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Home My WebLink AboutMiscellaneous - 42 OLD CART WAY 4/30/2018 42 OLD CART WAY 210/107.B-0085-0000.0 J 42 OLD CART WAY 210/107:8-0085-0000.0 J' Lcl 2 V Commonwealth of MassachusettsZ. orms �D City/Town of North AndoverSystem Pumping Record Form 4 NDovER MENT DEP has provided this form for use by local Boards of Hmay be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out 1. System Location: forms on the computer,use 42 Olde Cart Way only the tab key Address to move your North ReaoiAg A4 aLp MA 01845 cursor-do not City/Town State Zip Code use the return key. 2. System Owner: George Lepke Name ICS Address(if different from location) City/Town State Zip Code 978-957-&99k-&M Telephone Number B. Pumping Record 1. Date of Pumping 5/19/08 2. Quantity Pumped: 1500 Date Gallons 3. Type of system: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ® No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: Good 6. System Pumped By: Jason Elliott L90-471 Name Vehicle License Number Jason Elliott Septic Pumping Company 7. Location where contents were disposed: GLSD Q. Q,4,4 5/20/08 Signature of HaulerN Date Signature of Receiving Facility Date t5fonn4.doc•03/06 System Pumping Record•Page 1 of 1 Town of North Andover, Massachusetts Form No. 1 IAORTH BOARD OF HEALTH ti APPLICATION FOR SITE TESTING/INSPECTION TE �9SSACHUS��h Applicant LAME ' ADDRESS} (� TELEPHONE Site Location f r Engineer Q NAME DRESS TELEPHONE Test/Inspection Date and Time .4 CHAIRMAN,BOARD OF HEALTH Fee___/.�KD Test No. 6-96 S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH oL 19 O F �^ F A M % R D'.AT,E ° APPLICATION FOR SITE TESTING/INSPECTION p�AA TED PPP`.�5 ��SSACHUS�� t Applicant NAME ADDRESS TELEPHONE Site Location ' Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time r CHAIRMAN,BOARD OF HEALTH Fee Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. I J f -! I II I I TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: . _O SYSTEM OWNER &ADDRESS SYSTEM LOCATION )l (example: left front of house) I (� " �Z j DATE OF PUMPING: q-5 -0[ QUANTITY PUMPED 150 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: COMMENTS: CONTENTS TRANSFERRED TO: TOWN OF 74JO SYSTEM PUMPING RECORD,,- R [()y J i-f VA OF r1EA DATE: A SYSTEM OWNER& ADDRESS SYSTEM LOCATION-----�—P (example:left front of house) oil COJA- DATEOFPUNIPING: o O-` QUANTITY PUMPED : Q GALLONS CESSPOOL: NO YES S PTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D2 Lowell Waste P-OcD op 0mum- too OTO�OAJ APFRout5D 0yE5 D►jo SS '' 5EP7'IG S-Y STE,A -PEstc�J - -- -- i�PP�{ovC"v PA r6 z-3 1 APRzovPJ6 AuTijoi�iTy COASIT JS �I�PPr�v� 1A1-6 • .., e �Z�45ONS DLoc- 73F 5fprf(-, SY5TCM of STA u,d-Tlo" « i YFX4VAT(WJ )"SP6-6TioAj P4 Q P/JSS [j FAit_ x,16-V NotSuRE WILL MLIC TO 5E�" 7-1-6oT 57L)-"P ��NAL t.NSPFcrlon� wm p l-t,5 N� w cW5� TD LcFicz-p— res ovi 1. f��tiD 4PPROVEP Q/,TC Z-7 �6PPr�vwG Air t��i,�, 7 Zloe�� APPITIOMAL 1�5Fbc Iotj DtS�CiP��ov�D DArC ,: .-. Ft&)4L APPROVAL i APPi3o\1vJG 6u i N0911 li Page 3 ORDER OF CONDITIONS Lot 3 - Old Cart Way DEQE #242-407 12a. Notice of Intent for Domenic Teoli, 77 Colonial Drive, Lawrence, MA dated April 8, 1987 and received by the NACC April 13, 1987, b. Plan entitled Plan of Land in North Andover, MA. , showing proposed driveway house construction drawn for Domenic Teoli and David & Joan Howard by Merrimac Engineering Services. Inc. , dated April 1987 scale 1"-40' C. Plan entitled Plan of Subsurface Disposal System in North Andover, .Mass as .prepared for Domenic Teoli and Paul Maus Lot 3 Old Cart Way, Teoma Estates, dated October 1985, rev. Nov. 6, 1986, revised April 3, 1987 by Merrimack Engineering Services Inc. , Scale 1"-20' 13. In advance of any work on this project, the applicant shall notify the NACC and shall arran$e an on-site conference among the NACC, the Contractor and the applicant to ensure that all of the. Conditions of this Order of Conditions are understood. This .Order also shall be made a part of the contractor's written contract. 14. The applicant, or its successors, shall notify the NACC in writing of the identity of the on-site construction supervisor hired to coordinate construction during the work on the site and to ensure compliance with this Order. 15. The applicant shall submit to the NACC necessary documentation for the driveway easement to access Lot #2. 16. Prior to any construction on the site, a double row of staked hay bales shall be placed as shown on the plan referenced in Condition 12c. This barrier shall be inspected and approved by the NACC prior to the start of construction. This row of hay bales shall remain intact until all disturbed areas have been mulched, seeded, and stabilized to prevent erosion. The applicant shall submit revised plans incorpor- ating the"new erosion control barrier prior to the commencement of any activity on the site. 17. The applicant shall have on hand at the start of any solid disturbance, removal or stockpiling, a minimum of twenty-five (25) hay bales and sufficient stakes for staking these bales. Said bales shall be used only for the control of emergency erosion problems, and shall not be used for the normal control of erosion, as described in Condition #15. 18. Upon completion of construction and grading, all disturbed areas located outside resource areas shall be stabilized permanently against erosion. This shall be done either by sodding, or by loaming, seeding, and mulching according to Soil Conservation Service standards. If the latter course is chosen, stabilization will be considered once the surface shows complete vegetative cover has been achieved. a F A. I • zo Lr-k r4,�C� , S- y Illi(, IAl(—Q, S,77 FL- Z[D,F) rrIST za sf5pn6 I V11 M .'7Auk F'y1Si I CA x WY,4SD 0 ,'. iE�Tyt' tit, = Za�,� �c�s�--- ,B xi �C�►Fy 'f1��Tl�J� N�v� l►JS��i�1� ��iG iu�T�c.u�7o,� �_J--- _—f— �i4 DL,D CAZ;r kJA\ )0. 1AuDou,-Z , MAr TtiE "AS 13,.),CTJI I Q L06A-T1 o�-O � A tZs—:-- 1 u 0w-j Fou.-mA�-;c�. k>ITR PLA Q S 4 S EC(F c.A-nOK., PQ- PF,E-PA TZ.EL) BY 'M>='e�M►�GtG �"�G�u��.�11.:.1�1 �E Q,v s c..E.S DA-i"�D; � I • r • 1 7 t N A,S_6uI1,T�► S' GoT3 ► D- BOXZ 2.5 3&1 Z ' u �� Z 2� , -76-7- AS 6ZAS BUILT PLAN OF Acs= SUBSURFACE DIS SYSTEM LOCATED IN G� A,uwYF�z, MASS : ►sa. ' AS PREPARED FOR �°` USD M��(� co;LtsT,' ��•D �4� �•c_1 !r DATE: 6-7-Z-00 SCALE: �.. fir• �- ��;, , �o�# - Rvv'ER'f C. 3 C/L-1J �ttGGI 'V �� -Tt5oMA D..iLEY J C;Vt' MERRIMACK ENGINEERING SERVICES, INC. PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS 00 PARK STREET • ANDOVER. MASSACHUSETTS 01810 or TEL (617.).473.3553. 373-3721 J of SORT 6542 0 � r Town of North Andover ` '•.,,,,,.: HEALTH DEPARTMENT ,SSACHU CHECK#: - C� DATE: r � LOCATION: H/0 NAME: -� CONTRACTOR NAME: Type of Permit or License:(Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ TrashlSolid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers((DWI) $ Title 5 Inspector Ci- �^ $ Title 5 Report j $ ❑ Other:(Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments u 42 Old Cart Way /�f H Property Address Carla Lepke Owner owner's Name information is required for North Andover MA 01845 July 11, 2013 every 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. Important: When filling out A. General Information forms on the nlythe tab key r,use 1 Inspector: ::Z to move your Luke J. RoyTOW cursor-do not Name of Inspector use the return key. LJR Engineering, Inc. Company Name 234 Park Street Company Address North Reading MA 01864 refer' City/Town State Zip Code 978-664-8141 SI 4409, PE 47356 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 ce 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 -71111 It Inspector'+Sigature Date The system inspector shall submit a copy of this inspection report to the Approving pp g Authori ty(Board of Health or DEP)within 30 days of completing this inspection. If the system m 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 r � T 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 Old Cart Way Property Address Carla Lepke Owner Owner's Name information is required for North Andover MA 01845 July 11, 2013 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 42 Old Cart Way Property Address Co r(A' Lepke Owner Owner's Name information is North Andover MA 01845 Jul 11, 2013 required for y every 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 j 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 42 Old Cart Way Property Address Ccrf-(.a Lepke Owner Owner's Name information is North Andover required for MA 01845 July 11, 2013 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 42 Old Cart Way Property Address C.ar(Q Lepke Owner Owner's Name information is North Andover MA 01845 Jul 11, 2013 required for y every page. Cityfrown 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: 1. ❑ ® 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 i g g s equal to or less than 5m pp , provided that no other failure criteria are triggered. A co of th gg copy a 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 I Y ea nterim Wellhead ❑ 9 ( 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 42 Old Cart Way Property Address C4rfa Lepke Owner Owner's Name information is North Andover MA 01845 Jul 11, 2013 required for y every page. Citylrown 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): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 42 Old Cart Way Property Address Ca HA Lepke Owner Owner's Name information is North Andover MA -01845- Jul 11, 2013 required for Y every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: SII Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage Not available ( Y 9 (gPd))- Detail: I Sump pump? ® Yes ❑ No Last date of occupancy: Current Date Vj/t4 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•3/13 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 z.• 42 Old Cart Way Property Address CaKa- Lepke Owner Owner's Name information is required for North Andover MA 01845 July 11, 2013 eve page. Ci frown every P g tY 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: Owner-Pumped approx. every 18 months, last time October 2012 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): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 42 Old Cart Way Property Address 6m,14. Lepke Owner Owner's Name information is y North Andover MA 01845 Jul 11 2013 required for , every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 25yrs +/- House constructed-As-Built Plan from 1988 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1-1.5' feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Building sewer in good condition Septic Tank(locate on site plan): Depth below grade: 6"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) 1,500gal i If tank is metal, list age: years I Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No I Dimensions: 10.5'x5.5'x6' Sludge depth: 1 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 42 Old Cart Way Property Address L'arlo,Lepke Owner Owners Name information is North Andover MA 01845 Jul 11, 2013 required for y every 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 32" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Stick with foot&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 in good condition, concrete inlet&outlet baffles in place -Liquid at proper operating level at outlet invert 11 W 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 42 Old Cart Way Property Address Coad A.Lepke Owner Owner's Name information is North Andover iytA 01845 July 11 2013 required for , every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): N r IN 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 42 Old Cart Way Property Address Lama'_.Lepke Owner Owner's Name information is North Andover MA 01845 July 11 2013 required for , every page. Cityfrown 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 0-1/8 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.): -Box solid in place, evidence corrosion of concrete above liquid level -Liquid at proper operating level at outlet inverts with equal distribution - Replaced cover A 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.): I * 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 Old Cart Way Property Address = p�ja Lepke Owner Owners Name information is North Andover required for -b1A ---01845 July 11, 2013 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leachinggalleries 9 number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1 -20'x50' ❑ 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 signs of hydraulic failure -Vegetation normal 14/A Cesspools (cesspool must be pumped as part of inspection) locate on siteIan • P )• 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 42 Old Cart Way Property Address Carla_;LeP ke _ Owner Owner's Name information is North Andover MA 01845 Jul 11, 2013 required for y every 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.): is or 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 Old Cart Way Property Address GA.r1Q. Lepke Owner Owners Name information is required for North Andover . MA 01845 July 11, 2013 every page. Cityfown -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 0 51 •= '� AH Y R C.F�APitfl�t..l�j � t t i � L t 1 ' U A ——T1l�t� — — '45—1 A I Q D CD . � D=8DX coy-,"a' 74,7, 78g ':F T11-0 t5ins•3113 Title 5 Mom Inspection corm:JUosunace�eway �,, ,o,System•Page 15 of 17 Commonwealth of Massachusetts 1.y 213" Title 5 Official Inspection Form Subsurface Sewage DisposalSystem Form-Not for Voluntary Assessments . 42 Old Cart Way Property Address (.a ria-Lepke Owner Owner's Name information is required for North Andover MA 01845 July.T 2013 every page. Cityfrown 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: 6 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. October 1985, Revised January 1986 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: Obtained from system design plan on record -Shows ESHGW at 48".The grade was raised by 24" with construction of the system resulting in total 72"depth to ESHGW from existing grade. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 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 �H 42 Old Cart Way Property Address Gp v ,Z Lepke Owner Owner's Name information is North.Andover MA 01845 Jul 11, 2013 required for Y every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17