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HomeMy WebLinkAboutMiscellaneous - 475 FOSTER STREET 4/30/2018 (2) 475 FOSTER STREET • 2101104._ B_0206-0000.0 I Commonwealth of Massachusetts City/Town of SEP 1 a MR Y Pumping System Pum in Record TOWN OF NORTH ANDOVER H'=ACTH DEPgRTM�NT Form 4 M DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left/Right front of house/Rig rear , Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address City/Town v[ "`( State \J �. Zip Code 2. System Owner. Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 6- Cs 1. Date of PumpingDate 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes a No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition oPOT: ste 0—� ��� \A � 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. �Lq�her)contents were disposed: G.U.P Lowell Waste Water Sign t e Haule Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 4: TOWN OF ' J- SYSTEM PUMPING RECORD RECEIVED NO V 1 8 2005 DATE: TOWN OF NORTH ANDOVER HEALTH DEPARTMENT SYSTEM OWNER& ADDRESS SYSTEM LOCATION (example:left front of house) c DATE OF PUMPING: QUANTITY PUMPED : GALLONS CESSPOOL: NO ES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE _ EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste Commonwealth of Massachusetts City/Town of .v System Pumping Record OCT 0 2 2013. Form 4 i TOWN OF POK T6 A14DOVER LtE. LTH DEPAR i;v:-=+dT DEP has provided this form for us&by local Boards of Health. Other forms maybe used, but the information must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left/Right front of hous Le Rig rear of h , Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address 1 r �-•� ;---� -�� �. City/Town �--�" C Jam' state� Zip Code 2. System Owner. Name Address(if different from location) City/Town Stat i Code E Telephone Number i B. Pumping Record 1. Date of PumpingDate 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes LTJ"ivo If yes, was it cleaned? ❑ Yes ❑ No, " 5. CondAtion of System: 6. System Pumped By.- Neil y:Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location-where contents were disposed: Ca.L S. Lowell Waste Water 9 -)3 Sig a Haule Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 ( 4�D OF' H -11-) T I Fosr� Si NoI�TM /�Npov�l�� MA. ��P�� CAti T MI4-c,TDw�I F5 W' e-cvEc c_ TEA-1 Marc SEPTI c S-►S i EA-1 VESt C-� bPP►{ov�D DAr�' /PRWPJ6 /urt-(o►;�iTy ( oOAJP� Oi J5= DI�PPRovEp TE REASoNs Dw� r/ ScPrc c SYSTEM I,►,,SQA!..(,�Q`J'I Q/l.1 L X4V4T(O,IJ )Ajr- t�-.GTpotiJ D�JrG Q PASS [l F'4►c_ FINAL l Q6p6F :i low Re4 AVP(T(oJJA(, IA)sFbz::(oN j SIF-A►-�y� FVAL APPI;�DvAL �' D,o�� i-21,-X7_ APP)30vVJ6 - Health .a►dover,Nass SUBSURFACE DISPOSAL DESIGN CHECK LIST MILL V.,#JA) J 'Ljo,/ "LOT APPROM DATE_., DISAPPROM DATE Provided: Reasons: title V FAIL Reg 2.5 The submitted plan must show as a mia{amms a) the lot to be served-area,dimensions lot #'*abutters b location and log deep observation hoes-d�.stance to ties c location and results percolation tests-distance to ties - d design calculations & calculations showing required leaching area (e) location and dimensions of system-including reserve area (f) existing and proposed contours (g) location any wet areas Athin 1001 of sewage disposal system or disclaimer-check wetlands mapping (h) surface and subsurface drains within 2001 of sewage disposal system or disclaimer (i) location any drainage easements within 100' of sewage disposal system or disclaimer-Planning Board files (3) known sources of nater supply within 2001 Of sewage disposal o system or disclaimer (k) location of any proposed well to serve lit-1000 from leaching facility (1) location of water lines on property-101 2rom leaching facility (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, `is.ribution field piping and Otter elevations (r) maximum ground water elevation in area sewage disposal systema (s) plan mast be prepared by a Professional Engineer or other professional authorized by law to prepare such plans. Reg 6 Septic 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 (d) 251 from subsurface drains leg 10.2 Distribution Boxes (a) slope greater than 0.08 leg 10.4 b} sung BOARP"OF HEALTH Town of North Andover.,;Mass . Permit # Date 19 APPLICATION FOR WELL & PUMP PERMIT Application is hereby made for ,permit to drill a well (_) . Application is made to install Gump sys e . . Location: Address Lot # / - t 2, Owner ; ! Address � � Tel �-� - -- - - Well Contractor 6 - Address Pump Contractor A d d r e/ WELL CONTRACTOR (To e completed at time of pump test ) Type of Well Well used forj _Diameter of Well �; Size of Casing i I Depth of Bed Rock Depth casing into Bed Rock Was Seal Tested? Yes No (-) Date of Testing _ l' Depth of Well �� Well Ended in What Materia&'cG�c�Cj6'1 Depth to Water Delivers_ Gals .Per Min. for 4 hours Drawdown feet after pumping hours at Q-5 GPM Date of Completion Signature W ell Contractor PUMP INSTALLER (To be filled in efore/ nstallation) Size & Name Pump f=tj�C� v�L'L� Pump Type Usedi,i- �4�-�� Water Pump Delivers_ GPM Size of Tank Pipe Material Used in Well : Cast .Iron ( ) Galvanized ( ) Plastic Well Pit (-) or Pitless Adapter - Wassl eve used to protect pipe? Yes ( ) NO( � �Typeor Name Well Sea ? Date / Date Water analysis report submitted to Board of Health Date release given tD owner of. record & Bldg. Insp Health Inspector F �}crcr. � � � ,..-.• \off. Ia W ' L 1500 IL r � •Y �1 135,E 13.1-,S 1 N N A s 13v,L.-r- sem-,-1 C- if ifO L-27I Ali Ta•J�. 13 S.7 4. J \ i 8 G!ES X10.13972 4 \ 15TE L Sao \ 0 � Z/5 qo N c� z �, -)1,577 AS /A 4-4¢A AeE f h r e F.�.o NT.4�� E.1'CE?Tio.v Address J ?3 �s 5 , Title of File Page of Date File Open: Date file closed: Doc Document/Action Title Date of Refer to other Purpose of Document/Action and notes action Document/ document/ Num. Action Department Board of Appeals — Board of Health — Planning Board — Conservation Commission — Building Department Commonwealth of Massachusetts 1 Massachusetts 1 System Pumping Record System Owner System Location Date of Pumping: , 3' S Quantity Pumped: gallons Cesspool: No ❑ Yes ❑ Septic Tank: No ❑ Yes System Pumped by: 6a&,dm soevrA� License# Contents transferrred to : Greater Lawrence Sanitary District Date: Inspector: ('OmmO we Ith of Massachusetts _ [V ` 6:�� , Massacliusetts System Pumping Record System Owner System Location Date of Pumping: Quantity Pumped: / gallons Cesspool: No H Yes H Septic Tank: No Yes U System Pumped by: varwart Si &,¢ taed License# Contents transferrred to : Greater Lawrence Sanitary Ulstrict Date: __^_ Inspector' ,( �Commonwealth of Massachusetts Massachusetts System Pumping Record System Owner System Location Date of Pumping: �-'� v� � Quairiity Pumped: /S�- gallons Cesspool: No Yes Septic Tank: No Yes System Pumped by: gctt`edert 5,ri e"" tined License# Contents transferrred to : Greater Lawrence Sanitary District Date: _ Inspector- TOWN OF NORTH ANDOVER # SYSTEM PUMPING RECORD DATE: - 14— (L4 rQ�o 1 SYSTEM OWNER &ADDRESS SYSTEM LOCATION (example: left front of house) Lg,k� r o DATE OF PUMPING: 4^ / Li--,)QUANTITY PUMPED L� GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: COMMENTS: APR CONTENTS TRANSFERRED TO: COMMONWEALTH OF MASSACHUSETTS ` EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION Y Sy0 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 475 Foster Street_ EIVED _North Andover_ CC�I���U Owner's Name: Jim Boutin_ Owner's Address: 475 Foster Street ,�,Ov 200rj _North Andover,Ma 01845_ Date of Inspection:11/10/2005_ TH ANDOVER 10,TOWN E OI.TH DE ARTMENT Name of Inspector: Neil J.BBateson_ Company Name: ateson Enterprises Inc._ Mailing Address:_111 Argilla Road_ _Andover,Ma.01810_ Telephone Number:_(978)475-4786_ 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: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ils Inspector's Signature: Date: _11/10/2005_ 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. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:_475 Foster Street _North Andover— Owner: Boutin_ Date of Inspection:_11/10/2005_ Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_475 Foster Street _North Andover_ Owner:_Boutin_ Date of Inspection:_11/10/2005_ 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: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 475 Foster Street_ —North Andover_ Owner:_Boutin_ Date of Inspection:_11/10/2005 D. System Failure Criteria applicable to all systems: You must indicate`eyes"or`no"to each of the following for all inspections: _ No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool No Liquid depth in cesspool is less than 6"below invert or available volume is'/i day flow. No Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ No Any portion of the SAS,cesspool or privy is below high ground water elevation. _No7 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. No Any portion of a cesspool or privy is within a Zone 1 of a public well. _ No Any portion of a cesspool or privy is within 50 feet of a private water supply well. _No_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] _No_(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 lam• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply _ — the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone I1 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. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 475 Foster Street_ _North Andover_ Owner:_Boutin_ Date of Inspection:_11/10/2005_ Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No Yes_ ` Pumping information was provided by the owner,occupant,or Board of Health No Were any of the system components pumped out in the previous two weeks? Yes _ Has the system received normal flows in the previous two week period? No Have large volumes of water been introduced to the system recently or as part of this inspection? Yes _ Were as built plans of the system obtained and examined? _Yes_ , Was the facility or dwelling inspected for signs of sewage back up? Yes_ _ Was the site inspected for signs of break out? Yes _ Were all system components,excluding the SAS,located on site? _Yes_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _Yes_ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _Yes_ _ Existing information. _Yes _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 475 Foster Street North Andover– Owner:_Boutin_ – Date of Inspection:_11/10/2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4_ Number of bedrooms(actual): 4_ DESIGN flow based on 310 CMR 15.203_600 Number of current residents:_3_ Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes or no): No_ Laundry system inspected(yes or no): _ Seasonal use:(yes or no):_No Water meter reading:_On well water_ Sump pump(yes or no): Yes_ Last date of occupancy:— Current-COMMERCIAL/INDUSTRIAL Type of establishment:_ Design flow(based on 310 CMR 15.203):ygpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:_Pumped 2002,owner_ Was system pumped as part of the inspection(yes or no): Yes_ If yes,volume pumped:_1500 gallons--How was quantity pumped determined?_Measured tank Reason for pumping: Inspect tank&tees_ TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool^Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _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:_19 years old, 12/2/1986, as built plan_ Were sewage odors detected when arriving at the site(yes or no):_No Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_475 Foster Street_ _North Andover_ Owner:_Boutin_ Date of Inspection:_11/10/2005_ BUILDING SEWER_X_ (locate on site plan) Depth below grade:_22" Materials of construction: _ ._cast iron _X 40 PVC other Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.) _4"PVC thru wall.3"PVC in house,no leaks visible SEPTIC TANKS: X Depth below grade:_10" Material of construction: X concrete—metal_fiberglass__polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 10'x 5'x 4'_ Sludge depth:_6"_ Distance from top of sludge to bottom of outlet tee or baffle: 21"_ Scum thickness:_10" Distance from top of scum to top of outlet tee or baffle:_8" Distance from bottom of scum to bottom of outlet tee or baffle:_11"_ How were dimensions determined:_Tape Measure_ Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc._Pumped septic tank.Inlet tee ok.Outlet tee oL Depth of liquid at outlet invert.No evidence of leakage._ GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_475 Foster Street _North Andover - Owner:_Boutin_ Date of Inspection:_11/10/2005_ 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: Alar in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOXES: X Depth of liquid level above outlet invert: 0_ Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.):_D-box level&distribution equal.No evidence of leakage.Evidence of carryover,pumped d-box to clean_ PUMP CHAMBER:_(locate on site plan) Pump in working order(yes or no):— Alarm in working order(yes or no):_ Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): • Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_475 Foster Street _North Andover Owner:_Boutin_ Date of Inspection:_11/10/2005_ SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number:, leaching galleries,number: _X leaching trenches,number,length: 3 trenches 40'long_ leaching field,number,dimensions:_ overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.):_Soil ok.Vegetation ok.No sign of ponding to surface_ CESSPOOLS: Number and configuration: Depth—top of liquid to inlet invert: Depth of sludge layer:— Depth of scum layer:_ Dimensions of cesspool:— Materials of construction:_ Indication of groundwater inflow(yes or no):_ Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):_ PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): . Page 10 of 11 i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 475 Foster Street _ North Andover— Owner:_Boutin_ Date of Inspection:_11/10/2005_ 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. Driveway To well Garage House A B Porch Deck 1 Septic Tank 2 D-Boz A to 1=3615' Ato2=41' A to D-Boz=4112" Bto1=38'7" Bto2=42'3" B to D-Boz=6514" • Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 475 Foster Street_ _North Andover — Owner:_Boutin_ Date of Inspection:_11/10!2005_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water _4'_ Please indicate(check)all methods used to determine the high ground water elevation: _X Obtained from system design plans on record-If checked,date of design plan reviewed:_3/4/1985_ 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: As per design plan no water 4'below trenches.Water At 7'deep._ Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating-Water.& Sewer Lines-Septic Systems&Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 475 Foster Street, North Andover Owner: Boutin Date of Inspection: 11/10/2005 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. Neil J. Bat son Bateson Enterprises, Inc. TOWN OF SYSTEM PUMPING RECO RECEIVED JAN 13 2005 DATE: TOWN OF NORTH ANDOVER HEALTH DEPARTMENT SYSTEM OWNER& ADDRESS SYSTEM LOCATION (example: left lfront /of house/)S+ ^/ cy I W DATE OF PUMPING: ( r QUANTITY PUMPED : GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES l NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED To: G.L.S.D L/Lowell Waste TOWN OF NORTH ANDOVER SYSTEM PUMPING RECOtm DATE: (. SYSTEM OWNER &ADDRESS SYSTEM LOCATION (example: left front of house) � DATE OF PUMPING: Com$ UANTITY PUMPED �- GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: COMMENTS: � CONTENTS TRANSFERRED TO: 1 � C a, �. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS `t J DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET,BOSTON MA 02108 (617) 292-5500 TRUDY CORE Secretary ARGEO PAUL CELLUCCI DAVID B.STRM Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A t, 5 CERTIFICATION Property Address: 9 i�� �( rr��� 3y Narne of Owner 1�1 c? h r- V vt" Address of Ownar:�I r ` 1_. Date of Inspection: Pje �lle`� sK'f . O(814S Name of Inspector-( P,rin 1am s DEP system irsj�etor to Section 75.340 of title 5(310 CMR 15.000) Company Name: Marling Address• Telephone Number: CERTIFICATWN STATEMENT 1 certify that I have personally inspected the sewage disposes 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: -L-14,11sses _ Conditionally Passes _ Ned urther Evaluation By the Local Approving Authority "� a — F ti^ �d Inspector's Signapate. 5 ture: — 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 the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS TOWN O OR7'H AN&W—E-0/7 BOARD,OF HEALTH i JUN - 41999 P r revised 9/2/98 Pagel of 11 q0 Printed on R"Ied Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART IIA Lf (CERTCATI001(eattlnusd) Property Address, `1 h �_� Owner: Date of Inspection: INSPECTION SUMMARY: Check A, B, C, of A A. SYSTEM P 1 have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDMONALLY 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. 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 pipes)are replaced obstruction is removed g revised 9/2/98 Page 2oru . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A -� CERTIFICATION(continued) p Property Address: 4 ! S- �JcKAAA Owner: - Date of Inspection. J C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES 1N ACCORDANCE WITH 310 CMR 15,303(111(b)THAT THE SYSTEM IS NOT FUNCTIONING N A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE 131MONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING N A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENV6t011 MENT: 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 a private water supply wag. The system has a septic tank and soil absorption system and the SAS Is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indieat"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 revised 9/2/98 Page 3of11 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ern I b ft TION Ieonlmueidl ss Property Address: L4" " " s N��A4J Oup- owner: 1 H�(-Lti r1 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 two determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. ' Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or dogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or dogged 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 pipets). 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 p An 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 lessAhan 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 30,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area=IWPA)or a mapped Zone it of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412). Please consult the local regional office of the Department for further infognation. F revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST e S Property Address: "1 1 t'C_ ��-�J� `�` _ i��� /„'tj1 0J-0_X_ Owner: Date of inspection: H CW C-\V N Check if the following have been done:You must indicate either"Yes" or"No" as to each of the following: Yes o Purnnlno Infr)rmation was provided by the owner,occupant,or Board of Health, fC" None of the system components have been pumped for at least two weeks and the system has been•rseeivirV timmaf flow rates during that period. Large volumes of water have not been introduced into the system recently 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 back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System,have been located on the site. The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: Existing information. For example,Plan at B.O.H. V Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) 1 [ 5.302(3)(b)] ptabl U _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. r revised 9/2P/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C � t j11 ` ],SYSTEM INFORMATION ` Property Address: " 11 ! I Are, 4 Owner: l-•�0-,v-c—\ c—\ Dane of hrspection: '` FLOW CONDITIONS RESIDENTIAL: _ Design flow:_ A_Q_g.p.d./bedroom. Number of bedrooms(design): Number of bedrooms(actual)-4 Total DESIGN flow Number of current residents: Garbage grinder lyes or no):i Laundry(separate system) lyes or no)-�JO: If yes,separate.inspection required Laundry system inspecte4 (yes or no) Seasonal use(yes or no):NLT `t Water meter readings,if vailabie(last two year's usage(gpd): DF'\ WQ N uAt Sump Pump(yes or no �S Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gpd ( Based on 15.203) Basis of design flow Grease trap present:lyes or no)_ Industrial Waste Holding Tank present:lyes or no),_ Non-sanitary waste discharged to the Title 5 system:(yes or no)_ Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: C )V\QA_ U110 System pumped as part of inspection:(yes or no) _S If yes, volume pumpegl: (S-00gallons ` Reason for pumping: lV�S�2.L�C �1+1 <. TYPE OF Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system lyes or no) (if yes,ettach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other 2 PPROXIIMATE AGE of all components,date installed lif known)and source of information: J . �� Sewage odors detected when arriving at the site:(yes or no) � revised 9/„2/98 Page 6ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(confinuedl Property Address! L4115 KkD A-lv- Date of Inspection: BUILDING SEWER: (Locate on site plan"1' it Depth below grade-2a Material of construction: cast iron other lex TO j( Distance from private water supply well or suction line!3V—Q LA12F' alc Diameter U Comments:(condition of joints, venting, evidence of leakage,etc.) Lo �S SEPTIC TANK:_ (locate on site plan? Depth below grade: t c Material of construction:_ ons creta_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(Yes/No) � 1 t Dimensions: a� n�a K L4 h7, S = 11500elCv Sludge depth: 4 " t Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: i It Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bqttorp ok outlet oba How dimensions were determined: :>Q)�N"-CL I: 'C ' S(u Comments: (recommendation for pumping ndition of inlet an�utiet tees or b ffles,d�jp-th i level n relation t et nve t►u ,acturel integrity, eyi nce of leakage,e c.) J �'�� 1 �' i 7 kph v V Q-C R'L GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction:,concrete_metal,Fiberglass _Polyethylene_other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: --"- - - - Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (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.) F revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTBYI INSPECTION FORM PART C SYSTEJM f`i11F'ORMATION(eo►rtirruedt Property Address: y tj - � �-� Kb CAA& Owner: " \, Date of inspection: l TIGHT OR BOLDING TANK\O*'X(Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ Material of construction:!concrete_metal Fiberglass_Polyethylene_other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order:Yes_ No_ Date of previous pumping: Comments: (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 andistri ution is egpal,evidence of solids rryoy",evid ce of leakage int99..or out of box,etc.) ` �..` Q U` lklelA& lam/ PUMP CHAMBER:V4�e C Jl,\ S�3 -w� (locate on site plan) ^� Pumps in working order:(Yes or No) 4 Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances;etc.) revised 9�/2/98 Page 9ofIt w SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM N`FO,R-MATION teontlnue4i Property Address:'LA Esq �5v- unk Owner: H l uoc G\Y1 Date of Inspection: _ p � �c�C�'-R-1 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:_ leaching chambers,number:_ leaching galleries,number: I leaching trenches,number,length: `t�� �/ 6W'D x L( leaching fields, number,dimensions: / overflow cesspool,number: ., Alternative system: Name of Technology: Comments: inote condition ot soil, signs of hydraulic failure,level of ponding, damp soil,condition of vegetation, etc.) C,N\ C 9 C --t,C CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation,etc.) PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PARI C � SYSTf�lll 1114VItMAM N Io rod) rt Property Address: ` T ,— E ,X,, Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties at least t o permanent reference landmarks or benchmarks locate all we s within 1 ' (Locate where public water supply comes into use) � � � Q— 4 � 3 A- o If a 7 Lf a I►..r �� revised 9/2/98 Page to of it w • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM NFORMATIOIN towdim" Property Address° LA t]j �4-!K '. Owner: P(X Date of but-W ion: '5 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells t Estimated Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: V Obtained from Design Plans on record Observed Site(Abutting property, observation hole,basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) M w4ex- revised 942/98 Page It of It Tel: (978)475-4786 Fax: (978)475-5451 BATESON ENTERPRISES, INC. Excavating-Water.&sewer Lines-Septic Systems & Pumping Service 111 Argilla Road Andover,Mass. 01810 Title 5 Inspection Report Property Address: P Y Owner: Date of Inspection: .— My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations,and I hereby disclaim any further operation of your current septic system. ' w Neil J. Bateson Bateson Enterprises, Inc. Commonwealth of Massachusetts1p �p�Rd pFy No p Executive Office of Environmental Affairs /, q�Ty�F�i r Department of ; �6 Environmental Protection William F.Weld TrudyCoxe Governor ecretary Argeo Paul Celluccl David B. Struhs U.Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 4 1L` 'M l ^Q ` CERTIFICATION Property Address: 5 '�c>sA �T- VD'` Address of Owner. Date of Inspection: —11 L4'- (If different) Name of Inspector. Company Name,Address and Telephone Number. BATESON ENTERPRISES, INC. TEL:(508)475-1.174 Excavating-Water&Sewer Lines-Septic Systems&Pumping Service FAX:1508)475-5451 [� 1 1 1 Argilla Road Andover,Mass.01810 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _ Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ F ' Inspector's Signature: ! Dale: ue_a¢.�► The System Inspector s mit a of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is shard 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: Check A, B, C, or D: A] SYS SES: . �I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. 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 ini'iltration or exfdtration, or tank failure is inuninent. The system will pass inspection if the existing septic tank is replaced with a Fonforming 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 i J Pnnted on Recycled Paper e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 1 1 CERTIFICATION(continued) Property Address: "t �� �� 1�0 Owner. M�'S . M CX"em V\ Dale ofInspection: 9 (LA— 1*2 B) SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pans 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: i Cesspool or privy is within 50 feet of a surface water t 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 1 of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or leu than 5 ppm. 3) OTHER (revised 11/03/95) 2 t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: l �htJ�1J4W/r— Owner. Date of Inspection fn ^ T 1 1_p CJ ' _/K� r D) SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. _,_, Liquid depth in cesspdol 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 II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 4 Owner. l A \� [ja/t Date of Inspection: Check if the follo ve been done: the was requested of the owner, occupant, and Board of Health. _N✓ one of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates �unx�g t it period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _As//builcans have been obtained and examined. Note if they are not available with N/A. The fac' ' or dwelling was inspected for signs of sewage back-up. A�site does not receive non-sanitary or industrial waste flow The petted for signs of breakout. mponents,excluding the Soil Absorption System, have been located on the site. e 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. e size and location of the Soil Absorption System on the site has been determined based on existing information or app by non-intrusive methods. _The 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 Address: "1 � ,`tA--C�C� Owner. M�. r 1 O CLA,t%j-, Q� l Date of Inspection: `-t FLOW CONDITIONS RESIDENTIAL: Design flow: (63ons Number of bedrooms Number of current residents:3 Garbage grinder(yes or no): Laundry connected to syslepq (yes or no): 5 Seasonal use(yea or no):ICU Water meter readings, if available: Oh vjp—k1 Last date of occupan":CQ'�' " COMMERCIAL/INDUSTRLAL: Type of establishment: Design flow:_gallone/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information. System pumped as part of inspection: (yes or no) If yes, volume pumped: 15?2' Qns Reason for pumping: TYPESeptSTEM /Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records, if any) Other(explain) APPRO MATE AGE of all components, date installed(if known)and source of information: Sewage odors detected when arriving at the site: (yes or no) Pa (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFO1,R_MAT�IONN (continued) Property Address: Ll Owner. ` Date of Inspection: SEPTIC TANK (locate on site plan) Depth below grade: �b Material of construction:_ ncrete_metal_FRP_other(explain) Dimensions: 10 k \ Sludge depth: 4 11 Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:_1 11 !� 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 pum condition f inlet and o�utleet s or ba�fle9 dept} of 'qui level in relatio to outl t invert, tra integrity, eVience of leakage, eta! ' A }}-- `` C}�_ \ V\ D 2 cC, ct f GREASE TRAPV) (locate on site plan) Depth below grade: Material of construction: _concrete_metal_FRP—other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: ` Comments: a (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.) f (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Address: �' /� 1�C 1"' var Owner. M �Q/�C� Date of Inspection��f 14—_(l G TIGHT OR HOLDING TANK:V\0Ty (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 le I and distri utiq >e equal, evidence of solids carryo r, evide ce of leakage into or out of box e ) � cx�Q ov1 . Ef: � �-� t \ CK' (Q ATAAi(9�C c­%�.) -- ra PUMP CHAMBER:^0010— (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(continued) Property Address: L4 t1S �—if�' &4ee S_�' Owner. Date of Inepection: g_/(4_ 9' 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: T9Pe: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number- leaching __ �``e nn 1 4 1 ' leaching trenches, nuber,ler g h:y��Vvs C7 UiA--i leaching fields, number, dimensions: overflow cesspool, number: Comments: (note Condit' n f soil igns of hydraulic fail , vel o�ponding,cor�ition of v tation,etc.)SO\, r►�a.-1• rj( ©^F lute . Ili CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) PRIVY- (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.) (revised 11/03/95) g t w SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4Owner. . OA �tw\� �4,6 Date of Inspection: 0- ry-Q� SKE'T'CH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent nces landmarks or benchmarks locate all wells within 100' A-Aos A Aos3 =a6 ' I A-- Ao e 3 rta�n,� DEPTH TO GROUNDWATER � - Depth to groundwater: � feet ��JIl--- 7 -k-t'04A�S method of determination or approximation: a'Vlh.. (revised 11/03/95) g Commonwealth.of Massachusetts RECEIVED City/Town of System Pumping Record NOV 0 12006 Form 4 TOWN OF NORTH ANDOVER DEP has provided this form for use b local Boards of He H T DEPARTMENT y g Record must be submitted to the local Board of'Health or other approving authority. A. Facility Information Important: When filling out 1. System Location: forms on the computer,use �� -- only the tab key Address �--- to move your q1-7 5 --� C t �� J X'/ cursor-do not Gity/Town use thereturn State Zip Code key. 2, System Owner: Name Address(if different from location Crtyffown Stat — Zip Code Telephone Number B. Pumping. Record 1. .Date.of PumIn ping Date 2- Quantity`Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight.Tank. ❑ Other(describe* ).` 4: Effluent Tee Filter present? ❑ Yesto-- If yes, was it cleaned? El Yes ❑ No 5. Condition of.System: \ 6. System Pumped Name ? ehicle License Number Company .7. Location w1l re C ntents re sed:. Signatur of ul Date http://www.mass.gov/dep/water/a*pprovals/t5forms.htm#inspect t5form4.doc•06103 System Purttping Record•Page 1 of 1 i Commonwealth of Massachusetts E VXp City/Town of " System Pumping Record SE? 20 [011 Form 4 TOWN OF NORTH ANDOVER DEP has provided this form for use by local Boards of Health. Other f HEALT P information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. Syste ation: Left front of house, right front of house, left side of house, right side of hou Le r of hou a fight rear of house, left side of building, right rear of building, under deck. L-f ._ -� - tet- Cityrrown State Zip Code 2. System Owner: Name Address(if different from location) City/Town StateZip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes 2 No If yes, was it cleaned? ❑ Yes ❑ No 5. Conditionpf$ystem�r✓� 6. System Pumped By: Neil J. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc. Company 7. Location ere content s were disposed: Lo I Waste^3%r c Signat r Date t5form4.doc°06/03 System Pumping Record°Page 1 of 1 I