HomeMy WebLinkAboutMiscellaneous - 434 BOXFORD STREET 4/30/2018 434 80XFORD STREET
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Commonwealth of Massachusetts D
City/Town of ���Et�E
System Pumping-Record JUN 0 8 2015
Form 4
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
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 Locatione /Rig Eonof Nous , Left/Right rear of house, Left/right side of house, LeftRight side of buildhig, Left/Rront o uilding, Left/Right rear of building, Under deck
Address �Q i
ady/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
Citylrown StateZi Code
q
Telephone Number �`4;°
�•1
B. Pumping 9
Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons y
3. Type of system: ❑ Cesspool(s)
�Pticank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 2-90 If yes,was it cleaned? ❑ Yes ❑ No,
' 5. Condition of Syst �( to' 1
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number !�
Bateson Enterprises Inc
Company
7. Lo here contents were disposed: f
GL L S'. Lowell Waste Water
�:W0
Sign a Haul Date z
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
r
Commonwealth of Massachusetts
City/Town of
System Pumping Record OCT 0 2 2013
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
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 Locabo . Left ight n of house Right rear of house, Left/right side of house, Left/
Right side of buil and g, Left/Right rout of building, Left/Right rear of building, Under deck
Address w o J
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
Citylrown State
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 9-90If yes, was it cleaned? ❑ Yes ❑ No.
' 5. Condition of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Lowell Waste Water
<r
Si n
9 Haute Date
t5form4.doc•06/03 System Pumping .Record Page 1 of 1
DelleChiaie, Pamela
From: DelleChiaie, Pamela
Sent: Friday, December 02, 2011 10:24 AM
To: 'nbateson@comcast.net'
Subject: I.R. -434 Boxford Street-Scanned Health Dept. File (Septic)
Attachments: 20111202100423505.pdf
Hello Neil,
Attached is the scanned file for 434 Boxford Street- Scanned Health Dept. File (Septic) that you requested.
Unfortunately,there are no original plans in the file. I hope this helps. O
am R14SW4,
Pamela DelleChiaie
Departmental Assistant I Community Development I Health Department
Town of North Andover
1600 Osgood Street I Bldg 20 1 Suite 2-36
North Andover,MA 01845
,i' Office-978-688-9540
Fax-978-688-8476
Email-pdellechiaieotownofnorthandover.com
�C5 Website http://www.townofnorthandover.com/Pages/index
"We can never see the path of our life if we are too busy focusing on the pebbles under our feet."--Anonymous
If you are happy with the customer service you have received from town departments,please let us
know...feel free to complete the general Comment Form (link below):
http://www.townofnorthandover.com/Pages/NAndoverMA WebDocs/contact
i
PRINTED BY:Pamela DelleChiaie-PLEASE LEAVE IN PRINT-OUT TRAY.......THANK YOU.
DelleChiaie, Pamela
From: johnholloran@comcast.net
Sent: Tuesday, January 11, 20112:46 PM
To: DelleChiaie, Pamela
Cc: Sawyer, Susan
Subject: Re: I.R. -434 Boxford Street-Scanned copy of Health Dept. File
Thanks for this. It is much appreciated.
Seem sto me that we have a "newer" system than thought. Repairs and replacement done in 1995.
Thanks again.
JH
----- Original Message -----
From: "Pamela DelleChiaie" <pdellech.Atownofnorthand over.com>
To: iohnholloran@comcast.net
Cc: "Susan Sawyer" <ssawyer(Wtownofnorthandove r.com>
Sent: Tuesday, January 11, 20112:28:11 PM
Subject: I.R. -434 Boxford Street - Scanned copy of Health Dept. File
Attached is a scanned file copy of the information for 434 Boxford Street as you requested. Please call the office if you
have any further questions.
r'r'iot�cgan�la, �
Pamela DelleCliiaie
Departmental Assistant I Community Development I Health Department
Town of North Andover
1600 Osgood Street I Bldg 20 I Suite 2-36
Noah Andover,MA 01845
9 Office-978-688-9540
Q Fax-978-688-8476
CD Email-pdqllecliiaic(@to%-vllobor-thandover.com
Website littp•/hvmv townofnorthandover coni/Pa es index
"il'e con clever see the path of our We f we erre too busy focusing on the pebbles under our feel."—Anonymous
From: Lchnholloran@comcast.net Lmailto:johnholloran0comcast net
Sent:Tuesday,January 11, 20111:23 PM
To: Sawyer, Susan
Subject: Holloran -434 Boxford street
Susan -thanks so much for your time and information earlier today. It is very much appreciated.
Now you have my email address. If you could send along a scan of the file seeing that it is so thin, it
would be much appreciated.
Thanks again.
John Holloran
434 Boxford Street
1 IOF2
DelleChiaie,Pamela
PRINTED BY:Pamela DelleChiaie- PLEASE LEAVE IN PRINT-OUT TRAY....,..THANK YOU.
DelleChiaie, Pamela
From: Sawyer, Susan
Sent: Tuesday, January 11, 20114:09 PM
To: 'johnholloran@comeast.net; DelleChiaie, Pamela
Subject: RE: I.R. -434 Boxford Street-Scanned copy of Health Dept. File
It looks as though the tank was replaced, The 1995 report notes that the tank was leaking,then in 2000 the 1500 gallon
tank was noted as fine. Hence I believe it must have been replaced. If we find more information on that we will let you
know.
The leach area was not upgraded. It is likely 30 years old.
Susan
From:johnholloran@comcast.net jmailto:johnholloran@comcast.net1
Sent: Tuesday,January 11, 20112:46 PM
To: DelleChlale, Pamela
Cc: Sawyer, Susan
Subject: Re: I.R. - 434 Boxford Street- Scanned copy of Health Dept. File
Thanks for this. It is much appreciated.
Seem sto me that we have a "newer" system than thought. Repairs and replacement done in 1995.
Thanks again.
JH
----- Original Message
From: "Pamela DelleChiaie" <pdellech@townofnorthand over.com>
To: iohnholloranC�comcast.net
Cc: "Susan Sawyer" <ssawyerCa�townofnorthandover.com>
Sent: Tuesday, January 11, 20112:28:11 PM
Subject: I.R. -434 Boxford Street- Scanned copy of Health Dept. File
Attached is a scanned file copy of the information for 434 Boxford Street as you requested. Please call the office if you
have any further questions.
�aet,�igarrala,
Pamela DelleChiaie
Departmental Assistant I Community Development I Health Department
Town of North Andover
1600 Osgood Street I Bldg 20 I Suiten-36
North Andover,MA 01845
W Office-978-688-9540
I-aJ Fax-978-688-8476
0 Email-pdellechiaie(a to%vnofiiorthandover.com
'6 Website httD://%""v.to%vnofnorthandover,coni/Pages/index
"We cat)never see the path pf our We if we are too busy foensing on thepebbles under our feet."Anonynnnd
From: johnholloran@comcast.net [mallto:johnholloran(alcomcast nett
Sent: Tuesday,January 11, 20111:23 PM
I OF 2
DelleChiaie,Pamela
Page 10 of 11
OFFICIAL INSPECTION FORM—;NOS'FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Prdperty Address: 434 Boxford Street
North Andover,MA
Owner:Rick Tourney
Date of Inspection: 8000
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benclunarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
a
12 1z
0
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I
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10
Commonwealth of Massachusetts
City/Town of
System Pumping Record Lejrf�orms
t IVED
Form 4 If
el. `I �1 ?.010
DEP has provided this form for use by local Boards of Health. Omay be used, b the
information must be.substantially the same as that provided her0 1 'Ittlit3NbMft eck with your
local Board of Health tq determine the form they use. The Syste NWWt submitted to
the local Board of Health or-other approving authority.
A. Facility Information
1. System Location: Left side of house, Right side of house,4E 4�fro-n;'f Ouse; Right front of house,
Left rear of house, Right rear of house. Left rear of building. Right rear of building.
Address
City/Town State Zip Code
2. System Owner:
y���
Name
Address(if different from location)
Citylrown State �e
Telephone Number
B. Pumping Record
1. Date of Pumping -- 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe): ----
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No
5. Conditio of yste r ��
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatithere ontents were disposed:
L.S.D L IrWaste Water
Signatur f ut r Date
t5form4.doc•06!03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
RECEIVED
City/Town of
System Pumping Record 2009
E` Form 4
TOWN OF NORTH
DEPARTMENTER
DFP has provided this form for use by local Boards of Health. Othused, 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
Important: 7e�rear,
When filling out 1. System Location eft rof n left si of house. ight front, right rear, right side of house.
forms on the
computer,use
only the tab key Address
to move your
cursor- not
use the return City/Town State Zip Code
key.
2. System Owner:
04�-
Name
Address(if different from location)
Cityrrown Stat --
Telephone Number
B. Pumping Record --
1. Date of Pumping . Quantity Pumped:
Date Gallons
3. Type of system: Q Cesspool(s) Septic Tank Tight Tank
F1 Other(describe):
4. Effluent Tee Filter present? Yes alNo If yes,was it cleaned? 0 Yes No
5. Condition of System:
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
—SA Lowell Waste Water
igna ure of H u r Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
I
Commonwealth. of Massachusetts
RECEIVE
City/Town of i
System Pumping Record JAN 0 2 2006
Form 4
" TOWN OF
Nor
ANDOVER
HEALTF DEPAt r ENT
DSP has provided this form for use by local Boards-of Health. a Pumping ecord must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
When felling out 1. System Lo
forms onthe
computer,use �-•�\ C,��J`\
only the tab key Address
to move your ` �
cursor-do not
use lheiretum Cilyfrown State Zip Code
.key.
2. System Owner:
Name
Address(if different from location)
Cityfrown " Stat
. �—y�lam_^� Zip Cade
Telephone No`a&i
.B. Pumping Reeord
-1. Date.of Pumping Date 2• Quantity Pumped:
Gallons
3. Type of sys#ein: Cesspools) "®"peptic Tank. ❑ Tight.Tank
❑ Other(describe): —
4. Effluent Tee Filter present? ❑ Yes El–WoIf yes,was it cleaned? ❑ Yes" ❑ No
5. Condition of Systefrt::
6. System Pumped By;
Name vetiid6License Number L
Company '
7. Locatio' here cotiten#s w disposed::
Signal' e H uler Date \�J r
h.ttp://www.mass-.gov/dep/waterlapprovalt/t5forms:htm#in'spect
ISform4.doc•06103
Systeiri:Fumping Reco(d•Page 1 of 11
TOWN OF RECEIVED
SYSTEM PUMPING RECORD
DEC 0 2 2005
DATE: r✓" � TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
SYSTEM OWNER& ADDRESS SYSTEM LOCATION
(example:left front of house)
DATE OF PUMPING: .--�"' QUANTITY PUMPED : �' GALLONS
CESSPOOL: NO YES SEPTIC TANK,: NO YES
NATURE OF SERVICE: ROUTINEy EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACIMELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(El XPLAM
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste
I
Commonwealth of Massachusells
--AJ, Massachusetts
Svstem F'uinying Record
System Uwner System Location
73 1� Wc
Date of I'umpinb: •� I /c'1�J
Quantity Pumped:
gallons
Cesspool: No Yes �_� Seplic 'I'nnk: No �_� Yes
System Pumped by: Felt'edmo saam,&w License #
Contents transferrred tv : Greater Lawrence Sanitary District
Date: _--_-- — Inspector:
NEW ENGLAND ENGINEERING SERVICES
INC
4r
August 12, 2000
North Andover Board of Health
Town Hall Annex
27 Charles Street
North Andover, MA 01845
RE: TITLE V REPORT: 434 Boxford Street,North Andover
Dear Sirs:
Enclosed is a copy of the Title V report for the above referenced property. The systema}�ssed our
inspection.
If there are any questions please call me at my office, 686-1768.
Sincerely
j3�
BenjamiZ Osgood Jr., A.T.
President
1
i
60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)666-1768-(888)359-7645-FAX(978)685-1099
.
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS .
DEPARTMENT OF ENVIRONMENTAL PROTECTION
t
f f f f f
r t t r
TITLE 5
, t t
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 14 31{ $U x:i`o 2a S"T.
f)C) t2I1-t Ana 0062, ,KA
Owner's Name: R 1Ch 1'6AA N eY
Owner's Address: LA 3 q 1�0 x 1=:z>,2o S7F.
&) _ INNInxtiE 2, /YiR
Date of Inspection: _ 1410c:0
Name of Inspector: (please print)_gEnu3lRntiw C f�s�- � v 2
Company Name: A}gFw EN Gt_ftN o C-Ly(,�N�='�2w C- s E2u1 ccs :x,U
Mailing Address: 6c- t3Ec%G t-tw000 pp-.
N. �/hN D0JC-%Z. MA` Ot BIVE� <
Telephone Number: q Z$ 6 8G- i?6,
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
trainuig 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:
✓1?asses
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: (010.D
The system inspector shall submit a copy of this inspection report to the Approving Authority(Boprd of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority,
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does-not address how the system will perform In the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
,
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
t� PART A t
IrERTIFICATION(continued) .,
Property Address: 434 Boxford Street
North Andover,MA
Owner:Rick Tomney
Date of Inspection:8/3/00 „
ii
Inspection Summary: 'Check A,B,C,D or E/ALWAYS complete all of Section D
E II
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\yves,no
nally Passes:
ystem components as described in the"Conditional Pass"section need to a replaced or
r ,upon completion of the replacement or repair,as approved by the Boa of Health,will pass.
A , t termined(Y,N,ND)in the for the following stateme .If"riot determined"please
explain.
The septic tank is metals d over�0 years old*or the septic tank(� ether metal or not)is structurally
unsound,exhibits substantial unfit tion or exfiltration or tank failure is ' inert.System will pass inspection if the
existing tank is replaced with a comp ying septic tank as approved b e Board of Health.
*A metal septic tank will pass inspectio;'f it is structurally sound of leaking and if a Certificate of Compliance
indicating that the tank is less than N years Vs
is available.
ND explain:
Observation of sewage backup or break out high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or even distribution box.System will pass inspection if(with—
approval of Board of Health): '
bro�a pipe(s)are replaced'
ob ction is removed
stribution box is leveled or replaced
ND explain:
The system requ' pumping rgpre than 4 times a year due to broken or ob�stlucted pipe(s).Tlic system will
pass inspection if(wi pproval of the Board of Health): \\
broken pipe(s)are replaced
obstruction is removed
ND plain:
r ♦ . s,,.r .� " rlsS�.Yr
r r
Page 3 of 1
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
C F,RTIFICATION(continued)
Property Address: 434 Boxford Street
' North Andover,MA ' I
Owner:)(tick Tourney
Date of inspection:813100 c ,
i i I I
Further Evaluation is Required by the Board of Health:
i f f 1 1
Conditions exist which require further evaluation by the Board of Health in order to d ermine if the system
is failin to protect public health,safety or the environment.
1. Syste will pass unless Board of Health determines in accordance with 31 CMR 15.303(1)(b) that the
system not functioning in a manner which will prgtect public health,s ety and the environment:
Cesspoo or privy is within 50 feet of a surface water
_ Cesspool o rivy is within 50 feetbf a'bordering vegetated wed d or a salt marsh
2. System will fail unless the Bo'rd of Health(and Publi Water Supplier,if any)determines that the
system is functioning in a manner t t protects the pub 'c health,safety and environment:
_ The system has a septic tank and it absorpti n system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a sur cc wa r supply.
The system has a septic tank and SAS fhe SAS is within a Zone 1 of a public water supply.
The system has a septic tank and S S and-di AS is within 50 feet of a private water supply well;
r _ The system has aseptic taiik ai SAS and'the SA 's less than 100 feet but 50 feet or more from a
private water supply well".Met d used to determine dr ance
"This system passes if the 11 water analysis,.perfonned ata 11P certified laboratory,for coliform
bacteria and volatile organ' compounds indicates that the well is ee from pollution from that facility and
the presence of animoni itrogeri and nitrate nitrogen is equal to or ss than 5 ppm,provided that no other -
failure criteria are trig red.A copy of the analysis must be attached t its form.
3. Other:
r
r r
Page 4 of 11
OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i
' PART A ,
CERTIFICATION(continued) ,
'. Property Address: 434 Boxford Street f {
North Andover,MA
Owner:Rick Tomney
Date of Inspection: 813100
i D. System Failure Criteria applicable to all systems: i t
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 overloadedvor
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS o'r
cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less than'%day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply. <
j Any portion of a cesspool or privy is within a Zone 1 of a public well.
y Any portion of a cesspool or privy is within 50 feel of a private water supply well.
_X_ 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 eater quality analysis. (This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliforVi.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 dd'termined 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.
Large Systems:
To be sidered a large system the system must serve a facility with a des' flow of 10,000 gpd to 15,000
gpd•
You must indicat 'they"yes"or"no"to each of the following:
(The following criteria ly to large systems in addition to the eria above)
yes no
_ _ the system is within 400 feet o su drinking water supply
r I'
the system is within 200 f of a tributa ' a surface drinking water supply
the system is to d in a nitrogen sensitive area(In 'm Wellhead Protection Area—IWPA)or a mapped
Zone II of ublic water supply well
If you liav swered"yes"to any question in Section E the system is conside a significant threat,or answered
"yes" ' Section D above the large system has failed.The owner or operator of any a system considered a
significant threat under Section E or failed under Section ID shall upgrade the system in a dance with 310 CMR i
15.304.The system owner should contact the appropriate regional office of the Department.
A
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOP,VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST ;
Property Address: 434 Boxford Street r i
North Andover,MA :
Owner: Rick Tourney
Date of Inspection:8/3/00 i
Check if the following have been done.You must indicate"Yes"for"no"as to each of the following:
Yep, No -
Pumping information was provided by the owner,occupant,or Board of Health
_j/ Were any of the system components pumped out in the previous two weeks?
V — Has the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently oras part of this inspection?
_ &A 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 sigds 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?
_ Wad the facility owner(and occupants if different from owner)provided rith information on the proper
maintenance of subsurface sewage disposal systems?
Tlie size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
Existing information.For example,a plan at the Board of Health..
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))
I
• Page 6 of 11 � '1 -. • + . ...,'_�,-.{_�``'`-3'-�<' �'
. y
OFFICIAL INSPECTION FORM--NOT FJDR VOLUNTARY ASSESSMENTS
iSUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
""STEM INFORMATION ;
Property Address: 434 Boxford Street
± North Andover,MA `
Owner:Rick Tomney
Date of Inspection:8/3/00 ,
rLvW CONDITIONS
RESIDENTIAL ` ' '
Number of bedrooms(design): •-- Number of bedrooms(actual): i i
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): ---�
Number of current residents: q I
Does residence have a garbage grinder(yes or no): ND
Is laundry on a separate sewage system(yes or no):-W [if yes separate inspection required]
Laundry sy9tem inspected(yes or no): -
Seasonal use:(yes or no):6/-O
.Water mete+r readings,s,if:available last 2 years usage(
d))
iF
4 V
Sump pump(yes or no),
/V
Last date of occupancy: e-V VZG;,v'
COMMERCIAL/INDUSTRIAL
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 ,
Pumpingiecords
Source of information: –t t -Iq P'=I2 t30f+R C> o►- 1A I4L71I
Was system pumped as part of the inspection(yes or no):�u
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)
_hmovative/Altem�t�ve 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:
GU 141— 1ei&4
Were sewage odors detected when arriving at the site(yes or no):
Page I!of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C.
SYSTEM INFORMATION(continued) "
Property Address: 434 Boxford Street `_ 1
North Andover,MA
Owner:Rick Tomney
Date of Inspection:8/3/00 i
,
BUILDING SEWER(locate onisite plan) i i t
Depth below grade: 6
Materials of construction: cast iron _40 PVC_other(explain):
Distance from private water supply well or suction line: . 3o'
Comments(on condition of joints,venting,evidence of 1i akage,etc.):
SEPTIC TANK:_(locate onisite plan)
Depth below grade:
Material of construction:_✓.concrete_metal fiberglass_polyethylene
_other(explain)
If tank is metal list age:i Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: i,y Qa !,til i-t.oAj S
Sludge depth: ) " ,
Distance from top of sludge to bottom of outlet tee or baffle: 3.3
Scum thickness:, I j r
Distance from top of scum to top of outlet tee or baffle: : a
Distance from bottom of scum to bottom of outlet tee or baffle: 15`
How were dimensions determined: 6!1,g7AS 0 i2t:- e,71 e 14
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.): '
T-h-rJ tA-, t Aj 0 V- ry N D %TI o N. • 2 E C 0- t_L-►4-'i t a m
e2 F R 1��C'25 TV w%T1-t t n� h'` d c= r=I A,)(
GREASE TRAP:Nk(locate-on site plan)
Depth below grade:_
Material of construction:_,concrete`metal ' fibeiglass_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 dutlet tee orbagie:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Page 8 of 11
OFFICIAL INSPECTION FOAM--NOT FOR VOLUNTARY ASSES�MENTS .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ;
PART C .
SYSTEM INFORMATfON(continued)
' Property Address: 434 Boxford Street
North Andover,MA
Owner:Rick Tomney _
Date of Inspection:8/3/00 #
+ i
TIGHT or HOLDING TANK: (tank mpst 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; a
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,ete.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Conmients(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.): : ' '
p,vX tti) lsarrV eon9ra %-TNoA1 . r7+sr�K�'Tto� t=���� . ,vD
kFVVc�CA9c.L of 1.a'/l)�lG?L►-l: 1w� 0 r 004-105-
PUMP
o4-tDsPUMP CHAMBER: 1/tit(locate on site pian)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
f
_ A
14
Page 9 of 11 t r r t3,L,
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY`ASSESSMENTS ;
f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ;
PART C r
BVI INFORMATION(continued) ;
Property Address: :434 Boxford Street
North Andover-,MA i
:Owner:Rick Tomney
Date of Inspection: 8/3/00
` SOIL ABSORPTION SYSTEM(SAS): (locate on site'p)an,excavation not required)
If SAS not located explain why:
TYp�
leaching pits,number:_
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions: rtt io moo' X K�
overflow cesspool,number:_
iumovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of pOndhig,damp soil,condition of vegetation,
etc.):
CESSPOOLS:AJA(cesspool must be pumped as part of inspection)(loeate 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: ij r' (locate on site plan)
Materials of con§.truction: ;
Dimension4: r ,
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
i
1
( r 1 f f j:ifs'• it� r� � •
. Page 11 Gf l l
OFFICIAL-INSPECTIOIN FORM—. NOT FOR VOLTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIQN FORM
PART C
` CVSTfi,M INF6RMATION(continued)
Property Address: 434 Boxford Street
North Andover;MA
Owner:Rick Tomney
Date of Inspection: 8/3/00
i
SITE EXAM
Slope Z 70 s
Surface water No NC;
Check cellar ,V0 p
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained -
e from system design plans on record If checked,date of design plan reviewed:
_%e'�*'Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-{attach documen(ation)
v,'Accessed USGS database-explain: fZ r!nj .tit,+p5
You must describe how you established Elie high ground water elevation:
GiUf t.- 15,Q '-LAaPS \N n i c 04-Er" r,".t
• 5 1 Piz--Ps o F F� T'o s i 2.c 44 O%a iv -n-(t4/1.j to
T'. • T__.._ ell r/.IAA^ t
MERRIMACK ENGINEERING SERVICES, INC,
PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS
66 PARK STREET • ANDOVER, MASSACHUSETTS 01810 • TEL.(508)475-3555, 373-5721 • FAX(508)475-1448
January 24, 1996 �,s'`'` R
N4@+j�A,
0v
Ms. Sandra Starr
Board of Health
Town Hall Annex
120 Main Street
North Andover, MA 01845
RE: 434 Boxford Street Owner: Robert DeWolfe
Subsurface Sewage Disposal System Inspection
Dear Ms, Starr:
In regard to the septic inspection conducted December 5, 1995, and inspection report dated
December 14, 1995, for the subject property, please be advised that the existing septic tank has been
repaired by Stewart's Septic Service.
The subsurface disposal system now, passes the inspection as per the DEP Subsurface Sewage
Disposal System Inspection Form, Part A, Certification.
Please include this letter with your file for the property and feel free to contact me at this office
should you have any questions or comments.
Very truly yours,
MERRIMACK ENGINEERING SERVICES
---_. Ger%
Les Godin
Title V System Inspector
cd
cc: Mr. Robert DeWolfe
MERRIMACK ENGINEERING SERVICES, INC,
PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS
66 PARK STREET • ANDOVER. MASSACHUSETTS 01810 • TEL.(508)475-3555, 373-5721 • FAX(508)475-1448
January 22, 1996 1
ON
ko
Ms. Sandra Starr 1.1
Board of Health
Town Hall Annex
120 Main Street
North Andover,MA 01845
RE: 434 Boxford Street Owner: Robert DeWolfe
Subsurface Sewage Disposal System Inspection
Dear Ms. Starr:
In regard to the septic inspection conducted December 5, 1995, and inspection report dated
December 14, 1995, for the subject property, please be advised that the existing septic tank has been
repaired by Stewart's Septic Service.
The subsurface disposal system will now, with your approval, pass the inspection as per the DEP
Subsurface Sewage Disposal System Inspection Form, Part A, Certification.
Please include this letter with your file for the property and feel free to contact me at this office
should you have any questions or comments.
Very truly yours,
MERRIMACK ENGINEERING SERVICES
Les Godin
Title V System Inspector
cd
cc: Mr. Robert DeWolfe
Commonwealth of Massachusetts --.. '_ %`{ gal
too Executive Office of Environmental Affairsi RCH P"�
f N�9�N�A�
Department of �° j,,,;r ,
• Environmental Protection [A,, _ , 0y
Wllllarn F.Weld
ciowrnor - �j.J
Trudy toxo
sar tW C-OEA
Davld B.Struhs
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 143L{ BOXI'OIZD 9r, 1.10. Akjh6V1rlZ,, MA- Address of Owner: P_4,&f5ET Mwd/.FE.
Date of Inspectioa: 12-S 95 . (If different) Z I L✓AT]60JY (✓Ay
Name of Inspector: 1,IE'5 GDDt1.l t'l►At?L trill, rIA,. olgyq
Company Name,Address and Telephone Number: M15IL2.IMr1CK. E7)461 I kjIFMw& Sp�evlces
66 PA2I:!� O-.T-
AlleovEQ. N1A• 01$16
CERTIFICATION STATEMENT 502 0 L475-3S5.�-
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function►and
maintenance of on-site sewage disposal systems. The system:
_ Passes
Conditionally Passes
— Needs Further Evaluation By the Local Approving Authority
_ Fails '
Inspector's Signature: Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 Department of Environmental Protection.
The original should be sent tc tier ysteni owner and copies ser; to the buyer, if applicable and the approving au!hority.
INSPECTION SUMMARY:
Check A, B, C, or 0:
A) SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
III SYSTEM CONDITIONALLY PASSES:
VYSOne or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
Indicate yes no, or not determined (Y, N;or NO). Describe basis of determination in all instances. If"not determined', explain why not)
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exAltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
(revised 8/15/95) 1
One Winter Street o Boston,Massachusetts 02108 a FAX(617)5W1 049 a Telephone(617)292-5500
• C,G. 12-r5=9S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: L 3q &>YF017-0 Sj '
Owner: pCwo1,F�
Date of Inspection:
B]SYSTEM CONDITIONALLY PASSES(continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health):
broken pipes) are replaced
obstruction is removed
distribution box is levelled or replaced
_ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
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 the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ The vstem has a septic tank and soil absorption system and is within IOU feet to a surface water supply or tributary to a
surface water supply.
_ The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
y
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
._
supply well, unless a well water analysis 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.
D] SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
_ Backup of sewage into facility or system component due to an 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.
(revised B/15/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 2A.5L( E3�XF6Q. ) Si r
Owner. DGc r:GE�
Date of Inspection:
131 SYSTEM FAILS (continued): '
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 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
_, Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
EJ LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The design flow of system is 10,000 gpd or greater (La(ge System) and the system is a significant threat to public health and safety
and the environment because one or more of the following conditions exist:
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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 8/15/95) 3
/ f.
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
TOwneProperty Address: L43Lj gdX}clZ.p ST-
Owner
r.
Date of Inspectiom
Check if the following have been done:
(/ Pumping information was requested of the owner, occupant, and Board of Health,
V/None of the system components have been pumped for at least two weeks and the system has been receiving normal flow raft
during that period. large volumes of water have not been introduced into the system recently or as part of this inspection.
NL As built plans have been obtained and examined. Note if they are not available with N/A.
t//The facility or dwelling was inspected for signs of sewage back-up.
✓The system does not receive non-sanitary or industrial waste flow
L//The site was inspected for signs of breakout.
V/All system components, excluding the Soil Absorption System, have been located on the site.
I/ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees, material of construction, dimensions, depth of liquid,depth of sludge, depth of scum.
V The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
The facility owner land occupants, if d?Heren.! from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 8/2S/95) 4
l_•G,. 17.rc.<7�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: zqSq pOX FOR D !g7
Owner.
Date of Inspection:
FLOW CONDITIONS ,
RESIDENTIAL:
Design flow:3' p gallons(ASSUVIPD)
Number of bedrooms:,Z
Number of current residents:
Garbage grinder (yes or no):E
Laundry connected to system(yes or no):-)�
Seasonal use(yes or no):161-
Water meter readings, if available: l�
Last date of occupancy:(:(JfZfl�iLsr
COMMERCIAUINDUSTRIAL:_
Type of establishment: WIA
Design flow:____gallons/day
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:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
kleuEZ AYWAISL6
System pumped as part of inspection: (yes or no)
If yes, volume pumped: -750: gallons • \
Reason for pumping: Tb 11(SPECT C'o1 iD)T1a1 ( OFTA)-SK CS7itvG'(t�MGL�(J1
TY�F 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)
Other(explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information: 1 qeZ &I gr . As WV-Q"'rFL
Sewage odors detected when arriving at the.site: (yes or no)
(revised 8/15/95) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: qSZ{ P=OXfbRZ ST-
Owner:
Date of Inspection:
SEPTIC TANK:
(locate on site plan) .
Depth below grade:�� �7R c°�£2,
Material of construction. _concrete_metal _FRP other(explain)
1560 GA _. COM . , kR0Ggs7"
Dimensions: L= 10' W= lo' I.uV. = S0"
Sludge depth:_
Distance from top of sludge to bottom of outlet tee or baffle: ZO�
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 ba(fle:�T T wf_ T� tou-)
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity,evidence of leakage, etc.) lLuerC 6uTTCr TF--:S oor) c'oJ(p
L i q u)n v— t' PTH u )-JY— O t?..S _ I3C C.9t I_r Uc �4 015A r-
A-r }'1"1 Ot= 1-r AV_ ('P 14ES t Mt�tE ftoz\ t Sig t0 1-J
fL\4 bTTtC RoL,) 66EtuC toLj 1,01J &4611 oFvsE
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction: _concrete_metal _FRP—other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom r f rilm M bottom of outlet tee or baffle:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 8/;5/951 b
I � '
Z•c;. rz-ts•�c
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: ((fit( BoXFOIZD ST
Owner. t-�
Date of Inspection:
TIGHT OR HOLDING TANK:J)f A
(locate on site plan)
Depth below grade:
Material of construction: _Concrete metal_FRP other(explain)
Dimensions:
Capacity: Ralions
Design flow: Sallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:v 36 '
(locate on site plan)
Depth of liquid level above outlet invert: Liv,
Comments:
(note if level and distribution is equa!, evidence of solids ca!n•over, evidence of leakage into or out of box, etc.)
p- o Gema&' 54LO " Tb ; (Cr JJ4 S.j-, < 1.46( - Of= v 4 w
O:C 16FCLLIZ.Vr Fowwp - D-Boy, (-LT-4 S'-r (M(16v IOLr
(zu) I 62vALS i vIlo f Wo VtV �Jee OF OLLb(u BAS
PUMP CHAMBER:WA
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 8/25/95) 7
LG. 12-)r-fr
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 113L.( �DX Fa1—Q
Owner.
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) '
If not determined to be present, explain:
Type:
leaching pits, number:_
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions: 20'X q9 MPRo)(�
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
LAO SIG)js of Fc c.t, — A•S. IAPP941ZS To Avg H0p 1-
CESSPOOLS:
(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(cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 8/).5/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: y34 BOXC'OR-b 9T
Owner: DEwoc.Fe
Date of Inspection: 12-S c)-
SKETCH OF SEWAGE DISPOSAL SYSTEM: .
indude ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
OV
2b►
1�10 wi?�G S Fovu D,
wtTw)�l
100,
wALr---
uo
14.5' gp° v G mwnok..
1Li S 31 .3
zo' p' G✓E%G
DEPTH TO GROUNDWATER
Depth to groundwater.L•� _ feet Coe 6a'-,'eq)
method of determination or approximation: row OF ARY i0MA�is?GFTNT17i �t vr3 Le— IS zl S ' girl�►�
6(>ADE e,b-& SSvmg 2101 v IS- , p-ro
LOX W
Adotu4 :- .b ' L
v{ ,u ce Liv t !
(revised 8/15/95) 9
�•�. I2•rs=�s-
12/03/2010 08:03 9783528236 C M ROLLINS CO INC PAGE 01101
ashoba
Analyl tcal, LLC Tel,979-3914428 Fax:978-391-4643 LBbNumber, 118264
31A Willow Rm,d,Ayer MA 01432 Website:ht www.NasiobaAtial tical.com �- - Use this number wid,all M,r
y // lrespcmdcnce
CPn�1,
Charles M.Rollins Co., Inc. ReportDate: 12/2/2010
126 Depot Road
Boxford, MA 01921
Celilificate Pf Analysis
Lot#3 Berry Street, North Andover MA
Parameter Method Result MCL MRL Date of Anal,
.Vsiq Analyst
Wellhead
Samplod:11/2912010 4:$0:00 PM Gy Cllent
Total Collform Bacteria,11 00ML MF-SM9222B 0 0/Absent 0 11130/2010 10:30:00 AM M-MA1118
Calcium,MG/L EPA 200.7 28.9 Not Spec 1 11/30/2010 M-MA1118
Copper,MG/L EPA 200.7 NO 1.3 0.01 11/30/2010 M-MAI118
Iron,MG/L EPA 200.7 0.2 0.3 0.01 11/30/2010 M-MA1118
MagnesiuM,MG/L EPA 200.7 2.7 Not Spec 1 11130/2010 M-MAI118
Manganese,MG/L EPA 200.7 0.019 0.05 _ 0.005 11/30/2010 M-MA1118
tedium,MG/L EPA 200.7 _ q _ -See Note___ 1_- . i 91/30/2010 M-MA1118
Alkalinity,MG/L SM 23206 75 Not Spec 1 11/30/2010 M-MAI118
Ammonia,MG/L SM 4500-NH3-D ND Not Spec 0.1 11/30/2010 M-MA1118
Chloride,MG/L EPA 300-0 8.4 250 1 11/30/2010 M-MA1118
Chlorine,Free Residual,MG/L SM 4500-CL-G 0,2 Not Spec 0.02 11/30/2010 M-MAI118
Calor Apparent,Cu SM 2120D 10 15 1 11/30/2010 M-MA1118
Conductivity,UM-10$/CM SM 2510B 230 Not Spec 1 11/30/2010 M-MA1118
Hardness,Total,MG/L SM 234013 84 Not Spec 2 11/30/2010 M-MA1118
Nitrate as N,MG/1- EPA 300,0 NO 10 0.05 11/30/2010 M-MAI118
Nitrite as N,MG/L EPA 300.0 NO 1 0.01 11/30/2010 M-MA1118
Odor,TON SM 2150B 1 3 0 11/30/2010 M-MAI118
pH,PH AT 25C SM 4500-H43 &1 6.5-8.5 NA 11/30/2010 M-MAI118
Sediment,poalneg — MEG -- MEG 11130/2010 M-MAI118
Sulfate,MG/L EPA 300.0 14.8 250 1 11/30/2010 M-MA1118
Turbidity,NTU EPA 180.1 2.9 Not Spec 0.1 11/3012010 M-MA1118
MCL,Maximum Contaminant Level(EPA Limit),MRI. Minimum Reporting Level
Sodium GUrdelines-Mass 20,EPA 250, #=Result Exceeds Limit or Guideline
ND=None Detected(aMRL), *=Background Bacteria Noted
Massachusetts Certified David L.Knowlton
Laboratory#M 41118 Laboratory Director Page i of 1
b� Commonwealth of Massachusetts
City/Town of
System Pumping Record rded
I�CE11�w
Form 4
/ G
DEP has provided this form for use by local Boards of erg f�n iay b used, but the
information must be substantially the same as that proere. Before using th form, check with your
local Board of Health to determine the form they use. A T N d must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Locationnt of house, ight front of house, left side of house, right side of house, Left
rear of house, righ Cr side of building, right rear of building, under deck.
Cityrrown State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town Stat4-7,,
_6 r, r,Kipgode
Telephone Numberr/J
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition Of System:
0
& System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Lo * n where contents were disposed:
.L.S.D. Lowell Wastefflater
Signature 9f 06urr Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
1
; . ._..
� .
._ i
{ 4�
i
MERRIMACK ENGINEERING SERVICES, INC.
PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS
66 PARK STREET • ANDOVER, MASSACHUSETTS 01810 • TEL. (508)475-3555, 373-5721 FAX(508)475-1448
January 24, 1996
V�N OF
SO BOA
Ms. Sandra Starr
Board of Health
Town Hall Annex
120 Main Street
North Andover, MA 01845
RE: 434 Boxford Street Owner: Robert DeWolfe
Subsurface Sewage Disposal System Inspection
Dear Ms. Starr:
In regard to the septic inspection conducted December 5, 1995, and inspection report dated
December 14, 1995, for the subject property, please be advised that the existing septic tank has been
repaired by Stewart's Septic Service.
The subsurface disposal system now, passes the inspection as per the DEP Subsurface Sewage
Disposal System Inspection Form, Part A, Certification.
Please include this letter with your file for the property and feel free to contact me at this office
should you have any questions or comments.
Very truly yours,
MERRIMACK ENGINEERING SERVICES
P �
Les Godin
Title V System Inspector
cd
cc: Mr. Robert DeWolfe
}
MERRIMACK ENGINEERING SERVICES, INC.
PROFESSIONAL ENGINEERS • LAND SURVEYORS • PLANNERS
66 PARK STREET • ANDOVER, MASSACHUSETTS 01810 • TEL. (508)475-3555, 373-5721 FAX(508)475-1448
January 22, 1996
Ms. Sandra Starr �►� �'"
Board of Health j
Town Hall Annex
120 Main Street
North Andover, MA 01845
RE: 434 Boxford Street Owner: Robert DeWolfe
Subsurface Sewage Disposal System Inspection
Dear Ms. Starr:
In regard to the septic inspection conducted December 5, 1995, and inspection report dated j
December 14, 1995, for the subject property, please be advised that the existing septic tank has been
repaired by Stewart's Septic Service.
The subsurface disposal system will now, with your approval, pass the inspection as per the DEP
Subsurface Sewage Disposal System Inspection Form, Part A, Certification.
Please include this letter with your file for the property and feel free to contact me at this office
should you have any questions or comments.
Very truly yours,
MERRIMACK ENGINEERING SERVICES
x,& `
Les Godin
Title V System Inspector
cd
cc: Mr. Robert DeWolfe
. . . ='�
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
F N
Department of � �
• Environmental Protection r \_�g 5�
WllBam F.Weld
Trudy Coxe
U.-Y.EDEA
David S.Sttuhs
Com n aamm
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 1439 8cxFo2p 9T—, Wo. AijzovEV—; MR- Address of Owner. P6615Z-r-" DE WOLM
Date of Inspectioo: IZ-S-95 . (If different) Z 1 (✓ATLi,j-S L.,WV
Name of Inspector: LES Gobi l.f F't t QAZE�'b1.!, hI A, O I q y 9
Company Name, Address and Telephone Number: M15IZ2(M►ACK- SIFIZVICi—�S
66 PA2L. ST
A)JbD 95e, t-IA" 01810
CERTIFICATION STATEMENT SOS—LI7S-3555
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
_ Passes
Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection.
The original should be sen; to ti,r %sten, owner and copies ser,; to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D:
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
ei SYSTEM CONDITIONALLY PASSES:
VYSOne or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
Indicate yes, no, or not determined (Y, N;or ND). Describe basis of determination in all instances. If"not determined", explain why nod
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
(revised 8/15/95) 1
One Winter Street • Boston,Massachusetts 02108 • FAX(611)556-1049 • Telephone(617)292-WW
C.G. Iz-rs 9s
40 Printed on Recycled Papa < —
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: L1 3 q BDX Fb i2 D S'
Owner: DEwOI XI-
Date of Inspection: i2-S-9S
e)SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
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 the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT
THE SYSTEM 15 FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ The cvctem hes a septic tank and soil absorption system and is within IOU feet to a surface water supply or tributary to a
surface water supply.
_ The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a well water analysis 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.
D) SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacoed to determine what will be necessary to correct
the failure.
Backup of sewage into facility or system component due to an overloaded or dogged 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.
(revised 8/15/95) Z
C-4. f2-►s-qs
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: BbxFof?-D Si
Owner. Dec, r;LEf=
Date of Inspection: 2 S-
D)SYSTEM FAILS (continued):
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 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E]LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety
and the environment because one or more of the following conditions exist:
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 11 of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 8/15/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: L43q &6XJ:GJZS�
Owner. Dt`wOLF�
Date of Inspection:
Check if the following have been done:
1 pumping information was requested of the owner, occupant, and Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
NL As built plans have been obtained and examined. Note if they are not available with WA.
(/ The facility or dwelling was inspected for signs of sewage back-up.
✓The system does not receive non-sanitary or industrial waste flow
The site was inspected for signs of breakout.
ZAII system components, excluding the Soil Absorption System, have been located on the site.
V The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
Mees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
V The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
V /The facility ov.ner (and occupants, if differen! from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 8/15/95) 4
L-Gi 12-�s-qs
' Z
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: LIS Z4 BoxfGIiD
Owner. D�FLL)DZ.'F E
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow:�llons(Assvtqt5o)
Number of bedrooms: //
Number of current residents: ( ( IDA`/IWC)
Garbage grinder(yes or no):E
Laundry connected to system (yes or no):--,/—
Seasonal use (yes or no):&L- \
Water meter readings, if available: q (d,u SI-V wffL 1
Last date of occupancy:
COMMERCIAUI NDUSTRIAL:
Type of establishment: N/A
Design flow: aallons/day
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:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
kfokiL AyAf&AW--'
System pumped as part of inspection: (yes or no)
If yes, volume pumped: 7SO t gallons - \
Reason for pumping: Tb IUSPEG' CWJW I ib1._( OF TA)-;K.(STWCalma�
TYP/F 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)
Other(explain)
APPROXIMATE AGE of all components, date installed (if known)and source of information: _l'QgZ �l-�5� AS' pj�Z
Sewage odors detected when arriving at the site: (yes or no)
(revised 8/15/95) S
Z.-Gi. f2-�S9S I
' II
I
K
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 3y p0XfoR u ST-
Owner. IIaJOC.F�
Date of Inspection:
SEPTIC TANK:
(locate on site plan) ,
Depth below grade:21 l f� eTIZ .
Material of construction: oncrete_metal _FRP—other(explain)
i Sbo e_cA,_. cou , lr wcAsr Ew . 'fi se-s
Dimensions:
Sludge depth ,
Distance from top of sludge to bottom of outlet tee or baffle: ?O
Scum thickness:_ Lc
Distance from top of scum to top of outlet tee or baffle: Zi (l�� f�a�' vEL)
Distance from bottom of scum to bottom of outlet tee or baffle:�T —'�v� Ta �� -14utp t�Vt=(�
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in-relation to outlet invert, structural
integrity,evidence of leakage, etcl) ,UeUTC�`r T� /,00 c'o,t,.r D o
L.(Q v)D tCV- f . f PTi-iOF u TA)-JY- gA 2 4 63✓ C FFA lu u AT-
A-r-
f-fi i,xTt of u ,A(L PW'f+12-9 t"W E FRK\ t us t o )-_(
iFfZ CoL,) Liter tuC "Box OUE Tb C.Tc„r C 4.; GIG oFuSE
GREASE TRAP:_Pt
(locate on site plan)
Depth below grade:_
Material of construction: _concrete_metal _FRP—Other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottor* M srij- }* bottom of outlet tee or baffle
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 8/15/95) 6
ss-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 4jL4 l3DX F0R.D S F
Owner.
Date of Inspection:
TIGHT OR HOLDING TANK:W/A
(locate on site plan)
Depth below grade:
Material of construction: _concrete_metal_FRP other(explain)
Dimensions:
Capacity: gal Ions
Design flow: aallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:v
(locate on site plan)
Depth of liquid level above outlet invert: ec&ko w\/,
Comments:
(note if level and distribution i! equa!, evidence of so!ids care-over, evidence of leakage into or out of box, etc.)
I)- uJ G(FT-m- t<,� p�.E -M " 41 u S.'T—& < l.4cIL of �3 77 w
n 1. 1 k'1') Fo(cu40 1 Lk 1)- -Ec Y, -(c,' L,,L7 4 C./,a ZE 19T(I( dv loj 1
F(.au) I 64b-.N 1S c'Li10L1 6115 r~ O Eve2QJ46 OF VOLLbfif114C A
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 8/15/95) 7
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: Z(3 Z-{ B' X FDfLD S
Owner: pEwCX IFE
Date of Inspection: 12-S-qS
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type.
leaching pits, number:_
leaching chambers, number._
leaching galleries, number:
leaching trenches, number,length: ,
leaching fields, number, dimensions: ZO'X 44 9 fpvzX>
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
UO Ej6kfS &F F C.v(LC Q.A.S. A W, (L-9 TO pvC� wfl &T 7 F74e p+POS
CESSPOOLS: �Pt
(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 ground•sater:
inflow (cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc)
(revised 8/15/95) 8
r
PRINTED BY: Pamela DelleChiaie-PLEASE LEAVE IN PRINT-OUT TRAY.......THANK YOU.
DelleChiaie, Pamela
From: johnholloran@comcast.net
Sent: Tuesday, January 11, 20112:46 PM
To: DelleChiaie, Pamela
Cc: Sawyer, Susan
Subject: Re: I.R. -434 Boxford Street-Scanned copy of Health Dept. File
Thanks for this. It is much appreciated.
Seem sto me that we have a "newer" system than thought. Repairs and replacement done in 1995.
Thanks again.
JH
----- Original Message -----
From: "Pamela DelleChiaie" <pdellech townofnorthandover.com>
To: net
Cc: "Susan Sawyer" <ssawyer townofnorthandover.com>
Sent: Tuesday, January 11, 2011 2:28:11 PM
Subject: I.R. - 434 Boxford Street - Scanned copy of Health Dept. File
Attached is a scanned file copy of the information for 434 Boxford Street as you requested. Please call the office if you
have any further questions.
aa;%944 ,
Pamela DelleChiaie
Departmental Assistant I Community Development I Health Department
Town of North Andover
1600 Osgood Street I Bldg 20 1 Suite 2-36
North Andover,MA o1845
2 Office-978-688-9540
R Fax-978-688-8476
El Email-pdellechiaieotownofnorthandover.com
''F5 Website hnp://www.townofilorthandover.com/Pages/index
"We can never see the path of our life if we are too busy focusing on the pebbles under our feet."--Anonymous
From:johnholloran0comcast.net Lmailto:johnholloran0comcast.netl
Sent: Tuesday, January 11, 2011 1:23 PM
To: Sawyer, Susan
'Subject: Holloran - 434 Boxford street
Xan - thanks so much for your time and information earlier today. It is very much appreciated.
`u have my email address. If you could send along a scan of the file seeing that it is so thin, it
much appreciated.
I IOF2
DelleChiaie,Pamela
r
PRINTED BY:Pamela DelleChiaie-PLEASE LEAVE IN PRINT-OUT TRAY.......THANK YOU.
DelleChiaie, Pamela
From: Sawyer, Susan
Sent: Tuesday, January 11, 2011 4:09 PM
To: 'johnholloran@comcast.net'; DelleChiaie, Pamela
Subject: RE: I.R. -434 Boxford Street-Scanned copy of Health Dept. File
It looks as though the tank was replaced.The 1995 report notes that the tank was leaking,then in 2000 the 1500 gallon
tank was noted as fine. Hence I believe it must have been replaced. If we find more information on that we will let you
know.
The leach area was not upgraded. It is likely 30 years old.
Susan
From:johnholloran@comcast.net[mailto:johnholloranCa)comcast.netj
Sent:Tuesday, January 11, 20112:46 PM
To: DelleChiaie, Pamela
Cc: Sawyer, Susan
Subject: Re: I.R. - 434 Boxford Street- Scanned copy of Health Dept. File
Thanks for this. It is much appreciated.
Seem sto me that we have a "newer" system than thought. Repairs and replacement done in 1995.
Thanks again.
JH
----- Original Message -----
From: "Pamela DelleChiaie" <pdellech(a-)townofnorthandover.com>
To: net
Cc: "Susan Sawyer" <ssawyer(aD-townofnorthandover.com>
Sent: Tuesday, January 11, 20112:28:11 PM
Subject: I.R. -434 Boxford Street - Scanned copy of Health Dept. File
Attached is a scanned file copy of the information for 434 Boxford Street as you requested. Please call the office if you
have any further questions.
fiat a3rgwrda.
Pamela DelleChiaie
Departmental Assistant I Community Development I Health Department
Town of North Andover
1600 Osgood Street I Bldg 20 1 Suite 2-36
North Andover,MA o1845
2 Office-978-688-954o
Fax-978-688-8476
Email-,pdellechiaie(@townofnorthandover.com
Website hnp://www.townofnorthandover.com/Pages/index
e can never see the path of our life if we are too busy focusing on the pebbles under our feet."--Anonymous
a.johnholloran@comcast.net Lmailto:johnholloran@comcast.net1
Tuesday,January 11, 2011 1:23 PM
I IOF2
DelleChiaie,Pamela
ti
.. 7 Y
•Page 10 of 11
OFFICIAL INSPECTION FORM—;NO)'FOR VOLUN'T'ARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 434 Boxford Street
North Andover,MA
Owner:Rick Tomney
Date of Inspection:8/3/00
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.
a
a
F-lD0sc: 12IZIUC
b
�a.
1 .
Title 5 Inspection Form 6/15/2000 10
Commonwealth of Massachusetts
City/Town of
System Pumping Record RECEIVED
Form 4
JUL 'I 4 2010
DEP has provided this form for use by local Boards of Health_ CO) er forms may be used, b the
information must be,substantially the same as that provided her MYNEP J1R�VIiBldit Hirt eck with your
local Board of Health tQ determine the form they use. The Syste submitted to
the local Board of Health or--outer approving authority.
A. Facility Information '—�
1. System Location: Left side of house, Right side of house 9_ef�i`6nt of hsj use, Right front of house,
Left rear of house, Right rear of house. Left rear of building. Right rear of building.
Address
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State �� // -Q gaqe/
Telephone Number �iy-j Co
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned?
-1 Yes ❑ No
5. Condit' yste vpf -m oj
y
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati _ .whe .- ontents were disposed:
L.S.D L aste Water
Signatur f H6u.T
r Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts Zormsmayy
ED
City/Town of
System Pumping Record
20
09
Form 4
TOWN AfdDOVEft
RTMENT
DEP has provided this form for use by local Boards of Health. Othused, 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
Important:
When filling out 1. System Location eft cont rear, left si of house. . 'ight front, right rear, right side of house.
forms on the
computer,use
only the tab key Address
to move your 1–f
cursor-do not
use the return Citylrown State Zip Code
key.
___ 2. System Owner:
Name
Address(if different from location)
CitylTown Statei,.—� --Zip C.� 2�
Telephone Number
B. Pumping Record
1. Date of Pumping2. Quantity Pumped:
Date Gallons
3. Type of system: 8 Cesspool(s) Septic Tank Tight Tank
Ej Other(describe):
4. Effluent Tee Filter present? Yes No If yes,was it cleaned? 0 Yes [j No
5. Condition of System:
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
SS.D Lowell Waste Water
� - 5�—[ � _�
igna ure of H u r Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth. of Massachusetts RECE]ANDVER
City/Town of
System Pumping Record JAN o
w.
FOCItI 4 TOWN OF NORT
HEALTH DEP
DEP has provided this form for use by local Boards of Health. e s ecord must
be submitted to the local Board of Health or other approving authority. .
A. Facility Information
Important: -
When filling out 1. System Location:
fomes the C�.� K
&�computetor,use c-"'v` �
only the tab key Address
to move yourfR
cursor-do not l- <---� • V
use th&return Cityrrown State I Zip Code
key.
2. System Owner:
Name
Address(if different from location
Crtyfrown Stat
"6 _ Zip Cade
Telephone Number
.B. Pumping. Record
1. .Date of Pumping Date 2. Quantity`Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) epticTank- ❑ Tight_Tank:
El Other(describe).:
4. Effluent Tee Filter present? ❑ Yes [3-lqo If yes, was it cleaned? ❑ Yes:'F] No
5. Condition of System:
6. System Pumped By;
PLAti l
Name Vehicle License.Number
Company
7. Locatio here contents w disposed::
^f
Signat e H uler Oate
http://www.mass.gov/dep/waterlapprovals/t6forrns htm#inspect
t5fomi4.doc•06/03
System Pimping Record•Page t of 1
i
TOWN OF /V- RECEIVED
SYSTEM PUMPING RECORD DEC 0 2 2005
�� /)✓�� TOWN OF NORTH ANDOVER
DATE: ��// c.� HEALTH DEPARTMENT
SYSTEM OWNER&ADDRESS SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING. �� ='"" QUANTA PUMPED : ` 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 LEACIIFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTIIER(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste
I
i
Commonwealth of Massachusetts
Massachusetts
System Pumping Record
System Owner System Location
._.
1 a �7 WCC
Date of Pumping: 7� I� �9� Quantity Pumped:,/ cyo gallons
Cesspool: No Yes Septic Tank: No Yes
System Pumped by: Faredort Sita7ftaa License#
Contents transferrred to : Greater Lawrence Sanitary District
Date: ____ Inspector.
NEW ENGLAND ENGINEERING SERVICES t
INC
{� a ^
August 12, 2000
North Andover Board of Health
Town Hall Annex
27 Charles Street
North Andover, MA 01845
RE: TITLE V REPORT: 434 Boxford Street,North Andover
Dear Sirs:
Enclosed is a copy of the Title V report for the above referenced property. The systemap ssed our
inspection.
If there are any questions please call me at my office, 686-1768.
Sincerely
13�
BenjamitfC. Osgood
President
60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099
Y
COMMONWEALTH OF MASSACHUSETTS �� {
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
r 1
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: - 4 3 4 s3 x:t`o 20 S'T.
/1?o R�1-tn1
Owner's Name: Q 1 C1i, To M N EY
Owner's Address: '-13 Li Bax Fz7,Zs� ST.
D ck�J C 2 /VlF1
Date of Inspection: 01--3/0C,
Name of Inspector: (please print) P�cnrSlf}nn1n, C t�sC�-ems v 2
Company Name: A)Evy EN CG1.fTN O EQ1(�N�'7:(ZW C- sE2�►c.rS �.v c_
Mailing Address: 3 EL%G i-r W 000 pp--
/V-
l2,_/U_ '/-\,v t>ooc%z2 ntA' ota-\,t' ;
Telephone Number: q7&-, 686- 17&e
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:
✓Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: (/ Date: 1010'D
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1 - _
f( C w
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT'S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CRRTIFICATION (continued)
Property Address: 434 Boxford Street .
North Andover,MA
Owner:Rick Tomney
Date of Inspection:8/3/00
F i
Inspection Summary: Check A,B,C,D tor 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. stem Conditionally Passes:
_ On or more system components as described in the"Conditional/needd to a replaced or
< repaired.The stem,upon completion of the replacement or repair,as apa of Health,will pass.
Answer yes,no or not termined(Y,N,ND)in the for the followingot determined"please
explain.The septic tank is metal d overZO years old*or the septic tank( not)is structuralYy
unsound,exhibits substantial infil tion or exfiltration or tank failure is ' ent.System will pass inspection if the
existing tank is replaced with a comp ing septic tank as approved b e Board of Health.
*A metal septic tank will pass inspection' it is structurally sound of leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years Id is available.
ND explain:
Observation of sewage backup or break out h` static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or even distrt'bution box. System will pass inspection if(with
approval of Board of Health):
broke pipe(s)are replaced
ob ction is removed
stribution box is leveled or replaced
ND explain:
c�
The system requ" pumping more than 4 times a year due to broken or ob cted pipe(s).Tl a system will
pass inspection if(wi pproval of the Board of Health):
'z.
broken pipe(s)are replaced
obstruction is removed
ND plain:
Title 5 Inspection Form 6/15/2000 2
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ;
PART A
rF,RTIFICATION(continued)
Property Address: 434 Boxford Street
North Andover,MA
Owner:Rick Tomney
Date of Inspection:8/3/00
Further Evaluation is Required by the Board of Health: ;
Conditions exist which require further evaluation by the Board of Health in order to d _ermine if the system
is failin to protect public health,safety or the environment.
1. Syste will pass unless Board of Health determines in accordance with 31 CMR 15.303(1)(b)that the
system not functioning in a manner which will protect public health,s ety and the environment:
Cesspoo or privy is within 50 feet of a surface water
Cesspool o rivy is within 50 feet of a'bordering vegetated well d or a salt marsh
2. System will fail unless the Bo d of Health(and Publi Water Supplier,if any)determines that the
system is functioning in a manner t t protects the pub 'c health,safety and environment:
_ The system has a septic tank and it absorpti system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a sur ce wa r supply.
The system has a septic tank and SAS the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and S and th AS is within 50 feet of a private water supply well.
The system has a septic tank a SAS and the SA is less than 100 feet but 50 feet or more$oma "
private water supply well**.Me d used to determine di ance
**This system passes if the 1 water analysis,.performed at a EP certified laboratory, for coliform
bacteria and volatile organ' compounds indicates that the well is ee from pollution from that facility and
the presence of ammoni itrogen and nitrate nitrogen is equal to or ss than 5 ppm,provided that no other
failure criteria are trig red.A copy of the analysis must be attached t is form.
3. Other:
i
Title 5 Inspection Form 6/15/2000 3
Page 4 of 11 . R '
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS <
SUBSURFACE SEWAGE DISPOSAL SYSTEM_INSPECTION FORM
PART A
o CERTIFICATION(continued)
Property Address: 434 Boxford Street ;
North Andover,MA
Owner:Rick Tomney
Date of Inspection:8/3/00
i D. System Failure Criteria applicable to all systems: j c
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'/Z day flow
_)L 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.
�c Any portion of a cesspool or privy is within 50 feet of a private water supply well.
—g_ 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 coliforT.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 ddtermined 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.
Large Systems:
To be sidered a large system the system must serve a facility with a des' flow of 10,000 gpd to 15,000
gpd•
You must indicat 'ther"yes"or"no"to each of the following:
(The following criteria ly to large systems in addition to the teria above)
yes no
— —
the system is within 400 feet o s drinking water supply
— — the system is within 200 f of a tributa a surface drinking water supply
— — the system is to d in a nitrogen sensitive area(In ' Wellhead Protection Area—IWPA)or a mapped
Zone II of ublic water supply well
If,you hav wered"yes"to any question in Section E the system is conside a significant threat,or answered
" es" ' Section D above the large system has failed.The owner or operator of any a system considered a
significant threat under Section E or failed under Section D shall upgrade the system in a dance with 310 CMR
15.304.The system owner should contact the appropriate reg`lonal office of the Department.
4
Title 5 Inspection Form 6/15/2000
MIT
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B ,
CHECKLIST
Property Address: 434 Boxford Street
North Andover,MA
Owner:Rick Tomney
Date of Inspection:8/3/00
Check if the following have been done.You must indicate"yes"for"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?1
_ Has the system received normal flows in the previous two week period?
v/Have large volumes of water been introduced to the system recently oras part of this inspection?
A 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 sigrfs 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?
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:
Yes no
: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) [3 10 CMR 15.302(3)(b))
Title 5 Inspection Form 6/15/2000 5
( f.
Page 6 of 11 f
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
::SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
r �
""STEM INFORMATION
Property Address: 434 Boxford Street
North Andover,MA
Owner:Rick Tomney
Date of Inspection: 8/3/00
rt.0 W CONDITIONS
RESIDENTIAL
Number of bedrooms(design): -- Number of bedrooms(actual):3i i
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Number of current residents:A
Does residence have a garbage grinder(yes or no): t!1 D
Is laundry on a separate sewage system(yes or no): IJ0 [if yes separate inspection required)
Laundry system inspected(yes or no):=
Seasonal use:(yes or no):
Water meter readings,if available(last 2 years usage(gpd)): UuE t- .-
Sump pump(yes or no)
Last date of occupancy: CJ ago avT
COMMERCIAL/INDUSTRIAL
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
PumpingRecords
Source of information: -11 to I aq P I2 &V o R o o i- �'�t��►�-(
Was system pumped as part of the inspection(yes or no):�i9
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)
Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if known)and source of information:
k3U(L"r CIcgN
Were sewage odors detected when arriving at the site(yes or no): L
6
Title 5 Inspection Form 6/15/2000
Page 7 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTAI$Y ASSESSMENTS <
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
F PART C-
SYSTEM INFORMATION(continued)
Property Address: 434 Boxford Street '
North Andover,MA
Owner:Rick Tourney
Date of Inspection:8/3/oo
t
BUILDING SEWER(locate onjsite plan)
Depth below grade: 6
Materials of construction:_cast iron _40 PVC_other(explain):
Distance from private water supply well or suction line: ; 3o'
Comments(on condition of joints,venting,evidence of leakage,etc.):
17 i QLD �o a V,S Croo \iv g t45t/Vt��ti t
SEPTIC TANK:_(locate onsite plan)
Depth below grade: S
Material of construction:_;/Concrete_metal_fiberglass_polyethylene
_other(explain)
If tank is metal lost age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: i 6 c>0 G t4 b Lo,v S
Sludge depth: ) 'f
Distance from top of sludge to bottom of outlet tee or baffle: 33
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: 15
How were dimensions determined: 6L&g-AS 011 s'R c IA'
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
_ _T-f+Q tA, 1 AJ 01<= r y N D M o iy iZ t C'D o�
r�F �ZkSsj fL5 TV THkn,. h`•. ter= C,-aa
GREASE TRAP:Nk(locate-on site plan)
Depth below grade:
Material of construction:_concrete_metalfiberglass_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.):
S t S t 5
Title 5 Inspection Form 6/15/2000 7
Page 8 of 11
OFFICIAL;INSPECTION FORM= NOT FOR VOLUNTARY ASSESSMENTS .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C .
f SYSTEM INFORMATiON.(continued)
Property Address: 434 Boxford Street
North Andover;MA
Owner:Rick Tomney _
Date of Inspection:8/3/00
r
TIGHT or HOLDING TANK: (tank mpst 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: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: b
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.):
y,-D Eng 1.9-x4)h l4G—1 1 a! O 2 . o,.T 0(2-
PUMP
2 PUMP CHAMBER: A4 (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
i
Title 5 Inspection Form 6/15/2000 8
Page 9 of 11 `
OFFICIAL" INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ;
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
'BVI IN.-FORMATION(continued)
Property Address: 434 Boxford Street
North Andover,MA
1 Owner:Rick Tomney
Date of Inspection:8/3/00
SOIL.ABSORPTION SYSTEM(SAS): (locate on site`plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions: X 40,
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.):
CESSPOOLS:AZA(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.):
i s i
Title 5 Inspection Form 6/15/2000 9
. Page 11 bf 11
i
OFFICIAL-INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENT'S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
'qVSTP.M INFORMATION(continued)
Property Address: 434 Boxford Street
North Andover;MA
Owner:Rick Tourney
Date of Inspection: 8/3/00
SITE EXAM
Slope Z o�
Surface water A,-o Ne
Check cellar M p ivy p
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
__%,!�_Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Healtlr-explain:
Checked with local excavators,installers-(attach documentation)
v'Accessed USGS database-explain: 5,, rz')ESI M.-P5
You must describe how you established the high ground water elevation:
5€ 11- SLaD10'-� IAA(?5 \N0IA .kn-12 � lv•c� bP�Jw �srC•�afl
P2 O'Sb/_"CAI f S D 2`i' e.
• S rzi P 2--p5• o F F T-0siY2 Fi p.z Tt't�f iy
i
i
c
1
Title 5 Inspection Form 6/15/2000 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 2131-1 eo x FO R-D ST
Owner. DEwoc,EE
Date of Inspection: 12-S-q S
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two penrnanent references landmarks or benchmarks
locate all wells within 100'Q�,
Za'+ A�SpclG
Qo weizs 5owiD, I I ( I
'wAL
uo
)4.5' RD° v rh71e�.
i '
g S�rr�4 rr2
f
Zo Ae w L
DEPTH TO GROUNDWATER
Depth to goundwater.6- feet(ot?GaFate2)
method of determination or approximation: 66-1—- d� Dti2�( (' col (�\/�GF7l�TEr�� S+.�r)L 1S �/•S &XoL,-)
6QADE AgSvME -w•t .O'
(revised 8/15/95) 9
L.G- IZ-/Sgt i