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Home My WebLink AboutMiscellaneous - 467 SALEM STREET 4/30/2018 (2) N0. 467 SALEM STREET J210/038.0-0097-0000.0 ` ADDRESS DATE • ZTtEDj 6 Rg1'ED AYE PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 6/5/15 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Complete Repair of D-Box By: Warren Pearce At: 467 Salem Street Map 03800 L®t 0097 No th Andover, MA 01845 The1Is'�`ua ce of this ce ifiaa of shall not b construed as a guarantee that the system will function satisfactorily. � � g Y Y Michele Grant ` Public Health Agent J 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com f �1 � S�KxL�nl�6 North Andover Health Department (ommunity and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 467 Salem St. MAP: 038.0 LOT: 0097 INSTALLER: Warren Pearce DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS D-Box INSPECTION: ID DATE OF BED BOTTOM NS ECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned', ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on:. compacted firm base ❑ Cleanouts per plan A_ ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged Ic G' ❑ 1500 gallon tank has been installed l ✓lsl� H-10 loading _ ❑ Monolithic tank construction I �" ❑ Watertightness of tank has been achieved by visual testing nl, _,; i ❑ Inlet tee installed, centered under access port :r k- ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed_over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION-BOX nstalled on stable stone base -20 D-Box [ -nlet tee (if pumped or >0.08'/foot) ydraulic cement around inlet & outlets . Observed even distribution Speed levelers provided (not required) ❑ Schedule 40 PVC Pipe / 3J Comments: ^ kT � �c�s 0 h , 36- P— 5 s j Of tNOR7M 7245 j • O F Town of North Andover `�'• o.. HEALTH DEPARTMENT cHustt d n CHECK#: �11� DATE: Q LOCATION: H/O NAME: T�Vc��unJ . — n CONTRACTOR NAME: 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 $ ❑ SwimmingPool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ , VSeptic Disposal Works Construction(DWC) $1 r ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other:(Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer i I . Map-Block-Lot 4 Commonwealth of Massachusetts 038-- ---- ----------- BOARD OF HEALTH Permit No BHP-2015-0241 North Andover R P.I. FEE F.I. $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Warren Pearce Jr. - - -------------------------------------------------------------------------------------------- to(Repair)an Individual Sewage Disposal System. at No 467 SALEM STREET ---------------------------------------------------------------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. 131-113-2015 ate d June 02,20.1.5 ---------I - --CO ------- Issued On:Jun-02-2015 BOARD OF HEALTH � Application for Septic Disposal System Construction Permit - TOWN OF TODAY'S ATE NORTH ANDOVER MA 01845Full Repair $125.00- omponent Important: Application is hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on the computer, use ❑ R pair or replace an existing on-site sewage disposal syste only the tab key to move your El or replace an existing system component—What? cursor-do not use the return A. Facility Information key. _S 77 Address or Lot# tab ISI City/Town 2.- *TYPE OF SEPTIC SYSTEM*: ➢ ❑ Pump NJ Gravity(choose one) ***If pump system, attach copy of electrical permit to application*** ➢ ®,Conventional System (pipe and stone system) ➢ ❑ Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system.) ➢ ❑ Pressure Distribution S.A.S. (No D-Box) ➢ .❑ Pressure Dosed(D-Box Present)S.A.S. ➢ ❑ Does the system require an effluent filter? Yes No If yes, does plan specify make and model of filter? YES =(no further info, needed) NO=(installer must specify brand of filter before DWC issuance) What is the Make? What is the Model. 2. Owner Information Name L� Ste' Address(if different from above) City/Town State Zip Code Email address Telephone Number 3. Installer Information b-9/�)-rLym k4 V12—Pl. VLC_E__ 12 r& Y),a C_V_ Name Name of Company Address City/Town State Zip Code q7� h �� i � � �ey Telephone Number(Cell Phone#if possible please) 4. Designer Information o 0 Name Name of Company Address City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit-Page 1 of 2 • Application for Septic Disposal System To S D Construction Permit - TOWN OF ` $ 250.00- Full Repair NORTH ANDOVER, MA 01845 $125.00-Component PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: bgLResidential Dwelling or❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover. I understand that until a final Certificate of Compliance has been issued by this Board of Health, the installed system is not approved. zo y ,VoLh,k,( JR, P�Nlk-cfi- -7-0- ^ a 1 Name Date 1 Ii ti Appr B (Bod(d f Health Representat" e) am Date Application Disapproved for the following reasons: For Office Use Only: Z Fee Attached? Yes No 2. Project Manager Obligation Form Attached. Yes No um S stem? Ifso ttach ofElectrical Permit Yes No Apphr ntreceive copy of "Electra nspection Notes for Septic Sy ems" Yes No Handout? 4 eve, d approval lette rwork received? Yes_ No MISSing:' 5. dation As-Built? struction onl Yes No me sc e as approved p 6. .Floor Plans? W COn Ct►On Only). Yes No Application for Disposal System Construction Permit•Page 2 of 2 ' SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: L:z S )A Z,a-Vl k (Address of septic system) For plans by >" 1yo 0 V\ �'7 (Engineer) Relative to the application of (_J WC (Installer's name) And dated (Original ate Dated o ay s ate With revisions dated (Last revised date) I understand the following obligations for management of this project: 1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved dans and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner, contractor,project manager, or any other person not associated with my company schedules an inspection and the system is not ready, then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior.to the applicable inspections as indicated below. I understand that requesting an inspection without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a$50.00 fine being levied against me and/or my company. a. Bottom of Bed—Generally, this is the first (15) inspection unless there is a retaining wall,which should be done first. The installer must request the inspection but does not have.to be present. b. Final Construction Inspection—Engineer must first do their inspection for elevations, ties, etc. As-built of verbal OK (or e-mail to: healthdel2t@to-,vnofnorthandover.com) from the engineer must be submitted to the Board of Health,after which installer calls for an inspection time. Installer must ,be present for this inspection. With a pump system, all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade—Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible. 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board of Health staff or consultant. d.. Installation of tank, D-Box,pipes, stone, vent,pump chamber, retaining wall and other components. 6. As the installer, I understand that I am solely responsible for the installation of the system as per the appr�plans. No instructions by the homeowner,general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: (Today's Date) �Q_ (Name— runt ame—Signe O` NOR7.,y t 7092 3:•�" 0 Town of North Andover �` '• ' ` HEALTH DEPARTMENT �SS�cNus�t CHECK#: DATE: ." C-P I LOCATION: 40 151110 n H/O NAME: CONTRACTOR NA 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 $�� tTitle 5 Report $� ❑ Other(Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer of7092 No oT.�M .j F 0 • Town of North Andover `�'•�.; HEALTH DEPARTMENT ,SS�CHUStI CHECK#: l 1 1 DATE: I LOCATION: `i�� P 5j( T- vV, `—a H/O NAME: �_ l C� r CONTRACTOR NAMEf,� � �) b Type of Permit or License:(Check box) • Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $� Title 5 Report $ � ` r ❑ Other:(Indicate) $ vtl Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer SERVICE PUMPING&DRAIN CO.,INC. \ / 21911 Town of North Andover 4/23/2015 _Date Type Reference Original Amt. Balance Due Discount/ Payment' 4/23/2015 Bill 50.00 50.00 50.00 I Check Amount 50.00 1 � � l SP&D Checking Acct- 467 Salem Street North Andover — 50.00 SERVICE PUMPING&DRAIN CO.,INC. J \ 21911 Town of North.Andover / 4/23/2015 \ Date Type Reference Original Amt. Balancebue Discount Payment 4/23/2015 Bill 50.00 50.00 ' 50.00 Check Amount 50:00 � 1 J J SP&D Checking Acct- 467 Salem Street North Andover 50.00 PRODUCT SSLT104 USE WITH 91663 ENVELOPE d \ ` 00 Commonwealth of Massachusetts Title 5 Official Inspection Form RECEIVED Subsurface Sewage Disposal System Form -Not for Voluntary Assessments APR 2 7 2015 467 Salem Street Property Address T1 r0VV HEALTH DEPA NT Daniel & Bonnie Desmond Owner Owner's Name 5� information is required for every North Andover MA 01845 4-8-2015 page. City/Town State Zip Code Date of Inspection or v Y—� Inspection results must be.submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael J Wood use the return Name of Inspector key. Service Pumping & Drain Co., Inc. „y Company Name 5 Hallberg Park Company Address North Reading MA 01864 City/Town State Zip Code 978-276-0217 5021 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 4-21-2015 Insp ors Sig re Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. j t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17. Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 467 Salem Street Property Address Daniel & Bonnie Desmond Owner Owner's Name information is required for every North Andover MA 01845 4-8-2015 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: Ih have e not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 P Y 9 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 467 Salem Street Property Address Daniel & Bonnie Desmond Owner Owners Name information is required for every North Andover MA 01845 4-8-2015 page. Cityfrown 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 distribution box is deteriorating and needs replacement. The cement is cracked and weak ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection 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 467 Salem Street Property Address Daniel & Bonnie Desmond Owner Owner's Name information is required for every North Andover MA 01845 4-8-2015 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, I 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 5m provided that no other failure criteria are triggered. A co f pp , p gg copy h o the analysis must be attached to this form. 3. Other: i D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 P Y 8 I� Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 467 Salem Street Property Address Daniel & Bonnie Desmond Owner Owner's Name information is required for every. North Andover MA 01845 4-8-2015 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000g pd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 467 Salem Street Property Address Daniel & Bonnie Desmond Owner Owner's Name information is required for every North Andover MA 01845 4-8-2015 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 GPD t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 467 Salem Street Property Address Daniel & Bonnie Desmond Owner Owner's Name information is required for every North Andover MA 01845 4-8-2015 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 I 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 Z No Water meter readings, if available(last 2 ears usage(gpd)) 117 GPD average Detail: Water records were obtained from the town. Sump pump? ❑ Yes ® No Last date of occupancy: currently ioccupied Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 467 Salem Street Property Address Daniel & Bonnie Desmond Owner Owner's Name information is North Andover MA 01845 4-8-2015 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: owner Source of information: Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? gauge on the truck 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 467 Salem Street Property Address Daniel & Bonnie Desmond Owner Owner's Name information is required for every North Andover MA 0184.5 4-8-2015 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: The system was installed in 1980 according to as-built plans. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 14" Depth below grade: feet i 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.): There are no visible signs of failure or leakage. i Septic Tank (locate on site plan): 6" 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 9'x 5'x4' Dimensions: Sludge depth: 4" t5ins•3113 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 467 Salem Street Property Address Daniel & Bonnie Desmond Owner Owner's Name information is required for every North Andover MA 01845 4-8-2015 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle no scum at outlet Scum thickness <1"at inlet, none at the outlet Distance from top P of scum to to of outlet tee or baffle no scum at outlet Distance from bottom of scum to bottom of outlet tee or baffle >2 How were dimensions determined? tape measure/sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): There are no visible signs of failure or leakage, Both inlet and outlet tees are intact and appear to be working as designed. This system should be pumped annually as part of a maintenance plan. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete El metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 467 Salem Street Property Address Daniel & Bonnie Desmond Owner Owner's Name information is required for every North Andover MA 01845 4-8-2015 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: ElYes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): I "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 i i i C\ Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 467 Salem Street Property Address Daniel & Bonnie Desmond Owner Owner's Name information is required for every North Andover MA 01845 4-8-2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 1/2" below invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The d-box is deteriorated and cracked. it needs to be replaced. 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. i Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 467 Salem Street Property Address Daniel & Bonnie Desmond Owner Owner's Name information is required for every North Andover MA 01845 4-8-2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1, 23'x46- ❑ 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.): There are no visible signs of failure. I Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts a . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 467 Salem Street Property Address Daniel & Bonnie Desmond Owner Owner's Name information is North Andover MA 01845 4-8-2015 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information, (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 467 Salem Street Property Address Daniel & Bonnie Desmond Owner Owner's Name information is North Andover MA 01845 4-8-2015 required for every 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 Ac,Z0r�„ t� �jok A b y 315' f5 �A c Z 3r 7 I 5� SA . l5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments `t 467 Salem Street Property Address Daniel & Bonnie Desmond Owner Owner's Name information is required for every North Andover MA 01845 4-8-2015 page, City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 61 Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: basement floor Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 467 Salem Street Property Address Daniel & Bonnie Desmond Owner Owner's Name information is required for every North Andover MA 01845 4-8-2015 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater i ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Summary Record Card generated on 4!13/2016 3:07:59 PM by Maureen Me Way Page 1 Town of North Andover Tax Map # 210-038.0-0097-0000.0 Parcel Id 10400 467 SALEM STREET DAN & BONNIE DESMOND��- 467 SALEM STREET NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 0.97 Acres FY 2015 UB Mailin I� ndex Name/Address Type Loan Number Activellnact. From Until DAN&BONNIE DESMOND Owner 467 SALEM STREET NORTH ANDOVER,MA 01845 PIERSON,PATRICIA Previous Customer Inactive 8/19/2004 467 SALEM STREET NORTH ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id.16086.0-467 SALEM STREET Last Billing Date 1/7/2015 3160127 03 Cycle 03 Active UB Services Maint. Account No.3160127 Service Code Rate Charge MultipllerlUsers MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 49.40 /1 UB Meter Maintenance Account No.3160127 Serial No Status Location Brand Type Size YTD Cons - 13242194 a Active 00 METE METE w Water 0.63 0.63 369 Date Reading Code Consumption Posted Date Variance 3/4/2015 738 a Actual 15 19% 12/5/2014 723 aActual 13 1/15/2015 -35% 9/4/2014 710 a Actual 20 10/15/2014 24% 6/4/2014 690 a Actual 16 7/16/2014 14% 3/5/2014 674 a Actual 14 411112014 26°k 12/4/2013 660 aActual 11 1/17/2014 -21% 9/5/2013 649 a Actual 14 10115/2013 19% ._..6/712013 636 a Actual —12 7/24/2013 -8% 3/7/2013 623 a Actual 13 4/22/2013 16% 12/5/2012 610 a Actual 11 1/9/2013 -26% 9/6/2012 599 a Actual 15 10/15/2012 15% 6/7/2012 584 a Actual 13 7/16/2012 -7% 3/8/2012 571 a Actual 14 4/14/2012 15% 12/6/2011 557 a Actual 12 1/17/2012 10% 9/9/2011 545 aActual. 12 10/13/2011 -1% 6/2/2011 533 a Actual 11 7/20/2011 -18% 3/4/2011 522 a Actual 13 4/13/2011 -11% 12/7/2010 509 a Actual 16 1/12/2011 42% 9/3/2010 493 a Actual 11 10/15/2010 -18% 6/2/2010 482 a Actual 13 7/15/2010 -7% 3/4/2010 469 a Actual 14 4/14/2010 32% 12/4!2009 455 aActual 11 1/12/2010 -22% 9/2/2009 444 a Actual 14 10/15/2009 -4% 6/2/2009 430 aActual 14 7/20/2009 -1% 3/6/2009 416 a Actual 15 4/29/2009 4% 12/3/2008 401 aActual 14 1/20/2009 -15% 1� Septic System Information 467 SALEM STREET Printed On: Thursday,January 11, 200 System ID: BHS-2004-0054 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: Total Flow: Depth: Length: Length: Seasonal: No No Depth to Water: Diameter: Leaching: Grinder: Yes No Soil Type: Depth: Laundry: No No Haulin4/Pumpina Listing Quantity Tvpe System Tme Pumped Pumped By Transferred To Disposed At Date Pumped (gallons) Routine Septic Tank Andover Septic 06/28/2004 1500 Inspections: Inspected: Expires: Inspector: Status: 10/24/2006 Charles Roux Passes Comments: Title 5 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Page 1 of 1 i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ' i it sii V TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION ,� � Property Address: ( b Jai ly m 0 Owner's Name: ODE Owner's Address: (n ►M Q Q�N�} • t �±2 MEt.1I Date of Inspection: Name of Inspector: (Please print) eh pr l e q J (Z 01,A Company Name: TevAcs6wj4 _cewer getryiet Mailing Address: oltl P**eZ get. umd.tk 6 M.S.0 LB 76 Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority _ Fails ''// Inspector's Signature: Date ��`�T✓D The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use, i Title 5 Inspection Form 6/15/2000 page 1 I Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM • PART A CERTIFICATION (continued) PropertyAddress: Owner: Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I 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 exists. Any failure criteria not evaluated are indicated below.- Commen : V v e Lo w► d w G�'e' B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" ection need to be replaced or repaired. The system,upon completion of the replacement or repair,as app r ved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the follow' g statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic (whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank fa' re is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approv d by the Board of Health. *A metal septic tank will pass inspection if it is structurally sou d,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 hi static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneve distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s) a replaced obstruction is moved distribution x is leveled or replaced ND explain: The system required pumping more an 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the B rd of Health): bro en pipe(s)are replaced ob truction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) PropertyAddress: .41 Owner: Date of Inspection: C. Further Evaluation is required by the Boar/eB lth: Conditions exist which require further evaluhe Board f Health in order to determine if the system is failing to protect public health,safety or the envir 1. System will pass unless Board of Health din a cordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner whiot t public health,safety and the environment: Cesspool or privy is within 50 feet of a sterCesspool or privy is within 50 feet of a begetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Sup lier,if any)determines that the system is functioning in a manner that protects the public healt safety and environment: _The system has a septic tank and soil absorption system(S )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 thin a Zone I of a public water supply. The system has a septic tank and SAS and the SAS' within 50 feet of a private water supply well. The system has a septic tank and SAS and the S S is less than 100 feet but 50 feet or more from a private water supply well**Method used to deter ine distance **This system passes if the well water analysis erformed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds ind' ates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitr a nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) PropertyAddress: Owner: Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No V Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool -jZ- Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or — clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool NIL Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow IL- 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. ,L Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ V Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.[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 nitiogen is equal to or less that 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria exists 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 ith 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 th riteria above) yes no the system is within 400 feet of a surface inking water supply the system is within 200 feet of a trib ry to a surface drinking water supply the system is located in a nitroge sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of aPP ublic water su 1 well P If you have answered"yes"to any que 'on in Section E the system is considered a significant threat,or answered "yes"in Section D above the large sy em has failed. The owner or operator of any large system considered a significant threat under Section E failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner shoul contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:�`'� CI Owner: Date of Inspection: Check if the following have been done. You must indicate"yes"or"no"as to each of the following. i Yes No i V 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 a 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: Yes no Existing information.For example,a plan at the Board of Health. V/ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: -1, Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL ,�/l,� Number of bedrooms(design):�= Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example:110 gpd x#of bedrooms): q y d GP✓//gam Number of current residents: 141 Does residence have a garbage grinder(yes or,no): '_S9S 'war Q64C �o�- wig �./��(•�� Is laundry on a separate sewage system yes or no) [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): Water meter readings,if ava' able(last 2 ears usage(gPd)) :.5 Sump pump(yes or no) C �Vl"5 Ub Itl 1 � Last date of occupancy.Ayfl A. COMMERCIAIANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft, ): Grease trap present(yes or no): Industrial waste holding tank present es or no): Non-sanitary waste discharged to th itle 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: eq— Was q-Was system pumped as part of the inspection(yes or no): If yes,volume pumped: gallons-How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _ Tight tank Attach a copy of the DEP approval i Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no):A_ 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: Material of construction: cast iron 40 PVC other(explain): Distance from private water supply well or suction line.MA Comments(on condition of joints,venting,evidence of leakage,etc.): i SEPTIC TANK: (locate on site plan) Depth below grade: ✓nr �1�IA w�l 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: � S— X � I I $—D 0 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:. a _ Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to b m f Tnuieiand tee f e! How were dimensions determined ✓ Q Comments(on pumping recommendatio , outlet tee or baffle condition,structural integrity,liquid levels rel ted to utlet'nvert,evidence o I aka e,etc.): a e� 6 f yl ti L9 p GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiber ass_polyethylene_other (explain): Dimension: Scum thickness: Distance from top of scum to top of outlet tee/ndoutlet Distance from bottom of scum to bottom of oufle: Date of last pumping: Comments(on pumping recommendations,intee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage I I 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 6-1 5y l + Owner: Date of Inspection: TIGHT or HOLDING TANK:_(Tank must be pumped at a of inspection)(locate on site plan) Depth below grade: Material of construction: concrete_metal_fiberg ss_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or o): Date of last pumping: Comments(condition of alarm and float switches, c.): DISTRIBUTION BOX:/(If present must be opened)(locate on site plan) i Depth of liquid level above outlet invert: 0& Comments(note if box is level and distribution to outlets equal,any evidencpqrf solids carryover,any evidence of Z�Qe or out of box,e c� � � � OU,�'1 6 � �"'))1�)1Ntl ✓ PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump Cham er,condition of pumps and appurtenances,etc.): 8 • Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: U S� 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. • ''II v a LT't� s r- 10 CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no Comments(note condition of soil,signs of 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 draulic failure,level of ponding,condition of vegetation,etc): 9 P Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4D Vn 6 Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or Benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. o�T 419 S� I 10 Q Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C F SYSTEM INFORMATION(continued) Property Address:��)c11�e m 5 Owner: Date of Inspection: SITE EXAM Slope Surface water , Check cellar V Shallow wells Estimated depth to ground water. feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) _Checked with local Board of Health-explain: ,-Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: -pS - - c i - 11 Summary Record Card generated on 10/20/2006 11:02:24 AM by Lisa Warren Page 1 • Town of North Andover Tax Map # 210-038.0-0097-0000.0 467 SALEM STREET DAN & BONNIE DESMOND 467 SALEM STREET NORTH ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Size Total 0.97 Acres 'FY 2007 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until DAN & BONNIE DESMOND Owner 467 SALEM STREET NORTH ANDOVER, MA 01845 PIERSON, PATRICIA Previous Customer Inactive 8/19/2004 467 SALEM STREET NORTH ANDOVER, MA 01845 UB Account Maint. t Account No Cycle Occupant Name Active/Inactive Bldg Id. 16086.0-467 SALEM STREET Last Billing Date 10/16/2006 3160127 03 Cycle 03 Active UB Services Maint. Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7,82 1/ WTR WATER 01 ALL METER SIZE 56.34 /1 UB Meter Maintenance Serial No Status Location Brand Type Size YTD Cons 13242194 a Active ERT HH METE METE w Water 0.63 0.63 0 Date Reading Code Consumption Posted Date Variance 9/7/2006 253 a Actual 18 10/20/2006 -7% 6/9/2006 235 a Actual 17 7/10/2006 2% 3/22/2006 218 a Actual 22 4/17/2006 -5% 12/12/2005 196 a Actual 21 1/17/2006 -10% 9/12/2005 175 a Actual 26 10/14/2005 -14% 6/3/2005 149 a Actual 27 7/15/2005 34% 3/5/2005 122 m Manual estimate 20 4/5/2005 -21% 12/6/2004 102 a Actual 25 1/14/2005 -64% 9/9/2004 77 a Actual 18 10/8/2004 147% 8/17/2004 59 f Final Bill 40 8/17/2004 22% 4/13/2004 19 c Correction 34 5/17/2004 0% C/O 15+ERT 19=34 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS a DEPARTMENT OF ENVIRONMENTAL PROTECTION V V� TIFTLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Owner's Name RECEIVED Owner's Address: 4A1 S/7&1-n s'7" Al- JUL - 8 7OP4 Date of Inspection: q q- 7.2- 74 TOWN,,)i-NORTH ANUOViER Name of Inspector: (please print)` � All s/I HF-ALTH DEPARTMENT Company Name: rfS '/}{��., Mailing Address: - ro Telephone Number: 9�I$-3rJ�2-7/,f'7l CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: f Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: J—df!4- .. Date: (!�-. 2--e- O Ll r The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments .****This report only describes conditions at the time"of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. P Title 5 Inspection Form 6/15/2000 page 1 r r Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 41 �en� �,�- N• 0/VOOVe/2, ren . Owner: l e—l"SU Date of Inspection: -Q 4. Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D P A. System Passes:(J�� / 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: � w B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired:The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will.pass inspection if(with approval of Board of Health): broken pipes)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: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A tt '' CERTIFICATION(continued) Property Address: `T6 7 -';T. �Al e- C! Owner: 'i Date of Inspection: 6-,--2 -D C. Further Evaluation is Required by the Board of Health: �. Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety'and the environment: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance *This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen`is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: r 3 Page 4 of I 1 OFFICIAL INSPECTION FORINT—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) / c t PropertyAddress: Owner: Pie(.,� / , Date of Inspection: 1,o � -a D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _L-1 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool L,-,-Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool L/ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than'/2 day flow r —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. 1 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 nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as 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"to4ach 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. 4 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: (O7 j� • 0/V1`)DVe k Owner: P! P r Date of Inspection: &-c;29-04 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: y Does residence have a garbage grinder(yes or no):�v Is laundry on a separate sewage system(yes or no): [if yes separate inspection required] Laundry system inspected(yes or no):_ Seasonal use:(yes or no): /v6 Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): }/6 Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: / /t 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 Pumping Records Source of information: a Yv, Was system pumped as part of the inspection(yes or no):yj!�, S If yes,volume pumped/Svv gallons--How was quantity pumped determined? Reason for pumping: C// P ail_ ?-A-H iL $7-Qyc 7-1.1 TYP i,F SYSTEM _✓✓Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): 6 w Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: J(96)') ST Owner: Al R r1! ,A Date of Inspection:-4 -,,.I g-en BUILDING SEWER(locate on site plan) Depth below grade: 7v" Materials of construction:_,,-last iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): Jai��r s Eaa� ,�v i P�r13�� SEPTIC TANK: r:s (locate on site plan) rt Depth below grade: 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: T l Sludge depth: Ile Distance from top of sludge to bottom of outlet tee or baffle: 33 Scum thickness: ' Distance from top of scum to top of outlet tee or baffle: K- Distance from bottom of scum to bottom of outlet tee or baffle:/Y" How were dimensions determined: 61/ Si i E Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAP/4locate on site plan) Depth below grade:— Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / SYSTEM INFORMATION(continued) Property Address: )U 17 P_h 0 Owner: Pic A Date of Inspection: l TIGHT or HOLDING TANK:& (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOXf5- (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 7 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.): "Yd PUMP CHAMBER:` ) (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 * Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: q6 i N . GAILI)Ve /)k,7 Owner: i or Sid AJ Date of Inspection: la— g-D'7F SOIL ABSORPTION SYSTEM(SAS):y! S(locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: __1leaching trenches,number,length: __ / leaching fields,number,dimensions: .,5'_ overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): CESSPOOLS: /1-Mcesspool 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.): i e t PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM'INFORMATION(continued) Property Address: io� /1� t i�� Owner: ' Date of Inspection: — SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. i 6A4- 13" n � z-,F14 c!f r i GGr� 4 l 10 ' Page l l of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION(continued) Property Address: 4 kf)I /V, aA154�e4 LY-1 Owner: / P f,SA/V Date of Inspection: (p�2�� SITE EXAM / Slope Surface water .- Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground 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 excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: 0/4SL�Ppi('�cy,9�t'✓ l�r3Sr_=,eaP� 11 `-" irwHKI/s1NllUVER PAGE 02 11,6r4h ANl16ver 12.6. 4. MART Na rlh A/lr��ves- 47 W SEPTIC R It L.f o v t Lie- j 5l-pip 14 8RWFC3RD, M 01835 978-372-7471 Momw OF tLYT�mNcr DAMADMESs art e. parrs 1 I Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection William F.Weld GOVOMM Trudy Coxe ArW LL fr" Ceilucc! David 0.Stru sh C-nngakww SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 1/lD7 Sfr <c /'/• 144o.,e4- Address of Owner. (� , Date of Inspection: r Z1I9,y (If different) NameotInapector. Benjamin C. Osgood Jr. Company Name,Address and Telephone Number. New England Engineering Services, Inc. C 33 Walker Road, North Andover, Ma 01845 CERTIFICATION STATEMENT Tel. 508-686-1768 Fax. 508-685-1099 I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: (� Date: ,,/?IIcI'7 The System Inspector shall submit a copy of this inspection report to the A inspection. If the pproving Authority within thirty(30)days of completing this system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: i Check A,B,C,or D: A] SYSTEM PASSES: have not found any information which indicates that the system violates an of the Any failure criteria not evaluated are indicated below, y defined 310 CMR 15.303. B) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined".explain why not) The septic tank is metal, cracked,structurally unsound,shows substantial infiltration or exfrltration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 One Winter Street a Boston.Massachusetts 02108 a FAX(617)556-1049 a Telephone(617)292.5500 A CJ Printed on Recycled Papa -------------------- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address¢ y6 7 54lem 5AXe-l', /U• i9,,k ve ee Owner. lql"Cd►04 Zan 6Crnard1' Date of Inspection: s/a//9-7 BI SYSTEM CONDITIONALLY PASSES(continued) Bewage backup or breakout or high static water level observed in the distribution bar is due to broken or obstructed pipes) or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the Public health,safety'and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water — Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is leas than 100 feet but 50 feet or more from a private water supply w4 unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 3) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Addreex Y6 7 .5;,?.5;,?/e rrj S 4ir p i N tq v c1<nv✓eR- /0 p Owner. Rrcl�ar� 2ahbema.YQi Date of Inspection: DI SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria.,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 H of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.• (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PropertyAddreset y67S��jj�em St.-ee �� /V. 11,4o om ,M A Owner. R i c h Qr 1 Z a el rye 0/'CO i Date of Inspeotioo: Check if the following have been done: ,Pumping information was requested of the owner,occupant,and Board of Health. ✓None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water.have not been introduced into the system recently or as part of this inspection. ZAs built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow V"The site was inspected for signs of breakout. ZAll system components,excluding the Soil Absorption System,have been located on the site. V The septic tank manholes were uncovered,opened, and the interior_of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. zThe size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. ZThe facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub- surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Addresm L16 7 Salem Sl eel; /v'• 14r.L vet ivt A Owner. Date of Inspection: Ric k a,cg Z a m b e f-n a rA FLOW CONDITIONS RESIDENTIAL Design f1ow:_____jpllona Number of bedrooms:_ Number of currant reaidents:-5-- Garbage grinder(pea or no)---4;Z Laundry Connected to system(yes or no)-_.k4_ Seasonal use(yea or no):(/ Water meter readings,if available: g. f} )V,-,5 L "A Last date of occupancy:e✓r�Cn� COMMERCIALANDUSTRIAL Type of establishment: - Design IIow:_gallona/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present:(yes or no)_ Non-aauitary waste discharged to the Title 5 system: (yea or no)_ Water meter readinm if available: Last date of occupancy: OTHER:(Deem-ibe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information- Pu rn nformation:Purr a&0- `-ebot,,7� ue.ar System pumped as part of inspection: (yes or no). v If yea,volume pumped: ¢ llo,, Reason for pumping- TYPE umpingTYPE V SYSTEM V Septic taak/dktrlbution boz/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source of information:�S- b,,-# --r Sewage odors detected when arriving at the site: (yea or no) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Pr-PertY Addrem y6 7 Salem S,L, N• 4,0oo e Owner. f L(n ct t Zan >je r n a rc9 Date of Inspection: SEPTIC TANK_ . (locate as site plan) Depth below grade: fiy Material of construction: concrete metal_FRP—other(explain) Dimensions: /S"D[o GA LU A,/,I- Sludge lSSludge depth " j Distance from top of sludge to bottom of outlet tee or baffle: 2 Scum thickness: b if Distance from top of scum to top of outlet tee or baffle: D Distance from bottom of scum to bottom of outlet tee or baflle:1_ Comments: (recommendation for pumping,condition of inletd outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) fi Tc r s D o 19LN SHo..L.l9 Be- v'1 PED_ GREASE TRAP:_ (locate on site plan) Depth below grade: Material of construction:—concrete_metal FRP other(ezplain) 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: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of 1ealcage,etc.) I i (revised 11/03/95) g SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Addr—w //67 SQ1ern S-A,1 T1, /1/, lq,c� oo ee Owner. Date of Inspection: TIGHT OR HOLDING TANK_ (locate on site plan) Depth below grade: Material of construction:_concrete_metal_FRP other(explain) Dimensions: Capacity:_ gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert:_ Comments: (note if level and distribution is equal,evidence of solids ver,evidence of leak2ge into or out of box,etc.) ccs / %e, w /L f W v / s 6c "s er wr n TJ .be Cliec4e S y-lt n lRe YeGi'S 1q).-- PUMP q).—PUMP CHAMBER:_ (locate on site plan) Pumps in working order.(yes or no) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Addreaa: y6 7 S a/e en St, Al. 44Y4 Owner. Date of Inspection: SOIL ABSORPTION SYSTEM! (SAS):_ (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: leaching pits,number._ leaching chambers, number._ leaching galleries,number. leaching trenches,number,length: leaching fields, number,dimensions: / 23 X y6 overflow cesspool,number. Comments:(� condition of soil,signs/of h ulic failure, level of ponding, condition�oC vegetatioa,etc.) JP�C 1S C e..10% P u Q -C ✓Ov (1,1 4_7 LIQ✓c ✓�C4 O CESSPOOLS:_ (locate on site plan) Number and configuration: Depth-top,-6f liquid to inlet invert: Depth of solids layer. Depth of scum layer. Dimensions of cesspool: Materials of construction: Indication of groundwater. inflow(cesspool must be pumped as part of inspection) Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) PRIVY-_ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) (revised 11/03/95) g SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Addre= 7 Salem S tic e-f N• /�..�t;v e�{ Owner. R P c•k a,ck Date of Inapeotion: Z 4`' r n 41-'co; SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' i HOt�'s E i I t 1,50OC-pL t i j s—19-1'Z Q T1 0 A./ I Sox i Cl le -I DEPTH TO GROUNDWATER Depth to groundwater. 10)t feet method of determination or approximation: 8• d� ei-�/ti cS S c�i✓o ..� ]� �,,�� K (revised 11/03/95) 9 COhIjION-WEALTH OF MASSACHUSETTS 1eI ,EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS S : DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON NIA 02108 (617) 292-5500 l TRUDY CORE ` Secretan ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner �_/ /J }}�,I� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM d PART A CERTIFICATION Property Address: (p � Name of Owner /-'j ,{ Address of Owner: Date of Inspection: 1'��► ' . Name of Inspector:(Please Print) 1 am a DEP appr yed system inspector pursuant to Section 15.340 of Trde 5(310 CMR 15.000) Company Name: `� -4r - "Y3 J / a.- Mailing Address: Telephone Number: CERTIFICATION STATEMENT. 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes NConditionallyPasses _ Needs Further Evaluation By the Local Approving Authority Fails / Inspector's Signature: I I Datef The System Inspector shall•'submit'a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty.(30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd`or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to ttre s system owner and copies sent to the buyer, if applicable,.and the approving authority. NOTES AND COMMENTS 011 6 revised 9/2/98 Pap, Iofit : - ` • --n-d o�Recy(led Pape, • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A � �} CERTIFICATION Icontirwed) y "roperty Address: � 1 / Ale-, �..r ../0 Jwner: Date of Inspection: � % /r�" 0 G INSPECTION SUMMARY: Check A, 8, C, or D: );�;criteria TEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure 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 replacementtr repair';as approved-by the'Boardtof Health, will pass. Indicate yes, no,or not determined (Y. N, or ND). Describe basis of determination in all instances: If "not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed 1 revised 9/2/98 Page korlt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: ` ' /° Date of Inspection: t C. NFITHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the /// public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. -44 j4 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:. The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone i of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of aprivate water supply well. The system has a septic tank and soil absorption system and the SAS is less then 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER o, s i revised 9/2/98 ragc3gf:.tt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A . CERTIFICATION (continued) Property Address: r/ J / -2/ 1 L Owner: r Date of Inspection: D. SYSTEM FAILS: You must indicate either "Yes" or "No to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this 'determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. 1. Yes No — Backup of sewage into facility-or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. — 7 id level in the distribwtion box above outlet inve.t_due;to an overloaded or clogged SAS.or cesspool.. r — Static liqu � ,. ... e.. .. n 9' Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 3 Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public II! health and safety and the environment because one or more of the following conditions exist: Yes — the system is within 400 feet of.a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply 'the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM " PART B CHECKLIST Pfoperty Address,: ( C � / / Owner: . Date of Inspection: r f �✓ Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recent or as part of this . inspection. As built plans have been obtained and examined. Note if they are not available.with N/A., ; _ The facility or dwelling was inspected for signs of sewage beck-up. ) ti The system does not receive non-sanitary or industrial:waste flow. _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have.been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles ortees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _ Existing information. For example, Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable), [15.302(3)(b)T The facility owner (and occupants,if different from owner) were provided with information on the proper maintanan"-of SubSurface Disposal Systems. r revised 9/2/98 Pap.5ofII G SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION rroperty Address: Owner: Date of Inspection: } ! 'FLOW CONDITIONS i* RESIDENTIAL: Design flow: g.p.d./bedroo Number of bedrooms(design): Number of bedrooms(actual):_ Total DESIGN flow I Number of current residents: �� U C, Y� 12 Garbage grinder(yes or no):-Y,5 f Laundry(separate system) (r es or no): 1�/ �If yes, separate.inspection required Laundry system inspected lyes or no) Seasonal use(yes or no):_A! j Water meter readings, if.available (last two year's usage(gpd): Sump Pump(yes or no): / 9 r^ fi Last date of occ�upancy:��L.,e u7 f COMMERCIAL/INDUSTRIAL: tt 1 Type of establishment: /" r Design flow: gpd ( Based on 15.203) Basis of design flow —_ Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: lyes or no)_ Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)– If yes, volume pumped: A< Ugallons Reason for pumping: f ' TYPE 0 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) IIA Technology etc. Attach copy of up to date operation,and-maintenance contract t: . ',. t �*�Tigfit Tank Copy of DI=P Approval I Other / APPROXIMATE AGE of all components, date installed(if known)and source of information: Sewage odors detected when arriving at the site:(yes or no) G s. I revised 9/2/98 Page 6ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icontinued) 'roperty Address: 6 �5 f Owner: �t Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth.below grade: / Material of construction: cast iron 40 PVC_other (explain) Distance from private water supply well or suction line Diameter C, Comments: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK: (locate on site plan) . Depth below graders ( Material of construction:h'concrete_metal_Fiberglass Polyethylene_other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: A0 r/1 !!14 S Sludge depth:.. r Distance from top orsludge to bottom of outlet tee or baffle. Scum thickness; Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: ` How dimensions were determined: 'omments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) _ 75 c:7U t/ CGJ—1 g/ GREASE TRAP: (locate on site plan) Hj4 . Depth below grade:_ Material of construction:._concrete_metal_Fiberglass _Polyethylene_other(explain) - Dimensions l31'. Scum-thickneI.ss: s N k S h wt 3a,. iw-^°d,a.. . , ,xA 4. ' 9�u. F Distance from top of scum to top of outlet tee or baffle: Y Y Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: g Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) revised 9/2/98 Pagv7of11 C lit SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) i 'roperty Address: Owner: d j Date of Inspection: ��f�fi �i f j TIGHT OR HOLDING TANK: U ank must be pumped prior to, or at time of, inspection) (locate on site plan) ` Depth below grade:_ . Material of construction: concrete metal Fiberglass_Polyethylene_other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level. Date of nevi -Alarminworkin order: es_ No { q P Qus PUMPing x: : 3 r t l rrt Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: • (locate on site plan) / Depth of liquid level above outlet invert: Comments: (note if level and distribution is'equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER:_ (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order(Yes.or No) � . Comments: ar: d,aapp{ r y' (note condition of pump chber^�amcondition of,'pumps and urtenancesetc,l l 4 revised 9/2/98 PaFc8of11 w. .� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 4operty Address: 6 J Jwner: 6 Date of Inspection: // 1 J /� �,/�- �/ SOIL ABSORPTION SYSTEM(SAS): (locate on site plan, if possible; excavation not,required,location may be approximated by non-intrusive methods) If not located,explain: Type; leaching pits, number:_ Teaching chambers, number:_ ! leaching galleries, number:_ j� rp 4r leaching trenches, number, length:. leaching fields, number, dimensions: overflow cesspool,number: p'r1f 4 ° Alternative system: �' �. ;•r y � `_. ��S�; " dal i r `s,l ._ �f Name of Tlec'hnolo9Y Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) 1/tom 1 D /f `1✓l�?/14,co, '�jZ Z u/z-Ze- 4y 1,r CESSPOOLS:_ (locate on site plan) , . Number.and configuration: Depth-top of liquid to inlet invert: Depth of solids Ipyer: )epth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater. inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) nPRIVY: Fj (locate on site plan),k " °- ° m f. e ,. r f s t a „ ;t✓ . . z= Materials of construction: Dimensions: Depth otsolids: : Comments: sr' (note condition of soil,L signs of hydraulic failure, level of ponding, condition of vegetation, etc.) t revised 9/2/98 Page 9ofII SUBSURFACE SEWAGEDISPOSAL SYSTEM INSPECTION FORM to « PART C SYSTEM INFORMATION Icontirwed) Noperty Address:" )weer: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 'o. r I► Y .s 4 Vi jrrr { 4� revised 9/2/98 Page 10ofll SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Q operty Address: �j`� � Jwner: !! Date of Inspection: NRCS Report name Soil Type_ — Typical depth to groundwater, USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep .e SITE EXAM Slope Surface water r . Check Cellar Shallow wells �w�+!.NMINH�.^^ Estimated De to Groundwater �: Feet h; ` .' Please indicate all the methods used to determine High Groundwater,,Elevation: Obtained from Design Plans on record Observed Site(Abutting property, observation hole, basement sump etc.) t/"/ Determined from local conditions Checked with local Board of health t - Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) 49 1 v .r�/ l t 6 w t' `j J�.Jul► S' t revised 9/2/98 Page Itof11 ___'-. _ ^_ ., � ._.�,-.._. _ _. . __• -• __— _ ., ,-. � .i�, a.......-- .w.ryr:,.,..«-.ww a,.r.ras«.+.+..-....<w+w ._... ... n„s+wr aw.+w .... 1 ` B-S U-PF-ACE- -10WN�G U SEWFRAGE : DISPOSAL. SYSTEM 'AS-BUILT OWNER e JAYCO CONISTRUCTION LOCAT'f ONO LOT A - SALEM ST. N. ANDOVERs MASS, D A T E o 12- i z- so V PREPARED -Yo LOT A 1 J.J.FLYNN INC , 41 SECOND ST, NORTH ANDOVER NIASS. 101.78 ( 10 5) � p GRAVEL i 00 ` `' • � 0p f 0000 QO niJ E 00 N PROFILE \ P , oo u, a o) HORIZONTAL SCALE 1'= 40" VERTICAL-. SCALE I 4' i <v � ( X ) - DENOTES DESIGN EL EV, (0,/ i Q) p't" pit �p c.)• CO 5 . _ ^.... v...� �nw-�-...+.+-.+.rev.--vww+wrw�.�..v�wnr-..'^v-+n+f-�w++mrw..-r •�.-.-n.ww.vt..w.+r..r. .-ru+.rYv.+..+- -- •_. SU BSURFACE �1 - �41 SI-ANcRAGE DISPOSAL OWNERJ TYCO CONSTRUCTION L''C ATiON c' LOT B - SALEM ST. N. ANDOVER MASS. DATE o I2-I2—p0 PREPARED aYo I J.J.FLYNN INC. E 41 SECOND ST. ' NORTH ANDOVER, MASS. L t 1 ,✓ ,r `' GRAVEL ro 00 ` \\ o0 'X / 0 }� M R W K G . r PROFILE 00 06 "oy ro OQ o0 r �� ' ` U, HCt'1ZOt`�T �E SC!�LL I - 40 A .� VEPTECAL SCALE I"� 4� Al '• ' -�' `` f ,� ,� ` to ( X ) - DENOTES DESIGN ELEV. '1 f.'+• +ter. f- �,ps ,.,��'`,•�� A- OF 1 411 SCALE 1�- 30� CYR 17 1 :) or + ��SfONAL �..-....�...»+...a.-�r..�-..:+w ...+»-+Jrv..+,.en.-..++«.iJa�.4.r•.�winNY.M.+r.M^..��.H _._ - _" _ -.a��.�+..+-.n.....�+...w.-.rr ..w.wr.+...�«nn... v.*•� __.._._-«.s...�..,.wi.�.r.ww....u.,......,.ra.rw.w r,...�a+....................�w.r..rr.�,,,xu��s:�.+e.w.a:.rn:..«+..s^.:�«rr..+v.+a..cusm��,+w.«.,,nwrla��ri.rtw.q!r++r^�+a-�r..+en��P*.'•K".'rM^r............�..w. �l Board of Health �! North AndovergHa.ss SCTBMFACE DISposAL DESIGN CHEOK LIST l ,. Lar # i APPROM DATE DISAPPROVED DATE____ Provided: Reasons: Title V FAlI. Reg 2.5jfb he submitted plan must show as a minimum: ) the lot to be served-area,dimensions lot #,abutters -df - Title location and log deep observation holes-distance to ties ocation and results percolation tests-distance to ties design calculations & calculations showing required leaching area location and dimensions of system-including reserve area ) existing and proposed contours (g) location any wet areas within 100' of sewage disposal system or oe. disclaimer-check wetlands mapping (h) surface and subsurface drains within 1001 of sewage disposal system or disclaimer (i) location any drainage easements within 3.001 of sevage disposal ' system or disclaimer- g Board files 600 0) known sources of water supply within 2001 of sewage disposal system or disclaimer (k) location of any proposed well to serve lot-1001 from leaching facility (1) location of water lines on property-101 from leaching facility ,.-O(m) location of benchmark (n) driveways (o garbage disposals ✓ (P� no PVC to be used in construction (q) profile of system-elevations of basement, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and y Other elevations (r) maximum ground water elevation in area sewage disposal system �' (s) plan mast be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Reg 6 S tic Tanks (a) capacities-150,% of flow, water table, tees, depth of tees, access, pumping /,(b) cleanout (c) 101 from cellar wall or inground swimming pool j (d) 25+ from subsurface drains I Reg 10.2 Distribution Boxes (a) slop greater 0.08 Reg 10.4 b) sump t rt rth AncjoveriHaae. SEPTIC SYSTEM a INSTALLATICK CHECK DIST _ LOT WED DATE DISAPPHWID AVATI OK FAIL ReaMn8t3 3/ -- j _ A17 FAM OK 1. Distance Tot a. Wetlands b. Drains c. Well 2. Nater Line Location 3• No PVC Pipe Septic Tank a. . _Tees -_Length & To Clean Out Covers. b. Cement Pipe to Tank On Both Sides of Tank 5. Distribution Box j a. Covers & Box - No Cracks b. All Lines Flowing Equal Amounts c. No Back Flow Leach Field or Trench a. Dimensions b. Stone Depth c. Capped Inds d. Clean Double Washed Stone' 7. Leach Pits/ ' a. Dimensions r b. Stone/Depth c. Spla6h Pads ' d. Te ae�� e. CWOa t Pipe to Pit - Both Sides. f. C�ean Double Washed Stone 8. No Garbage Disposal 9. -Final Grading Inspection 10. Barricading Covered System 11. As Built Submitted. a. Lot Location - ,,�' b. Dimensions of System c. Location with Regard-to Pere Test d. Elevations e: Water Table s � PLAN SHOWING SUBSURFACE SEWERAGE : DISPOSAL S Y STEM,•..• &S --BUILT <� OWNER * �1'A`(CO CONSTRUCTION =:a "r — OVNANOR�'MLOCA ,0N0-fRSALEM ST. ASS. o oDATE t2- 1z_ 80 PREPARED $Yo - - LOT A J_J_FLYRIN INC . 41 SECOND ST. NORTH ANDOVERI MASS. �� 101.78 ( 105) 3` t ob' i l I , / \ GRAVEL N(D r.. ^ ti N U-1 co lh — . rye• , M rn II `• `— Vl � WM y/rl�l T R rcqz L .. F.e t e.... �-. r , .. .. � ... ..: ,�X,n�.a.!t.. \ r� {.....-. ...,5.,..♦ .r- r. v b- ,. ?� A', -� ..,. .. w -. - ... _ .. a . .,.. .- -: ....r ..,, ,sem :+aM'- .,•.. .. •. 1 . �,,y...•.. _. �.x.,,,.,.,, .Y g ,x .-..t _A�-o _.. 'x .v Ii. .... t. .. m �.. -.. qq ... .>a. .. ... _. s . ! .9Yt.L,,,.-. ,.l,w. ..... ., :, 5 ,•. _c ,k 9'r °i. .-. :.. pi� a _ ........ .'t:�:::, _.-- _ .. .. .w ,.'l ... x- w ... }:r'F. a,L .� afit..., .. .s .� .. ... _ .;. `"E.• .i i.. - F. '. -. .'?' 'L }�°,t.$u..,, ke. � r .f,`T a.,. - '� •� '� r. * '- - v W MM e b: Nei :�', r .a .. 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