist on next page. tons-3(13 TiUef Offidd InspectlonForm subsurface SenepeDispad SWtem-Page 16 d 17 • Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments q1 COG�r l)f it 1,v Property Address �/OMMA I7r�� ON ner Ory per's Name information is c /V required for every �NOc�V page. Cityrrown 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 ,a-System Information—Estimated depth to high groundwater 16—sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Ons-3/13 TItleSDffidel InspectlenFam Subsurface Savage Disposal Syalem•Page 17 of 17 t NEW ENGLAND ENGINEERING SERVICES INC } i"i)'v -- a SPR s April 1, 2004 North Andover Board of Health Town Hall Annex 27 Charles Street North Andover,MA 01845 RE: TITLE V REPORT: 41 Cedar Lane,North Andover, MA Dear Sir or Madam: Enclosed is a copy of the Title V report for the above referenced property. The system PASSED our inspection. If there are any questions please call me at my office, 686-1768. Sincerely Benjamin C. Osgffod, Jr. Certified Title 5 inspector 60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 6!/ c E D H 2 g N E /U09-2L( p-N'!>00C2 ivr A Owner's Name: 0 r/ r� l'jy 1 L i o Owner's Address:_!1Z CE©Rpz 49.vC-_ A10 ark AAADOOG/L Date of Inspection:- ��T 3 elo-1 Name of Inspector:(please print) Benj amin C. Osgood, Jr. CompanyName:New England Engineering Services Inc. Mailing Address:60 Beechwood Drive, 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 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 Needs Further Evaluation by the Local Approving Authority Fails �7 Inspector's Signature: (� �� l Date: 3 3v The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: CC191910— t-twi Owner: R�lyPl,voep 1,OA/ Date of Inspection:- 343 QZvt Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: E S I have not found any information which indicates that any ofthe 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: U D 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: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: U/ GSD 2 L�lrvcs Na2TX /fnir�v�L'� �.9 Owner: q}� p/,y E2 Dti I L LON Date.of Inspection: C. Further Evaluation is Required by the Board of Health: NO 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 1&303(l)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface_water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. —.The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliforr bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORINT—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_ 9/ CCP&2 L.,ge.F d10/LTN /fA 00 0-11 Owner: _ 19HU 11.VDFrL Date of Inspection: 3J3 o�o y 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 v Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool V 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 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 nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15303,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 m indicate either`�+es"or`no"to each of the following: (The folio criteria apply to large systems in addition to the criteria above) yes no — _ the system is within feet of a surface drinking pply _ the system is within 200 feet o to a surface drinking water supply the system is loca a nitrogen sensiti ea(Interim Wellhead Protection Area–IWPA)or a mapped Zone II u lic water supply well If you have answered"yes"to any question in Section E the cyst is considered a significant threat,or answered "yes"in.Section D above the large system has failed.The owner or. erator 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. Page 5 of 11 OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: k// Ciplqi2 4.t7•v6- �0 2?3l ANDUJc:� Owner._ t3lfuPLV-aCt 1Jh`��iON Date of Inspection: Check if the following have been done.You must indicate`lyes"or`ono"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) Y _ 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? d _ 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: 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)[310 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: (f FOA-r2 t.�r 1V o r2iK AQ 7 o,,(L- Owner: J;;3k0P1N0E2 QHI LC.ON Date of Inspection: 2,13alay FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example:110 gpd x#of bedrooms):--- Number of current residents: ^ Does residence have a garbage gander(yes or no): 1L0 Is laundry on a separate sewage system(yes or no):N O[if yes separate inspection required] Laundry system inspected(yes or no):— Seasonal use:(yes or no):N O Water meter readings,if available(last 2 years usage(gpd)): W OL-L, Sump pump(yes or no): Last date ofoccupancy_ -"Ll r"/r COMMERCIAIJINDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): and 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 meta readings,if available: Last date of occupancy/use: OTHER(descdbe): GENERAL INFORMATION Pumping Records Source of information: y Czs f}C� Qr 2y�NEf� Was system pumped as part of ffie inspection(yes or no): C) 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) _InnovativelAlternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Otho(describe): Approximate age of all components,date installed(if known)and source of information: •gn1, /9 /97S Were sewage odors detected when arriving at the site(yes or no): Page 7 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: N1 C 4 p oa Lgx)e i11®2i2-i s}N�Ov�(L Owner: r3!-I cs PI N D E(Z D H tO-0" Date of Inspection: h/oy BUILDING SEWER(locate on site plan) Depth below grade: Z Materials of construction: cast iron 40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): P>Pe t3Ecow cwo2 �..� �riy[S�-fc� $A-S��t2CN� SEPTIC TANK:_(locate on site plan) Depth below grade: /2" 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: 100� 0-111-lo )s Sludge depth: z,, Distance from top of sludge to bottom of outlet tee or baffle: 3 a" Scum thickness; L 1 " Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: ,M Egsoge sTJc lc, Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of etc.leakage, : ) T191V Py C c /•y &<�J ? COnra�7i�✓+. �ECt� .tic vy ,.us—AuR-�yt a r= J21-5 E'2- 7r� w D4(A-i :. �F -,ti is.K cliz GREASE TRAP:,Lbocate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: L1! CCflA Noa;rH A+vpouclL- Owner: p, V E(AJ D E/L DN((.L0A1 Date of Inspection: 7,l a a I0N 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/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: D 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.): Qi ax jti n)f. co"01 ills?r-iek, 'I S0..- 6 L✓iyt•vCe __ of 5c)L,Ins cA-2 /L PUMP CHAMBBRWA- (locate on site 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.): I • Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Lj t Gc vrh2 c-Y-ZNE Noa:p-e oL 2 Owner' t3 H 1 ti v �2 O K l W.v Date of Inspection:—T����. SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type _leaching pits,number: Z p,T s leaching chambers,number: leaching galleries„number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovativetalternative system Typetname of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): -C?F 0 P'rs k K OR's A!7 O.U0�ur4L- >70N5>rni(- o ec'yct� Oti)c pi?` c9.vu tT t.•-d--s ;=z ,v o TO, $e EM FrN CESSPOOLS:A40r (cesspool must be pumped as part of inspectionXlocate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (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.): Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 41 c E V6e LA-, /acNDOOC(L Owner: R H0 P I Nflc,- H)LLO,� Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. jc 9 23 ,�o Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: i-)1 C e'9 Piz- L,q,,y'j Owner: j314 Q P(N 9C_,2, Date of Inspection: 3i3a�oy SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground waterer 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 excavators,installers-(attach documentation) Accessed USGS databaso-explain: You must describe how you established the high ground water elevation: FILE# 197 Forest St. P\�1 M(508)774-27729 5 5 ! TOWN OF NORTH A,7 BCAr31) �� t i 2 4 1996 . .aJ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PROPERTY OWNER'S NAME: r /a,, d PROPERTY ADDRESS: C.�'G'Il, r' Q,ie ADDRESS OF OWNER: (if different) DATE OF INSPECTION: NAME OF INSPECTOR:__��,� •THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY• FILE# �p/7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A / CERTIFICATION Property Address: �� C&14a ' kne /V /¢446W/'Adress of Owner: e Date of Inspection:.5;r.f, 9, /$FAG (If different) Name of Inspector: �.44W,Wl-,0' Company Name,Address and Telephone Number: Currier Septic&Drain Service, Inc. 107 Forest Street, Middleton, MA 01949 (508) 774-2772 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Ila- G� h�,' Date:". The System Inspector shall submit a copy of this 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: Checl6 B, C, or D: A) SYSTEM PASSES: y I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. 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 dtermination in all instances. If"not determined", explain why not L) 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 conforming septic tank as approved by the Board of Health. (revised 8/15/95) 1 FILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (coeriHuEd) B) 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 C) FURTHER EVALUATION IS REOUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: k 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. 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. 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. (revised 8/15/95) 2 LFILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) D) SYSTEM FAILS(continued) Static liquid level in the distribution box above oulet invert due to an overloaded or clogged SAS or 1 J cesspool. ,v Liquid depth in cesspool is less than 6" below invert or available volume is less than.1/2 day flow. PL Required pumping more than 4 times in the last year N.QI 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 I I water supply. N Any portion of a cesspool or privy is within a Zone I of a public well. L Any portion of a cesspool or privy is within 50 feet of a private water supply well. i Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) 'A_RGE SYSTEM FAILS: The�f lowing criteria apply to large systems in addition to the criteria above: The design flo system is 10,000 gpd or greater(Large System)and the system is a significant threat t is health and safety an a environment because one or more of the following conditions exist: --� the system is within 400 f of a surface drinking water supply /— the system is within 200 feet of a tributaq to a s a drinking water supply _N the system is located in a nitro ensitive area Int rim Wellhead Protection Area (IWPA)or a mapped Zone II of a public wate ply well) The owner or operator o n such system shall bring the system and facility into ful Hance with the groundwater treatment progra quirements of 314 CMR 5.00 and 6.00. Please consult the local regio office of the Department for further yor ation. _f (revised 8/15/95) 3 FILE# a , 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: pumping information was requested of the owner, occupant, and 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. Z'The facility or dwelling was inspected for signs of sewage back-up. 'The system does not receive non-sanitary or industrial waste flow. 1'The site was inspected for signs of breakout. ZAll system components, excluding the Soil Absorption System, have been located on the site. _✓The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. _L/The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. / The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of SubSurface Disposal System. (revised 8/15/95) 4 FILE# • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL: Design flow: gallons Number of bedrooms:, Number of current residents: v��G✓� Garbage grinder(yes or<0: 16 Laundry connected to s ste or no):)k Seasonal use (yes ora Il� e d ! / Water meter readings, if available:2i ;L)a- L-� .11 C b✓1 S�i /�f�✓7 Last date of occupancy: 644�,-rzsL COMMERCIA /INDUSTRIAL• Type-ofe tablishmen t: Design flow: Ilons/day Grease trap present: (yes Industrial Waste Holding Tank presen . no) ��____,�,,, Non-sanitary waste discharged to the Title 5 syste or Water meter readings, if avialble: Last date-of-dccupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING R CO7DS and source of information: / / ter ' car#' o C ,-sNC Grcu�t�r� System pumped part of inspection: r no),?,=S If yes, volume pumped: AW gallons Reason for pumping: ;;fr.- � TYPE�F 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) Other(explain) AP)PROXIMATE AGE of all components, date installed (if known)and source of information: /V7:%Z Sewage odors detected when arriving at the site: (yes no (revised 8/15/95) 5 FILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SEPTIC TANK:An S (locate on site .A Depth below grade: Material of construction: oncrete_Metal_FRP—Other(explain) �l�41=.E"' kar � nCr4vlco Dimensions: /4U �l Baffle Depth Below Outlet Invert:_/S� Sludge depth: ' Distance from top of sludge to bottom of outlet tee or baffler Scum thickness: ' Distance from top of scum to top of outlet tee or baffle: 49"" Distance from bottom of scum to bottom of outlet tee or baffle: � Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet inve , structural integrity, evidence of lea a e,etc.) ., ;, �aeo H GREASE TRAP: U (IbeaLe on site p an) Depth below gra Material of construction:_ ete metal_FRP—other(explain) Dimensions: Baffle Depth Below Outlet Invert: 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 ba Comments: (recommendation for g, condition of inlet and outlet tees or baffles, depth of liquid le relation to outlet invert, structural intr' vidence of leakage, etc.) (revised 8/15/95) 6 FILE# s- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) TIGHT OR HOLDING TANK:Jjo (locate on site plan) Depth below e: Material of construc i concrete_metal_FRP—other(explain) Dimensions: Capacity: gallons Design flow:_ gallons/day Alarm level: Comments (condit�i )n- inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth below grade: do Al Depth of liquid level above outlet invert: Dimensions of D-Box:1a",0( `Depth of Sump: V Zo",t< 4 Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) ri m - iin PLS C PUMP CHAMBER: 0 (Ibcate,,on site plan] Depth below grade: Pumps in working order:(yes or no) Comments: (note conditions of pump chamber, condition of pns "d appurtenances, etc.) (revised 8/15/95) 7 FILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM (SAS): S (locate on site plan, if possible excava io�,not required, but may be approximately by non-intrusive methods) Depth to bottom of SASO 6 (Stone o Pi If not determined to be present, explain: 191V LOsMS 4ndian art St*o ve �ti C,-a���iec r Type: leaching pits, number:c2 7'D ear x leaching chambers, number: --? �� Q�e /02" �Qe.� fa leaching galleries, number: leaching trenches, number, length: leaching fields, number, dimensions: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) aa-c iel VertjAG , iUd o i h can :De a sPzx Ve tin nOr 6rcck.J- CkSSPOOLS: h�CJ (lodate`on site p an) Depth b61 grade: Number and c i uration: Depth-top of liquid et invert: Depth of solids layer. " Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool a pumped as part of inspection) Comn is (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetatio , PRIW:�O (10 to on site plan) Materials of construction-------_--., _...,.M.Dimensions: Depth of solids: --- �..-� - Comments: (note condition of soil, signs of h 44ailard;I-evel of ponding; ' ion of vegetation, etc.) (revised 8/15/95) 8 FILE# + E SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' C'2alQ r Z-a,-e A fo r = 30' ro G'Q/uc�v A &.6 D 9 to D 44L If A t-a P '0 LGA 4 to P7 GJ to D W FL DEPTH OF GROUNDWATER i Depth to groundwater: _feet method of determination or approximation: 71"e of r c� c �l a2q n: 1 c i, c u i r �i K 7 X71 raw.r�cl 8,y 71 (revised 8/15/95) 9 r NEW ENGLAND ENGINEERING SERVICES INC June 9 2000 North Andover Board of Health Town Hall Annex 27 Charles Street North Andover, MA 01845 RE: TITLE V REPORT: 41 Cedar Lane,North Andover Dear Sirs: Enclosed is a copy of the Title V report for the above referenced property. The systemap ssed our inspection. If there are any questions please call me at my office, 686-1768. Sincerely BeC. Osgood Jr.-,IVI.T. President TC jUN 12 4� 60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 r . . p. C©MMONWEALTH OF MASSACHUSEM EXECUTIVE'OFFICE OF ENVIRONMMNTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WRITER STREET,BdSTON MA 02108 (617)292.6li00 ARGEO PAUL CELLUCCI ])AVID 03,STRUIig Governor Cotaniiatoiaer�; SUBSURFACE SEWAGE DISPOSAL.SYSTEM-INSPECTION FORM - i PART A i CERTIFICATION PropertyAdoress:[I I CMAC, M AIVA00 N«ne of owner L^Cc 1 D,c)5ee, Address of Owner:/1.66�At LN. Date of Ins;,6-tion: ' llu Not l rl Anld 0 vff Name of inspector:(Please Print) Benjamin C. Osgood,Jr. I em a DEP approved system inspector pursuant to Section 15.340 of Title 5(310-CMR 15.000) Company N6me: New England #EngineeringServices Inc. Maung Address: 60 Beechwood Drive North Andover, MA Telephone Number: 978-686-1768 CERTIFICATION STATEMENT 1 certify that I have personally Inspected the sewage disposal system at this address and that the Informationreportedbelow Is true,accurate and complete as of the'time of Inspection. The Inspection was performed based on my training and experience In the proper function and maintenance of on-site sewage disposal systems. The system: V/Passes _ Conditionally Passes ; _ Needs Further Evaluation By the Local Approving Authority _ Fails inspectors Slgnatu<e: Date: The System Inspector shall,Zit copy of s inspection report to the Approving Authority(Board of Health or DEP)within thirty(301-days of completing this Inspection. If the system Is a shared system or has a design flow of th 10,000 gpd or greater, e Inspector and the system owner that[submit the report to the appropriate regional office of the Department of*Ervirorlmentat Protection. The original should be sent for system owper•and copies sent to the buyer.If applicable,and the approving authority, ' NOTES AND COMMENTS revised 9/2/98 PWIof11 el IRcr rRFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Property Address: 41 Cedar Ln. PART'A ! North Andover CERTIRCATION'(contiOued) :Owner:Larry Durkee Date of Inspection: 5/26/00 INSPECTION SUMMARY: • Check A, D: A; SYSTEM PASSES: / t t V 1 have not found any information which indicates that any of the failure conditions described in 310 CMR 15:303 exist. Any fatlure' criteria not eval4ated are Indicated below. I COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the 'Conditional Pass'section need to be"replaced or repairer.. The system,upon completion of the replacement or repair,as"approved by the Board of Health,will pass. Indicate yes,no,or not determined(Y.N.or ND). Describe basis of determination In all Instances. If'not determined',explain why not: The septic tank is metal,unless the owner or operator has provided the system Inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was Installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.. The system will pass inspection(f the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. _ Sewage backup or breakout.or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction Is removed distribution box is levelled or replaced - The system required pumpir(•g-mm than•four•tfines n yeardue to broken or vbstiacted pipe(sl. The systmn Vvilh'ptrss'• T inspection if(with approval of the Board of•Healdt): —"' ..'•"" broken pipes)are replaced obstruction is removed r 1 1 I ( r revised 9/2/98 PW2of11 �rt•,•I.7ti'. 1 -=ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMPART A 'Property Address: ,41 Cedar Ln. CERTIF(CATIbN(continued) r Noah Andover Owner:Larry Durkee Date of Inspection: 5/26/00 ^' C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: j Coriditiohs exist which require further evaluation by the Board of Health In order to determine If the system Is f"atfng to protect the`:: public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMWES IN ACCORDANCE WITH 310 CMR 1.5.303(1)(b)THAT THE SY". IS NOT FUNCTIONING IN A MANNER WH.ICHymj_rRaTECT•THE PUBLIC UEALTKAND SAFETY AND THE ElMaONME&T _ 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. 21 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. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply wap: _ The system has a septic tank and soil absorption system and the SAS is within 60 feet of a!private water supply wen. _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 60 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 aqua)to or less than 5 ppm. Methpd used to determine distance (approximation not valid).• ' 3) OTHER f f f ( r i revised 9/2/98 Pate 3erll . - • • • fir;h � SUBSURFSICESEWAGE DISPOSAL SYSTEM INSPECTION ORM i i PART A i CERTIFICATION fcontinued) , Property Address: 41 Cedar Lit. : North Andover Owner:Larry Durkee } Date of Inspection: 5/26/00 ! } D. SYSTEM FAILS: ' You must Indicate either-Yes"or"No". to each of the following: , 1 have determined that one or more of the following failure conditions exist as described In 310 CMR 16.303. The basis for this determination Is identified below. The Bpard of Health should be contacted to determine what will be necessary to Correct the failure. Yes No _ Backup of eeWage loto-facilityror-s"temcomponent-due tto an overloaded ot-ciaggediRASor•ceespoot•' • 1.�- moi. 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 112 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 pgvy is-within a Zone I of a public well. — Any portion of&,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 wall 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 org anIc-compounds,ammonianitrogen•and nitrate nitrogen. E.. LARGE SYSTEM FAiLS: You must Indicate either"Yes"or"No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow V 1'.0,000 gpd or greater(large System)and the system Is a significant thre¢t to.pubGc health and safety and the environment because one or more of the following conditions exist: Yes No the system Is within 400 feet of a surface drinking water supply l the system-(e-within200 teetofsrtfWutartrts�suf(eosdrk�kGywater-suKly —. ' -- the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area=IWPA)or a mapped Zone 0 of a public r water supply wap) r r The owner or operator of any such system shall upgrade the tystem in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further inforawtion. revised 9/2/98 PW4ofit i •I i - ;fig. x y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIQN FORM , PART B _ CHECKUST _ i_,,.•,, :yam LG. Property Address: 41 Cedar Ln. [ i` y�1• North Andover rss ` Owner:Larry Durkee ,.c Date of 5/26/0 Inspection: ;.? . 0 Check If the following have been done:You must indicate either'Yes"or'No'as to each of the following: Y_qE No I V _ Puhtping information was providedby the owner,occupant,or Board of Helh. y _ None of the 4stemcompowriu.iwuo been poaMpadxforJKJ$ast:tWO srwkc nnd-Lhe•syctem ha:6NaasulaingwawcalAow rates during that period. Large volumes of water have not been introduced into the system recently oras part of'this . inspection. �/ _ As built plans have been obtained and examined. Note if they are not available with N/A. V _ _ •The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. v _ The site was inspected for signs of breakout. _ All system components,excluding the Soil Absorption System,have been located on the site. The septic tank manholes were uncovered,opened,and the interior of the septic tank was Inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. The size and location of the Soil Absorption System on-the site has been dejetmined 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) _ 115.302(3)(b)) The facility owaar(and.occupeats,H differe.ot jram m=er).ware.protddad,suith inmrmat'. aon 1h-,n_r^�nar—idgal nand"I SubSurface Disposal Systems. revised 9/2/98 Pgeserit - --- ' �. SUBSURFACE SEWAGE DISPOSAq SYSTEM INSPECTION FORM PART C .~�. Property Address: 4 SYSTEM WFO(tMATION 1 Cedar Ln. North Andover r' Owner:Larry Durkee Date of Inspection: 5/26/00 FLOW CONDITIONS RESIDENTIAL: y Design flow. 6.p.d.lbedrooni. Number of bedrooms4design):_ Number of Bedrooms(actual): Total DESIGN flow 2Ghmber of current residents; rbage grinder(yes or no).-_pJO Laundry(separate system) (yes or no):_; If yes,separate Jnspaction.required- - • Laundry system Inspected (yes or no) , Seasonal use(yes or no) Water meter readings.If avallable(last two year's usage(gpd): WIeLL Sump Pump(yes or no):/VO Last date of occupancy:CUCCLn1T COMMERCIAL/INDUSTRIAL:' ' Type of establishment: Design flow: apd (Based on 15.203) Basis of design flow 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)_ Wpter meter readings,if available: - Last date of occupancy: OjHER:(Describe) Lest date of occupancy: GENERAL INFORMATION• PUMPING RECORDS and source of information: 5f lCtu6 flees u-�H 5 011,,AJCC System pumped as-part of inspection:(yes or no)-j,. If yes,volume pumped: gallons Reason for pumping: STYPE O YSTEM eptic tank/distribution box/soil absorption system Single cesspool Overflow cesspool :. Privy Shated system(yes,or nol Of yes,attach previous(nspeption records,if any) '• UA Technology etc:Attach copy of up to date operation and maintenance contract f Tight Tank Copy of DEP Approval I I Other -� APPROXIMATE AGE of ail components,date installed-(if known)-and source of infem►ation: -• 1 y J-1.� ,6,C-4' r Sewage odors detected whawarriving at the site:(yes or no) ' r•. revised 9/2/98 pate 6ofit -- A Or 0 . SUBS'.1RFACE SEWAGE DISPOSAL SYSTF]4t INSPECTION FORM • PART C Property Address: 41 Cedar Ln. SYSTEM INFORMATION(condnued) North Andover , OWner:Larry Mirkee Date of Inspection: 5/26/00 ! BUILDING SEWER- (Locate on site plant Depth below grade.-;k l , Material of construction: cast iron_40 PVC_other(explain) .' Distance from private.water supply well or su tion line Diameter Comments:(condition of foints,vepting,evidence offvakage,-etc.) "`•' �i�J',SHed BASeA46,y o-- A)OY VSA B46 SEPTIC TANK:_ (locate on site plan) Depth below grade. Material of construction: X concrete_metal_Fiberglass _Polyethylene—other(explain) If tank Is(petal,list age_ Js.age.confirmed by Certificate of Compliance_(Yes/No) Dimensions: 1000 6AUOeJS . Sludgedepth: Z„ Distance from top of sludge to bottom of outlet tee or t afffe_120L -' Scum thickness: < 1 " ,, . Distance from top of scum to top of outlet tee or baffle:. fa ,a Distance from bottom of scum to bottom of outlet tee , baffle: (b ; Now dimensions were determined:MCA06AJ& 5T.0 K . Comments: (recommendation for pumping,condition of inlet and outlet tees or-baffles,depth of liquid level In relation to outlet invert,•struetural4ntggrlty. evidence of leakage,etc.) T11.t1 A I n1 (� r)d L©n1 d iTs OA/, VC F f C I �tJ 0 e0144;T.V N, e ldem6 1 TA ltd F R Set TO W )T t4 A.' 6" eq F F;nr'. 1-I G•t"A d 9 GREASE TRAP:L� (locate on site pian! Depth below grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) D)menslons' 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: s Date of last pumping: Comments: (recommendation for pumping,condition of inlet and outlet tees.or baffles,depth of liquldJavel In relation to outlet Invert,structural integrity. evidence of leakage,etc.) revised 9/2/98 Pate 7of It S SUBSURFACE SEWAGE 61SPOSAL SYSTEM INSPECTION FOAM %; f PART C SYSTEM INFORMATION(contiquad) Property Address: 41 Cedar Ln. North Andover Owner:Larry Durkee -: Date of Inspection: 5/26/00 TIGHT OR HOLDING TANK; {Tank must bd'pumped prior to,or at time of.Inspection) i (locate on site plan) Depth below grade: " Material of construction:_cpncrete_metal_Fiberglass_Polyethylene_other(expinin) Dimensions: - Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order:Yes_ No, Date of previous pumping: Comments: (condition of Inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution Is equal,evidence of solids carryover,evidence of leakage Into or out of box,etc.) — '— Roy jnJC9Qv� 'r.0A1. ivo E� ��,vt� aE Le.4Kita TA) or out . AX .ae.uce O F c t A CAEa over. PUMP CHAMBER.W A (locate on site plan) Pumps in working order:(Yes or No) Alarms In working order(Yes or No) Comments: I: (note condition of pump chamber,condition of pumps and appurtenances,etc.) r revised 9/2/98 Page 8of11 Tt SCE SEWAGE DISPOSALJSYSTEM•pVSPECTI0.H FORM t Property Address: 41 Cedar Ln. PART r rM :SYSTEM INFORMATION(c«�!+�d) North Andover _ ' ' '•` Owner:Larry Durkee Date of Inspection: 5/26/00 ' SOIL ABSORPTION SYSTEM(SAS): Fr. (locate on alto,plan.Ifpossible;excavation not required,location may be approximated by non{ntruslve methods) If not located;explain; 1 1 ' Ty e: leeching pits;number, _P!�5 leaching chambers,number:_ leeching galleries,number: ' leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number:_ Alternative system: Name of Technology; Comments: (note condition of soil I signs of hydraulic failure,level of onding,damp soil,condition of vegetation,etc.) ABPA OF P,TS LOOKS /10tMAF nyD PD,u�..v(o nA^4f SO• I Q,C UN ilc,yA 1 UL(90TAT.ON e>,JB PIT nP0,VC'n A&2 0 i%OVNn TD -- E 3- A-1— CESSPOOLS -1—CESSPOOLS•V A (locate on site plan) Number and configuration: ; Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimenslohs 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 fallureAevel of ponding,condition of-vegetation,ete.l PRIVY:WIA pocate on site plan) f f Matedals of construction: Dimensions: Depth of soilds• Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation;etc.) r r 1 — revised 9/2/98 Page 9 of tl SUBSURF4CE VLTAGE DISPOSAL SYSTEM INSPEC7i0N FORM PART C Property Address: 41 Cedar Ln. SYSTEM INFORMA'nON(continued) _ r<. North Andover - - . . .'._ � s •<�.<.>`��� Owner:Lam Durkee � ,- Date of Inspection:5/26/00 �:•1.i':h.Lj 1 • 1 1 -__ .SKETCH OF SEWAGE DISPOSAL SYSTEM: ; , Include ties to at least tiro permanent reference landmarks or benchmarks locate all we within 100'(Locate where.public water supply comes into house) `3r' CEDAR LANE WELL 12 'f 41 CEDAR LANE 01 1 , r 51 4 1 4 S f > 1 � r revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION 911M PART O i SYSTEM INFORMATION(continued) Property Address: 41 Cedar Ln. .• E" North Andover Owner:Larry Durkee c.. spate of Inspection: 5/26/00 t ' NRCS Report name -4,Jt �, ; Esse r Ccs•-+✓�� • No�l'1,ree� ��\ Soil Type_ 1LNCKLE`i - ' 1 Typical depth to groundwater USGS Date website visit d Observation Well;checked 'Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater Feet Please Indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed.Site(Abutting property,observation hole,basement sump etc.) Determined from logia(conditions Checked with local Board of health Checked FEMA Maps- Checked pumping records Checked local excavators,installers Used USGS Data Describe'how you established the High Groundwater Elevation. Must be completed) n )�. ✓GS i�n L cites C rJ 1 ca k w cr c�3` e�ow CN a�':�.:/ Z)• t9-S.5•C-5 Pe► �Ks,CC ) (o � below revised 9/2/98 Pate uoru WELL DATABASE .�R yr ADDRESS: It AGE OF WILL: ? WELL DRILLER: WELL PERltiL�T,T: WELL LOCATION: � —WELL PERMIT DATE:- DEPTH-OF WELL:��� -"TYPE`OF R;LLL: a._ DRILLED b. DUG TYPE OF WATT BEARING RO CK_ WATER AiYALY=DATES \l�-'EIGH"MANGANESE:. Y HIGH IRON: Y N OT=CONTAMNANTS: Y , WELL DATABASE ADDRESS: AGE OF WELL: 2, REL DRILLER- .WELL PER1l=T: ? WELL .00ATION: WELL PERI NET DATE: DEPTH OFR ELL: 7 TYPE OF WELL: a_ DRILLED r b. DUG c. UNKNO WN TYPE OF WATER BEARING ROCK: WATER ANALYSIS DATE: ? ' HIGH iliL4NGA.NTESE: Y N HIGH IRON: Y N OTHER CONTANMNA_ TS: Y Ni DESIGNER'S CERTIFICATION This is to certify that the subsurface sewage disposal system installed at2/y/ve — a d1res s —, Subdivisi.on Lot. No. Town Lot No, and Town Nap Noe has been in- stalled In strict accordance with the plans and specifications ap- proved by the AMMIMM Board of Health. 'Mis certification includes the location, grades and materials of all components of the system. tore OF MASS, oc jo(oEPH 'ALLO Note: This must be delivered to the N0.. 464 OG- 'Board of Health within 48 hours -'0 I�GISTS following the approving inspection. LJOT - GE-:-I;;;#Ar2, LAP-Jr 4,91 1�'vG 1 �aT � q �'"� •T�$T P,T ���-'✓�,U._ __ _ _ -� � tip' � T � 00 f A � r sT t 47 '11719 oacti Ito 142"COW"w" + rj Ips? 0=1 � d r. L , 1 �4. BARBA,;.-•�j�,�'-��. ., .- - ,�LtO err Yo. 464 t = �So, . ,► fe gz ~�