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HomeMy WebLinkAboutMiscellaneous - 457 BOSTON STREET 4/30/2018 (2) 457 BOSTON STREET0 1 OOa7 0000. owl 2101107 1 w�BVI l Olt '� 1 pORTp 7893 Of i.. o y�y0 3? •..r OL F .•= J A Town of North Andover M�'•;;;o:• HEALTH DEPARTMENT ,SSACMU`+tt CHECK#: DATE: 6 -.2, -v?0 /7 LOCATION: V5:2 460 S Jon 34 H/O NAME: CONTRACTOR NAM : S 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 G $ Title 5 Report a` $50 -� P ❑ Other:(Indicate) $ He ent Initials White-Applicant Yellow-Health Pink-Treasurer + � S Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 457 BOSTON STREET Of 1405TH ANDOVER Property Address }{F}1LT JENNIFER ROGERS Owner Owner's Name information is required for every N.ANDOVER MA 01845 05/24/2017 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 f A. General Information on the compputer,uler, ►� , wME...,] use only the tab 1. Inspector: key to move your cursor-do not JOHN SOUCY use the return Name of Inspector key. SOUCY SEWER SERVICE INC Company Name 78 N BROADWAY Company Address SALEM NH 03079 Cityrrown State Zip Code 603-898-9339 13397 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 F her Evaluation by the Local Approving Authority O � v� 05/24/17 /pecto Date The°°ystem inspector shall sub a copy of this inspection report to the Approving Authority(Board of ealth or DEP)within 30 days of completing this inspection. If the system 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. l5ins.doc•rev.6116 Title 5 Official Inspection Form-Subsurface Sewage Disposal System•Page t of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 457 BOSTON STREET Property Address JENNIFER ROGERS Owner Owner's Name information is required for every N. ANDOVER MA 01845 05/24/2017 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: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 . 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 457 BOSTON STREET Property Address JENNIFER ROGERS Owner Owner's Name information is required for every N.ANDOVER MA 01845 05/24/2017 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 i t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 457 BOSTON STREET Property Address JENNIFER ROGERS Owner Owner's Name information is required for every N.ANDOVER MA 01845 05/24/2017 page. Cityrrown 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 E] ® or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than '/day flow I t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 457 BOSTON STREET Property Address JENNIFER ROGERS Owner Owner's Name information is required for every N.ANDOVER MA 01845 05/24/2017 page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 i Commonwealth of Massachusetts uRimTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 457 BOSTON STREET Property Address JENNIFER ROGERS Owner Owner's Name information is required for every N. ANDOVER MA 01845 05/24/2017 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins.doc•rev.6/16 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Foran -Not for Voluntary Assessments M 457 BOSTON STREET Property Address JENNIFER ROGERS Owner Owner's Name information is required for every N.ANDOVER MA 01845 05/24/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: i I Number of current residents: 5 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: SEE ATTACHED. Sump Pum ? ® Yes ❑ No p Last date of occupancy: 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 j Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 457 BOSTON STREET Property Address JENNIFER ROGERS Owner Owner's Name information is required for every N. ANDOVER MA 01845 05/24/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: CURRENT Date Other(describe below): General Information Pumping Records: Source of information: SOUCY SEWER SERVICE INC Was system pumped as part of the inspection? ® Yes ❑ No If yes,volume pumped: 1000 gallons How was quantity pumped determined? GAUGE ON TRUCK&MEASUREMENTS Reason for pumping: MAINTENANCE & INSPECTION 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 457 BOSTON STREET Property Address JENNIFER ROGERS Owner Owner's Name information is required for every N.ANDOVER MA 01845 05/24/2017 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: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5' 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.): NO EVIDENCE OF LEAKAGE. NO APPARENT OBSTRUCTIONS. Septic Tank(locate on site plan): 7" 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: 6' DIAMETER 2" Sludge depth: r l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 457 BOSTON STREET Property Address JENNIFER ROGERS Owner Owner's Name information is required for every N. ANDOVER MA 01845 05/24/2017 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 35" Scum thickness 2 11 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? TAPE &SLUDGE TOOL Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): TEES IN PLACE. TANK IS STRUCTURALLY SOUND. NO APPARENT LEAKS. 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of W Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 457 BOSTON STREET Property Address JENNIFER ROGERS Owner Owner's Name information is required for every N. ANDOVER MA 01845 05/24/2017 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.doc-rev.6/16 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 457 BOSTON STREET Property Address JENNIFER ROGERS Owner Owner's Name information is required for every N.ANDOVER MA 01845 05/24/2017 page. CitylTown 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.): (3) LINES, FLOW CHECKED GOOD. 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: i i t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 457 BOSTON STREET Property Address JENNIFER ROGERS Owner Owner's Name information is N.ANDOVER MA 01845 05/24/2017 required for every 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: (3)3'X 35' ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): NO SIGNS OF HYDRAULIC FAILURE. FLOWING NORMAL WITH NO BACKFLOW. 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 I Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc•rev.6/16 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 wM 457 BOSTON STREET Property Address JENNIFER ROGERS Owner Owner's Name information is required for every N.ANDOVER MA 01845 05/24/2017 page. CitylTown 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.): i t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 457 BOSTON STREET Property Address JENNIFER ROGERS Owner Owner's Name information is required for every N. ANDOVER MA 01845 05/24/2017 page. CitylTown 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 1 1 fes, �r k S�>1� t5ins.doc rev.6/16 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 457 BOSTON STREET Property Address JENNIFER ROGERS Owner Owner's Name information is required for every N.ANDOVER MA 01845 05/24/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 6'feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: 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: Dug hole with auger APPROXIMATELY 75'FROM S.A.S. DOWN SLOPE SIDE, NO WATER AT 4' (2'GRADE ADJUSTMENT) I Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 457 BOSTON STREET Property Address JENNIFER ROGERS Owner Owner's Name information is required for every N.ANDOVER MA 01845 05/24/2017 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 I i t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 i I Summary Record Card generated on 514/2011 10:40:19 AM by Karen Hanlon Page 1 Town of North Andover Tax Map # 210-107.D-0047-0000.0 Parcel Id 18585 457 BOSTON STREi T ROGERS, WILLIAM R III JENNIFER M GULLA 457 BOSTON STREET NORTH ANDOVER, MA 01845. Class 101 Single Family _ Property Type 1 Residential Zoning2 1 Residential Zoning3 1 ResidentikI Size Total 1 Acres FY 2017 UB Mailing Index Name/Address Type Loan Numbbr Active/Inact. From Until ROGERS,WILLIAM R III Payor JENNIFER Mi GULLA 457 BOSTON STREET NORTH ANDOVER,MA 4,!845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id.24431.0-451 BOS'(ON STREET Last Billing Date 2/61,2017 1090564 01 Cycle 01 Active UB Servi.es Malust. '\ccount No. 1090564 ao vices Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 1 1 9.18 1/1 WTR WAFER 01 ALL METER SIZE 68.40 111 UB Meter Maintenance A7,^nunt No. 1090564 Serial No Status Location Brand Type Size YTD Cons 36183545 a Active ERT HH b Badger w Water 1 1 2E1 Date Reading Code Consumption Posted Date Variance 4/`19/2017 306 a Actual 16 -9% 1/19/2017 290 a Actual 18 2/16/20-0 7 2O 10/1912016 272 a Actual 17 11/16/2016 •21% 7/22/2016 255 a Actual 22 8/16/2016 22% 4/22/2016 233 a Actual 18 5/25/2016 1% 1/22/2016 215 a Actual 18 2/19/2016 -12% 10/22/2015 197 a Actual 20 11/20/2015 9% 7/24/2015 177 a Actual 18 8/14/2015 27% 4/27/2015 159 a Actual 14 5/19/2015 -17% 1/30/2015 145 a Actual 19 2/20/2015 18% 10124/2014 126 a Actual 15 11/14/2014 -16% ':25/2014 111 a Actual 18 8/13/2014 _2% 4!24/2014 93 aActual 14 5/15/2014 1/27/2014 79 a Actual 19 2/14/2014 1 10/23;2013 60 a Actual 18 11/18/2013 10% 1,123/2013 42 a Actua! 16 8/15/2013 -4% 4/24/2013 26 a Actual 17 5/20/2013 9% 1122/2011, 9 a Actual 9 i 3i2013 11/3012212 0 n New Meter 2/13/2013 AIR Inquiry l G & L Laboratories ♦ Water Analysis 4 Food/Seafood Analysis ♦ Metals/Chemical Analysis f Microbiological Testing 246 Arlington Street, Quina, MA 02170 Tel: (617) 328-3663 Fax: (617) 472-0706 REPORT Lab.ID#: 80361 Report Date: 5/2/17 Total Pages:2 Attn: Ms.Kelly Merchant Continental Pools 8520 Corridor Road, Suite B Savage,MD 20763 Sample Received Date/Time: 4/28/17, 11:00 AM Sample Received Temperature: N/A Sample Collected Date/Time: 4/28/17,9:00 AM Sample Collected By: A.P.(Client) Sample Analyzed Date/Time: 4/28/17, 11:40 AM Sample Identification: One(1)pool water sample labeled: 1)Pool Sampling Location: Mill Pond,N.Andover,MA TEST RESULTS: Test Unit Result MCL Method Reference Total Coliform CFU/100mL Absent Absent SM 92228,21St Ed,2005 MCL:Maximum Contaminant Level Mod:Modified Method Exceed MCL t:Analyzed by Sub.Partner ;::Not in a scope of M-MA-1100 Mass.Cert.No.:M-MA-1100 cc:N.Andover BOH Report reviewed --- and approved by: Lab. Director Signed Date Page I of 1 1 ---� ��_ MG & L CHAIN OF CUSTODY RECORD LAB l.D. #: Laboratories DUE DATE: 246 Arlington Street,Quincy,MA 02170 Tel:(617)328-3663 Fax: (617)472-0706 COMPANY: SAMPLE TYPE CONTAINER TYPE ANALYSES ADDRESS: X15-v�O ��Y'V 1 t�OY 1 WATER P- PLASTIC -t 2 SOIL G-GLASS -� 3 SLUDGE V-VOA 4 OIL PHONE#: FAX#: 3D I'�R �/��/I 5 TISSUE P.O. #: 6 DRINKING WATER CLIENT CONTACT. OTHER PROJECT ID/LOCATION: N. SAMPLE SAMPLE CONTAINER SAMPLINGPRESERVATIVE IJ6 COMMENTS IDENTIFICATION TYPE SIZE TYPE # DATE TIME 0o L z 1 I^ er f RELINQUISHED BY: DATE: - - RECEIVED BY: DATE: y - Z p -l SPECIAL INSTRUCTIONS TIME: - - y¢� �?Cl�� TIME: - - ❑ RUSH, ....... BUSINESS DAY TURNAROUND E Q HED BY: DATE: - - RECEIVED BY: DATE: - - ❑ ROUTINE � Sample Disposal Information TIME: - - TIME: - - Are there any other known or suspected contaminats in these samples other than RELINQUISHED BY: DATE: - - RECEIVED FOR LAB BY: DATE: - - those listed above ? TIME: - TIME: - - ❑ Yes ❑ No If Yes, list known METHOD OF SHIPMENT Ellis & Associates ILTPTM Course Completion International Lifeguard Training Pro ram TM Prsonall Last Name. First Name: Middle Name: Date of Birth; Certificate Number, Fill ovir- v an 01-300-1029-3393 Mailing Address: City.. State/Provence: Postal Code: 8520 Corridor Road,Suite B Savage MD 20763 Country: `€mai Home.Phone:, Work Phone: US _ 30114981000 1 . ,7777 ILTP Course Type:(Please Check On, Training Course Type, Shallow Lifeguard.: Lifeguard E]Special Lifeguard ✓ New-Ori loge Renewal ;. ❑ g ❑ with Opeh Water Shallow Lifeguard Pool Life uard Special Facilities Lifeguard Training includes conscious unconscious and Training irciudes conscious,.unconscious and suspected Training includes conseious,unconscious and suspected neck and back rescue skill's for water depths . neck and back rescue skills for water depths not suspected neck and back rescue skills for water not to exceed 5 feet excluding open water exceeding 16 feet-excluding open water environments. depths-not exceeding 16 feet including wave pools environments AAOSIACEP(Emergency.Care;8 AAOS/ACEP (Emergency Care&:Safety.lnstitute- ope and `` n,waterenvironments AAOSIACEP Safety Institute-ESCl.org)Healthcare Provider - ESCt,org)Healthcare Provider CPR AED,Oxygen (Emergdh y Care&:Safety institute-ESCl-org) CPR,AED,Oxygen Administration and Standard First: Admiristra6oirand Standard.Pirsfkd training indudetl. He'althcare:Provider CPR,AEi7,Oxygen Aid training included; ra First Vain included. Adminisl tion•8;Standard irst Aid training in Training Center of Record'. Citi: Slate: ILTP -Continental Pools Inc Savage MD Completion Date: Expiration Date; Al 12/24/2014 x. 12/2V2015 ,< , I acknowledge that I have,seceived"g understean thie•t,TPTm Tratntr,g Program currlculurn and demonstrated.sald-s 11 and knowledge to required competencies.I further.understand that i0s my personal responsibility to maintain my skills and knowledge demonstrated during the ILTPT"course through regular and consistent in-service training.it is also the responsibility of my employer to provide site specific orientation and in-service training prior to working as a lifeguard.I further understand and acknowledge that Ellis&Associates and/or ILTPTm does not provide any protection whatsoever to my employer or myself. Jovan Filipovic LT lost c±nr / a�xr nor`cn >hot ; I hereby certify ttlat the holder of this ILTP TM Course Comp4etlon Crecientiai has successfully met all required skills competencies(Including but not limited to Prerequisite screening,rescue skills,BLS Skills,written and practical exams)and curriculum requirements as prescribed by the International Lifeguard Training Program"'A for the lifeguard classification indicated above.I have also reviewed the ILTPTm Course Completion Acknowledgment wi holder and am satisfied the card holder clearly understands said acknowledgment. Max Water Depth: `ft/m Updated Max Water Depth:______ft/m Instructor Name:___ InstructorID: � Date: instr-ctor^l�Jl dtpx6l ji For additional information regarding the International Lifeguard Training Program'please call or write to: Jeff Ellis&Associates,Inc.Business Office,508 Goldenmoss Loop Ocoee,FL 34761 Office: 1-800-742-8720 Facsimile:407-654-1723 F-mail:business(aiellis com Distribution:This certificate is issued from Jeff Ellis&Associates,Inc.Corporate Headquarters,Kingwood,TX. Revised 1/2011 Ellis & Associates ILTPT'" Course Completion International Lifeguard Traininq Program TM Pergonal Information Last Name: First Name; Middle Name; Date of Birth: Certificate Number: 101-300-1029-3394 Rn7inavic _._._ __-.-_.n4a*c, Mailing Address: City: State/Province: Postal Code: 8520 Corridor Road,Suite B Saa a MD 20763 Country: Email: Home.Phone: Work Phone: us ILTP Course Type:(Please Check On ) _ Training Course Type [J Shallow Lifeguard Pool Lifeguard Special Lifeguard ✓0 New-Original ❑ Renewal With Open Water Shallow Lifebuird: Pool Lifeguard " Special Facilities Lifeguard Training includes conscious,unconscious and. Training includes conscious,unconscious'and suspected Training includes conscious,unconscious and suspected neck and back rescue skiiis for water depths neck and back rescue skips for water depths not suspected neck.and back rescue skills for water not to exceed 5 feet,excluding open water exceeding 16 feet-excluding open water environments depths.not exceeding.16 feel including wave pools environments AAOSIACEP (Emergency Care-& AAOS/ACEP (Emergency Care&Safety institute- and open waterenvironments.AAOS/ACEP Safety Institute-ESCI.org)Healthcare Provider ESCI,org)Healthcare Provider CPR,AED,Oxygen (Emergency Care i3 Safety Institute-ESCLorg) CPR.AED,Oxygen Administratiomand Standard First Administration and Standard First Aid training included: Healthcare Provider CPR,AED,Oxygen Aid training included;....; Administration 8 Standard First Aid training included. Training CenterOlRecord: Gty Stater ILTP-Continental Pools, Inc "` -savage : MD Completion Date: Expiration Date' 1212412014 . 12`2412015 ,.. xd�' ShEli .. w� ��:. w Rl+ �4, s z,..c.,. , "Al n 1 acknowledge that I have,reoeived'`and gnderstaf)d'the IL'luTraining Program WiTlculuni and demMtrated said sidlis and knowledge to required competencies.I furTfier understand that d Is-ti y personal responsibility,to malnt;ib��my.skills and;knowledge demonstrated during the ILTPT"'course through regular and consistent rn service training.It is also the re5ponslbllity of my employer to.:provide.site specific orientation and in-service training prior to working as'a lifeguard.i further understand and,a'cknowledge that Ellis&-Associates and/or ILTPT"'does not provide any protection whatsoever to my employer or myself. Marko Bozinovic trst�tic41f0ilftx;rrror I hereby certify that the holder of this IL-I"P"A Course Completion Credential has successfully met all required skills competencies(including but not limited to Prerequisite screening,rescue skills,BLS Skills,written and practical exams)and curriculum requirements as prescribed by the International Lifeguard Training ProgramT"'for the lifeguard classification indicated above.I have also reviewed the ILTPT"'Course Completion Acknowledgment w holder and am satisfied the card holder clearly understands said acknowledgment. Max Water Deptl— ft/m Updated Max Water Depth: ft/m Instructor Name:.. _.-._ InstructorID: Date:_- _ Listructtx rJ�me V,vlaaa hnJelkovir For additional information regarding the International Lifeguard Training Program T"please call or write to. Jeff Ellis&Associates,Inc. Business Office,508 Goidenmoss Loop Ocoee,FL 34761 Office: 1-800-742-8720 Facsimile:407-654-1723 E-mail:businesses-ieliis.com Distribution:This certificate is issued from Jeff Ellis&Associates,Inc.Corporate Headquarters,Kingwood,TX. Revised 1/2011 ' S Septic System Information '• 457 BOSTON STREET ✓ 1 Printed On: Tuesday, September 05,.2 System ID: BHS-2002-1939 General System Information Latest Permit Information Calcaluted Design Flow: Test Pits Septic Tank Disposal Trench Design Flow: One TWO Capacity: Number. Design Flow Provided: Minutes per inch: Width: Width: I Total Flow. Depth: Length: Length: Seasonal: No No Depth to Water: Diameter: Leaching: , Grinder. No No Soil Type: Depth: Laundry: No- No Hauling/Pumping Listing Quantity Type System Type Pumped Pumped By Transferred To Disposed At Date Pumped allons Routine Septic Tank Andover Septic 04/11/2002 1000 Routine Septic Tank Andover Septic 08/05/2004 1000 Routine Septic Tank STEWARTS SEPTIC GLSD 08/01/2005 1000 Inspections: Inspected: Expires: Inspector. Status: 08/04/2006 Benjamin C.Osgood,Jr. Passes Comments: Title 5 i i I GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Page 1 of 1 NEW ENGLAND ENGINEERING SERVICES, INC. 1600 Osgood Street Bldg 20 Suite 2-64 North Andover,MA 01845 Tel: 978-686-1768 Fax: 978-327-6138 August 21, 2006 Ms. Susan Sawyer RE COV FIE D North Andover Board of Health 1600 Osgood Street Bldg 20 North Andover, MA 01845 AUG 2 S 2006 TOWN Or >.: Ah'��( . r HEALTH L>Ei'k,kl RE: TITLE V REPORT: 457 Boston Street No.Andover,MA Dear Ms. Sawyer: Enclosed is the Title 5 Report for the above referenced property. The system PASSES the inspection. If there are any questions please call me at my office, 686-1768. Sincerely, enj a t di n C. Ms#6d, Jr. Certified Title 5 Inspector I NORTIV Of . oy'�1.0 3L�,r• •, p`. F 9 , Town of North Andover � '• HEALTH DEPARTMENTCHU / CHECK#: LOCATION: H/O NAME: 0ze&C1�� CONTRACTOR NAME: t/ &55 Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ TrashlSolid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Ti�tl 5Inspector $ 2".Title 5 Report $ �< ❑ Other:(Indicate) $ �I I 178 2 Heath Agent Initials White-Applicant Yellow-Health Pink-Treasurer COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION e TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 457 Boston Street North Andover,MA 01845 Owner's Name: Jen Rogers Owner's Address: 457 Boston Street North Andover,MA 01845 Date of Inspection: August 4,2006 Name of Inspector: (please print) Benjamin C.Osgood,Jr.Certified Title 5 Inspector Company Name: New England Engineering Services Inc. Mailing Address: 1600 Osgood Street Building 20 Suite 2-64,North Andover,MA 01845 Telephone Number: 978-686-1768 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of the on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15340 of Title 5 (310 CMR 15.000).The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails / Inspector's Signature: mac., eo2 Date: -5 y d t The system inspection shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 2 6f 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 457 Boston Street North Andover,MA 01845 Owner's Name: Jen Rogers Date of Inspection: August 4,2006 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: V 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: /V 0 One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): Broken pipe(s)are replaced Obstruction is removed Distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): Broken pipe(s)are replaced Obstruction is removed ND explain: ' 3of11 � OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 457 Boston Street North Andover,MA 01845 Owner's Name: Jen Rogers Date of Inspection: August 4,2006 C. Further Evaluation is Required by the Board of Health: IVO Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and (SAS)Soil Absorption System and the(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 the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organize compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: i .4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 457 Boston Street North Andover,MA 01845 Owner's Name: Jen Rogers Date of Inspection: August 4,2006 D. System 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 overload or clogged SAS or cesspool. --.,c Static liquid level in the distribution box above outlet invert due to an overload or clogged SAS or cesspool c Liquid depth in cesspool is less than 6"below invert or available volume is less than'/Z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any Portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrogen is equal to or less than 5ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) AJO(Yes/No)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. You must indicate either"yes"or"no"to each of the following: (The followin 'teria apply to large systems in addition to the criteria above) Yes No The system is within eet of a surface drinking water supply The system is within 200 feet of a ' tary to a surface ' g water supply The system is located in a nitrogen sensitive Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you answered"yes"to any question in S 'on E the system is considered a sigm nt threat,or answered"yes"in Section D above the large system has failed. The o or operator of any large system considered a signiTisant threat under Section E or failed under Section D shall upgrade the s in accordance with 310 CMR 15.304. The system owner sho contact the appropriate regional office of the Department. .5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 457 Boston Street North Andover,MA 01845 Owner's Name: Jen Rogers Date of Inspection: August 4,2006 Check if the followinp,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 an 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 sign of break out? Were all system components,excluding the SAS,located on site? Were all 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? Jam' Was the facility owner(and occupants if difference from owner)provided with information on the proper maintenance of the subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No Y 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(3)(b)] .6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 457 Boston Street North Andover,MA 01845 Owner's Name: Jen Rogers Date of Inspection: August 4,2006 FLOW CONDITIONS RESIDENTIAL ,3 Number of bedrooms(design) Number of bedrooms(actual): DESIGN flow based in 310 CMR 15.203 (for example: 110 gpd x #of bedrooms) Number of current residents: '3 Does residence have a garbage grinder(yes or no):� Is laundry on a separate sewage system(yes or no): /Vo [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no): 6Z 0_ Water meter readings,if available(last 2 years usage(gpd)x Xj ELL- Sump Pump (yes or no): �5 Last date of occupancy COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no) Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION G N O O Pumping Records p g ` Source of information: e ct!L i7 Was system pumped as part of the inspection( es or no): 1V Q If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank, distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attached a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: U ry K N Oki" Were sewage odors detected wen arriving at the site(yes or no): A/ 7411 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 457 Boston Street North Andover,MA 01845 Owner's Name: Jen Rogers Date of Inspection: August 4,2006 BUILDING SEWER(locate on site plan) Depth below grade:_ / Materials of construction: ✓ cast iron 40 PVC other(explain) Distance from private water supply well or suction line: 130/ Comments(on condition of joints,venting,evidence of leakage,etc.): �jpL G� XS &V&to iA—, � C✓r��T SEPTIC TANK: (locate on site plan) Depth below grade: to Material of construction:_ concrete metal fiberglass polyethylene Other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: j a J-.:;, r,-AL,t 0 .j 5 Sludge depth: 4- 1 Distance from top of sludge to bottom of outlet tee or baffle: a 2 Scum thickness: /— f Distance from top of scum to top of outlet tee or baffle: 4. Distance from bottom of scum to bottom of outlet tee or baffle /S" How were dimensions determined: .A grr4=•oRa' s i7C rC Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): TAoV% I%J CsoaV c.00D&Zb n. TEAS (N CsobO ce.,--04- 10 et. GREASE TRAP:a IA- (locate on site plan) Depth below grade: Materials 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 sludge to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc. 8'of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 457 Boston Street North Andover,MA 01845 Owner's Name: Jen Rogers Date of Inspection: August 4,2006 TIGHT OR HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Materials of construction: concrete metal fiberglass polyethylene other (explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidnence of solids carryover,any evidence of leakage into or out of box,etc.): $Z+X I j &-0-*,T) cv 0--10 ►vc,V c.C aF t.a f}K.A-!rE LN v�2 tPUrT:. No o CD-4CS C +(29vv,*eQ. LslbilL� S�d•� &cQ.��F}4 PUMP CHAMBER: A0'1{k (locate on sire plan) Pumps in working order(yes or no) Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 9of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 457 Boston Street North Andover,MA 01845 Owner's Name: Jen Rogers Date of Inspection: August 4,2006 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required If SAS not located explain why TYPE leaching pits number leaching chambers, number leaching galleries number ." leaching trenches,number in length 2 'J'K Ll 3 a 4 leaching fields,number,dimensions: overflow cesspool,number:- -innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure.Level of ponding,damp soil,condition of vegetation,etc) Atzil or— h+anAS Neaeylot. dr 101, CESSPOOLS:N l✓t" (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of Construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Material of construction: Dimensions: Depth of solids: Comments(note condition of soil signs of hydraulic failure,level of ponding,condition of vegetation,etc. 10of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 457 Boston Street North Andover,MA 01845 Owner's Name: Jen Rogers Date of Inspection: August 4,2006 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. V I STA,-IJCES N=r g IT 3J' D$ 73 Awe, P 11 of 11 , OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 457 Boston Street North Andover,MA 01845 Owner's Name: Jen Rogers Date of Inspection: August 4,2006 SITE EXAM Slope Surface water Check cellar �,,,AA p Qv M Shallow wells N u tj 0 Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record—If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health—explain: Checked with local excavator,installers—(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: rot OAA P 13e lo'.. c�sc.3 nisi-PS' t D rC�t w�it_! - & ` 66 LITTLETON ROAD,WESTFORD, MA 01886 978)692-8395 FAX(978)692-0023 1-800-649-TEST Report Number: A102029 Report ate: 8/10/06 Client: Sample Information: New England Eng. Services 457 Boston Rd 60 Beechwood Dr. N Andover MA N.Andover MA 01845 Sampled by: Client Date Received: 8/7/06 Date Sampled: 8/05/06 Certificate of Analysis Test Parameter EPA Limit Results Units Total Coliform(P) 0 0 per100ml Fecal Coliform/E.coli(P) Absent Absent perl00m1 Iron(S) 0.3 # 0.32 mg/L Manganese(S) 0.05 <0.01 mg/L Sodium See Note 54.8 mg/L Chloride(S) 250 37.9 mg/L Hardness Not Spec. <2 mg/L Nitrate-N(P) 10 <0.01 mg/L Nitrite-N(P) 1 <0.05 mg/L pH(S) 6.5-8.5 # 6.1 SU Legends: (P)=Primary EPA Standard,(S)=Secondary EPA Standard,#=Exceeds EPA Limit, TNTC=Too Numerous to Count, *=Background Bacteria Noted,'=Exceeds Advisory Limit Sodium Advisory Limits,Mass.=20,NH=250. This water sample as submitted is considered SAFE to drink according to EPA guidelines. However,one or more parameters exceeds secondary limits as denoted by he s Massachusetts Certification#MA048 Michael P.Carlson, for Thorstensen Laboratory Inc. Commonwealth of Massachusetts H City/Town of NO. ANDOVER w System Pumping Record2113 ±' i; Form 4 DEP has provided this form for use by local Boards of Health. Other forms^frmay be used,-but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out 1. System Location: forms the 450 BOSTON ST. computer,use only the tab key Address to move your NO. ANDOVER MA 01845 cursor-do not city/Town State Zip Code use the return key. 2. System Owner: r� GARY GRANT Name Address(if different from location) F. City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 12/10/12 2. Quantity Pumped: 1000 Date Gallons 3. Type of system: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ® No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: JAMES H. CURRIER H79 406 Name Vehicle License Number J's SEPTIC & DRAIN Company 7. Location where contents were disposed: GLSD ,Q 12/10/12 Signatur6of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 I Commonwealth of Massachusetts ' ►�:� W City/Town of No Andover N System Pumping Record �1T �' 2013 � Form'4 TOWN OF NORTH ANDOVER I' �M HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, use only the tab 457 Boston St key to move your Address cursor-do not No Andover MA use the return City/Town State Zip Code key. 2. System Owner: Rogers Name reomi Address(if different from location) City/Town State Zip Code Telephone Number Q. Pumping Record )() 1. Date of Pumping Date 2. Quantity Pumped: I \',�. ns 3. Type of system: ❑ Cesspool(s) "��Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes []/No 5. Condition of System: 6., Syst m P ped By- j Name Vehicle Lcee Number Stewart's Septic Service Company 7. Loca ' ere contents were disposed: tewart's Pr treatment Plant, 20 So. Mill Bradford, Ma 01835 S au er Date Signat of Receivin acility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 TOWN OF NORTH ANDOVER t10RTH APPLICATION FOR PLAN EXAMINATION 0 ,"'So ,676 0 L 0 t ~ A 41Permit NO: Date Received +� O'A Date Issued: ��sS Area IMPORTANT: Applicant must complete all items on this page LOCATION 7 &5160 / 41& Print PROPERTY OWNER R Print MAP NO.: PARCEL: ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Resid tial Non- Residential ❑)[ew Building ne family Addition ❑Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Repair, replacement ❑ Assessory Bldg ❑ Commercial " ❑ Demolition ❑ Moving(relocation) ❑Other ❑ Others: ❑ Foundation only DESCRIPTION OF WORK TO BE PREFORMED vno� wt's-�.`�►c sc. �,. ,,.Gln . c s tN4.�f n.s.•►-� - r.,,'ly rcYj Identification Please Type or Print Clearly) OWNER: Name: k/J t t( Oce✓'�,: Phone: Address: ys ��5 76n St'/-e.-CT CONTRACTOR Name:[.,.L Ja,-d Z%;L _ Phone: !2>8 9191 -?'75-oZ Address: �O (, ,y, �f-r�r�'F ' ��r r;y D 14 IS /, _r s� Supervisor's Construction License:—,nC, 3 91 l Exp. Date: (o Q$ Home Improvement License: 13 S Exp. Date: CI-2 41 O ARCHITECT/ENGINEER A LAO InJzhs��tr Name: Phone: '7 81" Q,(o — (05/3 Address: 113 A) IA 9. 1e0L-,4 z'1r-% A62y0 Reg. No. 3 I U;L S FEE SCHEDULE.BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost :$ 2c-)o . 0o FEE:$ Check No.: Receipt No.: Page W4 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work Addition Or Decks wBuilding Y Permit Application ,,Surveyed Plot Plan e,Workers Comp Affidavit kl'�'hoto Copy of H.I.C. And C.S.L. Licenses t Copy Of Contract 2 ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler I'lah ,4nd Hydraulic Calculations (If Applicable) ,d/Mass check Energy Compliance Report (If Applicable) New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:INSPECTIONAL SERVICES DEPARTMENTMFORM05 Page 4 of 4 10/19/2006 11:34 978-372-7183 RAM ENGINEERING PAGE 02 R.A.M. ENGINEERING ROBERT A. MASYS, P.E. 180 MAIN STREET HAVERHILL, MA 01830 TEL. 978-372-0449 FAX. 878-372.7183 October 19, 2406 Ms. Susan Sawyer North Andover Board of Health North Andover, MA. RE : 457 Boston Street, North Andover, MA. Dear Ms. Sawyer, Please be advised, that at the above site, the frost wall will be 11' +/-from the septic trenches. The building wiD be cantilivered out approximately 3 feet. There will be no columns under this section of the building. ff you have any questions, or need more information, please contact me. Ve y yours, P.E. 1 . i TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION O� NORrN 4t�so ,61�' C » L #_Permit N0: 0 Date Received Date Issued: C3 �9S-W HuS IMPORTANT: A plicant must complete all items on this page LOCATIONS � G PROPERTY OWNER a Print MAP NO,; Print PARCEL: _ ZONING DicTurrT• TYPE AND USE OF BUILDING HISTORIC DISTRICT YES ❑ TYPE OF IMPROVEMENT PROPOSED USE Resid tial Non- Residential ❑I*w Building ne family Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Repair, replacement ❑ Assessory Bldg ❑ Demolition ❑Commercial :r ❑ Moving(relocation) ❑Other ❑ Foundation only ❑ Others: DESCRIPTION OF WORK TO BE PREFORMED pp Identification Please Type or Print Clearly) OWNER: Name: lam} LL; ` w' r Phone 9>8 985 a o0.�?_ Address: y S CONTRACTOR Name:—'—' ,. �"1so2 Address: ✓ f ` l qL5 ^6�y �sOA_ Supervisor's Construction License: Exp. Date: /G 08 Home Improvement License:_ 13�7 �► 2 Exp. Date: 6h q D ARCHITECT/ENGINEER 14(W to 65te.e(r Name: Phone:_ 7 8 91 l - X513 Address: 1!3 �l/u/(�• �f, 624/2,0 Reg. No. 1 U g FEE SCHEDULE: ost : G PERM. Total Project Cost : $12.00 PER$1000.00 OF THE TOTAL EST/MATED COST BASED ON$125.00 PER S.F. $ 17�, 2yo , env FEE:$ Check No.: Receipt No.: Page IoF4 t Commonwealth of Massachusetts City/Town of NORTH ANDOVERMA SSA - ,SEMTi ,D - SystemPumping Record Form 4 SEP - 6 2006 DEP has provided this form for use by local Boards of Health. T '? H�NGovER be submitted to the local Board of Health or other approving autioir�Hf"` p eco d mug A. Facility Information Important: When filling out 1. System Location: forms computer, use use only the tab key Address --- to move your cursor-do not _._,--- use the return CityfTown , • State Zip Code key. 2. System Owner: Address(if different from location) - --- - - ---- - City/Town --- ---..------------ State _ —.__---- •Zip Code `--.._.. Telephone --•--------.....------•---------- Number . Pumping Record - -- 1. Date of Pumping v __ Date 2. Quantity Pumped: --------•---.-- - ... Gallons 3. Type of system; ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ other(describe): --- 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 8. kePumped By; Vehicle License Number . c5t ate, Company 7. Location where contents were disposed: Si ature of Hau Date http://www.mass-gov,/dep/water/ provals/t5forms.htm#inspect t5form4.doc•06/03 System Pumping Record• Page 1 of •� WE t..OEWED 1"O'4"N u� h G�x f; SEP - 7 2005 UA I'k 0� �j� �YTT-B 1 f'UMPiNG RF_�C`l"? 1TOWNOFNORTH HEALTH DEPARTMENT E REss Sti Q OF _...... ._.._.___ . _ _ tssP�>OL Np rUKt Gr nRv?cue: ,XWL;Pi.N 0,001) mNt)vrlo v ( UL-L (`U t;l)1 t? KRARQIOT'S 0"A" -�- BAJ'F1.$8 'N PLAN 1 OXcUslva SOLIDS -..._. L��aLV f'LOODED OL fD CA RR Yo nR 1 1 RECEIVED SEP = 7 ?004 ISS ' NORTH ANDOVE; UA FE � i© MPINQ RECORD TOWN OF NORTH ANDOVER HEALTH DEPARTMENT SYSTFM OWNfit�k AO +R SYSTEM LOCATION t [SATE OF PUMPIWI' -_ - ._-QUANTITY Pt3MPED: -/G{'�^ �:G�3PCXJL.: NC) r/�ES SaPtic Tank: NU_ YES Lam' NA FURE OF SERVICE; RUt)"CINE _._ EM 'KOENCY ubahRYA t'1CMS; OWV CONDITION _ FULL ,W COVER HEAVY GREASE � Ru4�'PI.ES IN PI,AG� R007`:� _ _ LBAC"ML[)RL NEACJK - EXCESSIVE So LIDS FLOODED SOLID CARRYOVER­__O'TgER EXPLAIN Sy�rorn Pumped bar UMMI NTA CUN MN I'S FKANSFERRED "CU _ Jv YR�)k e, 114 A< - WATER ANALYSIS PARAMETERS As a minimum, the following parameters should be tested for private Wells: - Coliform Bacteria* - Ph* - Alkalinity - Color - Conductivity - Hardness - Iron - Manganese - Calcium - Magnesium - Sodium* - Turbidity - Nitrates* - Nitrites* - sulfates * Considered primary contaminants and shall meet EPA Standards. A well with a quantity of water less than the following shall be considered inadequate for a single family dwelling: Well Depth Gallons Per Minute For Four Hours 0 - 150 feet 5 - 6 150 - 200 feet 4 200 - 250 feet 2 - 3 250 - 300 feet 1 - 2 350 and over 1/2 MJR/cjp � -F 0 hkz64PP��'l TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: I SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) ys /�65kAJ /l/v. DATE OF PUMPING: QUANTITY PUMPED daJ GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY r' OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK T EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: COMMENTS: CONTENTS TRANSFERRED TO: rf S C e t•�s ' Ir°1 itr, ' (�t • xr)} �ii + y t/.J h', tira�A qS` t{ir t ;� ,' fill tl rq�.�;��l+rlr �1?1• ib'f� ��.(Nb re �!f ti, �, i t�y r .{, 4•_. \.. - "�1' , F .,.� 1 ♦-}, \ .,ly, t fel, i..- 1 i i- ;� r +'.` x A TOWN OF NORTH ANDOVER {, SYSTEM PUMPING RECO K 12D a a F f. a '�•. !wt?i lµ 1att1 a"1• (` iR+�}•� r tt ■T,p•/■��'• /�e�/^ ,t •t d.r..�i hah ds •},I��'t} ,• j.. . i 'I �r^ Ar .• il'• -.11"� +� w,f� � ''\�,��°''�14t�+sr -4'r r'.' t� i,.,• , 'f"1 �> rc' a ttf( 55 ', e 'SXSTEM O• ,,., • WATER 'ADDRESS R•;�. SYSTEM'LpCATION *� 't y�lr f +� y �'. f (exam �p�} i{. N 4d't! ('�tr r, 41` ` _ , Y'C ��Y••froot of house) f>nwtlr'+�xryr �' ? t��. ,T'tisAr�,IF#+►�'.:I�,.wf;�'r�ar`'"' .,.,•....,�},�i..�'/ I.�/� ! r ,;A1�file' �•Aa' Nii1,.^»4r•� �j 7��Cjr� r• tys+ /' y•.•yr< t,i..:'• {' t - { � a' i�( f t... rrx1T.; �,(n.a��j!{rP.,far• �. + , ,..:, ,,,.5�, ry:. 4 ,! -• .. ..,r.. a WING: U Q ANTITY PUMPED t , t `tiv ..GALLONS I olltM NO YES' .- SEPTIC TANK: NO Y}N\ y (r 'p 1A� ,R;.�n�jr•,7°{ btl' ..a i� t a_':: .. .• VICE: RO UTINE.,. ,,, EMERGENCY . CY 1✓; I�k ,! {( :• 'n .ANC r },e 'f, ••, �. �r�,1 w ,. .. .. ..... • .... ' r I } 4 Igorri0�C f � t VAT�MarlMrr�t r , Pl IFr CONDITION BEAVY GREASE., --- FULL TO COVER ,!r l e ° ,57r';,ti n j�� r^( ` , '.1 ROOTS -----� BAFFLES IN PLACE QLD R EXCESSIVE SOLIDSFLOODED .,""...' LEA RUNBACK SOLIDS CARRYOVER OTHER +> (EXPLAIN) LAIN) sJ�`gy1�1 '/I.4',l�,t � �4 I.l r`J;Af �7 ry,7., e1 •i, t t t �[Y77� +�4�iT7�7�,�f'�7^' ,���f{hti��`�( ' a 4 {!� � �r� ' ' e. • . . • pq Ul 00, �:1"�'r' �r(rl�,�ktry:,,a�q „, _r �rL 1 r i`% a •i,'. I "�r,,. 4 t�� _,��f✓ �`"1^14tiv.P"\.! 4t�'i '`Ity a r + r, , � l jr, �'l i �a� a }ra;�� }, n �� f S`}Rr�•e'/t�1' , � 4 'T.'"e}; 5'j4'"��t fr:'M• �.In � t� i,����!JI�°4�'tf��pi e 6,,tN b N tjrrt"sy��r y�r•��I,�y��.�11,,t .{ t e1 ' 1. ' ,• s � t• ` M yx t r 1 r Ary , p � d.l '.r'�'t�js � '' ¢ ' AR Ads i'•rt;t'Jt't,,tv Sv 4,�� f r �'llr 1! •4+�I I I/ V N K'& . h '{?fie Wf S I i Int+r! f a•I' ' r COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION F Q 5� TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 457 Boston St. N.Andover,MA 01845 Owner's Name: Joseph Golden Owner's Address: Same Date of Inspection: 6/18/01 Name of Inspector:(please print) Paul G.Jenner Company Name: Paul G.Jenner Associates,Inc. Mailing Address: 31 Riley Avenue East Weymouth,MA 02189 Telephone Number: __(781)337-8617 FAX#: (781)337-1802 CERtiFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based o my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a EP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: XXX Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ails Inspector's Signature: Date: June 28, 2001 The system inspector shall submi a copy of th' 1ns on report to the Approving Authority(Board of Health or DEP)within 30 days of completing this ins If If the systemfis 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. f Or . Notes and Comments: `�� Q.- A, :) . JUL ` 6 2001 ****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. Paul G.Jenner Associates,Inc. Title 5 Inspection Form 06/15/2000 Page 1 of 12 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 457 Boston St. N.Andover,MA 01845 Owner: Joseph Golden — Date of Inspection: 6/18/01 — Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes:YES X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N/A One or more systems components as described in the"Conditional Pass"section need to be replaced or, repaired. The system upon completion of the replacement or repair,as approved by the Board of Health, will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health.*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: distribution box is leveled or replaced 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 obstruction is removed Paul G.Jenner Associates,Inc. Title 5 Inspection Form 06/15/2000 Page 2 of 12 r r OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 457 Boston St. N.Andover,MA 01845 Owner: Joseph Golden Date of Inspection: 6/18/01 C. Further Evaluation is Required by the Board of Health: NO Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. i, The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Paul G.Jenner Associates,Inc. Title 5 Inspection Form 06/15/2000 Page 3 of 12 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 457 Boston St. N.Andover,MA 01845 Owner: Joseph Golden Date of Inspection: 6/18/01 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool No Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or Cesspool No Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow No Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). number of times pumped No Any portion of the SAS,cesspool or privy is below high ground water elevation No Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface Water supply. No Any portion of a cesspool or privy is within a Zone 1 of a public well. No Any portion of a cesspool or privy is within 50 feet of a private water supply well. No 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO (Yes/No)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: N/A To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well 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. Paul G.Jenner Associates,Inc. Title 5 Inspection Form 06/15/2000 Page 4 of 12 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 457 Boston St. N.Andover,MA 01845 Owner: Joseph Golden Date of Inspection: 6/18/01 Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes No Yes Pumping information was provided by the owner,occupant,or Board of Health No Were any of the system components pumped out in the previous two weeks? Yes Has the system received normal flows in the previous two week period? No Have large volumes of water been introduced to the system recently or as part of this inspection ? N/A Were as built plans of the system obtained and examined?(lf they were not available note as N/A) Yes Was the facility or dwelling inspected for signs of sewage back up? Yes Was the site inspected for signs of break out? Yes Were all system components,excluding the SAS,located on site? Yes 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 ? Yes Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No No Existing information.For example,a plan at the Board of Health. Yes Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] Paul G.Jenner Associates,Inc. Title 5 Inspection Form 06/15/2000 Page 5 of 12 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 457 Boston St. N.Andover,MA 01845 Owner: Joseph Golden Date of Inspection: 6/18/01 FLOW CONDITIONS RESIDENTIAL:YES Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): N/A Seasonal use:(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Well Sump pump(yes or no): Yes Last date of occupancy: Curr COMMERCLUJMUSTRIAL: N/A Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: 99/Owner Was system pumped as part of the inspection(yes or no): Yes If yes,volume pumped: 1000 gallons--Reason for pumping: Maint,Structural,Measurements How was quantity pumped determined? Gage/Dimensions TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy No Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Unknown Were sewage odors detected when arriving at the site(yes or no): NO Paul G.Jenner Associates,Inc. Title 5 Inspection Form 06/15/2000 Page 6 of 12 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 457 Boston St. N.Andover,MA 01845 Owner: Joseph Golden Date of Inspection: 6/18/01 BUILDING SEWER(locate on site plan) Depth below grade: 15" Materials of construction: X cast iron 40 PVC other(explain): Distance from private water supply well or suction line: 90' Comments(on condition of joints,venting,evidence of leakage,etc.):No abnormal signs observed at time of inspection. SEPTIC TANK: YES (locate on site plan) Depth below grade: 6" Materials of construction: X concrete Metal fiberglass polyethylene other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 8'L x 4'W x 4'6"D Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 31" Scum thickness: I" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 14" How were dimensions determined: Before,During and After Pumping Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Inlet and outlet tees in place as required,all water levels were at an appropriate height;tank is structurally sound and watertight at time of inspection.Recommend pumping every 12—18 months. GREASE TRAP: NO (locate on site plan) Depth below grade: Materials of construction: concrete Metal fiberglass Polyethylen e other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Paul G.Jenner Associates,Inc. Title 5 Inspection Form 06/15/2000 Page 7 of 12 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 457 Boston St. N.Andover,MA 01845 Owner: Joseph Golden Date of Inspection: 6/18/01 TIGHT or HOLDING TANK: NO (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Materials of construction: concrete Metal fiberglass polyethylene other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: YES (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 is structurally sound and watertight and providing even distribution.No carryover was observed at time of inspection. PUMP CHAMBER: NO (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Paul G.Jenner,Associates,Inc. Title 5 Inspection Form 06/15/2000 Page 8 of 12 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 457 Boston St. N.Andover,MA 01845 Owner: _Joseph Golden Date of Inspection: 6/18/01 SOIL ABSORPTION SYSTEM(SAS): YES (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: X leaching fields,number,dimensions: 1—20'x 30'Approx. overflow cesspool,number: innovativelalternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.):SAS had no surface breakout,wetness,or signs of hydraulic failure observed at time of inspection.No signs of abnormal vegetation observed.All appears to be in good working order. CESSPOOLS: NO (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: NO (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.): Paul G.Jenner Associates,Inc. Title 5 Inspection Form 06/15/2000 Page 9 of 12 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 457 Boston St. N.Andover,MA 01845 Owner: Joseph Golden Date of Inspection: 6/18/01 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. 6) //1'l/ 3 Mgw/tk a 1,51 � it 1W Paul G.Jenner Associates,Inc. Title 5 Inspection.Form 06/15/2000 Page 10 of 12 +� OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 457 Boston St. , N.Andover,MA 01845 Owner: Joseph Golden Date of Inspection: 6/18/01 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells N/A Estimated depth to ground water >3.5 Feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record—If checked,date of design plan reviewed: X 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: Excavated 1' below bottom of d-box and below field with no signs of any groundwater or wetness Paul G.Jenner Associates,Inc. Title 5 Inspection Form 06/15/2000 Page 11 of 12 ATTENTION THIS REPORT DOES NOT CONSTITUTE A GUARANTEE, WARRANTY OR REPRESENTATION THAT THE SYSTEM WILL CONTINUE TO OPERATE AND FUNCTION IN GOOD WORKING ORDER. THIS REPORT IS SOLELY LIMITED TO REPORTING WHETHER THE SYSTEM MEETS THE CRITERIA SET FORTH IN 310 CMR 15.303; THERE MA Y BE LOCAL LA WS OR REGULATIONS APPLICABLE TO THE SYSTEM WHICH THIS REPORT DOES NOT ADDRESS. THIS REPORT CONSTITUTES THE ENTIRE REPORT. THIS REPORT WAS PREPARED ON BEHALF OF THE PERSON NAMED ON THE FRONT PAGE OF THE REPORT AND THE ONLY PERSON AUTHORIZED TO REL Y UPON THE CONTENTS OF THIS REPORT IS SAID PERSON; ANY MA TTERS WHICH SAID PERSON INTENDS TO REL Y UPON MUST BE CONTAINED IN WRITING IN THIS REPORT AND SAID PERSON A CKNO WLED GES THAT THEY ARE NOT RELYING UPON ANY ORAL COMMUNICATIONS OR DISCUSSIONS CONCERNING THIS REPORT. Paul G.Jenner Associates,Inc. Tide 5 Inspection Fonn 06/15/2000 Page 12 of 12 Jta,n 29 01 05: 04p lloyd 19787627427 p. 2 06/29/2001 11:01 9786920023 • THORSTENSEN LAB Prar,E Et 1 JZ �►�t�n MA0188 LITTLETON ROAD,WESTFOFiO, 86 Report Ntunber 56723 (978)892-6395 FAX(976)692.0023 1400.60-TEST Clicnt. Report Date: 6/28/01 Sample Information: Karen Smith 2 Maytum Way 457 Boston Street MiddletonMA 01949 N.Andover MA Sampled by: Client Date Received: 6/21/01 Date Sampledr 6/21/01 Certtfi are of ai t;'s ]'estP, ar`aaetr Total Coliform(p) EP= t't ksu 0 'ts uni Arsenic(P) 0 0.05 per100ml <0.002 Calcium mg/L No Limit Copper(S) 1.3 15.3 mg/L Iron(S) 0.3 <0.02 mg/L Lead(P) 0.015 q 77 mg/L Magnesium <0.001 mg/L Manganese(S) No Limit 4.00 OS mg/L Potassium 0 0.50 mg/L Sodium No Limit 1..2 mg/L See Note Zinc SA 10.1 mg/L Alkalinity(S) 0.01 mg/L No Limu 39.5 Ammonia•N mg/!, Chloride No Limit 0.03 mg/L (S) Chlorine 250 22.7 mg/L No Limit c, .02 0 Color{$j 25 mg/L Conductivity k 50 CPU Fluoride($) No Limit 221 umhns/cmt Hardness 4.0 0.1 mg/L No Limit Nitrate-N(P) 55 mg/L 10 <0.01 mg/L (P) Odor 1 <0.01 mg/L PH(S) 6.5-8.5 2 TON Sulphate(S) 6,6 SU Turbidity 250 19.3 mg/L Not Spec. 22.4 Sediment NTU Total Dissolved Solids pas/nog nes Legends: S00 129 mg/L (P)I-Primary EPA Standard,(S)=Secondary EPA Standard,#=Exceeds EPA Limit, 7NTC,Too Numerous to Count, Background Bacteria Noted,,—Exceeds Advisory Limit Sadtum Advisory Limits,Mass.=20,NH-250. This water sample as submitted is considered SAFE to drink according to EPA/FRA guidelines. However,one or more parameters exceeds secondary limits as denoted by the#sign. Massachusetts Certification N MA048 New Hampshire Certification#2739 Michael P.Carlson,for Tholstensen Laboratory Inc. Jun 29 01 05: 05p lloyd 19787627427 p. 4 • 06/29/2001 1.1:01 978692002-3 THORSTENSEhJ LAB PAGE 03 J� tib LITTLETON ROAD,WESTFORD, Wow (978)692-8386 FAX(978)692.0023 1-B00.gq�TEsT Report Number: W.56723 Client: Repon Date: 6129/41 Sample taken at: Katon Smith 2 Mayturrt Way 457 Bo6ton Street Middleton MA 01949 N.Andover MA Sample taken by: Client On: 6/21/01 EPA524.2 ,MCL RESULTS PARAMETER Benzene MCL RESULTS Carbon Tetrachloride 5 0 ND 1,1-Dichloroethane 1, I-Dichloroethylene 5.0 ND ND 7,0 1,2,2,2-Tetrachloroethane 1,2-Dichloroethane ND 1,3•Dichloropropane ND p-Dichlorobenzene S.0 ND Chloromethane ND S.0 Tricbloroethytene ND Bromomethane ND 5.0 ND 1,2,3-Trichlor ro 1,1.1-Triehloroetltane 200.0 1�tD oP Pane ND NO 20. Vinyl Chloride 1.2.4-Trirnethylbenzenc - Chlorobcnzene ND 1,1.1,2-Tetrachloroethane ND 100.0 ND Chloroethane ND o•DichJorobenzenc 600.0 -- ND trans.1,2-DichloToethylenc 100.0 ND I,2,3'xrichloropropane -- ND 2,2-Dichloropropane ND ND cts•l,2-Dichloraethylene 70.0 -" ND 1,2•Dichloropropanc 5.0 o•Chlorotoluene ,Ethylbenzene 700.0 ND P-Chlorotoluene ND ND Bromobenzene ND Styrcrae 100.0 ND -- ND Tetrachloroethylene 1.3-Dichloropropene NID Toluene 20 .0.0ND n-Propylbenzene ND Xylene(total) 10000.0.0 Naphthalene n-Butylbenzene ,• ND Dtchloromcthanc S,p ND -- ND 1,2,4-Trichlorobenzenc Nexaclilorobutadiene ND 70.0 ND 1,3.5-Triniethyibetumc 1,1,2-Trichloroethane 5.0 ND ND ND Chloroform p4sopropyltoluene ND -- ND Bromodiehloromethane Isopropylbenzene ND ND tcr.gutylbenzenc -__- ND Clilorodibromomcthane •- ND sec•Butylbenzene sromofotm ND Fluorotrichloromethane •- ND m-Dichlotobenzene _ ND ND Dichlorodifluoromethane Dibromomethane ND -- ND Bromochloromethane - Methylene Chloride .. ND - ND 1,2-Dibromo-3-Chlozopzopane .. 1,1-DlChloropropene - ND 1,2-Dibromoethane ND *MTBE ND ND Recoveries of Internal Standards% *Optional 4-8179moiluorobenzeneND=None Delected 102 MCL—Maximum Contamination Level 1,2-Dichlorobenzene-d4 100 Results arc in ug/L Detection Limit-0.5 ug/L Michael P.Carlson,for Thoratensen Laboratory Inc. JL4n 29 01 05: 05p lloyd 19787627427 p. 3 06/29/2001 11:01 9766920023 THORSTENSEN LAB PAGE 02 �� d�Gr��Q2�► , cYytC. 88 LITTLETON gpgp WESTFORO,MAO 1508 Report?\'umber: 56723 (878)692-s396PAX(978)092-0023 =Ax(ATBj 6p2-0023 ?- Client; Report Date: 06/29/01 NO649-TEgT Karen Smith Sam* Taken At: 2 Maytum Way 457 Boston Street Middleton MA 01949 N.Andover MA Sample Taken By: Client On; 6121101 W�.Qf.t'►cl�yrsis rest Parameter: EPA Limit Result Units Sulfides No Lunn <0.01 mg/L Massachusetts Certification MMA048 New Hampshire Certification#2739 Michael?,Carlson,fox Thorstensen Laboratory,Inc. jr' �r s x���.a f5 i�r t 3 tin - �.,4•• T,T.,._____.__._.___ .. ;r 1;stir i�"vFn�tf�V��tr�li� r ���i' r�Jv'tif�'1� r�'t � u i r V t , 1. ! 1 f; i� 1 �l'�'.� .\• r WN' O.F NORTH'AJ'DOVER. SYSTEM PUM•PI.NC RCOR_D �2pp3 M OWNER & ADDRESS SYSTEM LOCATION Icft frons of housr) w �- 1 dv p.0 ©`a. U:� l (QUANTITY PUMPED l YESSEPTIC TANK; N0 YES -- NATURE OF SERVICE; ROUTINE. � EM1✓RGEN"CY ,r Ii PRYAT10 Sc ` s 'QMCQ PULL:TU COYCk. JI13.A`'YY CiZEAHC ' .8AFFLLS IN I'L,ACI LEACHFICLD IZUNl3AC'K.., C. XCESSI.YE SOLIDS . FLOODED SOLIpIS CARRYOVER ,,�,�,' RHRR (EX%A.IN) >> > I lM PUM . r , rNTS; 1 r I TR A P CCI I &D (R) a4C}L••' 7 � •Q -�y V"� t, 'v .1 ..,,�.n , t/t ...1 r \' . ;jr 1 1' - `II • F� 7 ANDOVER" MASSACH • . S USETT � - : • i, Fum n e rd• SYS; e, � p�.a g'.R co ti f' y+K.K1C'Y.Ys frx 1v5< 1, yi; %124A.1 y v t,. 1 f, Y tery pw. .1 ' ' t.,l.' �� /+ K E DEP,has prdWded this form for use by local Boards of Health, The be submitted to the local'Board of Health or other approving autho y, Pumping Reco4 k ry. SEP 7 2007 A. FaCility lt1f0�'ITl tlon TOWN OF NORTH ANDOVE'I �: .. HEALTH DEPARTMENT ,:IWhen f�unO out System location, form;on the':' . 'computer;use only the tab keyAddress ss to move your cursor•do not use the rotum CItY�o State ��..; zip Code keyr.h,:K'.5 1'ill'•j stem Owner, 'r - �� /,� ., a �`• ,i�.it:. '' • Name' Address(If different from location) Y ClbrlTovm State f� �gyZIPP Code ` 9e— Telep hone Number ,f Putnpfng Record 11* ,� 1`J Date of Pumping 6D ddb pate 2 Quantlty Pumped: Gallons 4f system;', ❑ Cesspool(s) peptic,Tank ❑ Tight Tank []..,,Other(describe); � 111 ,1..."•1. t:.!1�i i:,V i'.�',1.. �1'� 4 Effluent Tee Filter present?.❑ Yes o If yes, was If cleaned? El Yes ❑ No e> on of V VO"' 'ley.. "�,; ... 4•,,,... ,.:' :t, ::,.: ". ------------ 6 Sy Qsrt.Pumped By:'' N =��-: ':�• ��. ;;. :,'��n4�.,;aY'?�JN�iF. '+�1. +,,�+at• � "`f7:•;::,,h VehlcleLlCenee umber t i ,.�•� Jtf �f,',TY'�`t�,Jr fylt' \(������� ;/:N- j;l�. � ✓�]� . C-^..'�rwr�y,�~ir;,y}"�,,X1'1 ttl�•�j�l:�'/•Up•.t� t�. 1 �,VV1 ) �� („(/( 7;. location where Contents yvere.di;3posed 1 � , `•,, F ^ S nature of Hauler, a 1G �:.,;:N•�,•.'�, .. .: pate httpJlwww.mass.gov/dep�wafe�/approvals/t5forms,htm#Inspect t5forrM dote 08103 System Pumping Record Page t of t d AIJDOVER ,: �$�' ,e �� m n •' Rec'o'rd � ...__ _ � �'������.. �,., , , ,�,• �I ,Q.f SEP Q S 200 DEPhai provldad jn!i�lo�c, '�r .do Q JO I .�n`•'({0� ;0 l! B 10:e! 9r y ,. ,. ;:: ...� S y• ... ~• �, r_ ,,�, ,TaV,/,,N0I NPRT ANrppOVER HEALT,I DEPARTMENT raciliCy Informa�!on - Ow ------------- ner. ' h'alit l r ( /Vf�rinl rcrn buucn' BI Pumping Regord - - TYfle 91 eyslam; POP(.- Tai, G. Emuonl T98 Filla(.p(�w? .. . ,l„�;.i .;11'..,.x. - (✓ `1 "`� ^,� I �ll ',��,'1✓ / ` (' ,I��j: '1.41� ,i� '".y��j�.If, J,., ^, Von, V-1 Gd 7. LQ cn `�,�nere co�lsnls ware c:s;csac 97 m �o oe,.nveler/e,.P(ova)s/Iblorms 1, RECEIVED . . } it, 'I:ISEP. 0 8 2009,. - "1% 14 009. .'f114�ui,' ,{1/, O�P,h#I pJovldrd rhr�yro�m io/ Sao ^ '' Ivbfh1110d Ip u11 IoCil Sparc C� lo'' 01 BoarCI of qua!:.. !, ..r Ol,In p/ CIltO/ iA?coal„�^,•,Inp, rn, ` A. Facility Inl'orm�(ion 1 .'.Y ,'.I 11:lei {•, f J! S le V/ I 99ji, W ”"IY�(,;';', ;•,''•'r,',a1� , i' " ' , 7111 r s i ', ,,/•, �,��ff MAI IantbuVon) PumpIng.Reprd Oe(o o1Pum�lnp�� ;,, �',� •rYpe`cl ry�iem.�',:' G� Ce>>�ool(,� �1., , ,:` ►'� -4DI)C Teri,, Eh4uen)�1'4 " �F1110/"pylsent? r' Yo, o ,• ,�ti1, ''',i,�../,�,,�1•'lil�,Y��i�ld'J1i�"ij'LII�Ir�:.,..J• � � Y97. n'81 i; C.'88n0'J� •� T! S ;,6„ .C�l.dfyon o(.3y, jml'rti;: _ •y y, t:,�l ,Ir'. J,'�'�J'Ji•1',S•lu1';J1;�:�r r ,.' j'�'�� Jf . �' Sy P�'mped •' . ��r,,�;!',rS''�I/)�,it;, '��' ,l' ►� 'I � '"• � Vr�lUl 'Jc4nl I n�'T•► -- • f''1,+ .:J^hii•✓i;w , r�11l,iY,,t� , IJp�}IyV�1) li,,, GC �� ' .'.S','h��,• '/,l�a�,)1� If'1,•►,1��„�,,,I 't l' (�"Vj'�' it�r'11,,,1, / ' • .... `�s.: .., 1''I, loci on,whel �,•,�.;�,�. ,:., • ',;, ., 9,ooAlenla,ylrere dl�posoo: masa.pot/depeivilepp((9Yi/s%Ib(orm�,r,:�nain o�ll Commonwealth of Massachusetts City/Town of NORTH, ANDOVER, MASSACHUSETTS System Pumping Record Form 4 , DEP has provided this fort for use by local Boards of Health. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important When filling out 1. System Location: Pc forma on the q computer,use only the tab key Address to move your n RT-cin Ve- V,_. use�return City/Town State Zip Code key. 2. System Owner. 2 e, Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: v Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. tem Pumped By: Ic ame Vehicle License Number Company 7. Location Krhere contents were disposed: McA Signature of Hauler Date http://www.mass.gov/dep/wafer/approvals/t5forms.htm#inspect t5form4.doca 06/03 System Pumping Record•Page 1 of 1