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Miscellaneous - 444 SALEM STREET 4/30/2018 (2)
I 444 SALEM STREET E 210/037.6-0053-0000.0 to � 1 k l ` G L 3 3 Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 444 Salem street �r Property Address Beverly Spicer - - Owner Owner's Name information is required for every North Andover MA 01886 June 11 2014 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information `'on the computer, use only the tab 1. Inspector: JUN 17 2014 key to move your cursor-do not John DiVincenzo OF NogTHuse the return ]TOWN - i key. Name of Inspector _ EALTH,DEPARTMENT Stewarts Septic Serive r� Company Name 58 South Kimball street Company Address Bradford MA 01835 City/Town State Zip Code 978-372-7471 S113386 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ® Conditionally Passes ❑ Fails 7Nes Further Evaluation by the Local Approving Authority to Sign Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 444 Salem street Property Address Beverly Spicer Owner Owner's Name information is required for every North Andover MA 01886 June 11 2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 444 Salem street Property Address Beverly Spicer Owner Owner's Name information is required for every North Andover MA 01886 June 11,2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): dist box leaking around outlet inverts. ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 444 Salem street Property Address Beverly Spicer Owner Owner's Name information is required for every North Andover MA 01886 June 11,2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 444 Salem street Property Address Beverly Spicer Owner Owner's Name information is required for every North Andover MA 01886 June 11 2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form. ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. El ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply El ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts u - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 444 Salem street Property Address Beverly Spicer Owner Owner's Name information is North Andover MA 01886 June 11 2014 required for every , page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 444 Salem street Property Address Beverly Spicer Owner Owner's Name information is required for every North Andover MA 01886 June 11 2014 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ® Yes ❑ No Last date of occupancy: Occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °- 444 Salem street Property Address Beverly Spicer Owner Owner's Name information is required for every North Andover MA 01886 June 11 2014 page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Stewarts Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons gallons How was quantity pumped determined? Site guage on truck Reason for pumping: inspect tank Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 444 Salem street Property Address Beverly Spicer Owner Owner's Name information is required for every North Andover MA 01886 June 11,2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 14 years Were sewage odors detected when arriving at the site? El Yes ® No Building Sewer(locate on site plan): Depth below rade: P 9 14" feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 6"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 444 Salem street Property Address Beverly Spicer Owner Owner's Name information is required for every North Andover MA 01886 June 11,2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 29 Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? tape measure & sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Bith tees in good shape, liquid levels good no leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts u v Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 444 Salem street Property Address Beverly Spicer Owner Owner's Name information is required for every North Andover MA 01886 June 11 2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 444 Salem street Property Address Beverly Spicer Owner Owner's Name information is required for every North Andover MA 01886 June 11 2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box coroaded around outlet inverts. sand coming into box, needs replacing, no solids carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 444 Salem street Property Address Beverly Spicer Owner Owner's Name information is required for every North Andover MA 01886 June 11,2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2-50' ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No hydraulic failure, no ponding, no damp soils. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 444 Salem street Property Address Beverly Spicer Owner Owner's Name information is required for every North Andover MA 01886 June 11 2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments cw 444 Salem street Property Address Beverly Spicer Owner Owner's Name information is North Andover MA 01886 June 11 2014 required for every , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ and-sketch in the area below Lff drawing attached separately i I � e c - 1 TAW gg � z i 166 �l/ r t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 444 Salem street Property Address Beverly Spicer Owner Owner's Name information is required for every North Andover MA 01886 June 11 2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 48 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 9-5-2000 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: pulled files ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Taken from plans 9-5-2000 water at elevation 90.9 bottom of bed 94.43 aprox 4' above water table. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments tiM 444 Salem street Property Address Beverly Spicer Owner Owner's Name information is required for every North Andover MA 01886 June 11 2014 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts W City/Town of North Andover System Pumping Record wM Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from _e-p,u-wir g date in accordance with 310 CMR 15.351. RECEIVE® A. Facility Information JUN 17 2014 Important:When filling out forms 1. System L ca io TOWN OF NORTH ANDOVER on the computer, ���; HEALTH DEPARTMENT NT' use only the tab `'e - - key to move your Address cursor-do not North Andover Ma 01886 use the return key. City/Town State Zip Code 2. System Owner: �0 (C-C Name reran I Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping / 2. /`� p g clb Date Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) ,Septic Tank ❑ Tight Tank ❑ Grease Trap j ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If-yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: -C� C�(`rle ti Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart'sPre-treatment re treatment Plant 20 So. Mill Bradford Ma 01835 Signature of / V e o g'Facility Date t5 •03/06 System Pumping Record•Page 1 of 1 ..5� T— PUBLIC HEALTH DEPARTMENT Town of North Andover Coi-nmunity Development Division CERTIFICATE OF ' COMPLIANCE As of: 6/26/2014 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Complete Repair of D-Box By: John DiVincenzo At: 444 Salem Street Map 037.B Lot 0053 thA ndover, MA 01845 Th s anc f this ce t hall not e onstrued as a guarantee that the system will function satisfactorily. ch&e Grant Public Health Agent BLEJCOPY 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com A ..ter*-.."„yam • p RATED At4�,I North Andover Health Department (ommunity Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 444 Salem St. MAP: 037.13 LOT: 0053 INSTALLER: John DiVincenzo DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS INSPECTION: 6/26/14 D-Box DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6” stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROLPANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION-BOX Installed on stable stone base X H-20 D-Box Inlet tee (if pumped or >0.087foot) Hydraulic cement around inlet & outlets X Observed even distribution ©/ Speed levelers provided (not required) []' Schedule 40 PVC Pipe Comments: 3 leaks in pipes, 1 at the joint of the outlet pipe as well as seepage going into D-box. 2"d outlet pipe has s epage at pipe entering the d-box. Re- inspect. byl v� , ,� � .°..�:Y:� • t ' ° Commonwealth of Massachusetts Map-Block-Lot BOARD OF HEALT ----------------------- H Permit No North Andover -------------------- FEE ------------ --- FEE ----1-7--5-------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted ------- sr_ _ _____t s - .�.•- --- -- ----------------------------------------- to(Repair)an Individual Sewage Disposal System. (� atNo -------------------- -`/-�/---------5-;0 �, -- -----------s----- ✓'__�� --------------------- as shown on the application for Disposal Works Construction Permit No. Dated Issued On: ------------------- �AL B N°RTS Application for Septic Disposal System AIM M •S1, '�� '�' •� o� DATE ° -Construction Permit - TOWN OF TODAY'S s^, . ,�'•' $ 250.00—Full Repair ORTH ANDOVER , MA 01845 �aSAC/tt1`��4 $125.00 -Component Important: Application is hereby made for a permit to: When filling out - ❑ Construct a new on-site sewage disposal system* forms on the computer,use ❑ Repair or replace an existing on-site sewage disposal system* only the tab key to move your [:Repair or replace an existing system component—What? cursor-do not use the return key. A. Facility Information VV—.1t Address or Lot# 1�1 City/Town 2.-*TYPE 4 SEPTIC SYSTEM*: ❑ Pump [9 Gravity (choose one)- d***If pump system,attach copy of electrical permit to application*** Conventional System(pipe and stone system) ❑ Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D-Box)(Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D-Box Present)S.A.S. 2. Owner Information Name'� 7 / Address if different froabove) City/ S ate Zip Code Telephone Number 3. Installer.Information dtJl�/beefI s. S'� - ' � N'Z Name o ompany Address Z ' oC YX City/Town Zip Code �2��2/ iq2 � goy q 7 �- Telephone Number(Cell Phone#if possible please) 4. Desiqner Information Name Name of Company Address City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 °ATN Application for Septic Disposal Svstem I Of s.Bio , '�q0 3� �' -• �� =Construction Permit - TOWN OF TODAY' DATE ORTH ANDOVER MA 01845 $ 250.00—Full Repair $125.00-Component s� se PAGE 2 OF 2 A. Facility Information continued.... 5. Type of Building: []Residential Dwelling or❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of No rt n ov r, not t place the system in operation until a Certificate of Compliance has bee s e by hr Bo d of Health. e Date Application proved By: ( of Health Representative) Name Date plic on Disapor t e following reasons: For Office Use Only: 1. Fee Attached? Yes No 2. Project Manager ObEgation Form Attached? Yes No 3. Pump Svstem? If so,Attach copy of Electrical Permit Yes No 4. Foundation As-Built?(new construction ronly): Yes No (Same scale as approved plan) 5. Floor Plans?(new construction only): Yes No Application for Disposal System Construction Permit•Page 2 of 2 A SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: (Address of septic system) For plans by / �/� (Engineer) Relative to the application of �O/tJ c� V 1Uc��/ (Installer's name) Rnd dated Dated / rigina ate I(Io sdate-T- With revisions dated (Last revised date) I understand the following obligations for management of this project: 1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner,contractor,project manager,or any other person not associated with my company schedules an inspection and the system is not ready,then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection,without completion of the items in accordance . with Title 5 and the Board of Health Regulations may result in a$50.00 fine being levied against me and/or my company. a. Bottom of Bed-Generally, this is the first (V5 inspection unless there is a retaining wall,which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection—Engineer must first do their inspection for elevations, ties, etc. As-built of verbal OK (or e-mail to: healthdept(@townofnorthandover.com) from the engineer must be submitted to the Board of Health,after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system,all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade—Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation)and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible. 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board of Health staff or consultant. d. Installation of tank, D-Box,pipes, stone, vent,pump chamber, retaining wall and other components. 6. As the installer,I understand that I am solel-y responsible for the installation of the system as per the approved 121ans. No instructions b4 th t homeommuer. dneral contractor, or aLly other persons shall absolve me of this obligation. — Undersigned Undersigned Licensed Septic Installer: L (Today's Date) T (� I N GY,/V:2o arae—Print (Mme—Signed) I TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE s , DATE OF COMPLIANCE: 9/13/00 This is to certify that the individual subsurface disposal system constructed O or repaired (X) by Mike Reilly at 444 Salem Street has been installed in.accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. d Board of Health Inspector f TOWN OF NORTH ANDOVER SEWAGE DISPOSALY S STEM INSTALLATION CERTIFICATION Tu dersigned hereby certify that the Sewage Disposal System ( ) constructed-, ( The by-- , located at !r�L-C"1 was installed in conformance with the North Andover Board of Health approved plan, System Design Permit # dated with an approved design flow of gallons per day. The materials used were in conformance with those specified on the approved plan; the system was installed in accordance with the provisions of 310 CMR 15.000, Title 5 and local regulations, and the final grading agrees substantially with the approved plan. All work is accurately represented on the As-built which has been submitted to the Board of Health. Bed inspection date: Engineer Represintlitive Final inspection date: Engineer Representat e Installer: _� Lic.#: Date: a-/f.60 Design Engineer: AS-BUILT CHECKLIST LOT NUMBER, STREET NAME ASSESSORS RS MAP &PARCEL NUMBER SS LOT LINES &LOCATION OF DWELLINGS �J4 71t� LOCATIONS &DIMENSIONS OF SYSTEM, INCLUDING RESERVE TIES TO LOT LINES & DWELLING, WELLS a. FROM SEPTIC TANK / b. FROM LEACH AREA LOCATIONS OF DEEP HOLES & PERC / TESTS ELEVATIONS OF DISPOSAL SYSTEM TOP OF FDN ELEVATION J LOCATIONS OF WELLS, DRAINS, WATERCOURSES WITHIN 150' OF SYSTEM LOCATION OF WATER, GAS, ELECTRIC LINES, CABLE DISTANCES FROM CORNERS OF HOUSE TO CENTER OF TANK&D-BOX ORIGINAL STAMP & SIGNATURE IMPERVI A V IMPERVIOUS AREAS - DRIVEWAYS, ETC. NORTH ARROW LOCATION&ELEVATIONS OF BENCHMARK USED ti INSPECTION CHECKLIST FOR SEPTIC SYSTEMS Yes NO Initials A. Bottom of Bed 1. Excavation to proper depth 2. With trenches,sides of excavation are beneath B horizon 3. Edge of excavation specified distance from foundation,etc. Comments: B. Retaining Wall 1. Wall height and width as speci 2. Waterproofed 3. Wall minimum 10'to leaching facile 4. Wall meets specifications of plan Comments: C. Building Sewer 1. Pipe diamet4 minimum 4" 2. Schedule 40 pipe 3. Watertight joints 4. Inlet to tank cemented 5. Slope minimum 0.01 or 1/8"per foot minimum 6. Pipe properly set on compact firm base 7. Pipe laid on continuous grade in straight line 8. Cleanouts precede all change in alignment and grade 9. Manholes at any 90°change 10. 10' minimum offset to water line Comments: D. Septic Tank 1. Level 2. 1,500 gal minimum 3. Gas baffle present on outlet 4. Manhole to grade 5. Manholes over center and each tee 6. 3-20"manholes 7. Inlet tee minimum 12"under invert 8. Outlet tee minimum 14"under invert 9. Outlet line cemented 10. Air space 3"above tees 11. 2"-3"drop from inlet to outlet 12. Pipe set 13. Compact base with 6"of 1/4"crushed stone under tank 14. Tank is watertight Comments: /1 E. Pump Chamber Yes NO �/ 1. If separate from tank,compact base with 6"of "st a underneath 2. Minimum 2"pipe to d-box if gravity system 3. 20"access manhole 4. Tank level 5. Watertight 6. Tank size agrees with plan specification 7. Manhole to grade 8. Check valve and bleeder hole present 9. Alarm in building on separate circuit 10. Alarm functions 11. Manual operating switch 12. Pump delivers liquid to d-box Comments: F. Distribution Box 1. D-box level 2. Minimum 0.1 T'(2")drop from inlet to outlety- 3. Minimum 6"sump 4. Outlet pipes show equal distribution 5. Compact base with 6"of stone beneath box 6. Box is watertight ` 7. All lines cemented with hydraulic cement 8. Schedule 40 pipe 1/ Comments: G. Soil Absorption system '7 L pv e- 1. All stone double-washed-% 1 ''/z" r -pea stone- Bucket test done? 2. Minimum 2"of pea stone above distribution lines 3. Minimum 6"stone beneath pipe 4. Distribution lines capped or connected together, O J 3 U 5. Grading meets 3:1 slope 6. Minimum of 9"of fill graded over system 7. Toe of slope stops minimum 5' from edge of property; if not,then swale. Comments: H. Leach Trenches 1. Minimum 2 trenches 2. Length of trenches agree with plan. (Max.length 100') 3. Width of trenches agree with plan-Minimum 2';maximum-4'. i-< ` eY 4. Vent present if<50 feet or specified fes` 5. Distance between trenches minimum 4'and maximum of 6' -= 6. Minimum distance between trenches 10' 7. Pipe slope minimum 0.005 or 6"per 100' 8. Depth of trenches below outlet invert minimum of 6". `� 9. Pipes set on stable base. Yes NO Comments: 1. Leach Field 1. Maximum length of field 100' 2. Pipe slope minimum 0.005.or 6"per 100' 3. Separation between pipe 6'maximum 4. Pipes connected at end 5. Separation between adjacent fields 10'minimum 6. Pipes set on stable base 7. Maximum 4' separation from edge of field to first line 8. Minimum two distribution lines 9. Maximum perc rate 20 mpi Comments: I Leaching Pits 1. Minimum inletpipe 4" 2. Pits of concrete 3. Sidewall between 12"and 48Xcem 4. Access manholes on each pit 5. Pipes cemented with hydrauli Comments: K. Final Grade I. Slope over soil absorption system minimum 0.02 2. All system components covered by at least 9"soil 3. Cover soil free of stones larger than 6" 4. Grading slopes away from dwelling 5. No areas over system that may pond Town of North Andover, Massachusetts F°""No.a NORTh BOARD OF HEALTH • t /� y al o m � '°•,:.o��^'`� DISPOSAL WORKS CONSTRUCTION PERMIT 9SSACHUSEt 6 r AppIican AME D ESS TELEPHONE Site Location Permission is hereby granted to Construct ( ) or Repair ( an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CHAI N,BOARD OF HEALTH Fee D.W.C. No. INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the property atA' relative to the application of dated for plans by i l ,, c@nd dated _(DQ with revisions dated I understand and agree to the following obligations for management of this project: 1. As the installer I am obligated to call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system is not ready then item two shall be applicable . 2. As the installer I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against my company. a) Bottom of Bed—generally first inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. b) Final Inspection—Engineer must first do their inspection for elevations,ties,etc. As-built or verbal OK from engineer must be submitted to BOH after which installer calls for inspection time. Installer must be present for this inspection. With pump system all electrical work must be ready and able to cause pump to work and alarm to function. c) Final Grade—Installer must request inspection when all grading is complete. Does not have to be on site. `.y 3. As the installer I understand that persons or companies not associated with my company may not perform the work required by my company to complete the installation of the system identified in the attached application for installation. I further understand that work by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system, and/or revocation or suspension of my license in the Town of North Andover plus significant fines to all persons involved. 4. As the Installer I understand that I must be on site during the performance of the following construction steps: a) Determination that the proper elevation of the excavation has been reached b) Inspection of the sand and stone to be used. c) Final inspection by Board of Health staff. d) Installation of tank,D-box,pipes,stone,vent,pump chamber,retaining wall and other components. 5. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer Date: — APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERI IIT DATE: ck �---c_ Cti-RRENT LNSTALLER'S LICENSE, LOCATION: 4 e\.em , LICENSED L`i-ST ULER: F SIGNATURE: TELEPHONEm CM g. 47 is o cE:ECX ONE: REPAIR: NEW CONSTRUCTION: IF NEW CONST'UCTION, PLEASE ATTACH FOUNNDATION AS-BUILT. Administrative Use Only 575.00 Fee Attached? Yes ✓ No Foundation As-Built? Yes No Floor Plans? es No Approval Date: 2! o v Aug-03-00 09:30A Paul D. Tut-bide, PE/PLS 978-465-0313 P.02 s August 3, 2000 Sandra Starr North Andover Board of Health Administrator Office of Community Development and Services 30 School St. North Andover,MAO 1845 RE: Title V review for 444 Salem Street Dear Sandra, Enclosed find the"Checklist for North Andover Septic System Plans"for the above- mentioned site. The following is a list of all the `Problem' areas and deficiencies Port Engineering has found. o The easterly property boundary and abutter's name has not been identified on the plan dated 4-4-00 as prepared by Merrimack Engineering Services. (3 10 CMR 15.220(4)(a)and NA 8.025. o Final grading on east side of Trench 1 does not satisfy the requirements of CMR 310 15.211(1)[4]. Minor changes in grading will be needed to provide a 15' offset to the slope. o The proposed finish grade of 97.5' +/-does not provide the minimum cover of 9" over the proposed septic tank as required by CMR 15.228(1). If you have any questions or comments please feel free to contact me. Sincerely PORT Paul D. Tutfiide,PE/PLS ENGINEERING Civil Engineers& Land Surveyors One Hurriv Street Newburyport,MA 01950 (978)465-8594 C 1 Server MA8Mp28841Salem Street 444—MAMMA= Of NORTFI�� Town Of North Andover Community Development & Services William J. Scott « * 27 Charles Street Director(978)688-9531 - -•.,'' ' North Andover, Massachusetts 01845 Fax 978-688-9542 August 3, 2000 Board of Appeals Bill Dufresne . (978)688-9541 Merrimack Engineering Services 66 Park Street Building Andover, MA 01845 Department (978) 688-9545 Re: 444 Salem Street Conservation Dear Mr. Dufresne: Department (978) 688-9530 The proposed design for the septic repair at the above-referenced site has technical deficiencies that must be addressed before the plans can be approved. Health They are as follows: Department (978)688-9540 The easterly property boundary and abutter's name has not beef identified. (3 10 CMR 15.220(4)(a) and NA 8.02) Public Health IV`W'j Final grading on the east side of Trench 1 does not satisfy the requirements of Nurse 978 688-9543 o CMR 310 15.211(l)(4). ( ) The proposed finish grade of 97.5' +/- does not provide the minimum cover Planning of 9"over the proposed septic tank as required by CMR 310 15.228(1). Department (978) 688-9535 Please keep in mind that all resubmittals require a$60.00 fee. Feel free to call the office if you have any questions. Sincerely, Sandra Starr,R.S., C.H.O. Health Director Cc: M. Lundgren File 7/<It Aug-16-00 04:31P Paul D. Turbide, PE/PLS 978465-0313 P.02 August 16, 2000 Sandra Starr North Andover Board of Health Administrator Office of Community Development and Services 30 School St. North Andover,MA 01845 RE: Title V Review for 444 Salem Street Revision Dear Sandra, I find that the design plan with a revision date of August 7,2000 adequately addresses the concerns outlined in my report dated August 3,2000. If you have any questions or comments please feel free to contact us. For Port Engineering Associates, Inc Paul D. Turbide,PE/PLS PDT ORI ENGINEERING Civil Engineers& Land Surveyors One Harris Street Newburyport,MA 01950 (978)465-8594 1lserver1pinabh128841Salem444rev.doc p►ORTH Town Of North Andover Community.Development & Services William J. Scott p Director 27 Charles Street (978)688-9531 *A"°► • `'�' North Andover, Massachusetts 01845 43SACHO`��t Fax 978-688-9542 Board of August 17, 2000 Appeals (978)688-9541 Bill Dufresne Building Merrimack Engineering Department 66 Park Street (978)688-9545 Andover, MA 01810 Conservation Department Re: 444 Salem Street (978) 688-9530 Health Dear Bill: Department (978)688-9540 This is to inform you that the revised septic system plans dated 08/7/00 for the site referenced above has been approved for repair. Public Health Nurse (978) 688-9543 Variances given: Planning 1. Depth to ground water Department (978) 688-9535 Because of the variance there can be no addition of rooms to this house unless on sewer. If you have any questions, please do not hesitate to call the Board of Health Office at 978-688-9540. Sincerely, Sandra Starr,R.S., C.H.O. Health Director SS/smc cc: Spicer File I I �, .. t i I Wo ----�---- M�� �li� rc I'P)e 1. ro 1p A/ y .N . SL N A k y 2�' 111 F kki. 0 { p r ���,�,�f a. ee ee�r�c�i� FORM - U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approval/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. APPLICANT �1 e d� ,J . j` PHONE (� 7 4 i .. ASSESSORS MAP NUMBER LOT NUMBER Z,R SUBDIVISION -LOT NUMBER STREET _ � C ivy c� �_e. STREET NUMBER OFFICIAL USE ONLY �. l..■ .................................................... ................. OMNIENDATIONS OF TOWN AGENTS I DATE APPROVED CONSERVATION ADMINISTRATOR ` DATE REJECTED COMMENTS DATE APPROVED TOWN PLANNER DATE REJECTED i COMMENTS I DATE APPROVED F OD INSPECTOR-HEALTH DATE REJECTED /�-_-/ . . t'( DATE APPROVED SEPTIC INSPECTOR-HEALTH DATE REJECTED COMMENTS t /<� A% I i i i PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED FIR$DEPARTMENT DATE REJECTED i COMMENTS RECEIVED BY BUILDING INSPECTOR DATE Grp �I N 0 '; (capecitabine) A ' ! .464 A t re s �0 f F q D • � j�X36' �'� „ S pool // V 7 6 _..cam h v, ... Y3-038 IF T �orn� l�••! ..w/J`�ir a./i mon:''�� /. �, . is 4•.f t • FORM - U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all-necessary approval/permits from Boards.and Departments.having jurisdiction have been obtained. This does not relieve the applicant and or l=downer from compliance with any applicable requirements. so............................................■.............................■ APPLICANT r PHONE i% -S e ASSESSORS MAP NUMBER R '-I LOTNUMBER D .� SUBDIVISION LOT NUMBER STREET �-el �� � STREET NUMBER .■.............................■ ■...................../........arm..ado....■ OFFICE USE ONLY OE RECO VvIENDATIONS OF TOWN AGENTS •••••••••••••• g•�• ••••••• •• - DATE APPROVED CONSERVATION ADMINISTRATOR DATE REJECTED COMMENT'S DATE APPROVED TOWN PLANNER DATE REJECTED CON DAENTS DATE APPROVED FOOD INSPEQTOR-HEALTH DATE REJECTED DATE APPROVED /12-�'�� ~?SE.. C 1149ACTdR-HEALTH DATE REJECTED CONMIENTS /�'f a i vaz a.-` w � - �'a/I i 1�� ... -" -t- PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT DATE APPROVED FIRE DEPARTMENT DATE REJECTED CON PvJENTS RECEIVED BY BUILDING INSPECTOR DATE FORM - U - LOT RELEASE FORM INSTRUCTIONS: This form.is used to verify that all-necessary approval/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. APPLICANT ef/• S 1 C'er PHONE &0�' 3P �-3F ASSESSORS MAP NUMBER LOT NUMBER _ SUBDIVISION LOT NUMBER STREET STREET NUMBER `L`L OFFICIAL USE ONLY RECOMMENDATIONS OF TOWN AGENTS DATE APPROVED CONTSERVATION ADME41STRATOR �IQ� fDATE REJECTED COMMENTS C0U DATE APPROVED TOWN PLANNER DATE REJECTED CONIIy1ENTS DATE APPROVED FOOD INSPECTOR-HEAL�� -- DATE REJECTED DATE APPROVED SEP SPE -BR2NLTH DATE REJECTED COMMENTS PUBLIC WORKS-SEWER 1 WATER CONNECTIONS DRIVEWAYPERMIT DATE APPROVED FIRE DEPARTMENT DATE-REJECTED COMMENTS RECEIVED BY BUILDING INSPECTOR DATE i Town of North Andover, Massachusetts Form No.Z' • poR*h BOARD OF HEALTH o � P DESIGN APPROVAL FOR Ss4CMU5f� SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM p. Applicant Test No. Site Location I" `T" Reference Plans and Sp s. r ENGINEER IGN DATE Permission is granted for an individual soil absorption sewage disposa stem to be installed in accordance with regulations of Board of Health. S• z HAIRMAN,BOARD OF'-HEA LTH Fee �j� Site System Permh'No:'�� SEPTIC PLAN SUBMITTAL FORM LOCATION: NEW PLANS: $125.00/Plan REVISED PLANS: YES $60.00/Plan SITE EVALUATION FORMS INCLUDED: NO DATE: 7- DESIGN ENGINEER: DATE TO CONSULTANT: *If you want your plans expedited, please submit four plans and included a stamped y�a� envelope with the correct amount of postage to mail plans to Port Engineering. When the submission is all in place,route to the Health Secretary. PAGE 1 OF 5 Commonwealth of Massachusetts Application for Local !Upgrade-Approval� Title 5, 310 CMR 15.000 DEP Approved form required by 310 CMR 15.403(1) To be submitted to Local &wroving Authority/Board of Health: For the upgrade of a failed or nonconforming system with a design flow of <10,000 gpd, where full compliance, as defined in 310 CMR 15.404(1), is not feasible. To be submitted to DEP: For the upgrade of a failed or nonconforming system with a design flow of 10,000 up to 15,000 gpd and/or for upgrade of a state or federal facility, where full compliance, as defined in 310 CMR 15.404(1), is*not feasible. NOTE: Local upgrade approval shall not be granted for an upgrade proposal that includes the addition of new design flow to a cesspool or privy or the addition of new design flow above the existing approved capacity of a system constructed in accordance with either the 1978 Code or 310 CMR 15.000. 1) Facility/system owner Name t21 k- j-,t4tW26aN Ad ' Phone Address of facility ti�1' 2) Applicant'(if different from above) Name ''fit- 0- Address Phone # 3) Type of facili - _1� esidential _commercial _school _ institutional i (specify) JUL ,V0 I DE!ARROVED FORM-t2WM PAGE 2 OF 5 4 Type of existing system yp s) conventional system _privy cepoo Other (describe) Type of soil absorption system (trenches, chambers, pits,etc.) F 5) Design flow based on 310 CMR 15.203 a) Design flow of existing system�J gpd Approved? _fires approval date Ll�i�►L no why? b) Design flow of proposed upgraded system 34v gpd c) Design flow of facility gpd 6) Proposed upgrade of existing system is a) </Voluntary Required by order, letter, etc. (attach copy) Required following inspection required by 310 CMR 15.301 (provide date inspection form was submitted to the approving authority) (date) F b) .Describe the proposed upgrade to the system C.e . e f% 2 1—n71ic �- c) Which of the following are applicable to the proposed upgrade? ffA Reduction of setback(s) (list setbacks to be reduced with proposed setback distances) A Percolation rate of 30-60 minutes per.inch (state actual Pere rate) DO AMOM FORM-IIWM -K PAGE 3 OF 5 Up to 25% reduction in subsurface disposal area design requirements (state required & proposed size) Relocation of water supply well (identify well, describe relocation) r� Reduction of required separation between bottom of SAS & high groundwater (specify proposed reduction & perc rate) 1/1761 A�A Other requirements of 310 CMR 15.000 that cannot be met (specify sections of the Code) System upgrades that cannot be performed in accordance with 310 CMR 15.404 & 15.405, or in full compliance with the requirements of 310-CMR 15.000, require a variance pursuant to 310 CMR 15.410-15.417. 7) If the proposed upgrade involves-a reduction in the required separation between the bottom of the soil absorption system-and the-high groundwater elevation, an Approved Soil Evaluator must determine the.high ground water elevation pursuant to 310 CMR 15.405(1)(i)(1). The evaluator must be a member or agent of the local approving authority: Distance from soil absorption system to high groundwater ---,L feet As determined by: Evaluator's name Evaluator's signature Date of evaluation 3-1 X57 MW AMOVO FORM-00195 PAGE 4 OF 5 8) Notice to Abutters No application for upgrade approval in which the setback from property lines or a private water supply well is reduced shall be complete until the applicant has notified all abutters whose property or well is affected by certified mail at least ten days before the Board of Health meeting at which the upgrade approval will be on the agenda. Such notice shall include the date, time and place where the upgrade approval will be discussed. If the Department is the approving authority, then such notice to abutters must be completed prior to the date of submission of the application to the Department. The notices to abutters shall include a copy of the completed application form and shall reference the standards set forth in 310 CMR 15.402 through 15.405. List of affected Abutters: Abutter Name Date notified Address Abutter Name Date notified Address Abutter Name Date notified Address Abutter Name Date notified Address 9) Explain why full compliance, as defined in 310 CMR 15.404(1), is not feasible (each section must be completed): a) an upgraded system in full compliance with 310 CMR 15.000 is not feasible: 417--rl A c-rlj rThCS, 1(-Vao POr /9//\/1. b) an alternative system approved pursuant to 310 CMR 15.283-15.288 is not feasible: DO AMOV®FORM-UMM i r� PAGE 5 OF 5 c) a shared system is not feasible: ,u d) connection to a sewer is not feasible: 10) An application for a disposal system construction permit, including all required attachments (e.g. plans & specifications, site evaluation forms), must accompany this application. Is the DSCP application attached? _yes no s 11) Certification "I, the facility owner, certify under penalty of law that this document and all attachments, to the best of my knowledge and belief, are true, accurate, and complete. I am aware that there may be significant consequences for submitting false information, including, but not limited to, penalties or fine and/or imprisonment for knowing violations." aci t owner's signature Date Print Name Name of,preparer Date /.6 �►u'K-r 4rJ t),o V 9-V, OA of /,g Telephone # & address of preparer NOTE: Title 5, 310 CMR 15.403(4), requiresz the system owner or operator to submit to the Department a copy of the local upgrade approval upon issuance by the Board of Health and prior to commencement of construction. Der APMOVM FORM-12MI95 NORr� Massachusetts of North Andover, F Form No. 1 O �1�ED ,6'94, BOARD OF HEALTH 0 ATED �9SSgCHUSE� APPLICATION FOR SITE TESTING/INSPECTION Applicant NAME ADDRESS Site Location TELEPHONE Engineer NAME ADDRESS Test/Inspection Date and Time TELEPHONE Fee s CHAIRMAN,BOARD OF HEALTH Test No. 9ck S.S. Permit No.,__p W.C. No. —�C.C. Date—_Plbg. Permit No. I E " / D BOARD OF HEALTHTEL//. 688-9540 NORTH ANDOVER, MASS. 01845 APPLICATION FOR SOIL TESTS DATE: LOCATION OF SOIL TESTS: ` qq S4L� JT4,5;E'T Assessor's map & parcel number. -rwt 3'1 rs / rL 53, OWNER: Rug-jCL /15ka-/aJ TEL. NO.: ADDRESS: S7-C&-�,O ENGINEER: Ya?a1/Yl�tG1K- TEL. NO.: CERTIFIED SOIL EVALUATOR: Intended use of land: r idential subdivision, single family home, commercial Repair testing Undeveloped lot testing N. A. Conservation Commission Approval: THE FOLLOWING MUST BE INCLUDED WITH THIS FORM: 1. Proof of land ownership (Tax bill, deed, or letter from owner permitting tests) 2. Plot plan 3. Fee of 1276.00 per lot forenv construction. This covers the minimum two deep holes and two percolation tests required for each disposal area. Fee of$75.00 per lot for repairs or upgrades. GENERAL INFORMATION 1. Only Certified Soil Evaluators may perform deep hole inspections. 2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans. 3. At least two deep holes and two percolation tests are required for each septic system disposal area. 4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative. 5. Full payment will be required for all additional tests within two weeks of testing. 6. Within 45 days of testing, a scaled plan (no smaller than 1"-100') shall be submitted to the Board of Health showing the location of all tests (including aborted tests). 7. Within 60 days of testing soil evaluation forms shall be submitted. 1} PLAN OF INLAND . . r f NORTH ANDOVER, . MASS. 0M, Owned by - Thomas Bunker" ': Scale:40 feet to an inch- Nov.22,1960 g ROBERT E. ANDERSON Civil Engineer and. Surveyor ®' North Reading, Mass., ._ zo 71 -Y- %.ia.��,.,-^':-.. � .Cly" � 1YaJ'•��3 ,M�Rt y bti 1 Yx�� Acres "Al AM . p ft r t n3 Z V ✓e h k ? A S q t ;4,4e iro R Q� rT Co rnr�i et wi/'�i, u// Zon n9 •'`� i T 1`C f SA NOF Mq �� SSe ROBERT sE. ANDERSON :_' NO.7386 .lFs) i� .:'�''s�-rin � " `l "4"' 6s�'•� " mi3' r L S#Q6 pF hr �' gg `a dt Fr1'e tSt y 1 �• 19 PP ,:::n .�e�Y�T ,�& ICY,��� � •�,11 ��y^£ 3L, t�i�` ��M i.r'< P� �5 ^4 k�� .4,`F �. �z�,}a 7 1 ��. �•'�4-5+ ';q� k`9'`v Pt ,.. ,t5t�y.)�.�'i. ��p',,,��y'�rw � ��''{pa"� �'��?, '�,� � ��, r1 `4� yyf 1 m. l 1�i t 4r � 'A� i �$'• a'�4��'°nf94 1�`�� 4 ��� � C i� yip°q�?• .� � '�' a iw �+ +��#vl��� i J \ to 67, ��'--'i i ,) xis t Q12-5 Ai tHE ri ea . r W i�.lr -, f` ����';� � III i j ; ," _ .pk` _. 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'•• r .s��,_',� N �tt� .S��k4r�f.�� r�4rz.��l�l�r#t z,�r� - ��� �'.�,,,js & - .. V ll, 1. X11 • I- I 01 - 7 O O U.I UJ UJ UI U.I , lLI Ill UJ U_ ul i j FORM 11 - SOIL EVALUATOR Fp1 Page 1 Commonwealth of Massachusetts /)0 /,, , Massachusetts Coil SuiW 111ty d ssessme t for On-site S wave. DbO. sal Parformed By: ..._.. 3-:......6. ........._... _...._. Witncssed By: ........................................................__........_......................................... . Lai I A"-Cu.ad 41LI41 CZ New Construction ❑ Repair I4-11" Office Review Published Soil Survey Available: No Yes s .Year Published 1.2 Publication Scale f: Soil Map Unit..... Drainage Class Soil Umitations • ••••-•• Surficial Geologic Report Avallibie: No GK Yes ❑ Year Published ._.............. Publication Scale ........•...•••••. GeologicMaterial (Map Unit)_..................._....__.....................................................:._.._._.__..___.._..._........_._..............._.. Landform ......._......................................................__..._........................................................................................................................... Flood Insurance Rate Map: Above 600 year flood boundary No ❑ Yes Within600 year flood bounds ryNo ,Ak Within 100 year flood boundary No (� Yes ❑ �.. �1 Q ` Wetland Area: - National Wetland Inventory Map (map unit► . ....................... ----.---.�-�.--.�.—.-.-.— Wetlands Conservancy Program Map (map units.....................-....... - -- ----- --•-- -- Current Water Resource Conditions (USGSi: Month .- Range : Above Normal ❑ Normal Below Normal ❑ Other References Reviewed: C15 YoRM 1t - SOIL RVAW&TOR vlum Pagel On.A* Review • Deep Nola Number I_ Oate•_T�� Time• ��:`"'` Weather __f • ._ Loostlon(Identify on site plan) Lend Use &-AP- ------_ 81096(!61 -�- "Surface Stbnee vacatedon _ ....._.._....__....._.........._•__ Landform posldon on landsoaps (sketch on the backl Olstanos4 from; Open Water Body �� ` feet Dralna0e way. t� feet, Possible Wet Area Z perty li feet Prone,sem_ _... fest Drinfdng Water WON .tom.. feet Other DE popthtf d6urtaa Sol Houma Shcl*x• Sol IAAUft tstnaare t. ept. V 40 1,57 Y .c F-4-5-F-4-5- Z sy r, ss parent Material(060109101 _ ____ __ .__....... Depth to Bedrock: papth„to arcundwster Standlne Water In the Hole: nn::!� Weeping from Pit Few: Estimated Seasonal Nigh around Water: �� FORM 11 - SOIL EVALUATOR FOR PQge 3 &gMinadw fo &Mn&Ao Water Tactile Method Used: ❑ Depth observed standing in observation hole.• Inches ❑ Depth weeping from slde of-observation hole— inches — 1.� Depth to soli mottles ... . Inches ❑ Ground water adjustment .... feet Index Well Number _-. Reading.Data Index well level-.._..a...... Adjustment factor ._._. Adjusted ground water level Deoth of Naturally Oo4unfng P_ endous MIMIM . Does at least four feat of naturally occurring pervious material exist in.pll areas + observed throughout the area proposed for the 6011 absorption system? If not, what is the'depth of natutelly ocourring pervious material? rtification , I certify that on Idatel I have passed the examination approved by the Department of Environmental Proteotion and that the above analysis was performed by me consistent with the required training experdee and experience described in 310 CMR 16.017. Signature _ w��� Date S'� FORM 12 - PERCOLATION TEST COMMONWEALTH 'OF MASSACHUSETTS lvoe � -� Massachusetts Percolation Test Date: Observation Hole # Depth of Parc Start Pre-souk End Pre-soak ' Time at 12" / Time at 8" Time at 6" Time W-61 / Rate Min./Inch s Site Passed tom' Site Falled ❑ Performed By: Witnessed By: n, 11-0 T7,v La Comments: ...................................... n Q2 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PRO'T'ECTION ONE WIlVTER STREET,BOSTON AIA 02108 (817)292-5500 TRUDY COXE SeMVtW ARGEO PAUL CELLUCCI DAVID B.STRUHS Govemo= SUBSURFACE SEWAGE DISPOSAL SYSTBIA NOWECTION FORM Commts:s><oner PART A --inRCA711ON Property Address: 444 Salem Street, North Andover Name of Owner:Muriel Lundgren Address of Owner:444 Salem Street,North Andover,MA.01845 Date of Inspection:2/16/2000 Name of Inspector: Neil J.Bateson I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: Bateson Enterprises Inc. Mailing Address:111 Argilla Road Andover,MA 01810 Telephone Number:(978)475-4786 CERTIFICATION STATEMENT 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 X F Inspector's Signature: Date:2!16/2000 The System Inspector shall submit a c of this inspection report to the Approving Authority(Board of Health or DEP)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 to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page I of 11 Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:444 Salem Street,North Andover Owner:Lundgren Date of Inspection:2/16/2000 INSPECTION SUMMARY: Check A, B, C,or D.- A. :A.SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: B.SYSTEM CONDITIONALLY PASSES: One or move system components as described in the'Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. 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,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is 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 complying septic tank as approved by the Board of Health. 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 leveled 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 revised 9/2/98 Page 2 of 11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:444 Salem Street,North Andover Owner:Lundgren Date of Inspection:211612000 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 IN ACCORDANCE WITH 310 CMR 15.303(1)(b)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 surface water. Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. , The system has a septic tank and sal absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more frau a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free frau pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:444 Salem Street,North Andover Owner:Lundgren Date of Inspection:2/16/2000 D.SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: _X I have determined that one or more of the following failure conditions exist as described 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. Yes No 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. 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 _Yes_ 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- You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 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: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area @ IWPA)or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:444 Salem Street,North Andover Owner:Lundgren Date of Inspection:2/16/2000 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No _X Pumping information was provided by the owner, occupant, or Board of Health. _X_ 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. _N/A_ As built plans have been obtained and examined. Note if they are not available with NIA. _X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow.The site was inspected for signs of breakout. _X All system components,excluding the Soil Absorption System,have been located on the site. _X 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. The size and location of the Soil Absorption System on the site has been determined based on: _WA Existing information.For example,Plan at B.O.H. _X_ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [I 5.302(3)(b)) _X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 912198 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 444 Salem Street,North Andover Owner:Lundgren Date of Inspection:2/16/2000 FLOW CONDITIONS RESIDENTIAL: Design flow::_N/A ..g.p.d./bedroom. Number of bedrooms(design):_N/A Number of bedrooms(actual- 3-Total DESIGN flow_N/A_ Number of current residents: Garbage grinder(yes or no):_No Laundry(separate system)(yes or no):–No—If yes,separate inspection required Laundry system inspected(yes or no) Seasonal use(yes or no):_No_ Water meter readings Dec.97 to Feb.00=10,722 ft'x 7,5=80,415 gals./776 days=104 gals./day Sump Pump(yes or no):_Yes_ Last date of occupancy:_Current_ COMM ERCIALIINDUSTRIAL: Type of establishment: Design flow: grd(Based on 15.203) Basis of design flow 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:Pumped Oct 99 -Owner System pumped as part of inspection:(yes or no)No_ If yes,volume pumped: gallons Reason for pumping: TYPE OF SYSTEM _X_ 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) VA Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components,date installed(if known)and source of information:39 years old- owner Sewage odors detected when arriving at the site:(yes or no)_No revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:444 Salem Street,North Andover Owner:Lundgren Date of Inspection:2/16/2000 BUILDING SEWER:X (Locate on site plan) Depth below grade:24" Material of construction: X cast iron_ 40 PVC _ other(explain) Distance from private water supply well or suction line: Diameter:4" Comments:4"cast iron thru wall to septic tank SEPTIC TANK:X (locate on site plan) Depth below grade: Inlet 12"deep,Outlet 8"deep. Material of construction:_X_ concrete_metal_Fiberglass_Polyethylene_other(explain) If tank is metal,list age_Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions:8'x 5'x 4' X 7.5=1200 gallons. Sludge depth:2" Distance from top of sludge to bottom of outlet tee or baffle:22" Scum thickness:0 Distance from top of scum to top of outlet tee or baffle:3" Distance from bottom of scum to bottom of outlet tee or baffle:20" How dimensions were determined:Subtract scum&sludge depths to baffle length. Comments: Inlet baffle ok.Outlet baffle badly corroded.Depth of liquid at outlet invert. No evidence of leakage. GREASE TRAP:None (locate on site plan) Depth below grade: Material of construction: concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:444 Salem Street,North Andover Owner:Lundgren Date of Inspection:2/16/2000 TIGHT OR HOLDING TANK:_None (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: Material of construction: concrete_metal_Fiberglass Polyethylene_other(explain) Dimensions: Capacity:_gallons Design flow:_gallons/day Alarm present Alarm level: Alarm in working order:Yes_No Date of previous pumping: Comments: DISTRIBUTION BOX.:_X_ (locate on site plan) Depth of liquid level above outlet invert:Below inverts 2" Comments:D-box badly corroded.Evidence of D-box leaking–below inverts.Heavy roots in D-box. PUMP CHAMBER:—None,gravity system_ (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: Revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued)) Property Address: 444 Salem Street,North Andover Owner: Lundgren Date of Inspection:2/16/2000 SOIL ABSORPTION SYSTEM(SAS):X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: Type: leaching pits,number leaching chambers,number: leaching galleries, number: leaching trenches,number,length:2 trenches 50'long leaching fields,number,dimensions: overflow cesspool,number: Alternative system: Name of Technology: Comments:Soil ok.Vegetation ok.No sign of ponding to surface. CESSPOOLS:None (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: PRIVY:None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:444 Salem Street,North Andover Owner:Lundgren Date of Inspection:2/16/2000 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply canes into house) Drive Way House Water Meter A B 1 A to 1 =21' Septic Tk. Ato2=23'8" A to D-Box=26' 2 Bto1 =21' B to 2=25' B to D-Box=28' D- box 50' revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 444 Salem Street,North Andover Owner:Lundgren Date of Inspection:2/16/2000 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater 2 1Feet Please indicate all the methods used to�determine High Groundwater Elevation: Obtained from Design Plans on record _X Observed Site(basement sl P) —X—Determined from local conditiIns —X—Checked with local Board of he alth Checked FEMA Maps Checked pumping records Checked local excavators,installers Used USGS Data I Describe how you established the High Groundwater Elevation. Must be completed) Transfer elevation of high water level in sump pump to D-Box outlet inverts. revised 9/2/98 Page 11 of 11 Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating-Water.& Sewer Lines-Septic Systems &Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 444 Salem Street, North Andover Owner: Lundgren Date of Inspection: 2/16/2000 My report contained medherein does not constitute a 'antee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. 41ateson Ne Bateson Enterprises, Inc.