HomeMy WebLinkAboutMiscellaneous - 41 SUMMER STREET 4/30/2018 41 SUMMER STREET
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Commonwealth of Massachusetts •' '.
low City/Town of
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tem Pumping Record dSEF �' 3 20113
Form 4 TOWN OF NORTH ANDOVER
IV HEALTH DEPARTMENT
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DEP has provided this form for use,by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house,Rig rear f ho , Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Cityrrown State Zip Code
2. System Owner. Uj
Name
Address(if different from location)
Citylrown Zi Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2• Quantity Pumped: Gallons ;
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No.
5. Condion of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location Wkere contents were disposed:
GLS. Lowell Waste Water
Signitufe 9t Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Donald Foss
APPLICATION FOR SEWAGE DISPOSAL INSTALLATION
HEALTH DEPARTMENT- NORTH ANDOVER, MASS.
I hereby make application for a permit for a sewage disposal installation at
Summer St. . I will install this system in ac-
cordance with all the laws of the Commonwealth of Massachusetts and regulations of
the Board of Health of the Town of North Andover.
Further, I will construct the house sewer of bell and spigot pipe, the minimum
diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre-
ceding the septic tank, where the grade shall not exceed 2%. I will install a con-
crete septic tank of 1000 gal in size. A manhole (s) permitting easy cleaning
will be provided with removable cover (s) of iron or concrete within 12 inches of
the ground surface. I will provide subsurface disposal field with 4 inch perforated
or open jointed pipe and laid in a series of trenches, the bottom of which will pro-
vide a minimum of 180 lineal (square) feet of effective absorption area.
The pipes will be laid on a '6 inch layer of washed gravel or crushed stone ranging
in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar
material to a height of 2 inches above the crown of the pipe. The joints of these
pipes will be protected from clogging and before filling the trench, 2 inches of
gravel or stone 1/8" to 1/4" (dia.) will be placed over the course gravel or stone.
The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single
the line will exceed 100 feet in length and in any case, two lines of tile will be
installed. A minimum of 6 feet will be maintained between the center lines of the
disposal field trenches and the average ,depth of trench shall not exceed 36 inches.
No part of the installation will be less than 100 feet from any private water supply,
25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line.
I further agree not to cover an portion of this installation until approved b
� v p pp y the
inspection officer, as provided below, and to incorporate any additional requirements
that may be attached to the permit. Plot Plans must be submitted with application.
DATE 4/6/68
Signature of Applicant
I hereby issue the above permit for the Board of Health of the Town of North
Andover, Massachusetts.
DATE
Y
Signat'¢e of Health Agent
I have inspected the uncovered system indicated above and find everything done
as described.
DAT
t
Signature of Ind cting Officer
Percolation Test 6 min CInr Gr);l
Garbage Grinder nn
5 +Y
ti l�
BOARD OF HEALTH
TOWN OF NORTH ANDOVER, MASS.
P ' /6
i �. 37i
1. NAME---Z"_U DATE 3S (o
r
2. ADDRESS LOT NO. TEL. 3 Q Q
3. NO. OF BEDROOMS DEN YES NO Y
4. GARBAGE GRINDER YES NO
i
5. SHOW DIMENSIONS OF HOUSE
6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES
7. SHOW DIMENSIONS OF LOT
8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL
9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM
10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC.
11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE
NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY.
n
BOARD OF HEALTH OF NORTH ANDOVER , MASSACHUSETTS
SEWAGE DISPOSAL �/
DATE2&,ZC J
NAME OF APPLICANT
LOCATION
Address of lot no.
BUILDING: Dwelling Other
SYSTEM: New Repair
GENERAL DESCRIPTION OF LAND
_ J-tt�-4, _
SUBSOIL: Clay__)( Gr vel Sand
PERCOLATION TEST minutes per inch.
MINIMUM INSTALLATION RECOMMENDATIONS
CONCRETE SEPTIC TANK gallon capacity.
LEACH FIELD /L2 lineal feet of drain pipe.
0AL
William J. Drk' soll , Engineer
Board of HealthJ
I
r
COMMONWEALTH OF MASSACHUSETTS
Vn a
EXECUTIVE OFFICE OF NVIRONMENTAL AFFAIRS
d DEPARTMENT OF E IRONMENTAL PROTECTION
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TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 41 Summer Street_
-North Andover_ RECEIVED
Owner's Name:_Donald Foss_
Owner's Address:_41 Summer Street_
North Andover,Ma 01845_ SEP — 3 2004
Date of Inspection 8/19/2004_ TOWN OF NORTH ANDOVER
Name of Inspector: Neil J.Bateson_
HEALTH 0EPARTMElYii
Company Name: Bateson Enterprises Inc._
Mailing Address:_111 Argilla Road_
_Andover,Ma.01810_
Telephone Number:_(978)475-4786
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 fimction and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
_X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
F '
Inspector's Signature: �-� Date: _8/19/2004_
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: 41 Summer Street
_North Andover—
Owner:_Foss
Date of Inspection: 8/19/2004
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X I have not found any information which indicates that any of the failure 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.
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 I 1
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 41 Summer Street
_North Andover—
Owner: Foss
Date of Inspection:_8/19/2004
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well".Method used to determine distance_
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 41 Summer Street_
—North Andover—
Owner:_Foss
Date of Inspection:_8/19/2004
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no!'to each of the following for all inspections:
Yes No
_ No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
_No_Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
No Liquid depth in cesspool is less than 6"below invert or available volume is V2 day flow.
_No_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_ _No_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
_No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_No_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
_No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_No_ 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 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 most serve a facility with a design sow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
_ the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—1WPA)or a mapped
Zone 11 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.
Page 5 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:_41 Summer Street
_North Andover—
Owner:_Foss
Date of Inspection:_8/19/2004_
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
Yes_ _ Pumping information was provided by the owner,occupant,or Board of Health
No Were any of the system components pumped out in the previous two weeks?
Yes_ _ Has the system received normal flows in the previous two week period?
No_ Have large volumes of water been introduced to the system recently or as part of this inspection?
N/A — Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Yes_ _ Was the facility or dwelling inspected for signs of sewage back up?
Yes_ _ Was the site inspected for signs of break out?
Yes _ Were all system components,excluding the SAS,located on site?
_Yes_ _ 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?
_Yes_ _ 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
_Yes` _ Existing information.
_No_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable)[3 10 CMR 15.302(3)(b)]
Page 6 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:_41 Summer street
_North Andover—
Owner:_Foss_
Date of Inspection:_8/192004_
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):_N/A_ Number of bedrooms(actual):_4_
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):_N/A_
Number of current residents:_2
Does residence have a garbage grinder(yes or no): No_
Is laundry on a separate sewage system(yes or no):_No_
Laundry system inspected(yes or no):_
Seasonal use: (yes or no):_No
Water meter readings:_Yes,066318ft3
Sump pump(yes or no): Yes_
Last date of occupancy:—
Current-COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sqft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:_Pumped six years ago,owner
Was system pumped as part of the inspection(yes or no): Yes_
If yes,volume pumped:_1000_gallons--How was quantity pumped determined?_Measured tank_
Reason for pumping: Inspect tank&tees_
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
_Single cesspool
Overflow cesspool
Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_hmovative/Altemative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
_Other(describe):_
Approximate age of all components,date installed(if known)and source of information:_House built 1968,Info at
B.O.H.
Were sewage odors detected when arriving at the site(yes or no):_No
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_41 Summer Street
_North Andover—
Owner:_Foss
Date of Inspection:_8/19/2004_
BUILDING SEWER_X_ (locate on site plan)
Depth below grade:_28"_
Materials of construction: _X_cast iron _40 PVC other
line:Distance from private water supply well or suction line —
Comments(on condition of joints,venting,evidence of leakage,etc.):_4"Cast iron thru wall to tank 4"Cast
iron in house,no leaks visible._
SEPTIC TANK: X
Depth below grade:_16"
Material of construction: X concrete—metal_fiberglass_polyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions:_7'x 5'x 4'
Sludge depth: 6"_
Distance from top of sludge to bottom of outlet tee or baffle: 21"_
Scum thickness:_6"
Distance from top of scum to top of outlet tee or baffle:_8"_
Distance from bottom of scum to bottom of outlet tee or baffle: 15"
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.)_Pumped septic tank.Inlet baffle ok.Outlet bate ok.Outlet
tee ok.Depth of liquid at outlet invert.No evidence of leakage._
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 41 Summer Street_
North Andover
Owner: Foss_
Date of Inspection: 8/19/2004_
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 must be o ened (locate on site plan)
X—( present P )
Depth of liquid level above outlet invert: _0"_
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.)_D-Box level&distribution equal.No evidence of leakage.Evidence of
carryover,pumped d-bog to clean.
I
PUMP CHAMBER:_(locate on site plan)
Pump in working order(yes or no):_
Alarm 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: 41 Summer Street
Owner:_Foss
Date of Inspection: 8/19/2004
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:_
leaching chambers,number:
leaching galleries,number:
_X leaching trenches,number,length:_4 Trenches 50'long_
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.):_Soil oL Vegetation oL No sign of ponding to surface._
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site len)
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
a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_41 Summer Street_
_North Andover—
Owner: Foss_
Date of Inspection:_8/19/2004_
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
Driveway
Water Meter Garage
House
A
A to 1 =25'2"
A to 2=27110" Porch
A to D-Boz=317"
B
Bto1=15'5" 1
B to 2=14' Septic
B to D-Boz=14'7" Tank
2
D-
Box
50'
Pool
Page I 1 of 11
a
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 41 Summer Street
—North Andover—
Owner:_Foss
Date of Inspection:_8/19/2004_
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water _>6'_
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)
X Accessed USGS database-explain: _Essex County Soil Map_
You must describe how you established the high ground water elevation:_Essex County Soil Map,Sheet#36,
Canton Soil,Water>6'Deep._
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Tel: (978) 475-4786
Fax: (978) 475-5451
BATESON ENTERPRISES, INC.
Excavating-Water.& Sewer Lines-Septic Systems&Pumping Service
1 I 1 Argilla Road Andover, Mass. 01810
Title 5 Inspection Report
Property Address: 41 Summer Street, North Andover
Owner: Foss
Date of Inspection: 8/19/2004
My report contained herein does not constitute a guarantee of future usage and the functionality of the existing
septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further
operation of your current septic system.
Neil J. ateson
Bateson Enterprises, Inc.
` 0
COMMONWEALTH OF MASSACHUSETTS
NEW EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON. AIA 02108 617-292-5500 _ /
� ry
WILLIAM F.WELD JUL L 4 , , TRUDY CORE
Govcmo: I Sccrctan
ARGEO PAUL CELLUCCI ' DAVID B.STRUHS
Lt.Gov_cmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM__ - Commissioncr
PART A
CERTIFICATION
Property Address: Lj Ski w.V--," `aT /" ` Address of Owner:
Date of Irwection: -- fo— (If different)
or:
Name of Inspect..
d s'stem i s
ector ursua to ion 15.340 of Title 5
310 CMR 15.000)
IamaD . ppr e , y n �,
Company Name;
Mailing Address: 1 l UQC v ra. 18 I v
Telephone Number: —
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-sit: sposal systems. The system:
_ P✓asses
Conditionally Passes
Need Furth r Evaluation By the Local Approving Authority
_ f 1
i Date:
Inspector's Si nature. .
Signature:
ITT
The System Inspector shall tubmit 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: Check A, B, C, or D:
A] SYSTEM SES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
s] SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty(20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exhitration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a confprming septic tank
as approved by the Board of Health.
(zivipad 04/25/99) Paye 1 of 10
DEP on the World Wide Web: http:/Mrww.magnet.state.ma.us/dep
A Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: L41
Owner:
Date of Inspection:
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). Describe observations:
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
q
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by.the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
a WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
.The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation.not valid).
3) OTHER
(revised 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATIIO,�N (continued) ^
Property Address: JV w.1N�P� i - �i��t}'� ��4 �.Jsa f
Owner:
at., of Irtspectiott:
Dj SYSTEM FAILS:
You must indicate either "Yes" or"No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
_ Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
_ Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped_.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
. r .
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ Any portion of a cesspool or privy is less than. 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA) or a mapped Zone 11 of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(rwif!�d Q*/35/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: Si bl.,t, �—,
Owner:
Date of In„ ection: C�
Check if the following have been done: You must indicate either "Yes"or"No" as to each of the following:
Yes o
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 bock-up.
The system does not receive non-sanitary or industrial waste flow.
s pe g
The site was inspected for signs of breakout.
f� System,c
All system components, excluding the Soil Absorptiony , have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
_ Existing information.Ex. Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) 115.302(3)(b)j
(revised 04/2S/07) page 4 of 20
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
! Property Address: L SV VbCS' O"UtW
Owner:
Date of Inspection: p,
FLOW CONDITIONS
RESIDENTIAL:
Design flow: LIQ ¢.p.d4edroom for S.A.S.
Number of bedrooms:
Number of current residents:
Garbage gander(yes or no):_p
Laundry connected to syst (yes or no).- '��1/t,c�� n4z^
Seasonal use (yes or no � � C��hf� �� `� � ca
Water meter readings, if available (last two (2)year usage (gpd): ,
Sump Pump lyes or no,. N� Zo qt�
Last date of occupancy.CURC" v � /
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flow: gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
lastdate of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
4 _ P�
System pumped as part of ins cion: (yes or no) Q=
If yes, volume pum ` Ion
Reason for pumping: �y5p _.
TYPE OF'5VMM
Septic tank/distribution box/soil absorption system
5g � P�
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
(/A Technology etc. Copy of up to date contract?
Other
APPROXI TE AGE of all omponents, date installed (if known) and source of information: � c "'2SN
a-S
T NJ
Sewa a odors detected when arriving at the site: (yes or no)
8, g Y —
(roviaed 0}/25/97) Payo 5 of 20
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
c +SYSTEEMf IN,FFOtRMATION, (continued)
Property Address: �Nu-1f/V��ifp � • t"�{ � ���`=�J �
Owner: o ^�
Date of In:
_ (b
BUILRING SEVVEI /
(locate on site plan)
1�
Depth beloty grade:
Material pf const (/�ast iron 40 PVC other f explain)
Distance frQrtl P€tyrate water supply well or suction lire
D)ameter
C'M'Te t$: (crop iti n of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:.✓
(locate on site plan)
1�
Depth below grade: [e)
Material of construction: _ ncrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions: `71 5 k `
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: L4 s ('
Distance from top of scum to top of outlet tee or baffle.
Distance from bottom of scum to bo f o�tlhet`tee or baffle:
How dimensions were determined: =��"'
Comments:
(recommendation for pumping, con n of in t an ou tees o baffles, depth f liquid level in -la ion to out fit i`n�vveen,ststtudural j
integrity, i n �of leak ge, et . C✓ iZ� S�
L
Ull I Ma
mwgQQ
o
GREASE TRAP: ��
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(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.)
(Vjyv*#po 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
O,per: p S
Date of IrlsPection
TIGHT OR HOLDING TANK Clank must be pumped prior to, or at time, of inspection)
ate on
(locsite plan)
Depth below grade:
Material of construction: _concrete _,metal _Fiberglass_Polyethylene other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
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: a
Comments:
(note if le I and ydistri utipV is eq al, evidence of solid carryover, evdente of leakage ' to out f x, etc.)
p
PUMP CHAMBER: ��
(locate on site plan) v
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.)
(rwi.eo 0{/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: Li ( U� — On`,-.Vk "L*X-
owner:
IV70!s�'S'
Dale of inspection:
SOIL ABSORPTION SYSTEM (SAS):
(locate on site pian, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type_:
leaching pits, number:_
leaching chambers, number:_
leaching galleries, number: �J��L� I
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(not ondaipn of s il, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
\\ C
N U
CESSPOOLS..W Q
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY: n�
(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.)
(s4�vimed Of/25/97) Psgo 0 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: S K
Owner:
Date of lnspgction:
'-1-- 16--x?
SKETCH OF SEWAGE DISPOSAL SYSTEM: v4e
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house) ,
CN I
A 45
a� 110 it
P-)
�lILI
(revised 04/25/97) Tags 9 of 10
i
' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEMINFORMATIONINFO RMATION (conti ued)
Property Address: J�U� 1" 41(k
Owner:
Date of Inspection:
Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtain �r6m Design Plans on record
Observatio ite (Abutting property, observation hole, basement sump etc.)
fx
n
termine i m local conditions
eck with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. Must be completed)
V
40
J -3-y5�
(seviged 0*/25/97) PaY• 10 of 10
TEL: (5 010 475--1 -17.1
a FAX: (5011) 475-5.451
RM N ENTERPRISES, INC.
fxwollno-w"19r 4 Spwar -'sVNttc systvins A r1 mipinb SUIVWC;
111 Argilla Road y Andover, Mass. 01 H 10
Title 5 lospection Report
'S' s-4--
SCJ
A�lr# r
----------------------------- ----
r-1
-- '
Pot@ Of InspectjoP ; -- --- - ------ - -
my t:ppa;'t Foptailled herein does not conSLi Lut=e a guarantee
of future uogge 4od the functionality of Lhu exisLiny septic
qy#tpmt Such report issued 1)erewitii is merely based upon my
OboarVit1Q44, aria I hereby disclaim any > urt.i►er operuLioii
of your current septic system.
lSatesuu Eul..:rl�ri5es fnc .
Page 11 0l ! t
a�
4�"\N Commonwealth of Massachusetts
City/Town of RECEIVED
System Pumping Record
Form 4 SSP 16 2008
TOWN OF NORTH P, DO/ER
DEP has provided this form for use by local Boards of Health. Other fo sl ma:Abe=used,� t�e
information must be substantially the same as that provided here. Before using this form,chec wlth your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer,use
only the tab key Address
to move your U V-\,VA ems'
cursor-do not Cityfrown State Zip Code
use the return
key. 2. System Owner.
Name
ILEI Address(if different from location)
City/Town State4p Code
, 17173
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes D-401 If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System: r ^
6. SysteTjL,�—
uBy:
Name Vehicle License Number
Company
7. Locatio ere conte is vT disposed:
Signatu of au Date
t5form4.doc-06/03 System Pumping Record.Page 1 of 1
TOWN OF
SYSTEM P, PING RECORD
RECEIVED
DATE.
E
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
r-� (example:left front of house)
-3u V�-k
DATE OF PUMPING: QUANTITY PUMPED : C GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
p �
COMMENTS:
CONTENTS TRANSFERRED To: G.L.S.D Lowell Waste
Commonwealth of Massachusetts
City/Town of RECEIVED
System Pumping Record
Form 4 y-P 1 12011
DEP has provided this form for use by local Boards of Hea11MMOMm,
d, but the
information must be substantially the same as that provide check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. Syste tion: Left front of house, right front of house, left side of house, right side of hou-
r
ou , Le
r r of hous right rear of house, left side of building, right rear of building, under deck.
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town Stat Code
<s2)
Telephone Number
B. Pumping Record q- �- v
1. Date of Pumping Date 2• Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. LocT.,
here contents were disposed:
.Lwell WOstQ Water .
Signatqfe qVH&rer Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1