HomeMy WebLinkAboutMiscellaneous - 42 LACY STREET 4/30/2018 _ 42 LACY STREET _
210/105.D-0051-0000.0
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North Andover Board of Assessors Public Access Page 1 of 1
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NORTH I��rfh An lover Board of Assess®rs
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�^r.0�tr'Sg9 Sroperty
CMuge Record Card
Parcel ID :210/105.D-0051-0000.0 FY:2012 Community:North Andover
SKETCH
Click on Sketch to Enlarge Click on Photo to Enlarge
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42 LACY STREET
Location: 42 LACY STREET
Owner Name: WENTREMONT,PATRICK&KELLY
Owner Address: 42 LACY STREET
City: NORTH ANDOVER State: MA Zip: 01845
Neighborhood:6-6 Land Area: 1.06 acres
Use Code: 1.01-SNGL-FAM-RES Total Finished Area: 1964 sqft
Total Value: 410,500 410,500
Building Value: 203,100 203,100
Land Value: 207,400 207,400
Market Land Value: 207,400
Chapter Land Value:
LATESTSALE
Sale Price: 540,000 Sale Date: 08/27/2004
Arms Length Sale Code: Y-YES-VALID Grantor: FORTIN,ROBERT
Cert Doc: Book: 9013 Page: 215
http://csc-ma.us/PROPAPP/display.do?linkld=1895205&town=NandoverPubAcc 3/29/2012
Residential Property Record Card
PARCEL ID:210/105.D-0051-0000.0 MAP:105.1) BLOCK:0051 LOT:0000.0 PARCEL ADDRESSA2 LACY STREET FY:2012
PARCEL INFORMATION Use-Code: 101 Sale Price: 540,000 Book: 9013 Road Type: T Inspect Date: 08/12/2005
Owner: Tax Class: T Sale Date: 08/27/04 Page: 215 Rd Condition: P Meas Date: 08/12/2005
D'ENTREMONT,PATRICK&KELLY Tot Fin Area: 1964 Sale Type: P Cert/Doc: Traffic: M Entrance: X
Address: Tot Land Area: 1.06 Sale Valid: Y Water: Collect Id: RB
42 LACY STREET Grantor: FORTIN,ROBERT Sewer: Inspect Reas: S
NORTH ANDOVER MA 01845 Exempt-B/L% / Resid-B/L% 100/100 Comm-B/LP/o Indust-B/L% / Open Sp-B/L% /
RESIDENCE INFORMATION LAND INFORMATION
Style: CL Tot Rooms: 7 Main Fn Area: 1054 Attic: NBHD CODE: 6 NBHD CLASS: 6 ZONE: R1 ri
Story Height: 2.00 Bedrooms: 4 Up Fn Area: 910 Bsmt Area: 910 Seg Type Code Method Sq-Ft Acres Influ-Y/N Value Class
Roof: L Full Baths: 3 Add Fn Area: Fn Bsmt Area: 1 P 101 S 43560 1.000 206,910
Ext Wall: FB Half Baths: Unfin Area: Bsmt Grade: 2 R 101 A 0 0.060 456
Masonry Trim: Ext Bath Fix: 0 Tot Fin Area: 1964 VALUATION INFORMATION
Foundation: CN Bath Qual: T RCNLD: 203077 Current Total: 410,500 Bldg: 203,100 Land: 207,400 MktLnd: 207,400
Kitch Qual: T Eff Yr Built: 1980 Mkt Adj: Prior Total: 410,500 Bldg: 203,100 Land: 207,400 MktLnd: 207,400
Heat Type: HW Ext Kitch: Year Built: 1978 Sound Value:
Fuel Type: O Grade: G Cost Bldg: 203,100
Fireplace: 1 Bsmt Gar Cap: Condition: A Aft Str Val1:
Central AC: N Bsmt Gar SF: Pct Complete: Aft Str Val2:
Aft Gar SF: 576%Good P/F/E/R: //100/82
SKETCH PHOTO
FM
12 144 Sq. 2
24 39
G FU1FN116
576 Sq.R 910 Sq.Ft
24 26
24 3S }
Parcel ID:210/105.D-0051-0000.0 as of 3/29/12 Page 1 of 1
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
42 Lacy Street
Property Address
Daniel E &Sarah P Tiber
Owner Owner's Name
information is
required for every North Andover MA 01845 5/20/2016
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
ImporttaEC i Dant:When
filling out forms A. General Information
on the computer, JUN 0 12016
use only the tab 1. Inspector:
key to move your
cursor-do not Anthony M. Campano TOWN OF NORTH ANDOVER MENT
use the return Name of Inspector HEAT TN DEPART
key. \,
y,1ra��—�� Campano Engineering &Title 5 Inspections
v
V��� Company Name
30A Elm St.
17- Company Address
Pepperell MA 01463
Cityrrown State Zip Code
978-433-2212 12780
Telephone Number License Number
B. Certification
I certify that 1 have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
a" , S a 20
ector's Signature Datef
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 Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
42 Lacy Street
Property Address
Daniel E &Sarah P Tiber
Owner Owner's Name
information is
required for every North Andover MA 01845 5/20/2016
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
�I
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
42 Lacy Street
Property Address
Daniel E &Sarah P Tiber
Owner Owner's Name
information is
required for every North Andover MA 01845 5/20/2016
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
W Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
42 Lacy Street
Property Address
Daniel E &Sarah P Tiber
Owner Owner's Name
information is
required for every North Andover MA 01845 5/20/2016
page. Cityrrown 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 42 Lacy Street
Property Address
Daniel E&Sarah P Tiber
Owner Owners Name
information is
required for every North Andover MA 01845 5/20/2016
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) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins.3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 5 of 17
1 II
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
42 Lacy Street
Property Address
Daniel E &Sarah P Tiber
Owner Owner's Name
information is
required for every North Andover MA 01845 5/20/2016
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): ? Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
t5ins•3/13 Title 5 Official Inspection Foran:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 42 Lacy Street
Property Address
Daniel E&Sarah P Tiber
Owner Owner's Name
information is
required for every North Andover MA 01845 5/20/2016
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 4
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:
WELL
Sump pump? ® Yes ❑ No
Last date of occupancy: OCCUPIED
Date
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
42 Lacy Street
Property Address
Daniel E &Sarah P Tiber
Owner Owner's Name
information is
required for every North Andover MA 01845 5/20/2016
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ 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 UA system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
42 Lacy Street
Property Address
Daniel E&Sarah P Tiber
Owner Owner's Name
information is
required for every North Andover MA 01845 5/20/2016
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:
Per owner the house was built in 1978
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.5
feet
Material of construction:
® cast iron ❑40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 37
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
No evidence of leaking, all exposed joints are in good condition.
Septic Tank(locate on site plan):
Depth below grade: 1
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
Tank liquid level was good just below the outlet invert. Both inlet and outlet baffles were in place and
composed of concrete. The oultlet baffle showed some normal deterioration.
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 7'LX5'WX5'D
Sludge depth:
2"
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 42 Lacy Street
Property Address
Daniel E &Sarah P Tiber
Owner Owner's Name
information is
required for every North Andover MA 01845 5/20/2016
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
30"
Scum thickness
2"
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
14"
How were dimensions determined?
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.):
Tank should be pumped every two years, inlet and outlet Baffle in place and composed of concrete,
tank liquid level was good in regards to the oultet invert. The oultlet baffle showed some normal
deterioration. No evidence of leakage.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
a U Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
wM 42 Lacy Street
Property Address
Daniel E &Sarah P Tiber
Owner Owner's Name
information is
required for every North Andover MA 01845 5/20/2016
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ® No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
a W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M ' 42 Lacy Street
Property Address
Daniel E &Sarah P Tiber
Owner Owner's Name
information is
required for every North Andover MA 01845 5/20/2016
page. CityrTown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-Box is level and distribution is equal, no evidence of solids carryover or leakage in or out of the
box.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
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
42 Lacy Street
Property Address
Daniel E&Sarah P Tiber
Owner Owner's Name
information is
required for every North Andover MA 01845 5/20/2016
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions: 1 app. 25'X40'
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
No sign of hydraulic failure or ponding or damp soil. The soil present during the excavation of the D-
box was course sand and gravel with 4"of top soil and mowed lawn.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
a Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
42 Lacy Street
Property Address
Daniel E &Sarah P Tiber
Owner Owner's Name
information is
required for every North Andover MA 01845 5/20/2016
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
42 Lacy St
Property Address
Daniel E&Sarah P Tiber
Owner Owner's Name
information is North Andover MA 01845 5/20/2016
required for every
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
CIL
41
C - )0 5 ,
c
= 27
sus-F�+
L
t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
42 Lacy Street
Property Address
Daniel E &Sarah P Tiber
Owner Owner's Name
information is
required for every North Andover MA 01845 5/20/2016
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: 5
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Leach field is built in front of the house with the bottom of leach field 4 feet above basement floor
elevation. The location of the high water was estimated based on the house's is location in reference
to the elevation of the pond in the back yard which is 5 feet below front yard elevation.
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
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
wM 42 Lacy Street
Property Address
Daniel E&Sarah P Tiber
Owner Owner's Name
information is
required for every North Andover MA 01845 5/20/2016
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems) completed
® 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
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Commonwealth of Massachusetts 'L
Tale 5 official Inspection For
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
42 Lacy Street
Property Address
Kelly and Patrick Dentremont
Owner Owner's Name
information is North Andover MA 01845 1-14-12
required for State Zip Code Date of inspection
every page. Cityrrown
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: A. General Information KEECEIVED
When filling out n
forms on the U 2
computer,use 1 Inspector: JAN
only the tab key
to move your Benjamin C. Os ood, Jr. NORTH
cursor-do not Name of inspector HEALTH DEPARTN ENT
use the return �
key. none
Company Name
.� q6 16 Hillside Avenue, Unit 3
Company Address
Amesbury MA 01913
State Zip Code
cityrrown
978-834-6585 870
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
[ Needs Further Evaluation by the Local Approving Authority
. e r 1-14-12
Inspector's nature Date
The system inspector shall bmit 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.
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
42 Lacy Street
Property Address
Kelly and Patrick Dentremont
Owner Owner's Name
information is North Andover MA 01845 1-14-12
required for State Zip Code Date of Inspection
every page. cityrrown
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E t always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes","no"or"not determined"(Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old"or the septic tank(whether metal or not)is
structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
° 42 Lacy Street
Property Address
Kelly and Patrick Dentremont
Owner Owner's Name
information is MA 01845 1-14-12
required for North Andover
State Zip Code Date of Inspectionevery page. CitylTown
B. Certification (cont.)
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):
Q distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
Q The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y Q N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N Q 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
Commonwealth of Massachusetts
� m
Title 5 Official Inspection Form
t Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
' 42 Lacy Street
Property Address
Kelly and Patrick Dentremont
Owner Owner's Name
information is North Andover MA 01845 1-14-12
required for City/Town state Zip Code Date of Inspection
every page.
B. Certification (cont.)
2. System will fall 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 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
El ® 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 Y2 day flow
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
42 Lacy Street
Property Address
Kelly and Patrick Dentremont
Owner Owner's Name
Information is MA 01845 1-14-12
required for North Andover
State Zip Code Date of Inspection
every page. Cityfrown
B. Certification (cont.)
Yes No
Required pumping more than 4 times in the last year NOT due to clogged or
El ® 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.
❑ [D 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
El
criteria exist as described in 310 CMR 15.303, therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ® the system is within 400 feet of a surface drinking water supply
❑ ® the system is within 200 feet of a tributary to a surface drinking water supply
❑ ® the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304.The system owner should contact the appropriate
regional office of the Department.
J
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
° 42 Lacy Street
Property Address
Kelly and Patrick Dentremont
Owner Owner's Name
information is North Andover MA 01845 1-14-12
required for State Zip Code Date of inspection
every page. Cityrrown
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?
El ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as NIA)
® ❑ 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?
M ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example,a plan at the Board of Health.
® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): NIA Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
42 Lacy Street
Property Address
Kelly and Patrick Dentremont
Owner Owners Name
information is MA 01845 1-14-12
required for North Andover
/Town State Zip Code Date of Inspection
C
every page. ity
D. System Information
Description:
5
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)): well
Detail:
Sump pump? ® Yes ❑ No
current
Last date of occupancy: Date
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Commonwealth of Massachusetts
Title 5 Official Inspection Form
ystem Pone-Not for Voluntary Assessments
Subsurface Sewage Disposal S
42 Lacy Street
Property Address
Kelly and Patrick Dentremont
Owner Owner's Name
information is North Andover MA 01845 1-14-12
required for State Zip Code Date of Inspection
every page. cityrrown
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Pumped summer 2011
Source of information: -
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ 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):
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
42 Lacy Street
Property Address
Kelly and Patrick Dentremont
Owner owner's Name
information is North Andover MA 01845 1-14-12
required for State Zip Code Date of inspection
every page. city/rown
D. System Information (cont.)
Approximate age of all components,date installed (if known)and source of information:
33 years old per as built
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
1.5'
Depth below grade: feet
Material of construction:
®cast iron ❑40 PVC ❑other(explain):
N/A
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Pipe looks good in basement
Septic Tank(locate on site plan):
1'
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
1000 gallons
Dimensions:
2"
Sludge depth:
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
42 Lacy Street
Property Address
Kelly and Patrick Dentremont
Owner Owner's Name
information is MA 01845 1-14-12
required for North Andover state Zip Code Date of Inspection
every page. cityrrown
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
30"
2"
Scum thickness
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle 14"
measure tape
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.):
Tank in good condition Cross baffle intact Recommend installation of sch 40 pvc outlet tee
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Commonwealth of Massachusetts
Title 5 official Inspection Form
s Subsurface Sewage Disposal System Foran-Not for Voluntary Assessments
42 Lacy Street
Property Address
Kelly and Patrick Dentremont
Owner Owner's Name
information is North Andover MA 01845 1-14-12
required for state Zip Code Date of Inspection
every page. Ckyrrown
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage,etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). is copy attached? ❑ Yes ❑ No
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal system Form-Not for Voluntary Assessments
42 Lacy Street
Property Address
Kelly and Patrick Dentremont
Owner owner's Name
information is North Andover MA 01845 1-14-12
required for gtate Zap Code Date of Inspection
every page. c4frown —
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
a°
Depth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any
evidence of leakage into or out of box, etc.):
Distribution box in OK condition. Distribution normal. No evidence of leakage in or out. No solids
carryover.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
Commonwealth of Massachusetts
Tithe 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
42 Lacy Street
Property Address
Kell and Patrick Dentremont
Owner Owner's Name
information is MA 01845 1-14-12
required for North Andover state zip code Date of Inspection
every page. cityrrown
D. System Information (cont.)
Type:
❑ leaching pits number.
❑ leaching chambers number.
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions:
1 20'x 45'
❑ 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.):
Area of trench is grass and looks normal No evidence of ponding, damp soil, or unusual vegetation
Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
42 Lacy Street
Property Address
Kelly and Patrick Dentremont
Owner Owner's Name
information is North Andover MA 01845 1-14-12
required for North A state Zip Code Date of inspection
every page. cityfrown
D. System information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Commonwealth of Massachusetts
Tithe 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
42 LacyStreet
Property Address
Kelly and Patrick Dentremont
Owner Owner's Name
information is North Andover MA 01845 1-14-12
required for State Zip Code Date of Inspection
every page. Cityr town
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate
all wells
within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
A* y7i 51`FI Nr i. <
f�.o6�L
21
2 &A 146
31
2-
'T'AN ik
ov
Commonwealth of Massachusetts
<L
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
42 Lacy Street
Property Address
Kelly and Patrick Dentremont
Owner Owner's Name
information is MA 01845 1-14-12
required for North Andover State Zip code Date of Inspection
every page. cityrrown
D. System information (cont.)
Site Exam:
Check Slope
® Surface water
® Check cellar
® Shallow wells
5
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
System built in front of house with bottom of leach field 4 feet above basement floor elevation.Water
table in glacial outwash area where this house is located is dictated by the elevation of the pond in
the back yard which is 5 feet below front yard elevation.
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
42 Lacy Street
Property Address
Kelly and Patrick Dentremont
Owner Owner's Name
information is DgY!Town North Andover MA 01845 1-14-12
every page.
required for _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
92 LACY STREET �Complaint Detail MLE
I05.D-0051
Report
Printed On: Wed Mar 01,2006
Complaint#: CT-2006-000027 Status: QClosed GIS#: 6528 Violator:
f µpRTM , Address: 42 LACY STREET Map: 105.13 Address:
C= t..•o .•�• OCL - —
Date Recvd.: Feb-28-2006 Time Recvd.• 12:12 PM Block: 0051 ,
Category: Housing Lot: Type:
•�a GeoTMS Module: Board of Health District: Trade:
�t ti••..a•viae Recorded By: Pamela DelleChiaie Zoning: Structure:
SSAGNUSt ------ - - -- - ---- --------
Description
Complaint: Michele Grant took a call from Paula Kolar on 2/27/06 a tenant at this address. Property is owned by Homenet,617.489.7090.
There is an area of*u6peercfa3(ceiling?) 3'x3'section looks +eld. Had a company come into check the basement at renters request. Basement seems dry_
- --
Comm 611
Callers
Date Time Name Phone Best Time To Reach Recorded By Response
Feb-28-2006 12:12 PM Paula Kolar (978)686-5403 Q Pamela DelleChiaie
Actions Taken
GeoTMS Module Status Date Time Response Type Action Taken Comments
Board of Health REFERRAL Feb-28-2006 10:30 AM Follow-Up by Health 2/28/06-Ms.Grant spoke to Vicki;
Inspector 67.489.7091 or 617.489.7090;at the
property management company. Th old
any oun nothing significant. Case
closed
GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Page 1 of 1
NORTH ANDOVER HEALTH DEPARTMENT
27 Charles Street • North Andover, MA 01845
Tel. 978 688-9540 • Fax: 978 688-9542
email: healthdept@townofnorthandover.com
Complaint Investigation/Inspection Report
OWNER j `- G�
ADDRESS '
DATE C;2' 02
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Paw "j IaA 9 7Y- &a n;:g e)
44 4
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MAR-2-2006 14:41 FROM:HDMENET INTERNATION 10617) 4697091 TO:19786889542 P.1
Facsimile Cover Sheet
To: /'1'l�c�t,�ile
RECE -D
Company: /u• /%d , d,_ l-ka
MAR 0 3 2006
FAX: 90g-- 6:?P— �,6Y42_,
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
From: HomeNet International,Inc.
Phone: (617)489-7090
FAX: (617)489-7091.
E-Mail: Homenet(a),homenetinternational.com
Date: 31 a/0�
Number of Pages: ((
Comments:
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MAR-2-2006 14:43 FROM:HOMENET INTERNATION 10617) 4897091 TO:19786889542 P.6
DEC-17-2605 05:06 AM r'101
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MSPECTION SERVICES OF AMERICA 1148
MOLD REMEDIATION SERVICES
159 MAIN STREET
WILMINGTON MA 01887.2004
(978)4584761 2.877.655.4762
ppprD� Tp Pr10Ne DATE
afary J08NAME
Cmr.erA%end RP awe .lox LWATitTrl
ev
AMMMECT DATE OP PLANE JOB PHONY
419M 1- 1 1
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We hereby submit speoMonfam end softow for.
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W8PfOPOW hereby to furnish material and labor--compie a in accordance with above specifications,for the sum of:
AWA1 � ��drl APOV!J CJ060 dollars($; "AQ 0•&2V-
Payment To be moxa
MI meteAd a WaanNstl se faff&iww-
to be w spedted AN wo,*to be aornpleted In a NoftMennca
menriar ecmidlrp to aq 84WO PNtress.Any dbnSM or OWWW Qom above rpaetAntronA A Atlttl0dtld
Are
Mr*h+bg extra coats WIN be aracutad only upon WAWA*Mara,Ung*M aeooma on aelra
charge Par and Move the suftata. A/aptowneran wnlinpenl upon stdkea,aea►deMs or ap fo.Thfe o ai ba ,L/
delays beyond cur eonlmi.owner to carry ow tornado and ottw necanery hum-rance.Our p► P� 1T1ay r
wedred ere Arty covered by W&"aws Caeroansalbn mamnes. withdrawn by us ft not accepted wiUtm d W,
Adceptanee of Proposal -The above pdws,wumkath.
and tbndlNone ale aattetactory and en harsby accepted.YOU are authorlted to do the Signature
Wit as soecffied.Paymer><will ht!made as oWrred above.
Date of Awsptance: swan
To Aporder
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MAR-2-2006 14:43 FROM:HOMENET INTERNATION 10617) 4897091 T0:19786BB9542 P.5
' i3135 AEC M. 2085
FR: ALICIA COW2 #1&9% p=° `vl
p�O-LAD!$8P'�'M INC. Mold Analysis Report
NQit•1MA®LS Spore Tftp Us
1975 NoMh Cotnmonos P8*1 ey N,.Mb earhae e"SOP Ilia
Wanton,FWda 33326 Report Numbein 121905-0198
ToN Free:800.427-0650 aggej"WDbtor 12118/2004
ft"Ort paw 12/15/1005
41L Laa4 tit.Ir.Andover.MA .! ___}
Suenl Pawadl,QA Mineglr
MAN
DEBRIS:L04T
lnspe von 5erAm of ArneliCa
159 Matin Street
WNmlogtorR MA 01887
I•tealtett (978)658.9762
Pam; (978)648-3313
sat
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ipiettota'r Mold Caettl�oelel 1101240- "Pea
v"A:am ar WW4 4 aha Wheift In V&t"ete U"It bas alar peeswaaa of ehwaeed Ttir/WW WAid ammo or 4mlord s tar
these sord4e 1,060"9 oft.p"Obedenal adnler win be asemwry to determft the 61)p"e0118%adlo"a to take to Correct
aha Wide"tntllalte6. Indoor mold!pores or toton(et Ib►the aprcpiC
(f NOI The prnpte!In this Mort
do not Indraee the prs0eraa dsisvatrQ
ietattons arrhr.
K vicor+ove .tie tarrrpM U6 MOVOrac4ealC0.
TNe ntak)IdaIRIAed M thea report Is albrh aa0aeaaeed wlttr.excess molesMe and Gore be
W. to taw oP
it
high tevals.91n0a meld raqulrN aaatrr 10�faw,n u<IffWORWnt to D
mold,water damp ar enemy ada l should be addressed Irnntodlatidy in all IrdeatKra,int►odurwol of water murk be
sf wpod and Do sio n or water damp dstrrmalnrd.Meld can Grow On VIMONy any Orp Me aurfate,as Wv as rnobture
W"tloRVA aha SIM&"M WA 'ecOVOW M aieatrra11ONt M a ah ba --E--11 N -IraM,Mod III W" wsl
~tiam,OMUW"M the moiabrre probidn remNma YnMaeovarad or amadersaad,aldldlnD mat &N.suer as drywall
arra it to-INA-0 WA m mow WwRobaet,00r1s a =zkt s tar nmld WMth.dfwt teak Moldure probie"rmW
Indude reef teats,plumbin4 Teaks,landscaping or gumers that direct webs'No or under the buT(ding,and unwermw
combustion apOGancas OWN as We sterna WaW dwOrd bVI&V matwlaia aupporting mold growth shadd be dared
or mpbced a q WMV mo ttanl6(o In artier ee ensure a#*my envnvmnent,SOCOM mtrWMW arar wAm and
rtlheditllilna m01d wntarrMnettan should be bared OA%%#natant of wWW a mntwidubw abd the ousts at d 9a-
The eaaal.4aemnrn 4"Ohrna at"WN"Possum are runmr memo,aye Irdill"n.aeu0h,a���a�Q of
asthma.N%ftk%O rs two peofft d hop"prosMrrra that eppm hike r4 wed�ntokr o► a&
a.ntltrnMant exparune eWd 00■Mor Ohyrklarla far a mkrrd to OnOWdast0ls who are tral"ad in
mor+raala0 spaWlrat A+td era louordedsaebla about tftaea WOOf errAaiuraar.
Shm d Is Nbr011y piamt��Oor emkow4ft sed we Nro tl s f�Mta biiwMdn t IttOoora aha Ci on.
oubdawa,.b k Im�Osltbla tti elgniMbl ellt mtM4 amA tiatlr tiporra ham 1M'►a lndasor.rr�feernsaat.
The deb MA Ilmtt of N"1110"91!10"M optltat mkrpeMy M one(urtGal spore of one fungal at►uelura,The
4utntlErtYn1 ft"thry ftw&WON tv ml*w#"tram praaa vakif PttavWM tr prasoesrlrrp procedure.Conant us
to d inererne your Warman"Raft. a>r AT 1�■9„ti7'.051i0 !Nd Of REPORT
POR fool_IIIIPOIIMIA710M,PLEAS!CALL PR04 AA
alae attutrnit�lorrrMlNemnsasaeaisNad bt 4llaia.Aald4PrAa be.am I m EPA•A 01M 0lslda IRIlteld,MtatlOua,and your ttlald awd tltr NYC Deg d"sW*
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1110 drsalrrtsnf b net,Iron arasroa and 110611 be used far MPO w"ll Ourpsrr a*.*ww*tlwr Pis no hsderw rsr.tadens for.uluadna ashartlr
he.at.lMaM dMt�l aorstr,ale.ilen and r.naadt see rsm m Peden at w,6Mwim d=IP 0 nraa lMtrntMb►rs q sa0nrrrt+tor s�ns0 m
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and rarertmor.go=m pnrleaam d no amrlpb aneap
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PROOII fN inc.MkN M a0fae0 mor kVOW wrnnNW mor la harsh of pmprr9►Mon crab b aMnlll/a sans b lhb.liurTr.p far snstpris.Tlas t�I.AI
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aam 3
MAR-2-2006 14:42 FROM:HOMENET INTERNATION 10617) 4897091 TO:19786889542 P.4
Ltl:-1 r-2000 104:1 ► NPI r--WO
° 13:34 DEC iS. 2003 FR= FLICIA GOMEZ 4?W50 PAGE' 314
PRO-LABISSPTM INC. Mold Analysis Report
1675 North Commeme ftrkwAy NON VIAM E SPM Trap M3
Moon,Florida 33326 Amswo Mea+ad Sam aoP slip
Toll Free;ADO-477-0650 Report Number. 121309.912b
Reoe4V4d bates 12/15/1005
DIAAMMM
42 Lacy St.,N.Andover,MA ROCK bete: 12/iS/2005
Saab h"
Suaw Psrpol,QA Nanager
Camments:
inspection SeMee9 of Arner(m OEMS-LIGHT
159 Main Street
Wftington, IMA 03887
Phoney (976)638-9763
tau: (970)6SB-3323
0sneli:
the following fungal dewAptlons are pertinent to samples collected.General CRamctal:adon of mold Is made with respect to
their most common impact to human health,Many genera of maids have aoades with varying characterlsUts.
spwu Name Desaemp"011
CLADOSPORIUM COMMONLY FOUND ON DEAD PLANTS,WOODY PLANTS,FOOD,STRAW,SOIL,PAINT
AND TEXTILES.COMMON CAUSE Of EXTRINSIC ASTHMA(IMMEDIATE•tYPE
HYPERSENSITIVITY:TYPE I).ACUTE SYMPTOMS INCLUDE EDEMA AND
Y AL1Y
PENICn.UUM/ASPERGILLUS THIS GROUP OF SPORES IS CONSIDERED COMMON TO INDOOR ENVIRONMENTS,
COMMONLY FAUNA 1N SOIL,FOOD,CELLULOSE,AND AM CONWOEA1:D A COMMON
CONTAMINANT OF FOOD.IT tS ALSO FOUND IN PAINT AND COMPOST PILES.IT MAY
CAUSE HYPMSENsmvrtY PNEUMONITIS AND ALLERGIC ALVE0UTt5 IN
SUK4"MW 11111TAM".CE3tAMON t MM OF rA FT41MSIC IASNYMA
(IMMEDIATE-TYPE HVPERSENSCTnRTY:TYPE i),ACUTE SYMPTOMS INCLUDE EDEMA
AND BRONCHIOWASMS:CHRONIC CASES MAY OEVELOP PULMONARY EMPHYSEMA.
MANY SPECIES PRODUCE MYCOTOXINS,WHICH MAY BE ASSOCIATED WITH
OISEASE IN HUMANS AND OTHER ANIMALS,TOXIC PRODUCr?0N IS DEPENDENT ON
TKE SPkQ§S nil A STM1I WLTNLK A St'KIES AH,OR-4%F=40 MCI VQR.TM
PftHOMYCPS GAOWS ON DEM GIASS AND PLANTS,PAOLONGCD EXPDSUAE CAN CAUSE Fk=
GL (HAYFEVER
Page:2
MAR-2-2006 14:41 FROM:HOMENET INTERNATION 10617) 4897091 TO:19786BB9542 P.3
DEC-17-2085 04:13 AM 11.00
• 13:33 DEC 15, 2005 FR: ALICIA GSM #'M50 PAGE: 2/4
PRC•LABISSPTM INC. Mold,Analysis Report
1675 North Commerce Parkway NON-VIABLE!!pore Trap M4.
Weaten,Flodde 33326 Am"s Mood 89PTM XV s,to
Toll Free: 800.427.0!180 Report Nualben 121505-0195
ROGOW44 Date: 32116/2005
42 Lacy St.,N.Andover,HA Report Data.-_,12AW005
&d W
luso Suanl Parodl,QA Manager
Comments:
Inspection Services of America OEBRIS'LIGHT
159 Main Street
1M mington, MA 02887
Phones (976)658.9762
Icax: (97e)6sa 3323
llttsN;
Pro-Lob Number:
opt*Qokdoof
Collection location: - :: kl i� ' = :_.77
Y"j.
BaNRpI!sWllnitbllt
serial 0:
Spare IdImtlllaattien
. ..�MT'. -r!�F�!1!�,".'l;i:::,�sti!'til'.ii,'•r''•Il.l•�'1:�ir^�ir,fi'NY!�!S�f'�i},_r�i':...,.�:;:,:�.:: :.. ...:.:::v.. •71'-'r.:} .
s jy� ..'i.Y:: 1.'. :.h,: 'G. :ryrJ,,�i;.t, '-:1:�.?i.':i:i?i.• J'j7,...,IJ:..T
Tsui Itseuite(adorse/"a) ,age a
lmd"I"I Psrtk%s Raw catmt !!pores I III$ Raw Count openol I YS
'�'� :1��I�:.^T'f?: ,.�:',_ f .•i��r:��F .Il. 't i;�::t:_.f':i �1k. I.'�,I� D I
• ::1.},::: i }::... i.: .•i: {'.. ••�ff:':a �7L ""el,i'L�I'�.ly�'!b1,�:t:•"".!:�
No Fungi Detected
Msl"Is Oahe 12/13/2005 Analytls Dotal 12/29/2005
Aneios 22» 13 Analkieie 10: 13
Peac 1
NEW ENGLAND ENGINEERING SERVICES
INC
T(.1WOF NORTH ANDG'17R/
BQARI?OF HEALTH
JUr� I a
May 28, 2004
North Andover Board of.Health
Town Hall Annex
27 Charles Street
North Andover, MA 01845
RE: TITLE V REPORT:42 Lacey Street,North Andover, MA
Dear Sir or Madam:
Enclosed is a copy of the Title V report for the above referenced property. The system PASSED
our inspection.
If there are any questions please call me at my office, 686-1768.
Sincerely
25'L'
Benjamin C. Osgood, r.
Certified Title 5 inspector
60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTI
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION Ta`><'VN OF NORTH ANDOVER/-
BOARD OF HEALTH
Property Address: 11 2 t.-cc 8 y
PORTt El,-DoyC-4-
Owner's Name: (Lo S 2t AA;19 QV y T—J la).V
Owner's Address• 4 a t-.,4cc-y s ac-E,
A)o 2T1-i A/00 0,)C-C 44A-
Date of Inspection:
Name of Inspector:(please print)_Benjamin C. Osgood, Jr.
Company Name:New England Engineering Services Inc.
MailingAddress:60 Beechwood Drive,
North Andover, MA 01845
Telephone Number: 978-686-1768
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
t/passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: /Z
ft
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.•_ 42 LACEY STREET
_ NORTH ANDOVER,MA
Owner: ROBERT AND DOROTHY FORTIN
Date of Inspection: 5/12/04
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
L%5 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 failt:re 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:
t
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! of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:_ 42 LACEY STREET
NORTH ANDOVER,MA
Owner: ROBERT AND DOROTHY FORTIN
Date.of Inspection: 5/12/04
C. Further Evaluation is Required by the Board of Health:
L4— 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.
I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface.water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
System is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
— The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well".Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,for 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:_ 42 LACEY STREET
NORTH ANDOVER,MA
Owner: ROBERT AND DOROTHY FORTIN
Date of Inspection: 5/12/04
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for aIl 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
--bz Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow
./ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
IVO (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 must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the following:
(The folio criteria apply to large systems in addition to the criteria above) .
yes no ,�,......�_ .,..
_ the system is 400 feet of a surface dr g water supply
_ — the system is within 200 of a tributary to a surface drinking water supply
the system-is`located in a nitrogen five area(Interim Wellhead Protection Area—IWPA)or a mapped
Zo 11 of a public water supply well
If you have answered"yes"to any question in Section E the is considered a significant threat,or answered
"yes"in Section D above the,large system has failed.The owner or, ator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade a system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of th \epartmeit.
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:_ 42 LACEY STREET
NORTH ANDOVER,MA
Owner: ROBERT AND DOROTHY FORTIN
Date of Inspection: 5/12/04
Check if the following have been done.You mast indicate"yes"or`ono"as to each of the following:
Yes No
Pumping information was provided by the owner,occupant,or Board of Health
Were any of the system components pumped out in the previous two weeks?
Has the system received normal flows in the previous two week period?
_ Have large volumes of water been introduced to the system recently or as part of this inspection?
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Z_ 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?
1_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
✓_ Existing information.For example,a plan at the Board of Health.
_ V Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance
is unacceptable)[3 10 CMR 15.302(3)(b)]
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:_ 42 LACEY STREET
_ NORTH ANDOVER,MA
Owner: ROBERT AND DOROTHY FORTIN
Date of Inspection: 5/12/_04
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): ..r Number of bedrooms(actual): Z
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Number of current residents:
Does residence have a garbage grinder(yes or no):VC)
Is laundry on a separate sewage system(yes or no)•/ O[if yes separate inspection required]
Laundry system inspected(yes or no):—
Seasonal use:(yes or no):NO
Water meter readings,if available(last 2 years usage(gpd)): L&)E-c
Sump pump(yes or no):'-f f-
Last date of occupancy. C U Pr
COMMERCIALMi DUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sq%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: /u 0 2 17 u M PC 7 PC
Was system pumped as part of the inspection(yes or no):_W 4
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
4- owNEtit QuMQLD -ranytz p-r-mt_
TYPE OF SYSTEM . '.J.5" F cil oN
_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)
_Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if known)and source of information:
?Oy jq7
Were sewage odors detected when arriving at the site(yes or no):A�D
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_ 42 LACEY STREET
NORTH ANDOVER,MA
Owner: ROBERT AND DOROTHY FORTIN
Date of Inspection:_ 5/12/04
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: Zcast iron 40 PVC other(explain):
Distance from private water supply well or suction line: 30'
Comments(on condition of joints,venting,evidence of leakage,etc.):
4S 6520K-2 f Ar r3,�G.vt&,&,J7—
SEPTIC TANK:_(locate on site plan)
Depth below grade:
Material of construction: i,-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: /b o G,g-c-Lo"1z;
Sludge depth: o "
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:s—
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
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.):
GREASE TRAP;/�(locate on site plan)
Depth below grade:—
Material of construction: concrete metal fiberglass_j)olyethylene 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)
i
Property Address:_ 42 LACEY STREET
NORTH ANDOVER,MA
Owner: ROBERT AND DOROTHY FORTIN
Date of Inspection: 5/12/04
TIGHT or HOLDING TANK.-&n-(tank(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene othet(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
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.):
PUMP CHAMBER:/v r" (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_ 42 LACEY STREET
NORTH ANDOVER,MA
Owner: ROBERT AND DOROTHY FORTIN
Date of Inspection: 5/12/04
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:_
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
1-leaching fields,number,dimensions: l F-/L L DX y'
overflow cesspool,number:
innovativetalternative system Typelname of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
fmQ} diTe� sig n�
CESSPOOLS:W (cesspool must be pumped as part of inspectionxlocate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):_
Comments(note condition of soil,signs of hydrau
-lic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
Page 10 of 11
OFFICIAL INSPECTION FORM-=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:, 42 LACEY STREET
NORTH ANDOVER,MA
Owner: ROBERT AND DOROTHY FORTIN
Date of Inspection: 5/12/04
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.
yr
1{O0
T
tis
2z �i E�v
` Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_ 42 LACEY STREET
NORTH ANDOVER,MA
Owner: ROBERT AND DOROTHY FORTIN
Date of Inspection: 5/12/04
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
-'-k—Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
1.CP" I S no u OFFS K A-(ZIFA f&4-> +4l t314'C(k O F
L-T- is f0 —A--ng—Yl TAF>Ll & GLEyoFilaNy`"�s-1-e-m A2C 'N
C� �c C i p ,��Jc LEy f� IIQN 0-F POND
TO: NORTH ANDOVER, MASS �/ 19 77
BOARD OF HEALTH
FROM DESIGN ENGINEER Re: Soil Absorption Sewage
System Inspection
This is to certify that I have inspected the construction of the said disposal system at
Lo �- ,3 L ;q e �j North Andover, Mass.
SITE LOCATION
The grades and construction are as specified in my plans and specifications dated
19
a coa?.a,fl
eg F, , _:fn`eerf R6W,-5 itarian
S 1i3 f^
NORTH AI YWVI . BOARD OF IIEPLL TH
IN5TALLATId'i1 C-fDCK LIST
APPROVED�`,• _----�---__ DTSAPPRCVF:D _.V~'T^ -�_�-•- . ,_. -- EXCAVATION OK
Date: Date: I( -zo -l'1
D ,f Reason:
A Built Submitted
Check: Lot location, dimensions. of system, location in regard to
percolation tests, depth of system, water table
2.,'9�ce to Wetland Areas, Drains, Street & House, Drainage Easement and Wells.
3.; Ater Line Location
4. No PV Pine
y
5. Septic Tank - Te , Cement- e to Tank Joints on both side of Tank.
0
6. Distribution Box - No cracks in �Xor cover, all lines flow equally from box.
7. Leach Fields - Dime ions, StoneXths, Capped nds, Clean d le-t:7.shed stone
8. Leach Pits - Dimensions, Depth of Stone, Splash pa(7 tees, Cement-pipe to tank-
joints on both sides of tank, Clean double-i.-.shed stone
9.�Garbage Disposals
10. Final Grading 4f.barri cading of sub-surface syste )
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NORTH ANDOVER
SUBSURFACE DISPOSAL SYSTEM CHECK LIST 1 -17
I. General Information
Reg. 2. 5 The submitted plan must show as a minimum: �•
(a)&. the lot to be served
b) location and dimensions of the system (including
reserve area)
(c)ff-design calculations
(d)occalculations showing required leaching area
(e) pcexisting and proposed contours
(f)0 location and log of deep observation holes -
distance to ties
(g)hflocation and results of percolation tests -
distance to ties
(h)641ocation of any wet areas within 100 ' of the
sewagedisposal system or disclaimer
(i)ff,surface and subsurface drains' within 100 ' of
the sewage disposal system or disclaimer
(j ) location of any drainage easements with'
100 ' of the sewage disposal system or isclaime
My known sources of water supply within of
the sewage disposal system or disclaimer
(1)f location of any proposed well to serve the lot
(m)(y-, location of water lines on the property
maximum ground water elevation in the area of
the sewage disposal system
o)LG a profile of the system
no PVC is to be used in construction
�J(q)041ocation of benchmark
(r)04-plan must be prepared by a Professional Engineer
or other professional authorized by law to prepare
such plans.
II. Garbage Disposers 0Z
III. Septic Tanks
Reg. 6.1 (a) Capacities O1-- 150% of flow
Reg. 6 . 7 , (.b) Water tableOL
Reg. 6.8 (c) Tees &-e-
Reg. 6.9 (d) Depth of tees G'
Reg. 6.12 (e) Access GG
Reg. 6. 18 (f) Pumping Oe
(g) Cleanout 04
IV. Pumps
Reg. 9. 1 (a) Approval
Reg. 9.6 (b) Stand-by power
.' a
a '
V. Distribution Boxes
Reg. 10. 2 (a) Slope greater than 0.08 OL
Reg. 10.4 (b) Sump
VI. Leaching Pits
Leaching pits are preferred where the installation is
possible.
Reg. 11.2 (a) Calculations of leaching area (minimum 500 S.F. )
Reg. 11.4 (b) Spacing
Reg. 11.10 (c) Surface drainage 2%
Reg. 11. 11 (d) Cover material
VII. Leaching Fields
Reg. 15. 1 (a) Greater than 20 minutes/inch
Reg. 15.1 (b) Area (minimum 900 S.F. )
Reg. 15.4 (c) Construction of field (>
Reg. 15.8 (d) Surface drainage 2%
IX. Downhill Slope
(a) Slope y/x = (to be shown)
(b) y/x X 150 = (to be shown)
SOIL PROFILE & PERCOLATION TEST DATA
Town7City "' '�w No.&Street fes. Q
Lot No. , 3
Loc./Subdiv. Plan' 4zeqga= Owner �/er" -
-"""7
Investigator�6//&490alllO _ Observer
SOIL PROFILES-DATE
`p Elev.- 2. Elev. 3' Elev. 4.Elev.
0 0 0 0
W G�-
1 1 1 1
2 2 2
3 3 3 3
4 4 4 4
5 5 5 5
G G G G
V
7 7 7 7
O
8 \ 8 8 8
9 9 9
10 10 10 10
Benchmark Location
Elevation Datum
Percolation Tests-Date
Pit Number 1 2 3 4 5
Start Saturation
Soak-Mins.
Start Test-Time
Drop of 3"-Time
DroD of 6"-Time
Mins.lst "Dro r)7,�j
71ns.2nd 3"Dro , -
Notes & Sketche ;4riBag Frank C. Gelinas/& Associ es, North And.
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