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HomeMy WebLinkAboutMiscellaneous - 456 SALEM STREET 4/30/2018 (2) 456 SALEM STREET ' 210/038.0-0176-0000.0 I V M Commonwealth of Massachusetts RECEIVE® Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments DEC 01 2017 456 Salem Street TOWN OF NORTH ANDOVER Property Address Mike Frederickson Owner Owner's Name information is required for every North Andover MA 01845 11-18-17 page. Cityrrown 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 /P.,0,4 on the computer, C O use only the tab 1. Inspector: „p key to move your V cursor-do not Benjamin C. Osgood, Jr. use the return key. Name of Inspector Com my Company Name 157 Bluff Street Company Address Salem NH 03079 Cityrrown State Zip Code 603-458-2883 870 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 12x 11-18-17 nspect s 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 w u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 456 Salem Street Property Address Mike Frederickson Owner Owner's Name information is required for every North Andover MA 01845 11-18-17 page. Cityrrown 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 456 Salem Street Property Address Mike Frederickson Owner Owner's Name information is required for every North Andover MA 01845 11-18-17 page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Forth: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 ,M 456 Salem Street Property Address Mike Frederickson Owner Owner's Name information is required for every North Andover MA 01845 11-18-17 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 '/day flow t5ins•3173 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 456 Salem Street Property Address Mike Frederickson Owner Owner's Name information is required for every North Andover MA 01845 11-18-17 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a'surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of aprivate water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ® the system is within 400 feet of a surface drinking water supply ❑ ® the system is within 200 feet of a tributary to a surface drinking water supply ❑ ® the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins•3M3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 456 Salem Street Property Address Mike Frederickson Owner Owner's Name information is required for every North Andover MA 01845 11-18-17 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 •� Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 456 Salem Street Property Address Mike Frederickson Owner Owner's Name information is required for every North Andover MA 01845 11-18-17 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: 1500 gallon tank to 900 square foot leach field 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: current 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 456 Salem Street Property Address Mike Frederickson Owner Owner's Name information is required for every North Andover MA 01845 11-18-17 page. Cityrrown 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: Fall 2013 per town records Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 456 Salem Street Property Address Mike Frederickson Owner Owner's Name information is required for every North Andover MA 01845 11-18-17 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: Built in 1976 per information on file Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ® cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: n/a feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipe looks good in basement 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: 1500 gallons Sludge depth: '2 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 456 Salem Street Property Address Mike Frederickson Owner Owner's Name information is required for every North Andover MA 01845 11-18-17 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 28" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Measure stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank in good condition. Cross baffle intact. Concrete tee in good condition. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 456 Salem Street Property Address Mike Frederickson Owner Owner's Name information is required for every North Andover MA 01845 11-18-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 456 Salem Street Property Address Mike Frederickson Owner Owner's Name information is required for every North Andover MA 01845 11-18-17 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" 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 in good condition. No evidence of leakage in or out no evidence of carryover. Distribution to 4 outlet pipes equal. Box 30" below grade. 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 456 Salem Street Property Address Mike Frederickson Owner Owner's Name information is required for every North Andover MA 01845 11-18-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1-900 S.F. ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Area of system clean and dry. No evidence of ponding or unusual vegetation. Probing into stone reveals that stone is clean and dry. System has 4 leach pipes and is most probably 20'x 45' in size Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 456 Salem Street Property Address Mike Frederickson Owner Owner's Name information is required for every North Andover MA 01845 11-18-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids i 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 Forms Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 456 Salem Street Property Address Mike Frederickson Owner Owner's Name information is required for every North Andover MA 01845 07-23-14 page. Citylrown State Zip Code Daenspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately j TAN 11, �- b:Pox �Z3t qoo 5-F Ftect7 Drs , OOX Q O If cc Y_ H a�sE I�2►vl✓ _CEL L w t5ins•3N 3 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 ` Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 456 Salem Street Property Address Mike Frederickson Owner Owner's Name information is required for every North Andover MA 01845 11-18-17 page. CityTrown 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: >5feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: USSCS Maps You must describe how you established the high ground water elevation: Basement dry without a sump pump. USGS soils maps indicate water>6.0 feet below original grade. Leach field is less than 3' below grade. Leach field area is raised 3 to 4 feet above surrounding area and the yard slopes away in the rear with no observable wetlands within 100 feet. 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 w Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GSM , 456 Salem Street Property Address Mike Frederickson Owner Owner's Name information is required for every North Andover MA 01845 11-18-17 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 f � NO eT a,a $ 121 e.+� o F s Town of North Andover HEALTH DEPARTMENT CHECK#: _ DATE: /�-!�•�O�' LOCATION: f H/O NAME: CONTRACTOR NAME: 0-5q004 Tyne of Permit or License:(Check box) ❑ Animal $ ❑ Body Art Establishment $ y, ❑ Body Art Practitioner $ ;' ❑ Dumpster $ ❑ Food Service-Type: $ _ ` ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ kt; ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ i- ❑ Sun tanning $ f ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ` ❑ Title 5 Inspector $ Title 5 Report ❑ Other:(Indicate) $ Hea gent Initials White-Applicant Yellow-Health Pink-Treasurer Commonwealth of Massachusetts o- J Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , A56.Salem Street yam, Property Address Daniel and Debra Luciano Owner Owner's Name information is required for every North Andover MA 01845 07-23-14 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. RECEIVED Important:When A. General Informationfilling out forms JUL ZR 201 on the computer, use only the tab 1. Inspector: key to move yourN OF NORTH ANDOVER cursor-do notBenjamin C. Osgood, Jr. SALTH DEPARTMENT use the return key. Name of Inspector h N/A "�—v Company Name 24 Julie Ave ��� Company Address Salem NH 03079 City/Town State Zip Code 603-458-2883 870 Telephone Number .License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 07-24-14 Inspector 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. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 456 Salem Street Property Address Daniel and Debra Luciano Owner Owner's Name information is required for every North Andover MA 01845 07-23-14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ one or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old'or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 456 Salem Street Property Address Daniel and Debra Luciano Owner Owner's Name information is required for every North Andover MA 01845 07-23-14 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments • 456 Salem Street Property Address Daniel and Debra Luciano Owner Owners Name information is required for every North Andover MA 01845 07-23-14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Wealth (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 El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 456 Salem Street Property Address Daniel and Debra Luciano Owner Owner's Name information is required for every North Andover MA 01845 07-23-14 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. E] ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ® the system is within 400 feet of a surface drinking water supply ❑ ® the system is within 200 feet of a tributary to a surface drinking water supply ❑ ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments k 456 Salem Street Property Address Daniel and Debra Luciano Owner Owner's Name information is required for every North Andover MA 01845 07-23-14 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? El ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ' ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 456 Salem Street Property Address Daniel and Debra Luciano Owner Owners Name information is required for every North Andover MA 01845 07-23-14 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: 1500 gallon tank to 800 square foot leach field Number of current residents: 3 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: current 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: N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 456 Salem Street Property Address Daniel and Debra Luciano Owner Owner's Name information is required for every North Andover MA 01845 07-23-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Fall 2013 per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 456 Salem Street Property Address Daniel and Debra Luciano Owner Owner's Name information is required for every North Andover MA 01845 07-23-14 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Built in 1976 per owner Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ®cast iron ❑40 PVC ❑ other(explain): Distance from private water supplywell or suction line: n/a feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipe looks good in basement Septic Tank(locate on site plan): 61' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: Years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallons >2 Sludge depth: Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 456 Salem Street Property Address Daniel and Debra Luciano Owner Owner's Name information is required for every North Andover MA 01845 07-23-14 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. 28" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Measure stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank in good condition. Cross baffle intact. Concrete tee in good condition. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 456 Salem Street Property Address Daniel and Debra Luciano Owner Owner's Name information is required for every North Andover MA 01845 07-23-14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? 0 Yes ❑ No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 456 Salem Street Property Address Daniel and Debra Luciano Owner Owner's Name information is required for every North Andover MA 01845 07-23-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): 0" Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box in good condition. No evidence of leakage in or out no evidence of carryover. Distribution to 4 outlet pipes equal. Box 30" below grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No' Alarms in working order: ❑ Yes ❑ No" Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): i If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 456 Salem Street Property Address Daniel and Debra Luciano Owner Owner's Name information is required for every North Andover MA 01845 07-23-14 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1-900 S.F. ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Area of system clean and dry. No evidence of ponding or unusual vegetation. Probing into stone reveals that stone is clean and dry. System has 4 leach pipes and is most probably 20'x 45' in size Cesspools (cesspool must be pumped as art of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 456 Salem Street Property Address Daniel and Debra Luciano Owner Owner's Name information is required for every North Andover MA 01845 07-23-14 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.): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 456 Salem Street _ Property Address , — Daniel and Debra Luciano Owner Owner's Name — information is required for every North Andover MA 01845 07-23-14 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: ® hand-sketch in the area below ❑ drawing attached separately -TA N 1, 2-- -WIt, l0.7 i 1- b-oox _-3Z 3 ' 2-.9-P0x �jo0 �•f f=1LcC� D�sr, �2px 0 IS-010 &rq-c G-o N TAN iiL D O " t�Ecr- N e�sC P12►QC w Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 456 Salem Street Property Address Daniel and Debra Luciano Owner Owner's Name information is required for every North Andover MA 01845 07-23-14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells >5 Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: USSCS Maps You must describe how you established the high ground water elevation: Basement dry without a sump pump. USGS soils maps indicate water>6.0 feet below original grade. Leach field is less than 3' below grade. Leach field area is raised 3 to 4 feet above surrounding area and the yard slopes away in the rear with no observable wetlands within 100 feet. Before filing this Inspection Report, please see Report Completeness Checklist on next page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 456 Salem Street Property Address Daniel and Debra Luciano Owner Owner's Name information is required for every North Andover MA 01845 07-23-14 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 Of NOR7:,M 6961 . O Town of North Andover ` '-•,,,,• ,' HEALTH DEPARTM NT ,SSACMUst� l CHECK#: DATE. LOCATION: H/O NAME: - CONTRACTOR NAME: Type of Permit or License:(Check box) 0 Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ P S ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5Inspector $ Title 5 Report $� ❑ Other. (Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer 3 ot NOMiN 6961 OEi.`w 0 — oa Town of North Andover ' '• HEALTH DEPARTMENT cNus�� CHECK#: DATE: LOCATION: H/O NAME: CONTRACTOR NAME: .Pi Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool � $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ Title 5 Report $ � ; ((( X11 ❑ Other. (Indicate) $ a Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer IV'BC� .� Commonwealth of Massachusetts LTOHWEALTH 2 3 2009 Title 5 Official Inspection Form RTHANDOVER EPARTMENT Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 456 Salem Street I , Property Address Dan and Debbie Luciano Owner Owner's Name —� information is North Andover MA 01845 4-13-09 required for i/ every page. Cityrrown State Zip Code Date of Inspection a Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information 10N When filling out forms on the computer,use 1. Inspector: p only the tab key to move your Benjamin C. Osgood, Jr. t° cursor­do not Name of Inspector use the return key. Company Name P.O Box 932 Company Address Newburyport MA 01950 Citylrown State Zip Code 508-328-4633 870 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority C 4-1509 nspector 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. Commonwealth of Massachusetts p ' Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 456 Salem Street Property Address Dan and Debbie Luciano Owner Owner's Name information is North Andover MA 01845 4-13-09 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D 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): i ` <LCommonwealth of Massachusetts JD Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments t 456 Salem Street Property Address Dan and Debbie Luciano Owner Owner's Name information is required for North Andover MA 01845 4-13-09 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 456 Salem Street Property Address Dan and Debbie Luciano Owner Owner's Name information is North Andover MA 01845 4-13-09 required for State Zip Code Date of Inspection every page. Cityrrown 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 asses if the well water analysis, performed at a DEP certified laboratory, for coliform Y p Y bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or 4 -• 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 I ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 456 Salem Street Property Address Dan and Debbie Luciano Owner Owner's Name information is required for North Andover MA 01845 4-13-09 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No El ® 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. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered:A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. � ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ® the system is within 400 feet of a surface drinking water supply ❑ ® the system is within 200 feet of a tributary to a surface drinking water supply ❑ ® the system is located in a nitrogen sensitive area (interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. J Commonwealth of Massachusetts " Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 456 Salem Street Property Address Dan and Debbie Luciano Owner Owner's Name information is required for North Andover MA 01845 4-13-09 every page. Cityfrown 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? . ® :1 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: 3 of bedrooms(actual): Number of bedrooms(design): Number ( ) DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): j ` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 456 Salem Street Property Address Dan and Debbie Luciano Owner Owner's Name information is required for North Andover MA 01845 4-13-09 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 3 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected?. ❑ Yes ® No Seasonal use? _ _ ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: currentDate Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Commonwealth of Massachusetts x u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 456 Salem Street Property Address Dan and Debbie Luciano Owner Owner's Name information is North Andover MA 01845 4-13-09 required for every page. Cityrrown 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: 2008 per owner Was system pumped as part of the inspection? R- Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy '❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): ` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 456 Salem Street Property Address Dan and Debbie Luciano Owner Owner's Name information is North Andover MA 01845 4-13-09 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Built 1976 per owner Were sewage odors detected when arriving at the site? ❑ Yes ® 'No Building Sewer(locate on site plan): Depth below grade: 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.): Pipe looks good in basement Septic Tank(locate on site plan): 6" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, lista e: years ears Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 1500 Gallons Dimensions: <^II Sludge depth: Commonwealth of Massachusetts ° Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 456 Salem Street Property Address Dan and Debbie Luciano Owner Owner's Name information is required for North Andover MA 01845 4-13-09 every page. Cityrrown 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 28'• 2,' Scum thickness � 8„ Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Measure Stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank in good condition. Concrete tees in good condition Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 456 Salem Street Property Address Dan and Debbie Luciano Owner Owner's Name information is required for North Andover MA 01845 4-13-09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 in working order: El Yes El No Alarm level: 9 Date of last pumping: Date Comments(condition of alarm and float switches, etc.): " Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 456 Salem Street Property Address Dan and Debbie Luciano Owner Owners Name information is required for North Andover MA 01845 4-13-09 every p9 a e. 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 in OK condition. No evidence of leakage in or out. No carry over. Distribution equal. Box 30" below Grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: � n Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 456 Salem Street Property Address Dan and Debbie Luciano Owner i Owner's Name required for North Andover MA 01845 4-13-09 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1 900 sq.ft. ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs_of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Area of leach field looks normal. Probing with a crowbar in to stone reveals that stone is clean and dry. System has four pipes and is most probably 20'x 45' in size 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 0 Yes ❑ No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 456 Salem Street Property Address Dan and Debbie Luciano Owner Owner's Name information is required for North Andover MA 01845 4-13-09 every 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.): • J Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 456 Salem Street Property Address Dan and Debbie Luciano Owner Owner's Name information is required for North Andover MA 01845 4-13-09 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately .��S-RZrtLES t �raa�� 30• � I o•"i 32.3 �vo 5•� I.1ELf7 Z_D g�� Z�t-S D-l3aX Z pECI� w Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 456 Salem Street Property Address Dan and Debbie Luciano Owner Owners Name information is required for North Andover MA 01845 4-13-09 ' every page. CityrFown 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: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: Checked with local excavators installers- attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: Basement dry with no sump pump. USGS soil maps indicate water>6.0 feet below ground. Leach field only 3 feet below ground. Leach field area is raised above surrounding area by 3 to 4 feet. Yard slopes away in the rear with no observable wetlands within 100 feet. Before filing this Inspection Report, please see Report Completeness Checklist on next page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 456 Salem Street Property Address Dan and Debbie Luciano Owner Owner's Name information is required for North Andover MA 01845 4-13-09 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 4085 Town of North Andover HEALTH DEPARTMENT SACHU`+E CHECK DATE: ,V, LOCATION: 4 ONAME:ZL E: �.�_ CONTRACTOR NAME: - lea 17 rr v r : Type of Permit or License:(Check box) �y ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ Food Service-Type: $ 44. ' ❑. Funeral Directors $ ",. ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler . $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ . ❑ Title SInspector $ Title 5 Report 0 Other. (Indicate) $ Health Agent Initials --White-Applicant Yellow-Health Pink-Treasurer Town of North Andover of NORTk- OFFICE OF 3� g`tTllO ,!.�OOL COMMUNITY DEVELOPMENT AND SERVICES ° .: A 27 Charles Street 41L �9 ; North Andover,Massachusetts 01845 SA HU WILLIAM J.SCOTT Director (978)688-9531 Fax(978)688-9542 September 28, 1999 Mr.Luciano 456 Salem Street p MIn North Andover,MA 01845 Re: Title 5 inspection at 456 Salem Street Dear Mr.Luciano: The North Andover Health Department has received and reviewed the inspection report that was generated from the inspection of your septic system on S/12199. The system inspection has been determined that your system was no deemed to be"...failing to protect of threatening public health and safety or the environment..."as stated in Title 5 of the State Sanitary Code. However,from the report,this office has determined that you must: V/ Retain the'services of a North Andover licensed septic installer to obtain a disposal works construction permit and: Install a new ; inlet outlet tee in your septic tank -�- Repair or replace your leaking septic tank Repair or replace your damaged/unlevel distribution box Repair or replace damaged piping Retain the services of a licensed plumber to obtain a plumbing permit and: Remove your garbage disposal Re-route your laundry drainpipe to your septic system Other: Please have all work performed within 60 days of receipt of this notice. If you have any questions,feel free to call the Health Department at 978-688-9540. Sincerely, Sandra Starr,R.S. Health Administrator BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 e t COMMONWEALTH OF MASSACHUSETT'S EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET,BOSTON,MA 02108 617-292-5500 TRUDY COXE ARGEO PAUL CELLUCCI SECRETARY GOVERNOR DAVID B. STRUTHS COMINIISSIONER SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION PROPERTY ADDRESS:456 SALEM ST-NO ANDOVER,MA NAME OF OWNER:DAN LUCIANO DATE OF INSPECTION.94Z-99 ADDRESS OF OWNER: NAME OF INSPECTOR:(PLEASE PRINT) FRANCIS KING III I AM A DEP APPROVED SYSTEM INSPECTOR PURSUANT TO SECTION 15.340 OF TITLE 5(310 CMR 15.000) COMPANY NAME: ACTION-KING ENTERPRISES.INC. MAILING ADDRESS: 26 LIVINGSTON STREET LOWELL,MA 01852 TELEPHONE NUMBER: (978)452-7750 FAX: (978)1459-0770 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 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 X NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY FAILS s SPECTOR'S SIGNATURE: y 1, DATE: 8-12-99 W SYSTEM INSPECTOR SHALL SUBMIT A COPY OF THIS INSPECTION REPORT TO THE APPROVING AUTHORITY(BOARD OF IEALTH OR DEP)(WITHIN THIRTY(30)DAYS OF COMPLETING THIS INSPECTION. IF THE SYSTEM IS A SHARED SYSTEM OR IAS A DESIGN FLOW OF 10,000 GPD OR GREATER,THE INSPECTOR AND THE SYSTEM OWNER SHALL SUBMIT THE REPORT 'O THE APPROPRIATE REGIONAL OFFICE OF THE DEPARTMENT OF ENVIRONMENTAL PROTECTION. THE ORIGINAL HOULD BE SENT TO THE SYSTEM OWNER AND COPIES SENT TO THE BUYER,IF APPLICABLE ANI)THE APPROVING ,UTHORITY. 3TES AND COMMENTS kNK LEVEL APPROXIMATELY 4"BELOW OUTLET PIPE TO LEACHING AREA 'r)PI'll ANDOVER" he ALq r 0%_ ._ALTi A I SEP 2 2 1999 r PAGE 1 SUBSURFACE DISPOSAL SYSTEM INSPECTION FORM PART A i CERTIFICATION(CONTINUED) tOPERTY ADDRESS: 456 SALEM ST N ANDOVER,MA 01845 NNER:DAN LUCIANO kTE OF INSPECTION:8-12-99 SPECTION SUMMARY: CHECK A,B,C OR D SYSTEM PASSES: I HAVE NOT FOUND ANY INFORMATION WHICH INDICATES THAT ANY OF THE FAILURE COND11TIONS DESCRIBED IN 310 CMR 15.303 EXIST. ANY FAILURE CRITERIA NOT EVALUATED ARE INDICATED BELOW. 3MMENTS: i' SYSTEM CONDITIONALLY PASSES: E 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. DILATE YES,OR NO,OR NOT DETERMINED(Y,N,OR ND). 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(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 PAGE 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) tOPERTY ADDRESS:456 SALEM ST NO ANDOVER,MA 01845 NNER:DAN LUCIANO %TE OF INSPECTION:8-12-99 1 FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: X 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 A SURFACE WATER CESSPOOL,-.OR PRIVY IS WITHIN 50 FEET OF A BORDERING VEGETATED WETLAND OR A SALT MARSH. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IF FUNCTIONIING 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 TO A SURFACE WATER SUPPLY OR TRIBUTARY TO A SURFACE WATER SUPPLY. THE SYSTEM HAS A SEPTIC TANK AND SOIL 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 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 THE 5PPM. METHOD USED TO DETERMINE DISTANCE (APPROXIMATION NOT VALID) OTHER: kNK IS EXFILTRATING BY SOME OTHER MEANS. THE LINE LEADING TO THE D-BOX AND S.A.S LOOKS FINE. D NOT PUMP TANK FOR INSPECTION. PAGE 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) tOPERTY ADDRESS:456 SALEM ST NO ANDOVER,MA 01845 NNER:DAN LUCIANO kTE OF INSPECTION:8-12-99 SYSTEM FAILS: )U MUST INDICATE"YES"OR"NO"TO EACH OF THE FOLLOWING: /A 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 CONTACCTED TO DETERMINE WHAT WILL BE NECESSARY TO CORRECT THE FAILURE. 7,SNO _ 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 SURFACEWATERS DUE TO AN OVERLOADED OR CLOGGED SAS OR CESSPOOL. STATIC LIQUID LEVEL IN THE DISTRIBUTION BOX ABOVE 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. LARGE SYSTEM FAILS: )U MUST INDICATE"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: sS NO _ THE SYSTEM IS WITHIN 400 FEET OF A SURFACE DRINKING WATER SUPPLY _ THE SYSTEM IS WITHIN 200 FEET OF A TRIBUTARY TO A SURFACE DRINKING WATER SUPPLY. _ THE SYSTEM IS LOCATED IN A NITROGEN SENSITIVE AREA(INTERIM WELLHEAD PROTECTION AREA iWPA) OR A MAPPED ZONE II OF A PUBLIC WATER SUPPLY WELL. THE OWNER OR OPERATOR OF ANY SUCH SYSTEM SHALL UPGRADE THE SYSTEM INACCORDANCE WITH 310 CMR 15.304(2). PLEASE CONSULT THE LOCAL REGIONAL OFFICE OF THE DEPARTMENT FOR FURTHER information. PAGE 4 • ACTION-KING ENTERPRISES,INC. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST 20PERTY ADDRESS: 456 SALEM ST NO ANDOVER,MA 01845 WNER:DAN LUCIANO 4,TE OF INSPECTION:8-12-99 3ECK IF THE FOLLOWING HAVE BEEN DONE.YOU MUST INDICATE"YES"OR"NO"AS TO EACH OF THE FOLLOWING: NO J PUMPING INFORMATION WAS PROVIDED 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. i AS BUILT PLANS HAVE BEEN OBTAINED AND EXAMINED. NOTE IF THEY ARE NOT AVAILABLE WITH N/A. THE FACILITY OR DWELLING WAS INSPECTED FOR SIGNS OF SEWAGE BACK-UP. I/ THE SYSTEM DOES NOT RECEIVE NON-SANITARY OR INDUSTRIAL WASTE FLOW. THE SITE WAS INSPECTED FOR SIGNS OF BREAKOUT. ALL SYSTEM COMPONENTS,EXCLUDING THE SOIL ABSORPTION SYSTEM,HAVE BEEN LOCATED ON THE SITE. _ THE SEPTIC TANK MANHOLES WERE UNCOVERED,OPENED,AND THE INTERIOR OF THE SEPTIC TANK WAS INSPECTED FOR CONDITION OF BAFFLES OR TEE,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: EXISTING INFORMATION. FOR EXAMPLE,PLAN AT B.O.H. DETERMINED IN THE FIELD(IF ANY OF THE FAILURE CRITERIA RELATED TO PART C IS AT ISSUE, APPROXIMATION OF DISTANCE IS UNACCEPTABLE) (15.302(3)(b) THE FACILITY OWNER(AND OCCUPANTS,IF DIFFERENT FROM OWNER)WERE PROVIDED WITH INFORMATION ON THE PROPER MAINTENANCE OF SUBSURFACE DISPOSAL SYSTEMS. PAGE 5 ACTION-KING ENTERPRISES,INC. SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C SYSTEM INFORMATION 20PERTY ADDRESS: 456 SALEM ST NO ANDOVER,MA 01845 WNER:DAN LUCIANO ATE OF INSPECTION:8-12-99 ESIDENTIAL: SIGN FLOW: 440 ¢.p.d./BEDROOM JMBER OF BEDROOMS:(DESIGN): 4 NUMBER OF BEDROOMS(ACTUAL): 4 )TAL DESIGN FLOW: 440 JMBER OF CURRENT RESIDENTS: 2 ADULTS 1 CHILD kRBAGE GRINDER(YES OR NO) NO UJNDRY(SEPARATE SYSTEM)(YES OR NO): NO ;IF YES,SEPARATE INSPECTION REQUIRED \UNDRY SYSTEM INSPECTED(YES OR NO) YES :ASONAL USE(YES OR NO) NO ATER METER READINGS,-,`IF AVAII;ABLE: (LAST TWO(2)_Y_YEAR USAGE(Qpd) 3417 f JMP PUMP(YES OR NO) NO kST DATE OF OCCUPANCY: OCCUPIED )MM ERCIALANDUSTRIAL: ePE OF ESTABLISHMENT: N/A ZSIGN FLOW: GPD(BASED ON 15.203) kSIS OF DESIGN FLOW [LEASE TRAP PRESENT,(YES OR NO) DUSTRIAL WASTE HOLDING TANK PRESENT: (YES OR NO) )N-SANITARY WASTE DISCHARGED TO THE TITLE 5 SYSTEM: (YES OR NO) ATER METER READINGS,IF AVAILABLE: _ kST DAY OF OCCUPANCY: CHER: (DESCRIBE) kST DAY OF OCCUPANCY: GENERAL INFORMATION JMPING RECORDS AND SOURCE OF INFORMATION. 2 YHEARS(HOMEOWNER) SYSTEM PUMPED AS PART OF INSPECTION(YES OR NO) YES IF YES,VOLUME PUMPED GALLONS. REASON FOR PUMPING INSPECTION OF TANK AND BAFFLES ePE 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) _ I/A TECHNOLOGY ETC. ATTACH COPY OF UP TO DATE OPERATION AND MAINTENANCE CONTRACT. CHER: _ 'PROXIMATE AGE OF ALL COMPONENTS,DATE INSTALLED(IF KNOWN)AND SOURCE OF INFORMATION: 12 YEARS OLD :WAGE ODORS DETECTED WHEN ARRIVING AT THE SITE.(YES OR NO) NO PAGE 6 ACTION-KING ENTERPRISES,INC. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMA'T'ION(CONTINUED) 20PERTY ADDRESS: 456 SALEM ST NO ANDOVER,MA 01845 WNER:DAN LUCIANO kTE OF INSPECTION:8-12-99 JILDING SEWER: N/A OCATE ON SITE PLAN) :PTH BELOW GRADE: ATERIAL OF CONSTRUCTION: CAST IRON 40 PVC OTHER (EXPLAIN) :STANCE FROM PRIVATE WATER SUPPLY WELL OR SUCTION LINE AMETER 3MMENTS(CONDITION OF JOINTS,VENTING,EVIDENCE OF LEAKAGE,ETC.) :PTIC TANK: X OCATE ON SITE PLAN) :PTH BELOW GRADE: ATERIAL OF CONSTRUCTION: X CONCRETE-METAL-FIBERGLASS_POLYETHYLENE-OTHER(EXPLAIN) TANK IS METAL,LIST AGE IS AGE CONFIRMED BY CERTIFICATE OF COMPLIANCE-(YES,NO) MENSIONS: 10'X 5'X 6' .UDGE DEPTH: STANCE FROM TOP OF SLUDGE TO BOTTOM OF OUTLET TEE OR BAFFLE: :UM THICKNESS: :STANCE FROM TOP OF SCUM TO TOP OF OUTLET TEE OR BAFFLE: :STANCE FROM BOTTOM OF SCUM TO BOTTOM OF OUTLET TEE OR BAFFLE: :)W DIMENSIONS WERE DETERMINED: TAPE MEASUREMENT JMMENTS: ECOMMENDATION FOR PUMPING,CONDITION OF INLET AND OUTLET TEES OR BAFFLES,DEPTH OF LIQUID LEVEL IN EELATION TO OUTLET INVERT,STRUCTURAL INTEGRITY,EVIDENCE OF LEAKAGE,ETC.) DID NOT PUMP TANK DUE TO TAK LEVEL BEING 4"LOWER THAN OUTLET PIPE [LEASE TRAP: N/A OCATE ON SITE PLAN) -PTH BELOW GRADE: ATERIAL OF CONSTRUCTION:_CONCRETE_METAL_FIBERGLASS POLYETHYLENE_OTHER(EXPL,A.IN) MENSIONS: :UM THICKNESS: :STANCE FROM TOP OF SCUM TO TOP OF OUTLET TEE OR BAFFLE: STANCE FROM BOTTOM OF SCUM TO BOTTOM OF OUTLET TEE OR BAFFLE: kTE OF LAST PUMPING: 3MMENTS: ECOMMENDATION FOR PUMPING,CONDITION OF INLET AND OUTLET TEES OR BAFFLES,DEPTH OF LIQUID LEVEL,IN :ELATION TO OUTLET INVERT,STRUCTURAL INTEGRITY,EVIDENCE OF LEAKAGE. ,TC.) PAGE 7 ACTION-KING ENTERPRISES,INC. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(CONTINUED) 20PERTY ADDRESS: 456 SALEM STREET NO ANDOVER,MA 01845 WNER: DAN LUCIANO ATE OF INSPECTION: 8-12-99 [GHT OR HOLDING TANK: N/A (TANK MUST BE PUMPED PRIOR TO,OR AT TIME OF INSPECTION). OCATE ON SITE PLAN) :PTH BELOW GRADE: ATERIAL OF CONSTRUCTION:_CONCRETE-METAL_FIBERGLASS-POLYETHYLENE-OTHER(EXPLAIN) ISI MENSIONS: kPACITY: GALLONS :SIGN FLOW: GALLONS/DAY FARM PRESENT .ARM LEVEL: ALARM IN WORKING ORDER: YES-NO_ kTE OF PREVIOUS PUMPING )MMENTS: ONDITION OF INLET TEE,CONDITION OF ALARM AND FLOAT SWITCHES,ETC.) STRIBUTION BOX: X OCATE ON SITE PLAN) ?PTH OF LIQUID LEVEL ABOVE OUTLET INVERT: 0" )MMENTS: OTE IF LEVEL AND DISTRIBUTION IS EQUAL,EVIDENCE OF SOLIDS CARRY OVER,EVIDENCE OF LEAKAGE INTO OR OUT OF 'OX,ETC.) D-BOX LOOKED GOODAT TIME OF INSPECTION. WATER LEVEL WAS BELOW OUTLET FROM TANK DUE O EXFILTRATION. JMP CHAMBER: N/A OCATE ON SITE PLAN) JMPS IN WORKING ORDER(YES OR NO ARMS IN WORKING ORDER(YES OR NO) )MMENTS: OTE CONDITION OF PUMP CHAMBER,CONDITION OF PUMPS AND APPURTENANCES,ETC.) PAGE 8 ACTION-KING ENTERPRISES,INC. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM SYSTEM INFORMATION(CONTINUED) ZOPERTY ADDRESS:456 SALEM ST NO ANDOVER,MA 01845 WNER:DAN LUCIANO ATE OF INSPECTION: 8-12-99 )IL ABSORPTION SYSTEM(SAS): X OCATE ON SITE PLAN,IF POSSIBLE,EXCAVATION NOT REQUIRED,BUT MAY BE APPROXIMATED BY NON-INTRUSIVE METHODS). NOT LOCATED,EXPLAIN: VPE: LEACHING PITS,NUMBER: LEACHING CHAMBERS,NUMBER: LEACHING GALLERIES,NUMBER: LEACHING TRENCHES,NUMBER LENGTH 4 X 40' LEACHING FIELDS,NUMBER,DIMENSIONS: OVERFLOW CESSPOOL.NUMBER: ALTERNATIVE SYSTEM: _ NAME OF TECHNOLOGY )MMENTS: MOTE CONDITION OF SOIL,SIGNS OF HYDRAULIC FAILURE,LEVEL OF PONDING,CONDITION OF VEGETATION, :TC.) _ AREA OF LEACHING AREA LOOKED GOOD :SSPOOLS: N/A OCATE ON SITE PLAN) JMBER AND CONFIGURATION: -PTH-TOP OF LIQUID TO INLET INVERT: :PTH OF SOLIDS LAYER: :PTH OF SCUM LAYER: MENSIONS OF CESSPOOL: ATERIALS OF CONSTRUCTION: 'DICATION OF GROUNDWATER: INFLOW(CESSPOOL MUST BE PUMPED AS PART OF INSPECTION: )MMENTS: 40TE CONDITION OF SOIL,SIGNS OF HYDRAULIC FAILURE,LEVEL OF PONDING,CONDITION OF VEGETATION,ETC.) tIVY: N/A OCATE ON SITE PLAN) ATERIALS OF CONSTRUCTION: DIMENSIONS: :PTH OF SOLIDS: )MMENTS: OTE CONDITION OF SOIL,SIGNS OF HYDRAULIC FAILURE,LEVEL OF PONDING,CONDITION OF VEGETATION,ETC.), PAGE 9 ACTION-KING ENTERPRISES,INC. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(CONTINUED) ZOPERTY ADDRESS: 456 SALEM ST NO ANDOVER,MA 01845 WNER: DAN LUCIANO 4TE OF INSPECTION:8-12-99 (ETCH OF SEWAGE DISPOSAL SYSTEM: INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCES LANDMARKS OR BENCHMARKS COAT ALL WELLS WITHIN 100'(LOCATE WHERE PUBLIC WATER SUPPLY COMES INTO HOUSE) i r� b � � PAGE 10 ' ACTION-KING ENTERPRISES,INC. SUBSURVACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(CONTINUED) tOPERTY ADDRESS:456 SALEM ST NO ANDOVER,MA 01845 WNER:DAN LUCIANO kTE OF INSPECTION:8-12-99 ICS REPORT NAME SOIL TYPE TYPICAL DEPTH TO GROUNDWATER iGS DATE WEBSITE VISITED OBSERVATION WELLS CHECKED GROUNDWATER DEPTH: SHALLOW MODERATE DEEP TE EXAM SLOPE SURFACE WATER CHECK CELLAR SHALLOW WELLS ;TIMATED DEPTH TO GROUNDWATER: 6+ FEET ,EASE INDICATE ALL THE METHODS USED TO DETERMINE HIGH GROUNDWATER ELEVATION. _ OBTAINED FROM DESIGN PLANS ON RECORD _OBSERVATION OF SITE(ABUTTING PROPERTY,OBSERVATION HOLE,BASEMENT SUMP ETC.) DETERMINE IT FROM LOCAL CONDITIONS CHECKED WITH LOCAL BOARD OF HEALTH _CHECKED FEMA MAPS ,/ CHECKED PUMPING RECORDS CHECKED LOCAL EXCAVATORS,INSTALLERS USED USGS DATA ASCRIBE HOW YOU ESTABLISHED THE HIGH GROUNDWATER ELEVATION.(MUST BE COMPLETED) HECKED SURROUNDING AREA. WAS INFORMED BY THE BOARD OF HEALTH THAT A GROUND WATER AND SOIL SURVEY WAS PERFORMED IN THIS AREA IN 1997 AND SUPPORTED MY EVALUATION OF WATER DEPTH.6.+' PAGE 11 ` ACTION-KING ENTERPRISES,INC. 26 LIVINGSTON STREET LOWELL,MA 01852 TEL: (508)452-7750 FAX:(508)459-0770 2OPERTY ADDRESS: 456 SALEM ST NO ANDOVER,MA 01845 WNER: DAN LUCIANO 4,TE OF INSPECTION: 8-12-99 CTION KING ENTERPRISES,INC.HAS BEEN RETAINED BY THE OWNER TO PROVIDE AN INSPECTION OF THE ON-SITE EWERAGE DISPOSAL SYSTEM AS DEFINED BY 310 CMR 15.303.D.E.P.GUIDANCE INSTRUCTS THE INSPECTOR TO MAKE AN ;VALUATION OF THE SYSTEMS PERFORMANCE ON THE DAY OF THE INSPECTION. THE TITLE 5 INSPECTION IS NOT >ESIGNED TO PROVIDE INFORMATION TO DEMONSTRATE THAT THE SYSTEM WILL ADEQUATELY SERVE'I'HE USE TO BE 'LACED UPON IT BY THE NEW OWNER AS STATED IN 15.302. THIS INSPECTION IS NOT A WARRANTEE OR GUARANTEE OF 'HE SYSTEM FUTURE PERFORMANCE,AND DOES NOT EITHER EXPRESS OR IMPLY IT. PAGE 12