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HomeMy WebLinkAboutMiscellaneous - 412 FOSTER STREET 4/30/2018 (2) S l� .____. _ _ .. ._ ... - f Address Title of File Page of Date File Open: Date file closed: Doc Document/Action Title Date of Refer to other Purpose of Document/Action and notes action Document/ document/ filum• Action Department Board of Appeals — Board of Health — Planning Board — Conservation Commission — Building_Department y r. GREATER LAWRENCE SANITARY DISTRICT CHARLES STREET, NORTH ANDOVER, MASS. 01845 TRUCKED WASTEWATER DISCHARGE SLIP (.moi 1 thlSlip No. e ,2 K TOWN Company Name: .T a ..� .q .� r. ' '.�� fl Date: Hauler's Name: Address: r v , 0 o ► Telephone: P '&/- 7 YY- , j � g SOURCE #1 Date Pumped: 9-0? Name: Tank Size: �t Address: Q 091e X r MA's r Telephone: Signature: SOURCE #2 Date Pumped: Name: � U� ?L6-1,d Tank Size: 1 0 Address: All) IC 7e A. 3 1� Telephone: X00, Signature: SOURCE #3 Date Pumped: Name: Tank Size: Address: Telephone: Signature: To the best of my knowledge the above information is true and correct. Hauler's Signature Tank Ri7P' J� � r TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) Q DATE OF PUMPING: "` J'" ° QUANTITY PUMPED /,.4� O 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: A " t+ ' � 10 COMMENTS: CONTENTS TRANSFERRED TO: , COMMONATALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPART'MENT OF ENVIRONMENTAL PROTECTION ONE LINTER STREET. BOSTON. I►tA 02108 FI.•.9?•SS00 WILLIAM f 11'ELD TRL-DY COX Stcre Governor ut ARGEO PAUL CELLUCCI DA%1D B STRUF Ll.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commission. PART A CERTIFICATION hoperty Address:ill 2_ {�- � A.)G'9� A-"�,vt"'*'ddress of Owner: bale of Inspection: 8 20 /���- $ (If different) Name of Inspector: L,! l 4YiN� L� I am a DEP a ov system inspecto pursuant to Section 15.340 of Title S (310 CMR 15.000) Company Name: Mailing Address: - © 2- Telephone Number: -rte-- O o 7 Ca 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 (unacon and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionalk Passes _ Needs Further E%aluatton 8% the Local Approving Authority _ Fads Inspector's Signat Date: The S%,stem Inspector shall submit a copy of this ins report to the Approving Authority within thirty (301 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 own, and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: Al SYSTEM PASSES: I have not found any informatfoh 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: Al SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass' section need to be replaced or repaired. The system, up completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or NO). Describe bail$ 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 inspect6r with a copy of a Certificate of Compliance lattached) indicating that the tank was installed within twenty(201 years prior to the date of the inspection; the septic tank, whether or not metal, is cracked. structurally unsound, shows substmlial-Infiltration_or,exfiltration,.or tat failure is imminent. the system will pass inspection If the existing septic tank is reel' ��rith a catfo�m ng iseptibltank as approved by the Board of Health. • 7 23I tea•l..� o�/!!/f11 tate 1 et Ill e DEP an"Wald YAft WOW t'+Mp'IAVW r,napnat Stitt nu.ualtlap f> pr,Med^ Recip Pana► J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFI TION (continued) Property Address: Owner: Date of Inspection: u) SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static wat r level observed in the distribution box is due to broken or obstructed Pipets) or due to a broken, settled or uneven istribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipets) are replac obstruction is removed distribution box is levelled or replaced The system required pumping more than fou times a year due to broken nr obstructed pipe(s). The system will pass inspection if(with approval of the Board of ealth): broken pipels) are replac obstruction is removed C1 PURTHER EVALUATION IS REQUIRED BY THE BOARD F HEALTH: Conditions exist which require further evaluation by t e 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 ETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AN SAFETY AND THE ENVIRONMENT: Cess000l or privy is within So feet of a surf ce water ool or privy is within 50 feet of a bor errng vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEAL H (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER T T PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil abso tion 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 abso tion system and the SAS is within a Zone I of a public water supn'v well. _ The system has a septic tank and soil abso tion system and the SAS is within So feet of a private water supply well. _ The system has a septic tank and soil abso ption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well w ter analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that Is ility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than S ppm. Method used to determi a distance (approximation not valid). 3) OTHER 1 i L' (revised 04/25/97) page ! ei to 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1 7'6 /J,6�� ", \ � Owner: Date of Inspection: ��—1-04//I— D) SYSTEM FAILS: Zia You must indicate either "Yes" or "No' as to each of the following: I have determined that. he system violates one or more of the following failure criteria as defined in 31 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine w will be necessary to correct the failure. Yes No _ Backup.of sewage in facility or system component due to an overloaded or clogged or cesspool. Discharge or ponding o effluent to the surface of the ground or surface waters due an overloaded or dogged SAS or cesspool. Stant liquid level in the dist bution boa above outlet invert due to an.overload or clogged SAS or cesspool. Liquid depth in cesspool is lest han 6" below invert or available volume is I ss than 1/2 day flow Required pumping more than 4 ti es in the last year NOT due to clogg or obstructed pipe(s). Number of times pumped Any porton of the Soil Absorption Svst m, cesspool or privy is below the high groundwater elevation Anv porton of a cesspool or privy is wrthi 100 feet of a surface ter supply or tributary to a surface water supply. Any porton of a cesspool or privy is within a Zone I of a publi well. Any portion of a cesspool or privy is within 50 t of a priv a water supply well. Anv porton of a cesspool or privy is less than 100 t b greater than 50 feet from a private water supply well wrlh no acceptable Nater quality analysis. if the well has alyzed to be acceptable. attach copy of well water analysis for coltiorm bacteria, volatile organic compounds, ammo . nitrogen and nitrate nitrogen. E) URGE SYSTEM FAILS: You must indicate either "Yes' or "No" as to each of the following: The following criteria apply to large systems in addition the criteria ve: The system serves a facility with a design flow of 10, gpd or greater (L rge System) and the system is a significant threat to public health and safety and the tnviroament becau one or more of the f lowing conditions exist: Yes No the system is within 400 feet of a su drinking water supply the system is within 200 feet of a ibutary to a surface drinking water supp the system is located in a nitr sensitive area (Interim Wellhead Proteclion real-IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system sh I bring the system and facility into full compliance wit the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. P ease consult the local regional office of the Department f further information. treri�eA Oe/3s/f71 Mate 3 e! 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , PART 8 CHECKLIST Property Address: �� p���� /Aj Owner: /'�pc N t' f /ti Date of Inspection: Q Check if the following have been done: You must indicate either "Yes" or'No" as to each of►h. following: Yew No _✓ _ 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 pan of this inspection _ As built plans have been obtained and examined. Note if they are not available with N/A. ✓ _ The factlih• or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. The site %.as inspected for signs of breakout. All s%stem 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 construmon, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the 5otl Absorption System on the site has been determined based on: The faciliry owner Land occupants, if different from owner were provided with information on the proper maintenance of / Sub-Surface Disposal System. v Existine information. Ex. Plan at 8.0.H. Determined in the field tit anv of the failure criteria related to Part C is at issue, approximation of distance is unacceptable; I15.302(3)(b)] (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Propertv Address: Lf Z Po 5Tt� Owner- Date of Inspection: -2-6 RESIDENTIAL: FLOW CONDITIONS Design flow -' Qp.d./bedroom for S.A.5. Number of bedrooms: —41 Number of current residents: Garbage grijoer (yes or not: Laundry cor•nected to system Seasonal or no): Seasonal use Lyes or no): IV Water meter readings. if available (last two (2) year usage (gpd): /A Sump Pump Ives or no): Last date of occupants• C°Jv.V(lrlC'�-T COMMERCI AL/INDUSTRIAL: Type of establishment: Design flow-_ tallonsrdav Grease trap present: Ives or not_ Industrial Waste Holding Tank present: eves or no(_ hon-san(tan waste discnarged to the Title 5 system (yes or no)_ Water meter readings, if available Last date of oCcupanc- OTHER: (Describe Last date of occuoancv GENERAL INFORMATION PUMPING R ORDS and source f io grip !/".tom S�-stem pumped as pan of inS ton: lyes 6r no) If yes, volume pumped: gallons Reason for pumping TYPiE�F SYSTEM Septic tank/distribution box/soil absorriinn system Single cesspool Overflow cesspool Privy _f Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: er-, Of Sewage odors detected when arriving at the site: (yes or no) (sa.laod 04/25/97) Pat* 5 o! 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 7l L /1J6eCF-e, Owner: `���-�/N Date of Inspection: 26- g c BUILDING SEWER: (Locate on she plan) Depth below grade- material of construction: _cast iron'_40 PVC_other (explain) Distance from private water supply well or suction lir. Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: V (locate on site plant Al Depth below grade:!%)` C3 Material of construaion:0�concrete _metal _Fiberglass _Polyethylene _otherlexplain) If tank is metal. Inst age _ Is age confirmed by Cenificate of Compliance _NesiNol Dimensions: `h x ir,'6 Sludge depth- Dislance from top of sludge to bottom of outlet tee or baffle: 3 Z Scum thickness:_ Distance from top of scum to top of outlet tee or baffle 1110 1 Distance from bottom of scum to bottom of outlet tee or balite:: How dimensions were determined: Comments: (recommendation for pumping, condition of and outlet tees or baffles, depth of liqui level in relation to utlet invejtstructural integrity, evidence of leakage, etc.) / CeS '�" L / (.(n 11A Q pi 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.) (revised 04/75/97) Page 6 e! 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 2- Ak 441 A: ,)Gvt i,- -- Owner: Date of Inspection: g TIGHT OR HOLDING TANK: Tank must be pumped prior to, or 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/da% 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 amen: Comments: (note ir level-and distribution is equal. evidence of solids carryover, evidence of leakage into or out of b9x, etc.) PUMP CHAMBER:_ (locate on cite plan) Pumps in working order. (Yes or Not Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (swteed 02/23/971 Pogo 7 el 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continueO Property Address: �(Z Fu, ,TtK— Owner: N Date of Inspection: 6 ^ZOO Q SOIL ABSORPTION SYSTEM (SAS):1� 6 (locate on site plan, 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 leaching trenches, number,length- leaching fields, number, dimensions. / aa X vs overflow cesspool, number- Alternative umberAlternative system: Name of Technology: Comments: (note conditionp(s if, signs of hvdraulic failure, level of ponding, co dition of vegetation, etc.) a� - 6/\- CESSPOOLS: _ (locate on site plant Number and configuration Deoth-top of liouid to inlet invert. Deoth of solids laver: Depth of scum laver- Dimensions averDimensions of cesspool Materials of construction: Indication of groundwater- inflow roundwaterinflow (cesspool must be pumped as pan of inspection) 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.) (revised 04/2!/971 Page a of 10 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: IV6,cr( Owner: Date of Inspection: A.; 141^' —20 -- '7 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100• (Locate where public water supply comes into house) �D 1--ldx — 3 � � e % vs 2d J �"� (saVsaae 04/75/97) sage 9 of to SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (contin�/J ' Property Address: j 2 r--c,5 `e, /tJ6� /V'•ti ��---_ Owner: Date of Inspection: Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA maps Check pumping records Check local excavators. installers Use USGS Data Describe in vour own words how you established the High Groundwater Elevation. (Must be completed) Va- J,.—), d' d-X (revised 04/25/971 Hate 10 of 16