Loading...
HomeMy WebLinkAboutMiscellaneous - 475 WINTER STREET 4/30/2018 (2)L&OArite� 3 I 71 PUBLIC HEALTH DEPARTMENT Town of North Andover (om(myunnittyy Development Division A-1 %L:, OT CO% As ®f ,dune 1 7 2011 cr. This is to cert that the individuafsu6surface dtsposa(system received a SA`ITST,4CToRT IXS(PEC 707 of the: Pipe impair and mmoyafof gh'sti 6ution Box foran On Site Sewage DirposafSystem By: ToddBateson 473 Winter Street Map—l04�NTarceC-00 3 9VortkAndover, 9N,A 01845 The Issuance of this certificate shaffnot be construedas a guarantee that the system wifffunction satisfactorily. ffeafth Director 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fox 978.688.8476 Web www.townofnorthandover.com North Andover Health Department Community Development Division /���j�/ ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION / ADDRESS: � ��T MAP: LOT: INSTALLER. DESIGNER: PLAN DATE: BOH APPROVAL DATE N N• INSPECTIONS TANK INSPECTION: l DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: Syw V SITE CONDITIONS �� �— �3 � �✓�-1-- X ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ gallon tank has been installed loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by testing ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port Comments: (gas baffle/effluent filter) ❑ inch cover to within 6" of final 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 ❑ gallon Pump Chamber installed ❑ 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 ❑ Installed on stable stone base ❑ H-20 D -Box ❑ Inlet tee (if pumped or >0.08'/foot) ❑ Hydraulic cement around inlet & outlets ❑ Observed even distribution ❑ Speed levelers provided (not required) Comments: SOIL ABSORPTION SYSTEM (General) ❑ Bottom of SAS excavated down to C soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 40 Mil HDPE barrier installed ❑ Laterals installed and ends connected to header (and vented if impervious material above) ❑ Elevations of laterals and chambers installed as on approved plan ❑ Retaining wall (boulder / concrete / timber/ block) ❑ Final cover as per plan Comments: SOIL ABSORPTION SYSTEM (Gravel -less Chambers) ❑ Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ❑ Number of chambers per row: ❑ Number of rows (trenches): Comments: Total Chambers = BM = HR= HI = SYSTEM ELEVATIONS ROD ELEVATION AS -BLT INVERT ELEV DESIGN INVERT ELEV Benchmark Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 TOP Lateral 1 INVERT Lateral 2 TOP Lateral 2 INVERT Lateral 3 TOP Lateral INVERT Lateral 4 TOP Lateral 4 INVERT Lateral 5 TOP Lateral 5 INVERT Lateral 6 TOP Lateral INVERT Top of Chamber Bottom of Bed/Chamber SKETCH PLAN CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback ® Wetlands bordering surface water supply or trib. (in Watershed) Tank SAS Sewer ® Property line 10 10 -- ® Cellar wall 10 20 -- ® Inground pool 10 20 -- ® Slab foundation 10 10 -- ® Deck, on footings, etc 5 10 -- ® Waterline 10 10 10' ® Private drinking well 75 1001 50 ® Irrigation well 75 100 ® Surface Water 25 50 ® Bordering Vegetated Wetland , Salt Marsh, Inland / Coastal Banka 75 100 ® Wetlands bordering surface 1 Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws water supply or trib. (in Watershed) 150 150 ® Trib. to surface water supply 325 325 ® Public well 400 400 ® Interim Wellhead Prot. Area ® Reservoirs 400 400 ® Drains (wat. supply/trib.) 50 100 ® Drains (intercept g.w.) 25 50 ® Drains (Other) Foundation 10 (5) 20 (10) ® Drywells 20 25 1 Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws "¢RT", Commonwealth of Massachusetts Map -Block -Lot 104.A0083 -------------------- BOARD OF HEALTH Permit No N' BHP-2011-0718 NorthNorth Andover _________________. FEE $125.00 DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Neil J. Bateson --------------------------------------------------------------------------------------- to (Repair -PIPE REPAIR) an Individual Sewage Disposal System. at No 475 WINTER STREET as shown on the application for Disposal Works Construction Permit No. BHP -2011-071 Dated June 09, 2011 Issued On: Jun -09-2011 ------ - " ------ - - ------------------ F TH important: When filling out forms on the computer, use only the tab key to move your cursor- do not use the return key. 1�1 Application is hereby made for a permit to: ❑ Construct a new on-site sewage disposal system* 6--3—// TODAY'S DATE $ 250.00 — Full Repair $925.00 - Component ❑ Repair or replace an existing on-site sewage disposal system* tepair or replace an existing system component — What? A. Facility Information 4-17,s- Address or Lot # City/rown I 4VN U H 1 2.- *TYPE OF SERTIC SYSTEM*: TOWN OF NORTH ANDOVER ❑ Pump ravl ._ HEALTH DEPARTMENT ty (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) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D -Box Present) S.A.S. 2. Cli�,gl tPLT.tiS'df✓ Name 'Zlr 7� G✓i � ��� � �• , Address (if different from above) /"I• 7 CWrown 3. Installer Information Name ra " 1(.4 W - Address Qmll - o t 8'!y Cityfrown 4. Designer Information Address State Zip Code 8 9/0 Telephone Number Name of Compa�nyy WESON ENTERPRISES, INC. 44 A j " ANJOVEA MA 01810 State Zip Code %%JO k16 Telephone Number (Cell Phone # if possible please) Name of Company State Zip Code Telephone Number (Best#to Reach) Application for Disposal System Construction permit - Page 1 of 2 PAGE 2OF2 �M 6-3-11 - TODAY'S DATE $ 250.00 - Full Repair $125.00 - Component A. Facility. Information continued.... 5. Type of Building:esidential 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, and not to place the system in operation until a Certificate of Compliance has been issued his Board of Health. Name Date Application Approved By: (Board of Health Repres ntative) Name Date Application Disapproved for the following reasons: For Office Use Only: I Fee Attached. 2. ProjectManager Ohligation Form Attached. Yes No Yes No 3, Pump -Sy—stem? Ifso; Attach copy ofElectrical Permit Yes No 4. Foundation As -Built? (new construction ronly): (Same scale as approved plan) 5. Floor Plans? (new construction only): Yes No Yes No Application for Disposal System .Construction Permit Page 2 of 2 DelleChiaie; Pamela From: Sawyer, Susan Sent: Tuesday, May 31, 20114:03 PM To: DelleChiaie, Pamela Cc: Grant, Michele Subject: 475 Winter FYI Neil will be submitting a Title V for 475 Winter St. recommending a d -box repair due to corrosion of the concrete. This is one of Two D -boxes and is not necessary to the systems function. It was likely left there after a repair in 1988. D -box will be removed and replaced with pipe only. I told Neil it was his choice whether to have a clean-out or not. It is not required to have one. He may or may not be the installer, but whomever does it, this is what they need to do. Susan Swan SawyAl c 1600 Uagaad Sfxed JV4 20, unit 2-36 .Ncvc& andam, .Ma 01845 mice 978 688-9540 fax 978 688-8476 All email messages and attached content sent from and to this email account are public records unless qualified as an exemption under the [ http://www.sec.state.ma.us/pre/preidx.htm ]Massachusetts Public Records Law. Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records. For more information please refer to: http://www.sec.state.ma.us/r)re/preidx.htm. Please consider the environment before printing this email. 1 iaEPTiC SYSTEM INSTALL ER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for°the septic system for the property at: Al7,�- h/j,,br 5)/ (Address of septic system)// For plans by Relative to the application of I e � �4.5,AJ (installer's name) And dated Dated 'C' — 3 — // o ay s ate With revision 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 plansn�'or to performing any work on a site. I must have the apl2roved:121ans 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 shallbe 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 comtiletion: of the items in accordant my eompan� a.. Bottom of Bed - Generally, this is the first (1s) inspection unless 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: healtl dept@townofnorthandover com) from the engineer must be submitted to the Board of Health after which installer calls for an inspection time. Installer must be present for this inspection, With a pump system, all electrical work must be ready and able to cause pump to work and. alarm to function. c. Final Grade — Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than :rimple 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 ur3licensed to install septic systems in North Andover can constitute reasons for denial of the system and/ revocation or suspension of my lice_ nse to operate in the Town of North Andover zicrrr;4;„-.3„r 4",.,0. +„ „n ..e. ... .._a---� - f_ _ _ . 5. As the installer, I understand thatI 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 ofthe sand and stone to be used. c, Finallnspection by Board ofHealth staff or consultant. d. Installation oftank, D -Box, pipes, stone, vent, pump chamber, retaining wall and other components. 6. As the installer I understand that I am solei res onsible for the installation of the system as per the a4212roved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. v �I Commonwealth of Massachusetts Title 5 Official Inspection F Subsurface Sewage Disposal System Form - Not for Volunta 475 Winter Street Property Address Richard Peterson Owner's Name North Andover City/Town TOWN OF NORTH ANDOVER MA 01845 State Zip Code 6/17/2011 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Neil J. Bateson Name of Inspector Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover City/Town 978-475-4786 Telephone Number B. Certification Ma 01810 State Zip Code S115 License Number I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 6/17/2011 Insp' c is ignatur Date I The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and- under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 ,r t Commonwealth of Massachusetts uMw Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 475 Winter Street Property Address Richard Peterson Owner Owner's Name information is required for North Andover MA 01845 6/17/2011 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: After permit from B.O.H., install new outlet tee & pipe repair, inspection from B.O.H., septic sysyem now passes Title 5 Inspection. 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 • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 2 of 17 Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the rete_ m key. VIQ ILAO �;Xj Commonwealth otMassachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 475 Winter Street Property Address Richard Peterson Owner's Name North Andover City/Town MA 01845 State Zip Code 5/31/2011 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information JUN 14 2011 Inspector: TOWN OF NORTH ANDOVER Neil J. Bateson HEALTH DEPARTMENT Name of Inspector Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover City/Town 9784754786 Ma State S11 Telephone Number License Number B. Certification 01810 Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority '6 a"'11� 5/31/2011 Insp or Signature V Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 09108 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 7 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 475 Winter Street Property Address Richard Peterson Owner's Name North Andover MA 01845 5/31/2011 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: 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: 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 • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 475 Winter Street Property Address Richard Peterson Owner owner's Name information is required for every North Andover MA 01845 5/31/2011 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ® N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 475 Winter Street Property Address Richard Peterson Owner's Name North Andover MA 01845 5/31/2011 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: J [I 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 indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Outlet tee in septic tank & replace drop box with pipe 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 faci'ity or system component due to overloaded or clogged SAS or cesspool ❑ ED Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than % day flow t5ins - 09= Title 5 Official Inspection Forth: Subsurface Sewage Disposal System - Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 475 Winter Street Property Address Richard Peterson Owner Owner's Name No information is required for every North Andover ❑ MA 01845 5/31/2011 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). Nymber of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of -10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 475 Winter Street Property Address Richard Peterson Owner Owner's Name information is North Andover MA required for every dimensions, depth of liquid, depth of sludge and depth of scum? page. Cityrrown State C. Checklist 01845 5/31/2011 Zip Code Date of Inspection 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 facilityor dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 t5ins • 09/06 rifle 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 475 Winter Street Property Address Richard Peterson Owner Owner's Name information is required for every North Andover page. Cityrrown E D. System Information Description: MA 01845 5/31/2011 State Zip Code Date of Inspection Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d Yes 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Daterent Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? _ ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins - 09/08 Title 5 official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 475 Winter Street Property Address Richard Peterson Owner Owner's Name information is required for every North Andover MA 01845 page. City/Town State Zip Code D. System Information (cont.) Last date of occupancy/use: Date Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: 5/31/2011 Date of Inspection Pumped two years ago, owner 1000 gallons Measured tank Inspect tank & tees ® Yes ❑ No 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 - 09/08 ' 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 475 Winter Street Property Address Richard Peterson Owner Owner's Name information is North Andover required for every page. City[Town D. System Information (cont.) State 01845 Zip Code 5/31/2011 Date of Inspection Approximate age of all components, date installed (if known) and source of information: J Tank original, d -box & field installed11/22/1988, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: feet Material of construction: ® cast iron ® 40 PVC ❑ other (explain): — Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" cast iron thru wall, 3" PVC in house, no leaks visible Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 1 feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age:- years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Tx5'x4' Dimensions: 5" Sludge depth: ❑ Yes ❑ No t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 117 Commonwealth of Massachusetts Title 5 Official Inspection Form lu Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 475 Winter Street Property Address Richard Peterson Owner Owner's Name information is required for every North Andover MA 01845 page. Cityrrown State Zip Code D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge 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 22" 6" 8" 14" 5/31/2011 Date of Inspection 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 baffle ok. Outlet tee partially corroded off, needs to be replaced. Depth of liquid at outlet invert. No evidence of leakage. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness . feet ❑ fiberglass ❑ polyethylene ❑ other (explain): 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: t5ins • 09/08 Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 475 Winter Street Property Address Richard Peterson Owner Owner's Name information is North Andover required for every page. Cityrrown MA 01845 5/31/2011 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: Design Flow: Alarm present: Alarm level: gallons gallons per day ❑ Yes ❑ No Alarm in working order: Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ❑ Yes ❑ No "Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins - 09/08 Tide 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 475 Winter Street Property Address Richard Peterson Owner Owner's Name information is North Andover required for every page. Citylrown D. System Information (cont.) MA 01845 State Zip Code Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 5/3112011 Date of Inspection 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.): Drop box has carryover & side is collapsing. Needs to be replaced with pipe. D -box level & distribution equal, has flow levelers. No evidence of leakage. Evidence of carryover, pumped d -box to clean. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 09/08 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 475 Winter Street Property Address Richard Peterson Owner Owners Name information is required for every North Andover page. Citylrown D. System Information (cont.) MA 01845 5/31/2011 State Zip Code Date of Inspection Type: y _ ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields 1 field 23'x 35' 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 (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 •(X9/08 Tide 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not -'or Voluntary Assessments 475 Winter Street Property Address Richard Peterson Owner Owner's Name information is North Andover MA required for every page. Cityrrown State D. System Information (cont.) 01845 5/31/2011 Zip Code Date 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.): t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17. Owner information is required for every page. W t5ins • 09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 475 Winter Street Property Address Richard Peterson Owner's Name North Andover MA 01845 5/31/2011 City/rown 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 Din tvaeo'A I� :eta 'Iv 0 B ()- Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 475 Winter Street N D. System Information (cont.) Site Exam: ® Property Address ® Richard Peterson Owner Owner's Name information is required for every North Andover page. Citylrown N D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells MA 01845 State Zip Code 5/31/2011 Date of Inspection Estimated depth to high ground water: >4 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: 11/5/1975 Date ❑ Observed site (abutting property/obs`ervation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Design plan ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: As per original design plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins - 09108 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 475 Winter Street Property Address Richard Peterson owner Owner's Name information is required for every North Andover MA 01845 5/31/2011 page. City[To`nn State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information - Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file B t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 IC\- Commonwealth of Massachusetts City/Town of System Pumping Record Form .4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left front of house, right front of house, left side of house, right side of house, Left rear of house, right rear of house, left side of building, right rear of building, under deck. L4rj5� City/Town State Zip Code 2. System Owner: Name Address (if different from location) City/Town State Zip Code ;�)o &s- 6940 Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: Date Gallons 3. Type of system: ❑ Cesspool(s) [9 epS tic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes 0410 If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: kj6� CA, z � 6. System Pumped By: 7 Neil J. Bateson Name Bateson Enterprises Inc. Company L.S where contents.were disposed: F5821 Vehicle License Number t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 � jU+ c Summary Record Card generated on 5/19/20112:35:48 PM by Lisa Evans Town of North Andover Class 101 Single Family Size Total 1.04 Acres FY 2011 UB Mailina Index Name/Address RICHARD PETERSON HOLLY PEPLER 475 WINTER STREET NORTH ANDOVER, FAA 01845 GRANDIOUX, BERNARD 475 WINTER STREET N. ANDOVER, MA 01845 UB Account Maint. Account No Cycle Bldg Id. 18011.0 - 475 WINTER STREET 3180040 03 Cycle 03 UB Services Maint. Account No. 3180040 Service Code MISCFEE ADMIN FEE WTR WATER UB Meter Maintenance Account No. 3180040 Tax Map # 210-104.A-0083-OOQO.0 Parcel Id 16310 475 WINTER STREET RICHARD PETERSON HOLLY PEPLER 475 WINTER STREET NORTH ANDOVER, MA 01845 Type Loan Number Owner Previous Customer Property Type Active/Inact. From Inactive 4/2/2007 Occupant Name Active/Inactive Last Billing Date 4/6/2011 Active Rate Charge Multiplier/Users 0.635/8 7.82 1/ 01 ALL METER SIZE 92.65 /1 1 Residentia Until Serial No Status Location Brand Type Size YTD Cons 32938990 a Active 00 b Badger w Water 0.63 0.63 422 Date Reading Code Consumption Posted Date Variance 3/15/2011 611 'a Actual 23 4/13/2011 -220/c 12/14/2010 588 a Actual 29 1/12/2011 -580/c 9/16/2010 559 a Actual 73 10/15/2010 116% 6/14/2010 486 a Actual 32 7/15/2010 76% 3/17/2010 454 a Actual 19 4/14/2010 -300/c 12/14/2009 435 a Actual 26 1/12/2010 -380/c 9/16/2009 409 a Actual 46 10/15/2009 420/c 6/10/2009 363 a Actual 28 7/20/2009 650/c 3/17/2009 335 a Actual 19 4/29/2009 -13% 12/12/2008 316 a Actual 20 1/20/2009 -690/c 9/16/2008 296 a Actual 72 10/10/2008 800/c 6/10/2008 224 a Actual 36 7/16/2008 112% 3/14/2008 188 a Actual 17 4/11/2008 -27% 12/17/2007 171 a Actual 25 1/22/2008 46% 9/14/2007 146 a Actual 42 10/12/2007 38% 6/20/2007 104 a Actual 29 7/20/2007 152% 3/30/2007 75 f Final Bill 15 3/30%2007 -21% 12/13/2006 60 a Actual 15 1/19/2007 -41% 9/19/2006 45 a Actual 27 10/20/2006 45% 6/20/2006 18 a Actual 18 7/10/2006 -100% 3/24/2006 0 6 New Meter 0 4/17/2006 -100% COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: _475 Winter Street —North Andover_ Owner's Name: _Bernard Grandioux Owner's Address: _475 Winter Street _ North Andover, MA 01845_ Date of Inspection: _7/21/2006_ Name of Inspector: Neil J. Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address: _ll l Argilla Road_ _Andover, Ma. 01810_ Telephone Number: _( 978 ) 475-4786 xr , RECEIVED JUL 2 5 2006 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 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 F 'ls �— Inspector's Signature: Date: _7/21/2006_ 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 Winter Street_ _ North Andover_ Owner: _ Grandiouz_ Date of Inspection: _7/21/2006 _ 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 l l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _475 Winter Street_ _ North Andover— Owner: _Grandioux_ Date of Inspection: 7/21/2006_ 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: $dge 4 of l l OFFICIAL INSPECTION FORM _ NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _475 Winter Street _ _ North Andover_ Owner: _Grandioul_ Date of Inspection: 7/21/2006 _ D. System Failure Criteria applicable to all systems: You must indicate "yes" 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 _NoL 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'/z day flow. _No_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ _No_ Any portion of the SAS, cesspool or privy is below high ground water elevation. No Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface — water supply. _ _No_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _ _No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ _No_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure E. Large Systems: 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 `Sid' 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 11 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 l l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: _475 Winter Street _ _ North Andover _ Owner: _Grandiouz_ Date of Inspection: _7/21/2006_ 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 l l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: _475 Winter Street_ _ North Andover_ Owner: _Grandioux _ Date of Inspection: _7/21/2006_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): _4_ Number of bedrooms (actual): _4 DESIGN flow based on 310 CMR 15.203 _440 _ Number of current residents: 3_ Does residence have a garbage grinder (yes or no): No_ 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: Jes _ Sump pump (yes or no): No Last date of occupancy: _Current_ COMMERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): _gpd Basis of design flow (seats/persons/sgtetc.): — 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 2004, owner _ Was system pumped as part of the inspection (yes or no): Yes_ If yes, volume pumped: _1000 gallons — How was quantity pumped determined? Measured tank Reason for pumping: Inspect tank & baffle & tee_ 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: Tank Original, d -boxes & field installed 11/22/1988, as built plan _ Were sewage odors detected when arriving at the site (yes or no): No Pige 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _475 Winter Street _ North Andover _ Owner: _Grandioux_ Date of Inspection: 7/21/2006 BUILDING SEWER _ X _ (locate on site plan) Depth below grade: _24" Materials of construction: _X_ 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 " Cast iron thru wall, 3" PVC in house no leaks visible SEPTIC TANKS: X Depth below grade: _12" _ 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: _7' x 5' x 4' Sludge depth: _4"_ Distance from top of sludge to bottom of outlet tee or baffle: 23" _ Scum thickness: _4"_ 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: _17"_ 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 bade ok Outlet tee ok Depth of liquid at outlet invert. No evidence of septic tank leaking in or out. 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 Winter Street North Andover— Owner: _Grandioux_ Date of Inspection: 7/21/2006_ 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 BOXS: X Depth below grade _D -Box 1 is a drop box = 24"deep with a riser 6" deep. D -Box 2 = 3' deep with a riser 12" deep_ 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 2 level & distribution equal, has speed levelers. No evidence of carryover. No evidence of leakage. _ 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.): )gage 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _475 Winter Street _ —North Andover_ Owner: inspection: of Inspection: 7/21/2006_ 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: , _ leaching trenches, number, length: _X_ leaching field, number, dimensions: —1 field 23' x 35'_ 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 oL Vegetation oL 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 I 1 O FFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _475 Winter Street _ North Andover— Owner: _Grandiouz_ Date of Inspection: _7/21/2006_ SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building Driveway House Water A Septic Tank 2 1 B Drop D=Boz D - Boz Ato1=15'6" Ato2=17'6" A to Drop Boa = 2115" A to D -Box = 46' B to 1 = 28'11" Bto2=34'3" B to Drop Box = 3713" B to D -Box = 42' Page 1 l of l l OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _475 Winter Street _ _ North Andover— Owner: _Grandioug_ Date of Inspection: _7/21/2006_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water _ 6' _ 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: _11/5/1975_ 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: _ Original design plan _ ' i ownOT ivorin Nnaover Tax Map # 210-104.A-0083-0000.0 475 WINTER STREET GRANDIOUX, BERNARD 475 WINTER STREET N. ANDOVER, MA 01845 Class 101 Single Family Size Total 1.04 Acres FY 2006 UB Mailing Index Name/Address Type Loan Number GRANDIOUX, BERNARD Payor 475 WINTER STREET N. ANDOVER, MA 01845 UB Account Maint. Property Type Active/Inact. From Account No Cycle Occupant Name Bldg Id. 18011.0 - 475 WINTER STREET Last Billing Date 7/5/2006 3180040 03 Cycle 03 UB Services Maint. b Badger w Water Service Code Posted Date Rate MISCFEE ADMIN FEE 0 0.635/8 WTR WATER 4/17/2006 01 ALL METER SIZE UB Meter Maintenance 42 Serial No Status 27 Location 32938990 a Active 4/5/2005 ERT HH Date Reading Code 6/20/2006 18 a Actual 3/24/2006 0 n New Meter 3/24/2006 4372 r Replacement 1/3/2006 4339 m Manual estimate BUSHES 9/26/2005 4314 a Actual Trouble Code:03 6/21/2005 4272 a Actual Trouble Code:09 3/22/2005 4245 a Actual 12/16/2004 4228 a Actual Trouble Code:03 9/29/2004 4215 a Actual 6/16/2004 4180 a Actual 4/23/2004 4155 a Actual 12/16/2003 4124 n New Meter Active/Inactive Active Charge Multiplier/Users 7.82 1/ 61.02 /1 Brand Type b Badger w Water Consumption Posted Date 18 7/10/2006 0 4/17/2006 33 4/17/2006 25 1/17/2006 42 10/14/2005 27 7/15/2005 17 4/5/2005 13 1/14/2005 35 10/8/2004 25 7/30/2004 31 5/17/2004 0 12/16/2003 Size 0.63 0.63 1 Residential Until YTD Cons Variance -100% -100% 63% -42% 46% 68% 6% -50% -28% 93% 0% 0% .* BATESON ENTERPRISES, INC. Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 475 Winter Street, North Andover Owner: Grandioux Date of Inspection: 7/21/2006 Tel: (978) 475-4786 Fax: (978) 475-5451 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. Bateson Bateson Enterprises, Inc. 0? Forest St. FILE# OZ- l✓ / /4, �i Middleton, MA 01949 (508) 774-2772 CUAVJlj FA SEPTIC &DRAIN T0W of N7RTN A�iQt}VE3 SERVICE j4EALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PROPERTY OWNER'S NAME: PROPERTY ADDRESS: ADDRESS OF OWNER:_ (if different) DATE OF INSPECTION: NAME OF INSPECTOR: Wz,hl 764 Z,4 h4O, a204"�-'- . r", 4e, —h " w x 7, THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY 0 row;u o� raO rH AP1©wER `".�° (iOARU OF HEALTH COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS..,.,, a DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292.5500 i TRUDY CORE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Conunissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ..j....,..�,�� CERTIFICATION Property Address:�7,5_w,!/1L7M .57� h, Qi' Name of Owner Address of Owner: Y75 lvri &2 57" hn QirL Yl°i2 Date of Inspection: Z , 17, 9% Name of Inspector. (Please Print) I am a DEP approved system inspector pursuant to Section 15.340 of Titie 5 (310 CMR 15.000) Company Name: /I/ Mailing Address:0NZ 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 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 s Inspector's Signature: �.ate: Z 7 - The System Inspector shall submit a-Eopy of this inspection report to the Approving Authority (Board, of Health or DEP)within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of, Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. , NOTES AND COMMENTS revised 9/2/98 Page Iof11 Q•, Primed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) .'roperty Address: Owner: Date of Inspection: INSPECTION SUMMARY: Check & A C, Or A A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 1.5.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: STEM 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. 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, ik 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. Nv 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 Tequired pumping more than four times a year due to broken or obstructed pipe(s). The system will -pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) '�// S Wim.& sy �0 0�M Property Address: 7' 7 � . Owner: , /' — Date of Inspection: �/� 2,17-99 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment,' 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 (1)(b) THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: RIOL- Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. , 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF ANY) DETERMINES THAT THE SYSTEM IS / /FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: NQ 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 well. 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 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 11j2 revised 9/2/95 Page 3of11 0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 7� VViyIZ��-V Owner: Date of Inspection: Zi7,gq D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: -�ry'/�,i,- 1 have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facilityor 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 112 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. E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: A The following criteria apply to large systems in addition to the criteria above: I " Q The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes 1Vo o 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 upplythe 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 1:5.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Owner:G�' Address: �% ,/ ;y,1fi h4 �N Date of Inspection: /7 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. X _ None of the system components have been pumped:for-atJeasttwo 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. 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. i _ The site was inspected for signs of breakout. X _ All system components, excluding the Soil Absorption System, have been located on the site. X _ The septic tank manholes were uncovered, opened, and the interior of the septic.tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. V� The size and location of the Soil Absorption System on -the site has been determined based on: L _ 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) 115.302(3)(b)] _ The facility owner (and occupants, if different from.. owner).. were. provided. with informatio Subsurface Disposal Systems. n.on.the .proper xnainienauca.of revised 9/2/98 Page 5 of 11 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . / SYSTEM INFORMATION 'roperty Address: Owner: Date of Inspection: �✓�'� RESIDENTIAL: 97 FLOW CONDITIONS Design flow: LO g p.d./bedroom. Number of bedrooms (�: d4 Number of bedrooms (actual):L� Total DESIGN flow T Number of current residents: Garbage grinder (yes or no):P Laundry (separate system) (yes or no):I& If yes, separate inspection. required Laundry system inspected (yes or no) f Seasonal use (yes or no): V Water meter readings, if available (last two year's usage (gpd):�� �.� `�jGYXjCu F1 �Y 2 cif Sump Pump (yes or no):0 Last date of occupancy•_,,, -K COMM ERCIAL/INDUSTRIA L: Type of establishment: Design flow: apd ( Based on 15.203) Basis of design flow Greaae trap present: (yes or no)_ Industrial Waste Holding Tank pres ( as 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: PUMPING RECORDS and System pumped as part of inspect- iion: (---7- yes If yes, volume pumped:' gallons Reason for pumping: GENERAL INFORMATION (�a,4 flUGwvyiL` va J TYPE OF SYSTEM 7�s Septic tank/distribution box/soil absorption system I V Single cesspool �✓y Overflow cesspool Privy �Shared system (yes or no) (if yes, attach previous inspection records, if any) v I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed {if knowp).and source, of -information: —amu, � 10,2 Sewage odors detected when arriving at the site: (yes or no)/✓4 revised 9/2/95 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ��%S w�? l '571 hO a02-V(0Y,4 . Owner: Date of Inspection: GY/,ti►'C44r." z. i7, 99 BUILDING SEWER: (Locate on site plan) Depth below grade: 2-2 Material of construction: xcast iron _ 40 PVC _ other (explain) Distance fromprivate water supply well or suction line Diameter /1 C. r, Comments: (condition of joints, venting, evidencg of leakag%-eta _ _i ,c -• �� _ , SEPTIC TANK (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age Is.age.confirmed by Certificate of Compliance _ (Yes/No) T— w f1 Dimensions: Sludge depth: Distance from top of sldge to bottom of outlet tee or baffle: S6 Scum thickness: �tr i k,S T Pumped moi , q$ r Distance from top of scum to top of outlet tee or baffle: r/ it Distance from bottom of scum to bottom of outlet tee of baffle: / F How dimensions were determined: SLu je, Tu 9e Ti}p< /'V1 c,)J-14K6. Comments: (recommendation for pumping, condition of inlet an7d�outlet tees or b ffles, dpenth of li uid level in relation to evidence laokogg, etc.) 7;i& I [eG A/�- llt'&.t/1_ il� �ViV illi &1, GREASE TRAP: (locate on site 4 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.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C S;YS,TEEM/ INFORMATION (continued) Property Address: �S "' �ii> C/r" �' �Y• Owner: Date of Inspection: vlkll/er- IlvL; Z � i 7, TIGHT OR HOLDING TANK:/VO (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ Material of construction: _c71rete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Capacity:allons 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:e 7� Z' (locate on site plan) `I /P2 Depth of liquid level above outlet invert: ,omments: (note if level and distribution is equal, evidence of solids lolmeAl tol JR4de DcP /901/e, evidence of leakage into or out of box, etc . J--/ ­.—it n _ _ a X Vari eq lxtr✓� Le ( V��&0(eMrL, / q� qR IS b2,Nyil� ro 2 �� PUMP CHAMBER: Q, C)/wIer—RND 8�10td LevG�S�� (locate on site plan) 6) bu ff . Y,00de ` Pumps in working order: (Yes or No) Alarms in working order (Yes or No) �J�d Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) revised 9/2/98 Page 8oftt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Noperty Address: Owner: Date of Inspection: Z•/ SOIL ABSORPTION SYSTEM SAS):_ y( J (locate on site plan, if possible; excavatl6n not required, location may be approximated by non -intrusive methods) If not located, explain: !� / Type: I _ .�/ ( V 1-1. --_. _'" -7;f."F_-. /cJriG leaching pits, number:__ko /V (J l �� V y VV G � leaching chambers, number: 'l / leaching galleries, number: -l% leaching trenches, number, length: Q / leaching fields, number, dimensions: /I/!° Z? X33 overflow cesspool, number: -7 Alternative system: Name of Technology: IVV Comments: (note condition of soil, signs of hydraulic failure, level of p ndi dam soil, condition of ve etaI ✓� n�nlr �1� �Gf /J170/l). A/b CESSPOOLS: (locate on site 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/i n) lbel'fyJp a,'Zlleln s-)n/c v¢ k 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 G SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ` _r SYSTEM INFORMATION (continued) roperty Address: q7 Owner: Date of Inspection: SKETCH 6F—SEWAGE DISPOSAL SYSTEM: -- , ben include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) ay i i i i i %VO GULL L(S� 4.717- 71- ' T- Ib , A Z/'6 3P, 37Z " revised 9/2/98 v Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 14 ?roperty Address: ,V Owner: Date of Inspection: ..e , NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow-- Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater Ll Feet Please indicate all the methods used to determine High Groundwater Elevation: 0 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) av vV V Gv Im revised 9/2/98 Page 11 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property5 Owner's name H©r L In +e-jr stc%e � i Date of Inspection e 4 U r%-6 � 5PART A CHECKLIST Check *f the following have been done: /Pumping information was requested of the owner, occupant, and Board of Health. one 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. e- As built plans have been obtained and examined. Note if they are not /a'v�a�ilable with N/A. ' The facility or dwelling was inspected for signs of sewage back-up. The site was inspected for signs of breakout. All system components, excluding the SAS, have been located on the s'te. 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 s udge, depth of scum. The size and location of the SAS on the site has been determined based on.,existing information or approximated by non -intrusive methods. The`4facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION 0 FLOW CONDITIONS If residential number of bedrooms number of current resid�to garbage grinder, yes or laundry connected to tem, yes or no seasonal use, yes or no i If nonresidential, calculated flow: I Water meter readings, if available: Last date of occupancy GENERAL INFORMATION Pumping records ,and Source of ipformation: System pumped as part of inspection yes r no if yes, volume pumped Reason for pumping: CYl C l b'1'1' - %-I rr► 7 I e� Typf---s'ystem 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) Approximate age of all components. Date installed, if known. Source of information: _11 _ r---. %C> Sewage odors detected when arriving at the site, yes or no SEPTIC (locate SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued TANK: on site plan) depth belowgrade: material of construction: !'concrete metal FRP other(explain) .,dimensions: sludge depth distance from top of sludge 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 Comments: (rec`omrnendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,' evidence of leakage, recommendat' ns for repairs,...etc.) I-) t-. r' -% i) V t4 dry* l.. i .-A 421 -AA 4-. & to% n 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 bf leakage into or out of box, recommendation for repairs, etc.) PUMP CHAMBER: (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INF+ORMATION continued 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 and number leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions X 14 Q overflow cesspool, number Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc.) vq �.. 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, recommendations for maintenance or repairs,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, recommendations for maintenance or repairs,etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks t Ilocate all wells within 10.0' -------- (Ie: = LIZ I o 0 t. DEPTH TO GROUNDWATER %3# -Ir depth to groundwater method of determination or approximation: �5D� �,L S��ve� a I (21 " t....� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 1 PART C ` • FAILURE CRITERIA Indicate yes, no, or not determined (Y,. N, or ND). Describe basis of determination in all instances. If "not determined", explain why not) UH Backup of sewage into facility? Discharge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the distribution box above outlet invert? !�*L iquid.depth in cesspool <6" below invert or available volume< 1/2 day flow? Required pumping 4 times or more in the last year? number of times pumped Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: below the high groundwater elevation? "" within 50 feet of a surface water? within 100 feet of a surface water supply or tributary to a surface water supply? Y within a Zone I of a public well? _.lJ within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS)? N within 50 feet of a private water supply well? VV 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 analys for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D J CERTIFICATION Mame of Inspector /Company Name Aoc�o V e-?- Cy�� Company Address r 0 zii,Y MA_ certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and manitenance of on-site sewage disposal systems. Chec one: I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15.303. Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15.303. The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector's Signature Date(a Original to system owner Copies Buyer (if applicable) Approving authority t A I TO: NORTH ANDOVER, MASS PC-- 2-C 19 BOARD OF HEALTH FROM: DESIGN ENGINEER Re: Soil Absorption Sewage System Inspection This is to certify that I have inspected the construction of the said disposal system at 7`C 2 S T North Andover, Mass. SITE LOCATION The grades and construction are as specified in my plans and specifications dated zns F/ wrJ ED OJ LL- �P ouCD?�TC s s - StP"rl c Sy s -- A PIr{o�) Lip RQSoNs PAT; PC/AnJ 96 5) G1hJ C C< V/ -, E rX4V4T(o0 VUSP6.6 i iO&j t tiSP�cTlon� 4PP OOED APRT OoJ6 /urr-loi?ay Co�JpITU�,)S p4-rc F�ti P14-ri� NEo✓ �G� FI ��.D P(PE R[2�)AA t 10 P/,,rC i-L�-TF AVP►T(o�-)A1, I,�jSpb,j (ofjj () Qtjy) DISAPO° ov6p Dld i C I.r T4 Or L1 ?A 5 �1 R)L FVA /� PPI �jv,4 L 61,717-1 APP W LA)6 /6 U H4R 1 -t\% J WA- ^RrvISE6 111-1 77-- 15o•oa fill. tS9 a w � ONAL ■ � oh / - IW ♦ 1 �, l 4• ' � � SGpt1c Ti�1`11( j , iIrr (A ��"-�i3tT'r► EkeEb, t LZJrOQOQ � 00 ST, t# t0 ioseph i. bar-bagallo, r.s. 1 westward circle no. reading,mass. -A,. ITi p IF 1 ow k-. L IN G ouTLar. r� VIA �tZ � T ouTLr--j R� IMLMT ouTL ET 6i C (lo U fie pc .�. I9� C il 20 4� 4 SNC 6) a 'i 4� 4 SNC 6) a Joseph j. barbagallo, r.s. I ol �T 5-r- b -M.- 153.00 /Uv r Yly� 2 T�� ST I westward circle no. reading mass. AML. j UT LP -T. -';6 ll�-P.07 IF luLr--r Q,6ZCot I D Fro s � 4 xt Q V 1Nt,�r 14�.4Z a luLr--r Q,6ZCot I Fro �1Z 4 xt I4q. �7 1Nt,�r 14�.4Z 0 OUTLET 14q.25 � r� c d ,4 19 I ar � r o too �a 1 1 fo— %A i a � �- 70