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HomeMy WebLinkAboutMiscellaneous - 410 SUMMER STREET 4/30/2018 (2) -- � X1.5' � O�fl .:;� I D Commonwealth of Ia aisegseh t6t#s i!n2 ���0 RECEIVED f a Tide Official I sloect on Four ��` JUN p 9 2015 Subsurface SaW age 000sal sy Eprm.Not for Voluntary sMMents i 'TOWN OF NORTH ANDOVER 410 Surrtinler Street L DEPARTMENT Prcpei�+.Addr+r� t=srland: Owner puieee ss N�rne i _ irfasrrtatian 1F MArequ �- Mune ,2015 horth Ando everypage. C(tyfwn ver I SM6 Zip Code' pate of inspection Inspection results must.be submitted oft this form.Inspection forms may not be altered In any vway.Ple see.completeness checklist at the end of the form. httExrttantc@PIBTLfi 111 1't77ati€fn i When filling out introns on tha a computes,us4 1. Inspector; onlyr the tab k" to move your Desn,G Ltrssomb I1 :. currior-do not NPrle cif irta paeia�e uw the.return kar baan G,.Lue3comb It tt sorts C©mps3nY Nsrne � o P 4 LOX t 35 Con,pariy Address i l 019+i' hrliddlettan MA rt 9u ' Citp Tm%1n _ State 7r CnaJe 978-779.4085Si84tl_ Tt4*.nr*Nu nbo( -, LAA,rise Humber: �y B. Certiticatain l certify that 1 have persenamy inspectL-d the se%gage d isPeasat iiystem at this addr*$a end that the : tr>kearmetidn reported belovt is true,aaccur`at6 prod 400ttplete as of the time of the Inspec6an.The inape�tleri was per.5ormed h�$ed on mai training arta �xper enoe in the proper:function grid rnal>�Wrta,n a of ori sib sewage disposal'systems.lam a DV.P approved systema Insp+actor P111M ttt to Seactiaun 15.390 sof Title s(310 CMR 15,000).The system.- Passes Lj Conditlonally Pass res ❑ Feals l Meed!Further Evaluation icy the I Approving Authcrlty sone 8;2010_ Date. 1� arts.�.iga'tbtntre I a The system lneAectoi'sh€tll sulontt a?t c�Py ref this inspection toPoft 0 he Approving+�utho-1W(Bberd of Health flf 13EP)wjWn 30:days of cafrtplarang tl1i islspActiai.if t116 system Is a shairad&ysiilt Or. las a design flow of.10;000 cpd.or rt!at$r,On inspector an*Me system owner!hail submit the repgrt to the Appropripte regional o tMe of the CEP.The a3ftgiri I shauld be$ rtt tca the systertt c►wnQr and copies"Sent to thebuyer,if aPpl c le,and tbq,opproving aLdho ity. "- Thia report only desedbes cond!W*mS at the time of inspectlmn.and under the condfdons of use at fhot tirne.�This lnspection does'nit address hqw the syetern will peerform in tfie iat�re under tlt+e sante or diftrent conditions'of se. l - {�q Snt3 CEMBaJifiasllr�sazSionFcvr€r.5ucairlm�e9r$.tie2el`r�4�tei9a9aem.PeyuLMlr. s i i Commotnwalth of Massach4att's Title 5 Official 1 : ori. Fora sunsur(aoe Sewage Disposal System F�irm-Not tor Voluntary Assessments 410$simmer St et F cippyty A+ddse a `. Fadand t ;r Own®d6tYaLme i iinfonnaonpqui farts, North Andover 111}4 June� X1315 evor7c ll � y"i ouvn I. State Zip Cade Orta of loop"lion B. ce tification (cont.) ' In Ion Summary.Chea { {G,D ar IE P 41lyl�e�iYS Complete all t f Ssc III E) A) 90ternt Pas&es t: Z I have n9t found silly wocr iwn vrhiah indicates that any of the(allure arlteda desefted 413110 CPAR 15.'W3 or In 31 d CMR 15.304 exist.any failure criteria not evaluated are tndioted below. is comments: r't 3 s JUS' X; _r dam+. i? a i 131 System Conditionally Passes. l One or Mara system components ss described.in the°Q0nditiona1 Pmse section need to he I eplaced or repaired.The sy tcm; fi NJ FILE# .,a n d 9 REM A TITLE V INSPECTION TOWN OF NOKTH f ,* . > HEALTH DE1"MENT k , . Dean G. Luscomb II & Sons P.O. Box 135 Middleton MA 01949 a 978-774-4065 a Licensed Plumber # 20285 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM k ROPERTY OWNERS NAME Ferland 014-- PROPERTY ADDRESS I D U M M P Y J� Andover DATE OF INSPECTION A au (� NAME OF INSPECTOR u , ,.e QUALITY IS NUMBER ONE TO US Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Vey'e 410 Summer St. Property Address Ferland Owner Owner's Name information is North Andover MA August 18 2014 required for g , every page. Citylrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: n C EI ii`�I V E� When filling out A. General Information forms on the Stp u (aQj computer, use 1. Inspector: only the tab key to move your Dean G. Luscomb II TOVNN CIS'NORfl1 I�M 0 T cursor-do not Name of Inspector pw TH DEPARTMENT use the return key. Dean G. Luscomb II &Sons Company Name - P.O. Box 135 Company Address Middleton MA 01949 City/Town State Zip Code 978-774-4065 S1848 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 P P was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority August 18, 2014 Ins ctoes 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. t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 17 1. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 410 Summer St. Property Address Ferland Owner Owner's Name information is North Andover MA August 18, 2014 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check ,B ,D or E/always complete all of Section D P rY 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 stem components as described in the"Conditional Pass" section need to be. ® O p Y replaced or repaired. The system,upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. to Y F1 N ❑ ND (Explain below): Tank is precast concrete but is structurally unsound. Baffles are missing and tank is leaking approximately 6" below the outlet invert at this time. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �., 410 Summer St. Property Address Ferland Owner Owner's Name information is North Andover MA August 18 2014 required for 9 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): FYdistribution box is leveled or replaced ❑ ❑ N ❑ ND (Explain below): The system required pumping more than 4 times a year due to broken or obstructedpipe(s). The ❑ Y q P P 9 Y 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 ❑ P P Y 9 9 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Amm Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 410 Summer St. Property Address Ferland Owner Owner's Name information is North Andover MA August 18, 2014 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow t5ins•3/13 TiUe 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form "s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 410 Summer St. Property Address Ferland Owner Owner's Name information is required for North Andover MA August 18, 2014 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) La Systems: To be considered a large system the system must serve a facility with a design of 10,000 gpd to 15,000 gpd. For large systems, u must indicate either"yes" or"no"to each of the followin in addition to the questions in Section D. Yes No ❑ ❑ the system is within 0 feet of a su a drinking water supply ❑ ❑ the system is within 200 f o tributary to a surface drinking water supply ❑ ❑ the system is loc in a nitrogen sen i 've area(Interim Wellhead Protection Area—IWP r a mapped Zone II of a pu i water supply well If you have answered "yes" any question in Section E the system is co i ered a significant threat, or answered "yes" in S ion D above the large system has failed. The owner erator of any large system considere significant threat under Section E or failed under Section D sh pgrade the system in acco nce with 310 CMR 15.304. The system owner should contact the appr iate regional off of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 410 Summer St. Property Address Ferland Owner Owner's Name information is required for North Andover MA August 18, 2014 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? X / Were as built plans of the system obtained and examined? (if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ 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? ® El information 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. ® El approximation 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: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts °N Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 410 Summer St. Property Address Ferland Owner Owner's Name information is North Andover MA August 18, 2014 required for eve a e. Cityrrown State Zip Code Date of Inspection rY P 9 D. System Information Description: owner 1 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: E9 ef. X 7,S = 51185 1 730 749, 76 9a ' ,Ot"S 7,0 pe.— Sump erSump pump? ® Yes ❑ No current Last date of occupancy: Date C mmercial/industrial Flow Conditions: Type of Esta ent: n 310 15.203 Design flow based o ) g ( Gallonser da d P Y(9r' ) Basis of design flow(seats/persons/sq.ft., Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste dischar o the Title 5 system? Yes ❑ No Water meter re gs, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 • Y Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 410 Summer St. Property Address Ferland Owner Owner's Name information is required for North Andover MA August 18, 2014 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) L late of occupancy/use: Date other(describe below): General Information Pumping Records: Source of information: Last pumped in 2013. On average every 2 yrs- owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: No need at this time 7a�k �., b�pum pmt° ��,�► r'cpla,�c c� Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 410 Summer St. Property Address Ferland Owner Owner's Name information is required for North Andover MA August 18, 2014 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: PP 9 Were sewage odors detected when arriving at the site? ❑ Yes ® 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: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Main line and joints are in very good condition. Septic Tank(locate on site plan): 12tDepth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) Precast round - 1000 gallons If tank is metal, is a years Is y a Certificate of Compliance?(attach a copy of certificate) o Dimensions: 5'x 6'diam- 1000 gallons 1., Sludge depth: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 410 Summer St. Property Address Ferland Owner Owner's Name information is required for North Andover MA August 18, 2014 every page. Cityrrown 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 34" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 13" Distance from bottom of scum to bottom of outlet tee or baffle 3" How were dimensions determined? sticks and tape measure Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The septic tank is in very poor condition, it is leaking at approx 14" below the cover. The liquid is leaking out 6" below the outlet invert. The tank shows a lot of deterioration at this heigth. The liquid in the tank is not running at it's correct working heigth. Gase Trap(locate on site plan): Depth belo rade: feet Material of constructs ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ of explain): Dimensions: Scum thickness Distance from top of scum to top of outl a or baffle Distance from bottom of scu ottom of outlet tee or baffle Date of last pumpin Date t5ins•3/13 / Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Tale 5 Official Inspection Form oSubsurface Sewage Disposal System stem Form Not for Voluntary Assessments MM 410 Summer St. Property Address Ferland Owner Owner's Name information is North Andover MA August 18, 2014 required`or every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Corry- is(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels lated to outlet invert, evidence of leakage, etc.): � Ti ht or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Dept elow grade: Material o onstruction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑Rher(explain): Dimensions. Capacity: gallons Design Flow: gallons per y Alarm present: ❑ s ❑ No Alarm level: larm in working order: ❑ Yes ❑ No Date of last pumping: ate Comments(condition of alarm and float itches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ s ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments w„ 410 Summer St. Property Address Ferland Owner Owner's Name information is required for North Andover MA August 18, 2014 every page. CityrFown 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 Zero / 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.): The d-box is in good general condition. The liquid in the d-box is actually low as it does not get a normal flow from the tank because it is leaking. The d-box shows no signs of having any problems. This would indicate that the leachingfieldis in good shape. -aosc LS Chamber(locate on site plan): Pumps in workin er: ❑ Y .9-V6* O Alarms in working order: Yes ❑ No* Comments (note condition of pump chamber, c 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): 4 If SAS not located, explain why: Ilk/ JD-Aok t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments w 410 Summer St. Property Address Ferland Owner Owner's Name information is required for North Andover MA August 18, 2014 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: f ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 20'x 40' ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The SAS was located from d-box to level area of.yard. There are no signs of ponding or breakout in the yard to be noted The yard is covered with well maintained green grass. C ools (cesspool must be pumped as part of inspection) (locate on site plan): Number an figuration V Depth—top of liquid to I t invert Depth of solids layer Depth of scum layer I Dimensions of cesspool Materials of con ction Indic i of groundwater inflow ❑ Ye ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 410 Summer St. Property Address Ferland Owner Owner's Name information is required for North Andover MA August 18, 2014 every page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Commen note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t Priv (locate on site plan): Materials of co uction: O Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic e, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 r Commonwealth of Massachusetts L Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 410 Summer St. Property Address Ferland A Owner Owner's Name information is North Andover MA August 18, 2014 required for 9 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal Syst m: Provide a view of the sewage disposal system, including ties to at least two perma ent reference andmarks or benchmarks. Locate all wells within 100 feet. Locate where public water upply enters he building. Check one of the boxes below: ® hand-sketch in he area belo ❑ drawing attach,1 d separately �rGh�OC `L A � �i-!d Sccmm�l s�, 3 o � I D D-@ox �te„td 13 A0 l� /�A�T Fox = !l'/r/" (2 ion t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts w r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 410 Summer St. Property Address Ferland Owner Owner's Name information is North Andover MA August 18, 2014 required for every pzge. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope , &(/iP�/ v 9'r[c ® Surface water / J ne ® Check cellar 9cav%p 10(A" P ® Shallow wells AJ®VNe- Estimated depth 9 9 feet th to high round water: feet 4' 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: Pumping records only ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: The basement is 4' below grade with a sump pump in it. There was no other information available. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ;M r� 410 Summer St. Property Address Ferland Owner Owners Name information is required for North Andover MA August 18, 2014 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 RECEDED Commonwealth of Massachusetts S ' 3 2413 J WOVER City/Town of �(,� ��� TQWN OF NQRTH AfME'gf HEALTH DEPARTMENT System Pumping Record Facility Information: System Location: ` I'D &� Address K)-g-4,k. City/Town State Zip Code System Owner: wapd Name: Adress (if different from location of pump) City/Town State Zip Code Telephone Number Pumping Record Date of Pumping A ,%l _� Quantity Pumped gallons Type of System Septic Tank Grease Trap Other (what) System Pumped by: 1 �Q Company: ROOTER-MAN 46 Portland Street Lawrence, MA 01843 Location where content w e osed: 6r Signature of Hauler J Date s � Of NORT` 6792�y 3:�•" . .,'.roc Town of North Andover •�,,,,,.: HEALTH DEPARTMENT .Is�CHU CHECK#: Nrlin 17 , DATE: 1,A) L/'Ql'h -q LOCATION: H/O NAME: CONTRACTOR NAME: Tyne of Permit or License:(Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dum ster P $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ TrashlSolid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ I Title 5 Report $� ❑ Other. (Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer Jr _ - O Oi•: + � O' Town of North Andover HEALTH DEPARTMENT ,SSACNUSt4 , CHECK#: DATE: LOCATION: _ H/O NAME: _ s CONTRACTOR NAME: Tape of Permit or License: (Check box) 0 Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ Fr f ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ Title 5 Report $ ❑ Other:(Indicate) $ Health Agent Initials. White-Applicant Yellow-Health Pink-Treasurer •y-5� IrED_-4 . cop, PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 6/4/2015 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Complete Repair of Tank By: Robert Daigle At: 410 Summer Street Map 107.A Lot 0080 _North Andover, MA 01845 Th,& Issualice of tlf s c �ficate shall nt be construed as a guarantee that the system will function satisfactorily. 1 IC-L,., '. . / Michele Grant Public Health Agen 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com a J f �$ATEll P. , North Andover Health Department (ommunity and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 410 Summer St. MAP: 107.A LOT: 0080 INSTALLER: Robert Daigle DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: 6/4/15 DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan X Existing septic tank properly aband eno d (6/1/15) ❑ 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 X Bottom of tank hole has 6" stone base X Weep hole plugged X 1500 gallon tank has been installed H-10 loading X Monolithic tank construction X Water tightness of tank has been achieved by visual testing X Inlet tee installed, centered under access port s y� X Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port X Hydraulic cement around inlet & outlet Comments: Not ready on 5/29/15, no tank or stone yet, will call on Monday 6/1. 6/1/15 —water in the hold, will pump first, home is vacant PUMP CHAMBER Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: 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 ❑ H-20 D-Box ❑ Inlet tee (if pumped or >0.08'/foot) ❑ Hydraulic cement around inlet & outlets ❑ Observed even distribution ❑ Speed levelers provided (not required) ❑ Schedule 40 PVC Pipe Comments: OE MORTry,�M I 2 • O F L Town of North Andover � '••.,..°:.' HEALTH DEPARTMENT ,SSACMUStS CHECK#: DATE: '50 LOCATION: H/0 NAME: CONTRACTOR NAME: L/ Type of Permit or License:(Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ Septic Disposal Works Construction(DWC) $ Septic Disposal Works Installers(DWI) $ eP p ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other:(Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer ,1 ---'—'l - Map-Block-Lot . �. Commonwealth of Massachusetts 107.A0080 " - BOARD OF HEALTH � Permit No BHP-2015-0233 North Andover f EEE $125:00 --- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Robert-Daigle---- --------------------------- ---- ------- ------- -- -- to(Upgrade)an Individual Sewage Disposal System. at No 410 SUMMER STREET------------- ---- ----------------------------------- - as shown on the application for Disposal Works Construction Permit No. BHP-2 2-3 ated May 28,2015 FILE -- COPS ------- -------- ---- Issued On:May-28-2015 BOARD OF HEALTH •¢ w��,, Application for Septic Disposal System J • TODAY'S ATE • Construction Permit - TOWN OF $ 250.00- Full Repair NORTH ANDOVER, MA 01845 $125.00 -Component Important: Application is hereby made for a permit to: When filling out ❑Construct a new on-site sewage disposal system* forms on the computer, use epair or replace an existing on-site sewage disposal system Z- Repair *� only the tab key or replace an existing system component—What? 4nd to move your cursor-do not use the return A. Facility Information key. y` Address or Lot# +� RECENED ityrrown MAY 2 8 2015 2,*TYPE OF SEPft6 SYSTEM*: ➢ ❑ Pump ravity(choose one) TOWN OF NORTH ANDOVER ***If pump system, attach copy of electrical permit to application*** HEALTH DEPARTMENT ➢ ❑ 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) What is the Make? What is the Model. 2. Owner Information Na e Address(if different from above) City/Town State Zip Code Email address Telephone Number 3. Installer Information. Name V Kame of Company .. . /// � Address C�ff � City/Town State Zip Code 57e -K 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 Svstem 1( TODA 'S DA E ., Construction Permit - TOWN OF NORTH ANDOVER, MA 01845 25.00 -Component PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: Residential 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. I understand that until a final Certificate of Compliance has been issued by this Board of Hea , the i tal d system is not a77 .. ro L N me Date Application Approved By: (Board of Health Representative) Name Date Application Disapproved for the following reasons: For Office Use Only: L Fee Attached.? Yes No 2. Project Manager Obligation Form Attached. Yes No 3. Pump Svstem? If so,Attach coQv of Electrical Permit Yes No Applicant received copy of "Electrical Inspection Notes for Septic Systems" Yes No Handout. 4. Reviewed approval letter, all paperwork received. Yes No Mrssing.• 5. Foundation As-Built?(new construction only): Yes_ No (Same scale as approved plan) 6. Floor Plans?(new construction only): Yes No Application for Disposal System Construction Permit•Page 2 of 2 f� SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: -e <),-tim /g Laszlo (Address of septic system) For plans by a&V1 9 , szlo C- (Engineer) Relative to the application of /(Engineer) (Installer's nam /� 6 And dated 1 rigina ate Dated �6 o av 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 and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner, contractor,project manager, or any other person not associated with my company schedules an inspection and the system is not ready,then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection,without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a$50.00 fine being levied against me and/or my 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 inspection but does not have to be present. b. Final Construction Inspection—Engineer must first do their inspection for elevations,ties, etc. As-built of verbal OK (or e-mail to: healthdel2t@townofnorthandover.com) from the engineer must be submitted to the Board of Health, after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system, all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade—Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other 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 eneral contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: 1 (Today's Date) S (Name— Print) acne—Signe