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HomeMy WebLinkAboutMiscellaneous - 427 WINTER STREET 4/30/2018Lot & Street r� %j �%i �� ` Map/Parcel CONSTRUCTION APPROVAL Has plan review fee been paid: YES NO Permit# 9' 'A Plan Approval: Date:_L61_ Approved by: A Designer: ,% lU 0,5600 b, � � Plan Date: f /aha / �J� Conditions: Water Supply: CaEi�? Well Well Permit: Driller: Well Tests: Chemical---"- - __Dat Approved Bacteria I Date Approved-._._.., Bacteria II Date Approved Plumbing Sign -Off: Comments: Form "U" Approval Date Issued Conditions: Final Approval: Wiring Sign -Off: Approval to Issue By: YES NO All Permits Paid? YES NO Well Construction Approval? YES NO Septic System Construction Approval? YES NO Certification? YES NO Other YES NO Any Variance Needed? YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: APPROVED BY: SEPTIC SYSTEM INSTALLATION Is the installer licensed? Type of Construction: NEW New Construction: Certified Plot Plan Review YES NO Floor Plan Review YES NO Conditions of Approval from Form U YES NO Issuance of DWC permit: DWC Permit Paid? DWC Permit # 99A Begin Inspection: Excavation Inspection: Needed: Construction Inspection: Needed: As Built Plan Satisfactory: YES: NO YE NO I Installer: cf 6Q� �sGC�D� J� Approval of Backfill: Date: Final Grading Approval: Date: By: Final Construction Approval: Date: By: Certificate of Compliance: Approval: Date: NO Town of North Andover, Massachusetts Form No. 4 BOARD OF HEALTH January 6 19-9-8— CERTIFICATE 9 98—.CERTIFICATE OF COMPLIANCE This is to certify that the Individual. Soil Absorption Sewage Disposal System constructed ( ) or repaired (g) by Ben Os ood JR. - INSTALLER �. at 427 Winter Street has been installed in accordance with Board of Health Regulations as described in the Design Approval Site System Permit No., 992 dated—Dec-9— 19 CQ The issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. BOARD OF HEALTH UM 5 10' TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System ( ) constructed; (x) repaired, by _1�'edrr a�n>� located at „? '7 (;cl rt e2 - /V, was installed in conformance with the North. Andover Hoard of Health approved plan,. System Design Permit # 9 9 dated g 9 with an approved design flow of I/yoo_ gallons per day. Thema rW s used were in conformance with those specified on the approved plan; the system was installed id -Accordance with the provisions of 310 CMR 15.000, Title 5 and local regulations, and the -final grading agrees substantially with the approved plan. A.U. work is -accurately represented on. the As -built which has been submitted to the Board of Health. Installer:: j�laV,:r Date: Design Engineer: Date: NEW ENGLAND ENGINEERING SERVICES INC December 22, 1997 Attn: Sandra Starr, Board of Health administrator North Andover Board of Health 30 School Street North Andover, MA 01 845 Re: Septic System design 427 Winter Street Dear Sandra: Enclosed are three sets of revised plans for 427 Winter Street that have had the following changes made. 1. Added 50 foot distance to wetlands 2. Added note regarding bedrock in test pit 2 3. Added note regarding Board of Health approval of variance and local upgrade approval. If you have any questions please do not hesitate to call. Sincerely, Benjamin C. Osgood, Jr., EIT 33 WALKER RD. - SUITE 22 - NORTH ANDOVER, MA 01845 - (508) 686-1768 NEW ENGLAND ENGINEERING SERVICES INC Attn. Sandra Starr, Board of Health Administrator North Andover Board of Health 30 School Street North Andover, MA 01845 Re: 427 Winter Street septic design Dear Sandra: Enclosed you will find three copies of the proposed design plans for 427 Winter Street along with the soil evaluator sheets. This plan requires one local upgrade approval and one local bylaw variance. Please reserve a spot on the next Board of Health agenda so these requested variances and local upgrade approval can be discussed. If you have any questions please do not hesitate to contact this office. Yours truly, Benjamin C. Osgood, Jr., EIT Enclosures 33 WALKER RD. - SUITE 22 - NORTH ANDOVER, MA 01845 - (508) 686-1768 FORM 11 - SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No. — CHEEP OBSERVATION HOLE LOG* Depth from sail Horizon Surface (Inohes) so(USDATextu) l Color Msoiu ¢eiU �eYhe—w Weather Deep Hole Number bate:. e�.. . Time',, Location (identify on site p /rte:.,,,.? :,.......: ,.,. - % Slope (%1 _ Surface stones ..., ...... Land Use .....:. .: ..:.:..,,.. `� Vegetation •.., Landform � 11 - CO , .......: Position on landscape (sketch on the back) . Distances from: Open Water Body feet Drainage way feet Possible Wet Area feet Property Lina ............ feet Drinking Water Well .: (eat Othsr,....:.::..::..,.,,.,.....:..:.:,::::.. CHEEP OBSERVATION HOLE LOG* Depth from sail Horizon Surface (Inohes) so(USDATextu) l Color Msoiu ¢eiU Soil Other Mottling IStructure, Stones, Boulders, Consistency, 90 Z )- ZY/� - Parent Material (geo(og 6 be th to aundwatcr•, Standing Water in the Hole; Estimated Seaton! High Ground Water:_ -- L)EP APPROVED FORM - 12107195 ggPthtoBedrosk: _ _ - _. Weeping from Pit F4GO: - - -- Ap A.r+- V. FROM : R. C. TANGARD OCT. 17. 1997 5:17PH P 4 PHONE NO. : 617 ..--4 FORM 11 - SOIL EVALUATOR FORM Page 2 of 3 hooation Address or Lot No. On-site Review / 4>^.(.�! `7 �"ime:..Q �,c'3 Weather v ( y Deep Hale Number Date:. - 1 Location(identify on aite Ian} ,........... „ ,...... . Land Use Slope M �: Surface Stones :1 Vegetation Landform .:.. v,..,..,. Position on landscape (sketch on the back} Distances from: Open Water Body fea T Drainage way feet Possible Wet Area feet Property Line .:...._ ... , feet Drinking Water Well feet Other ....,........., . DEEP OBSERVATION HOLE LOG* �1 1 Depth from Surieae (Inches) $oil Horizon Soil Texture (USDA) Soil Color iMunsall) Soil Mottling Other (Structure, Stones, Boulders, Consistency, % Grovel) --L AoV rZ 1 rv�N� L/” nL����_,v MINIMUM OF 2 HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA Parent Material (geologic) Depthto8edrocka Depth to Groundwater: Standing Water in the Hole: — Weeping from Pit Face: Estimated Seasonal High Ground Water: DEP APPROVED FORM - 12/0719s -- NORTH ANDOVER BOARD OF HEALTH DESIGN REVIEW REPORT DATE l9k g FEE: O/ PERMIT # I o� _ DATE RECEIVED APPLICANT �J FF/ZL y SQU/T"}- MAP PARCEL ADDRESS 7 & /GU%l- DZ LOT # STREET # �a7 ENG . %V -AX, STREET U)l /U j6- ENGINEER'S- ENGINEER'S- ADD` WA6'4CZ PLAN DATE L/ CT a� a / c/7 REV. DATE CONDITIONS -OF. APPROVAL Vi9R - 3 I TD Ltd ll) , APPROVED DISAPPROVED REASONS -FOR DISAPPROVAL: 11 PLAN REVIEW CHECKLIST ADDRESS 4-2 7 Zj-)//Lj ENGINEER GENERAL f / 3 COPIES STAMP LOCUSy NORTH ARROW SCALE �. CONTOURS PROFILE(Sc) SECTION �'� BENCHMARK r SOIL & PERCS �__. ELEVATIONS WETS. DISCLAIMER WELLS & WETS' �f WATERSHED? DRIVEWAY -WATER LINE FDN DRAIN M&PX SCH40 TESTS CURRENT? SOIL EVAL ` - SEPTIC. TANK' MIN 15OOG:--- .17 INVERT DROP GARB.. GRINDER (2 comps: +2:00.)---.- 10' TO FDN MANHOLE ELEV GW _ . #.:. COMPS . D -BOX - — SIZE # LINES FIRST 2' LEVEL STATEMENTt'' INLET � < < - OUTLET D, ASO / (2" OR .17 FT) TEE" REQ.-' D� _. LEACHING MIN 440 GPD? R SERVE AREA 4' FROM PRIMARY' 100' TO WETLANDS 100' TO WELLS C--' 4' TO S.H.( 20' TO FND & INTRCPTR DRAINS i'� 400' TO SURFACE H2O SUPP 4' PERM. SOIL BELOW FACILITY MIN 12" COVER L_� FILL? (15') BREAKOUT MET? TRENCHES MIN 440 gpd SLOPE (min .005 or 6"/1001) s_ SIDEWALL DIST. 3X EFF. W OR D (MIN 61) RESERVE BETWEEN TRENCHES? IN FILL? MUST BE 10' MIN. 4" PEA STONE? VENT? (>3' COVER; LINES >50') BOT + SIDE = X LDNG = TOT (L x W x #) (DxLx2x#) (G/ft2) Copyright 0 1996 by S.L. Starr PITS MIN 440 LEACHING MIN 1 (13'x16') PIT MANHOLE/PIT GW MIN 4' BELOW BOTTOM EXC 2x EFF W OR D 12"-48" STONE BOT + SIDE x LOAD = TOTAL (L x. W x #) (2x(L+W)xD x #) (G/ft2) CHAMBERS - MIN 440 LEACHING GW MIN 4" BELOW COVER >3 FT - VENT MANHOLES 12"-48" STONE SPLASH PADS SLOPE .005 BED/TRENCH (Bed max. 60' X-6-01) MIN 13' X 16' PIT - - BOT + SIDE X LOAD = TOTAL (L x -W= x #) (2 x (L+W)xD x.#) (G/ft2) FIELDS = _ WF • _ _ y- MIN 440 GPD 900 ft2 BED GW MIN 4' BELOW BOTTOM.OF FIELD PIPE ENDS JOINED? _/ 4" PEA STONE? DIST LINE SLOPE .005?p-` >3'COVER-VENT SCH 40 ✓ MIN 12" COVER �r RATE X X - = TOTAL-L2�e/, 1--44-0 L W LDG DOSING -TANKS AND PUMPS DIMENSIONS X X = PUMP CAPACITY Spm L W D Vol. DISCHARGE SIZE DISCHARGE RATE DISCHARGE TIME 9Pm MANHOLES TO GRADE ALARM SEP. CIRC. GW`-- (Min. 1' below inlet) HWL LWL CHECK VALVE BLEEDER HOLE MANUAL OP. SWITCH ENUF STORAGE? Copyright © 1996 by S.L. Starr .i 40RTN 1 O 0 A - - ,SSACMUSEt� Town of North Andover, Massachusetts BOARD OF HEALTH DISPOSAL WORKS CONSTRUCTION PERMIT 19 Permission is hereby granted to Construct ( ) or Repair ( an Individual Soil"Absorption.. Sewage Disposal System as shown on the Design Approval S.S. No. Fee -Z D.W.C. No, --qQ. SEPTIC PLAN SUBMITTALS LOCATION: 411,127 (rV Sire@� NEW PLANS: YES REVISED PLANS: YES DATE: //A % DESIGN ENGINEER: 11 S60.00/Plan $25.00/Plan � .e r,4— 4 -C7-e / , When the submission is all in place, route to the Health Secretary f pORTM H r 9 ,SSAC14 Town of North Andover, Massachusetts BOARD OF HEALTH DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant �C-'`/—ye�y --Z5 QUI /-// Test No. Site Location -,' �,2 7 Z,6) Reference Plans and Specs. <- �c ENGINEER Form No. 2 Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. Fee 666 CHAIRMAN, BOARD OF HEALTH Site System Permit No.—22A M COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION Q TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Owner's Name: 17 Owner's Address: Date of Inspection: Q 3 Name of Inspector: lease print) Company Name: i wee Mailing Address` / 11�. / f Telephone Number: 97d- Pf?44sD OF HEALTH FMMAty 2 2003 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: d-' PoSasses Conditionally Passes _ Nee Further Evalu,4tion by the Local Approving Authority Fai g, Inspector's Signature: ate: The system inspector shall submit a copy of this inspection report to Approving Authority (Board of Health or DEP) within 30 days of codpleting 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. Title 5 Inspection Form 6/15/2000 page 1 y _y, Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: Inspection Summary: Check A,B,C,D or E /ALWAYS complete all of Section D 7A. Sy tem 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. 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 s ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ND explain: broken pipe(s) are replaced obstruction is removed - 2 '" T ajPage 3 of I I W" OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ' / 41-j4Y .//% • Owner: .1/% Date of Inspection:Q:15 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: —The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: ...VPage 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address• 54 //// �f /0, -/1 /1.//�i+� Owner: zee /i'/ Date of Inspection: ` D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: Yes No _ —0— ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ischarge 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 iquid depth in cesspool is less than 6" below invert or available volume is less than'/2 day flow _4,., -Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number �1f times pumped r/ 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. �i�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. 7Any 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.] (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as R described in 310 CM15.303. 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: t 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 following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply _ _ the system is within 200 feet of a tributary to a surface drinking water supply — _ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well 701 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. ,.t Page 5 of 11 ' r OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:4„ 7 Owner: Date of Inspection: 9 D 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 ? r/ Have large volumes of water been introduced to the system recently or as part of this inspection ? V 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 ? f/ Were all system components, excluding the SAS, located on site ? +Z _ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ? % V _ 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: r Yes Vo V 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 C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] ,t Page 6 of 11 r OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:__�� Owner: Date of Inspection:. ALOW CONDITIONS RESIDENTIAL Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 C 15.203 (for example: 110 gpd x # of bedrooms): Number of current residents: VVV Does residence have a garbage grinder (yes or no):z°S P_ eCar"AJOf d 2 L M,O�Q Is laundry on a separate sewage system (yes or no):if yes separate inspection required] Laundry system inspected (yes or no): _ Seasonal use: (yes or no):% CS Water meter readings, if available (last 2 years usage (gpd)): Sump pump (yes or no) -P® Last date of occupancyO C� 1 e GI COMMERCIALANDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sgft,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: b Was system pumped as o,�the inspection (yes or no): C'<" If yes, volume pumped allons -- How w ty pumped determined? Reason for pumping: /0ape C % —7-4 c TYP F SYSTEM eptic tank, distribution box, soil absotrptilm system _ Single cesspool Overflow cesspool — ivy _ 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: Were sewage odors detected when arriving at the site (yes or no):NO Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C s-�SYS/TEM INFORMATION (continued) Property Address: � / dx/) ) 7- Owner: /r/ ,L /-/ Date of Inspection: BUILDING SEWER (locate on site plan) Depth below grade: L/ Materials of construction: _cast iron V<0 PVC other (explain): Distance from private water supply well dr suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: _ ocate on site plan) Depth below grade: Q Material of construction: Crete _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) rt Dimensions:.5 Sludge depth: / '' Distance from top of sludge to bottom of outlet tee or baffle: 3. Scum thickness: 6 Distance from top of scum to top of outlet tee or baffle: % < Distance from bottom of scum to bot om�f—outlet tee or affle:� _ How were dimensions determined: / '? //'; ZL' Ll <0 / Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels GREASE TRAP: _(locate on site plan) e s Depth below grade: Material of construction: _concrete _metal _fiberglass polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7 . 0#Page8ofl1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: C ,lf/i Ot �^7 411,11,1r 2111 + Owner _ Date of Inspection: TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: 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 leak ge.,t' nto or out of box, / V7 f PUMP CHAMBER: (locate on site plan) Pumps in working order (yes or no): Alarms in working order (yes or no): Comments (note condition of pump chamber, ,pondition of pumps and appurtenances, etc.): Page 9 of 11 r OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM R PART C SYSTEM INFORMATION (continued) Property Address: Owner: _1 �-6el/ Date of Inspection: S / 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: le mg trenches, number, length: eaching fields, number, dimensions: / e4- �O overflow cesspool, number: innovative/alternative system Type/name of technology: Comments (note condition of 1, signs of hydraulic failure, level of one etc.): ig, damp soil, condition of vegetation, A) �Q � . ,0 CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth — top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow (yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM'INFORMATION (continued) Property Address: tit /Y. Owner: Date of Inspection: ` • 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. rr'�" =�, ;. v �+ 1vi t t C31 iv xf G T; i� f�lf -i � he 1.Cd1 9�.,,. �. }X �Y+6l�S ♦ } r � t��J/�x.� � Y t y � ' 1 S ,a 4x. +� Q �Q i'.46 . / 5 M (Y r� Nct 0 h Q � 7 / N �- Q. \1� .Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ©� 9,Z11 /% /.Y'%'�4 Owner: _ Date of Inspection: 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 Ovate etlevation: Obtained from system design plans on record - if checked, date f design plan reviewed: /,;2' a 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: WOZ7r Za6 11 ' Commonwealth of Massachusetts Title 5 Official Inspection Form &A Subsurface Sewage Disposal System Form - Not for Voluntary Assessments "< 427 Winter Street Property Address Stephen D'Onofrio Owner Owner's Name information is required for North Andover MA 01845 5/16/2013 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: A. General Information When filling out forms on the computer, use 1. Inspector: only the tab key to move your do Neil J. Bateson cursor - not use the return Name of Inspector key. Bateson Enterprises Inc. Company Name VkA 111 Argilla Road Company Address Andover MA 01810 City/Town State 978-475-4786 S115 RECEIVE® Telephone Number License Number MAY 2 0 2013 B. Certification I TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 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. 1 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 5/16/2013 Inspettoei Signatur Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 427 Winter Street Property Address Stephen D'Onofrio Owner's Name North Andover CitylTown B. Certification (cont.) MA 01845 5/16/2013 State Zip Code Date of Inspection 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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 427 Winter Street Property Address Stephen D'Onofrio Owner's Name North Andover MA 01845 5/16/2013 Citylrown 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 ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 Forth: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 427 Winter Street Property Address Stephen D'Onofrio Owner's Name North Andover City/Town B. Certification (cont.) MA 01845 State Zip Code 5/16/2013 Date of Inspection 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 ❑ ® 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 • 3113 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 427 Winter Street Property Address Stephen D'Onofno Owner Owner's Name information is required for North Andover MA 01845 5/16/2013 every page. Cityrrown 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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Owner information is required for every page. t5ins • 3113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 427 Winter Street Property Address Stephen D'Onofrio Owner's Name North Andover MA 01845 5/16/2013 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 ►1 ❑ 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? 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: 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): 3 Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 3 12"1n Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 427 Winter Street Property Address Stephen D'Onofno Owner's Name North Andover City/Town D. System Information Description: Number of current residents: MA State 01845 5/16/2013 Zip Code Date of Inspection Does residence have a garbage grinder? Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) ® Yes ❑ No ❑ Yes ® No ❑ Yes ❑ No ❑ Yes ® No Yes ❑ Yes ® No Current Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No 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 .r 427 Winter Street Owner information is required for every page. Property Address Stephen D'Onofrio Owner's Name North Andover Cityrrown D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: MA 01845 5/16/2013 State Zip Code Date of Inspection Date General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Pumped six months ago, owner 1000 gallons Measured tank. Inspect tankk & tees. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ® Yes ❑ No ❑ 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 Summary Record Card generated on 5/14/2013 12:14:00 PM by Karen Hanlon Town of North Andover Tax Map # 210-104.A-0067-0000.0 Parcel Id 16294. 427 WINTER STREET D'ONOFRIO, STEPHEN 427 WINTER STREET NORTH ANDOVER, MA 01845 rage 1 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.01 Acres FY 2013 UB Mailina Index Name/Address Type Loan Number Active/Inact. From Until D'ONOFRIO, STEPHEN Payor 427 WINTER STREET NORTH ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 18007.0 - 427 WINTER STREET Last Billing Date 4/10/2013 3180036 03 Cycle 03 Active UB Services Maint. Account No. 3180036 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 79.80 /1 UB Meter Maintenance Account No. 3180036 Serial No Status Location Brand Type Size YTD Cons 16336528 a Active 00 METE METE w Water 0.63 0.63 396 Date Reading Code Consumption Posted Date Variance 3/20/2013 1031 a Actual 21 4/22/2013 8% 12/13/2012 1010 a Actual 17 1/9/2013 -38% 9/19/2012 993 a Actual 30 10/15/2012 38% 6/18/2012 963 a Actual 21 7/16/2012 13% 3/20/2012 942 a Actual 19 4/14/2012 -3% 12/19/2011 923 a Actual 20 1/17/2012 -8% 9/16/2011 903 a Actual 22 10/13/2011 10% 6/1312011 881 a Actual 19 7/20/2011 28% 3/15/2011 862 a Actual 15 4/13/2011 5% 12/14/2010 847 aActual 14 1/12/2011 -41% 9/16/2010 833 a Actual 25 10/15/2010 32% 6/14/2010 808 a Actual 18 7/15/2010 11% 3/17/2010 790 a Actual 17 4/14/2010 -4% 12/14/2009 773 aActual 17 1/12/2010 -1% 9/16/2009 756 a Actual 19 10/15/2009 -22% 6/10/2009 737 a Actual 21 7/20/2009 38% 3/17/2009 716 a Actual 17 4/29/2009 -8% 12/12/2008 699 a Actual 17 1/20/2009 -29% 9/16/2008 682 a Actual 27 10/10/2008 21% 6/10/2008. 655 a Actual 20 7/16/2008 18% 3/14/2008 635 a Actual 17 4/11/2008 7% 12/17/2007 618 a Actual 17 1/22/2008 -32% 9/14/2007 601 a Actual 23 10/12/2007 3% 6/20/2007 578 a Actual 25 7/20/2007 51% 3/16/2007 553 a Actual 16 4/16/2007 -9% 12/13/2006 537 a Actual 16 1/19/2007 -34% 9/19/2006 521 a Actual 26 10/20/2006 21% 6/20/2006 495 a Actual 21 7/10/2006 17% 3/23/2006 474 a Actual 16 4/17/2006 0% Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 427 Winter Street Property Address Stephen D'Onofrio Owner's Name North Andover MA 01845 5/16/2013 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Tank original, d -box & leach field installed 1/2/1998, as built plan A'rI (lint Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 1.6 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.): 4" PVC through wall. 3 " PVC in house, no leaks visible. Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 0 feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: Tx 5'x 4' Sludge depth: 1" ❑ Yes ❑ No t5ins • 3113 Title 5 Official Inspection Forth: 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 r< 427 Winter Street Property Address Stephen D'Onofrio Owner Owner's Name information is required for North Andover MA 01845 every page. Cityfrown State Zip Code D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 26" 1" 8" 21" 5/16/2013 Date of Inspection 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.): Pumped septic tank. Inlet baffle ok. Outlet baffle ok. Unable to remove inlet cover. Outlet cover broken, install large d -box cover. Depth of liquid at outlet invert. No evidence of leakage. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): 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: t5ins • 3/13 Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form MOVES Subsurface Sewage Disposal System Form - Not for Voluntary Assessments t 427 Winter Street Property Address Stephen D'Onofrio Owner Owner's Name information is required for North Andover MA 01845 5/16/2013 every page. Cityfrown 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: Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ❑ Yes ❑ No * 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 427 Winter Street Property Address Stephen D'Onofrio Owner Owner's Name information is required for North Andover MA 01845 5/16/2013 every page. Citylrown 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 level & distribution equal. No evidence of leakage. Evidence of carryover, pumped d - box to clean. Pump Chamber (locate on site plan): Pumps in working order: Alarms in working order: ❑ Yes ❑ No* ❑ 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 • 3113 Title 5 Official Inspection Forth: 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 427 Winter Street Type: Property Address ❑ Stephen D'Onofrio Owner Owner's Name information is required for North Andover MA every page. City/Town State ® D. System Information (cont.) Type: ❑ leaching pits ❑ leaching chambers ❑ leaching galleries ❑ leaching trenches ® leaching fields ❑ overflow cesspool ❑ innovative/alternative system 01845 5/16/2013 Zip Code Date of Inspection number: number: number: number, length: number, dimensions: number: 1 field 20' x 45' Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetaion ok. No sign of ponding to surface. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow t5ins • 3113 ❑ Yes ❑ No 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 .�" 427 Winter Street Property Address Stephen D'Onofrio Owner Owner's Name information is required for North Andover MA 01845 5/16/2013 every page. Cityfrown 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 427 Winter Street Property Address Stephen D'Onofrio Owner Owner's Name information is North Andover MA 01845 required for every page. City/Town State Zip Code D. System Information (cont.) t5ins - 3113 5/16/2013 Date of Inspection 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: Z hand -sketch in the area below ❑ drawing attached separately 0 A b-�� — — 13'r7 r c � � 11oc�3ce 3, tq Q -Sax ; r 0 —Spy t�ouse_ 0e? ck I., G Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 3 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 427 Winter Street Property Address Stephen D'Onofrio Owner's Name North Andover MA 01845 5/16/2013 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: 4 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: 10/22/1997 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Design plan ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Test pit data on design plan 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 427 Winter Street Property Address Stephen D'Onofrio Owner Owners Name information is required for North Andover MA 01845 5/16/2013 every page. Cityfrown 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 - 3113 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System - Page 17 of 17 • Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left/ Right front of house, Left / i ear of hou , Left/ right side of house, Left/ Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address L4 a 7 W � V�e.-sSA- &1CxAA-& City/Town state Zip Code 2. System Owner. Name Address (if different from location) City/'Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): It� Yb QFC i C� State Zip Code Telephone Number Date 2. Quantity Pumped: Gallons Cesspool(s) ' B'Septic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes 3 -1 -No If yes, was it cleaned? ❑ Yes ❑ No. '5. Condition of System: �jo CVti-cxA �9i R k v\, Av"if rz A c� — "14C t5form4.doc• 06/03 6. System Pumped By: Neil: Bateson Name Bateson Enterprises Inc Company 7. Locatiore contents were disposed: F5821 Vehicle License Number '- f Date System Pumping Record • Page 1 of 1. la a " � p BOARD OF HEALTH 14,6 MAIN STREET TEL. 688-9 540 NORTH ANDOVER, MASS. 01845 APPLICATION FOR SOIL TESTS DATE: qh-a ki LOCATION OF SOIL TESTS: � 2-7 r /v Assessor's map & parcel number: 4c, e( rc6 TEL. NO.: ADDRESS: 4;52 7 bUl ✓t BCA cO�� ad k1 J 4- - ENGINEER: ,d ; IJ TEL. NO..- CERTIFIED O.:CERTIFIED SOIL EVALUATOR: �Zjo ,O J2 /SGC 0 C' Intended use of land: residential subdivision, single family home, commercial THE FOLLOWING MUST BE INCLUDED WITH THIS FORM: 1. Proof of land ownership (Tax bill, deed, or letter from owner permitting tests) 2. Plot plan 3. Fee of $175.00 per lot for new construction. This covers the two deep holes and two percolation tests required for each lot. Fee of $75.00 per lot for repairs or upgrades. GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system. 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan (no smaller than 1 %100') shall be submitted to the Board of Health showing the location of all tests (including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. DATE: LOCATION: ENGINEER: L_ D - k9� BOH WITNESS: PERCOLATION TEST # BOTTOM DEPTH OF PERC TEST: L+ TIME OF SOAK: ` 4/7 I 3 (At least 15 minutes long) TIME AT 12" `1 1'3 TIME AT 9" / 1 4y TIME AT 6" .5— 8 OVERNIGHT SOAK TIME STARTED NEXT DAY SOAK: TIME AT 12" TIME AT 9" TIME AT 6" (At least 15 minutes) 4 � .. ... .� i£.Te... .[ a .. ,.. .. t � '-�= atk ...�►^ti' .i:..'. i -r . +wc c, r,.a.e ^�'� �=:%�r a _ .$" .�F. �Pvc ,�., �� ��,, s_'�. r `- �';, �fj ;;:,yn, �} .>... ++� .� � c �� k �_:""g � '. .,�� - qty-��,�^���. . � � ��zt '�-r ,kit � F� s�,v�' T-�,� „t� t - i r � p 4�5� 5 `_.'xTM�.r h : � ` � � Y i7 `�` � -v' � �a�)' ae s a s "y' .� 1`� r Y , �.� y ,� � j, r�''� - �_� w+'`R.:' �� .,a�� ='-z__, s-'Y� �' 3 .GNS�r.- .i�-:�3:+,.,��k�.r3h' �.r. t w;i� q�:T' Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH OF,t4eo bgti0 y� <6 OL 1� 19 Z y APPLICATION FOR SITE TESTING/INSPECTION y�SArui15E��y Applicant OAWEU 1 DDRESSS TELEPHONE Site Location 4 )- W -i Engineer b -S NAME ADDRESS TELEPHONE Test/Inspection Date and Time 7 1/� CHAIRMAN, BOARD OF HEA TH Fee Test No. 0 0")�— S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. T A E ; T: h t�J7- Q© r 7: gpsERT W. RNITm �. 14051 I .. - _t� "fit c r ov's GA N -1)-Soo GAL 5 FPTI L 7ANt 00 94T -l- er- 44'--�- 5T, !! l a 1- ri C6 O 1-Y)