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HomeMy WebLinkAboutMiscellaneous - 478 BOSTON STREET 4/30/2018 (2) .� a U a �'1 • Commonwealth of Massachusetts u u Title 5 Official Inspection Form EcEI��° Subsurface Sewage Disposal System Form - Not for Voluntary Assessments NOVV 0 4 2014 °wM ,•' 478 Boston street TOWN OF NORI-14-A KIDOVER Property Address HEALTH DEPARTMENT Matchet Owner Owner's Name information is required for every North Andover MA 01886 10-16-14 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in an way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not John DiVincenzo use the return Name of Inspector key. Stewarts Septic Serive ry Company Name 58 South Kimball street Company Address Bradford MA 01835 City/Town State Zip Code 978-372-7471 S113386 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Ned Furth Evaluation by the Local Approving Authority 7he toy's Signat a Date system inspectorall s mit a copy of this inspection report to the Approving Authority (Board of Health or DEP)with 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 478 Boston street Property Address Matchet Owner Owner's Name information is required for every North Andover MA 01886 10-16-14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 478 Boston street Property Address Matchet Owner Owner's Name information is required for every North Andover MA 01886 10-16-14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): Septic tank has hole in side where seam is. It needs replacing. ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 i Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 478 Boston street Property Address Matchet Owner Owner's Name information is required for every North Andover MA 01886 10-16-14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) i 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i i Commonwealth of Massachusetts 4 w Title 5 Official Inspection Form _ a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 478 Boston street i Property Address j Matchet Owner Owner's Name information is required for every North Andover MA 01886 10-16-14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I 478 Boston street Property Address Matchet Owner Owner's Name information is required for every North Andover MA 01886 10-16-14 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week,period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 450 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 478 Boston street Property Address Matchet Owner Owner's Name information is required for every North Andover MA 01886 10-16-14 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: f fA CA I V\Gk Sump pump? ❑ Yes ® No Last date of occupancy: OccupiedDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts a W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 478 Boston street Property Address Matchet Owner Owner's Name information is required for every North Andover MA 01886 10-16-14 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Andover septic Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 i Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w, 478 Boston street Property Address Matchet Owner Owner's Name information is required for every North Andover MA 01886 10-16-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1975 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 28"feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 100' + Irigation well feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 14"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) Tank has large hole in seam septic tank 1/2 full. If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM a,e 478 Boston street Property Address Matchet Owner Owner's Name information is required for every North Andover MA 01886 10-16-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 20" Distance from bottom of scum to bottom of outlet tee or baffle Baffle out of liquid 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.): No Liquid near baffle. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 478 Boston street Property Address Matchet Owner Owner's Name informatifor every on is required North Andover MA 01886 10-16-14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 478 Boston street Property Address Matchet Owner Owner's Name information is North Andover MA 01886 10-16-14 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box has broken cover roots around outlet inverts. Box needs hydraulic coment around outlets Best off replacing while tank is being installed. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments i 478 Boston street Property Address Matchet Owner Owner's Name information is required for every North Andover MA 01886 10-16-14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1-20'x45' ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No hydraulic failure liquid level low due to hole in tank. Cornered lines. system has been dry for a long time. Cesspools.(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 478 Boston street Property Address Matchet Owner Owner's Name information is required for every North Andover MA 01886 10-16-14 page. City/Town State Zip Code Date of Inspection j D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): II 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts N v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 478 Boston street Property Address Matchet Owner Owner's Name information is required for every North Andover MA 01886 10-16-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins-3113 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 478 Boston street Property Address Matchet Owner Owner's Name information is required for every North Andover MA 01886 10-16-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells 6' Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 5-19-75 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: i Pulled file ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Water at elevation 99.5 bottom of bed 104.5. System 4' above water table. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3113 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 478 Boston street Property Address Matchet Owner Owner's Name information is required for every North Andover MA 01886 10-16-14 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed I ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Ail _ --- 174 i v , ` G e X i - - -I- - - - - - 0 25, R 145 ` j \\ j,/ d circle no. reading9ma9o. Tsml:'zT tz" Miu.Toy_,OIL cw+aR 3"W,ASNAO FIFASrVI+6 4" Pj AMILA'MD Ott IIISO, � IG,w4wjoceus"so Sura •in;- g, 114sappo+J AIL6A AN /A I N1It4cH �s 4w ti ELIO 6 cTlotJ it! i �7' �7 � I UV �to G�;� _ o `b a 1-1j7 � a� _._. amu°�. C•�LLA¢ �o ?�' 0 `" 0 .✓.��� �%.: Q E^X.�a-T� � C!.7' •)'•v�.j.,f '..%E.5{,Ifs{/... 1�'j*„-",�� i� i • 5�.�'fGED`j�6 • PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF. COMPLIANCE As of: 12/4/2014 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Repair of Tank and D-Box By: John DiVincenzo At: 478 Boston Street Map 107.D Lot 0077 rth Andover, MA 01845 T suance of this c ifi a s all no be construed as a guarantee that the system will function satisfactorily. 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' - FKtrd'r F ;t� (y 5 TI • Gv � ' � +,S,�r 1•. -'♦'• 'IySV� p ,d. �r a '.t C7 ..j it+ a " r -+l . � p�-• (C 'F,t'�« r � 1 cF S'�tlf.�F �' il` L.. .J•" px•4'� +l T �A�9 " �t i aY � � *,� '�c�{a3� e. _ ;�►�,n J�°r �yy "� , sv � � 4-i "� ' :' �' ,.., ,�Y�y' w�-,A `NI =',Ise' � iII:: +� — r y a ,�,� ����{f a it �i-•y ✓ • ' tl� Y w„,�' ' {r 4..� .�i k�i�i'.4�+! -t1,�'�y e�;, B' s� �`.• � + 'SE � .�.�'♦ .r � s gyp: A � �:'+.t}� �#,.. _ s •t,'•c '�` S' .. {'�"'��IS.�t *" "'f;y rr�'• �h '`' t 4 i' > �.¢'��r• :P�' <"^. � ��,"3, •t � ��ar�§'. i' 1,4 r'✓ r, +.',�. j '� c�•u„t 1 .' c"� ° Y wve y ♦ ,,4d.� ` • .'� ` a ''Yt •r t ''� k,� •r � ',.'v,�,,. .ems `a. r £. t`T ( ,k?-' a ” t ♦. t r r"� t, ? Sp,T r •i j'�'i tr.. r at r " `�St''[ ��1 n T c " �T?l1'.i ' #f t •1F R.71s y Yt n r n A� �,, a. • � i a a ....' to > � •- s.._•,... y ROr . F wlr . I _T � �Y"a o- rt��4 ��lrrjjyiiPPccc• �j�7DKy �y��fl y •r .'ai 1 max•`` � - i 111 } a ..off 1 i z1's � t ..fes t\ ti ( a . y b. • North Andover Health Department fommunity Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 478 Boston St. MAP: 107.D LOT: 0077 INSTALLER: John DiVincenzo DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK and D-Box INSPECTION: 12/3/1 I � ( I DATE OF BED BOTTOM INSPECTION. DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑/ Cleanouts per plan © Bottom of tank hole has 6" stone base Weep hole plugged 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port 1 �� IPA ,. ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION-BOX 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) Schedule 40 PVC Pipe Comments: U t�I�(vt 04' A I -=r l �I Issued On:Nov-21-2014 �—� r. �-,� - ------------ — r ,BOARD OF,EALTH .......................................................................................................... 478 BOSTON STREET .................................................................. Reference No: BHJ-2014-000078 ................................... ' Department: Permit No: BHP-2014-1293 ................................... North Andover BOARD OF HEALTH Fee .......................................................................Type: Account No: 1001001.1.5.0510.00 ...................... DWC-Component Repair PERMIT Receipt No: REC-2015-000737 .. ................................•---........ .............................. Paid By: ; Paid in Full On: Fri Nov 21,2014 J& S Development Corporation .................................... .---------------------•-------...........------........---------......................... Check No Received By: 13858 ...............•----------....------ Lisa Blackburn ....----...................•--..............--•---..............................------... ; DEPARTMENT'S COPY Amount: $125.00 � ---------------------------------------------------------------------------------------------------------------•. e Wn 1 • Application for Septic Disposal System 1 TODAY'S DATE qW $250.00—Full Repair Construction Permit - TOWN OF NORTH ANDOVER, MA 01845 $125.00-Component Important: Application is hereby made for a permit to: When filling out ❑Construct a new on-site sewage disposal system* forms on the computer,use ❑ Repair or replace an existing on-site sewage disposal system* only the tab key pair or replace an existing system component—What? to move your `t' cursor-do not use the return A. Facility Information � key. y 1-2e tabVQ Address or Lot# City/Town 2.-*TYPO OF SEPTIC SYSTEM*: ➢ ❑ lumpE]Gravity(choose one) ***If pump stem, attach copy of electrical permit to application*** ➢ Conventional System (pipe and stone system) ➢ ❑ Infiltrator or Biodiffuser(Gravel-Less)(Attach a copy of your certification to install this type of system.) ➢ ❑ Pressure Distribution S.A.S.(No D-Box) ➢ ❑ Pressure Dosed(D-Box Present)S.A.S. ➢ ❑ Does the system require an effluent filter? Yes No If yes, does plan specify make and model of filter? YES =(no further info. needed) NO=(installer must specify brand of filter before DWC issuance) What is the Make? What is the Model. 2. Owner Infor ation 141 Name Address(if different from above) City/Town State Zip Code Telephone Number 3. Installer Information Name -/ Name of Company / �f� C'drL�St l '�' SoG�T� /�/rnf�e, ter; S7' Addres. G 4,_e Cify/Town Stale Zip Code P,F-So7- 5_?;W Telephone Number(Cell Phone#if possible please) 4. Designer Information Name Name of Company Address City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 . _ •* • Application for Septic Disposal System TODAY'S DATE Construction Permit — TOWN OF NORTH ANDOVER, MA 01845 $125 00-component PAGE 2OF2 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 Nort ndo er. under and that until a final Certificate of Compliance has been issued by thi and f installed system is not approved. e Date ApplicatiQ46pproved By: ( and of Health Representative) Name/ Pl '" / Date Application Disapproved fr the following reasons: For Office Use Only: L Fee Attached. Yes ✓ No 2. Project Manager Obligation Form Attached. Yes No 3. Pump S sy tem? Ifso,Attach copy of Electrical Permit Yes \ No Applicantreceived copy of "Electrical Inspection Notes for Septic Systems" Yes No Handout? 4. Reviewed approvalletter, aZlpaperworkreceivedP Yes No Missing:' 5. Foundation As-Built?(new construction only): Yes No (Same scale as approved plan) 6. F1oorPians?(new construction only): Yes o Application for Disposal System Construction Permit•Page 2 of 2 SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at:Ve � /Sas16� s%rte f- 9 (Address of septic system) For plans by FF (Engineer) Relative to the application of -moi G�1.) L �i VwC.Q&zo (Installer's name) And dated / / --/ L (Original ate Dated o ay s ate With revisions dated (Last revised date) I understand the following obligations for management of this project: 1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner,contractor,project manager,or any other person not associated with my company schedules an inspection and the system is not ready,then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection,without completion of the items in accordance with Tide 5 and the Board of Health Regulations may result in a$50.00 fine being levied against me and/or my company a. Bottom of Bed—Generally, this is the first (1'� inspection unless there is a retaining wall,which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection—Engineer must first do their inspection for elevations, ties, etc. As-built of verbal OK (or e-mail to: healthdept�c@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 simple excavation)and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, significant fines to all persons involved are also possible. 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board of Health staff or consultant. d. Installation of tank, D-Box,pipes, stone, vent,pump chamber, retaining vall and other components. 6. As the installer,I understand that I am solely responsible for the installation of the system as per the approved 121ans. No instructions by the h meow er en ral contractor,or any other persons shall absolve me of this obligation. ///J)),/__'� Undersigned Licensed Septic Installer: (Toda 's Date ����' _ L/ A t Z ✓I ot)Cry ame—Print) ( a Sighed)— 1 r. f TO: NORTH ANDOVER, MASS fY o V 28' 19 7S 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 B aS TUw .57- , North Andover, Mass. SITE LOCATION The grades and construction are as specified in my plans and specifications dated ' i F,P�jN �F MASS ,`Reg. Prof ineer/Reg. Sana;ti.Arian 7 0 R �pF 8 � , , I--OT 5' • • I� O / {�Y r/ I 44 1 P Oo U1 pCY i 104 too _ - c� Joseph J. barbagallo, ms. 1 westward circle no. reading,mass. 12.1 1pk Fs I o A iA rp N y �1t�d1 '�I.L�3l5 r•►-1 ,_ r 5'So(=ATI t .-- Ave Z s'�-�---_ --- t'S' o 40 t - t 2 :w HVNIA 1 WI, �.�`�-d �b = O=J No t la&.aloscjv 'NIV/ 'NIV/SI IvUl.Mini`vS y -�-u ���t• i�srwus o�rKna�c+uMSK►v�„9I ..�" _�. " � b dol 91 ��ap audyaVyed ab �L-bl- 5 „off S,So 1 �, �ros,�•1•r►W MZt �_ .�— � �'• - REWLt S.L .a,�_�3.1 �J 6i �-k:� S�CalO � a Commonwealth of Massachusetts :City/Town of NORTH ANDOVER MASSACHUSETTS- Sy..Stem Pumping Record Form 4 0 C T 12 2006 DEP has provided this form for use by local Boards of Health. The $-stem Pumping Record mu: be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Location: forms on the . computer, use _ �g -_ only the tab key Address _ .- to move your -c7L cursor•do not use the return City/Town ., • key. Zip Code 2. System Owner: Name -_.._-.._.---•--_.�_-.__.--------. ... Address(if different from location) ��— City/Town -- _...- --------- State ------- --- Zip co e,�-�/—- Telephone Numbe�� ..v... _ _UIZ._.__._..._.._.. B. Pumping Record Date of Pumping Date '- 2• Quantity Pumped: — �--- Gallons 3. Type of system: ❑ Cesspool(s) El Septic Tank ❑ Tight Tank ❑ Qther(describe): 4. Effluent Tee Filter present? ❑ Yes Q--N-o If yes, was it cleaned? ❑ Yes ❑ No r 5. Condition of System: Cry!• � �drr . . 6. Sy em Pumped By: Name Vehicle License Number - -_...---- Company 7. Location where contents were disposed: PWI Si ature of Hau Date http://www,mas4;gov/dep/water/ proyals/t5forms.htm#inspect t5form4.doc-06/03 System Pumping Record •Page ! of L Nark, ANMVer 12-6- W , STFWART S SEPTIC TANK SERVICE )�G Nloin Sf 47 RAILROAD STREET Na ilh A ndaaei- ' . BRADFORD, MA 01835 N.a 1 Li r- IG1 -o6 jF 978-37277471 11'1 C4c, I Ll r- /. ? SOF MONIMY REPORT FOR MW OF ver UAM ADS cALr�Ns � • fir=s /560 1560 60 & �ca-d- 6 f � to W 5- 7 diEpic 33 Al 55 Fr nul --C1 c) I`'c:'!'i n ce p^� WELL DATABASE ADDRESS: AGE OF WELL: WELL DRILLR: WELL PERMIT : WELL LOCTION: (? C) WELL;PERMIT DATE: DEPTH OF WELL: TYPE OF WELL: a.. DRILLED ' DUG c. UNKNI OWN TYPE OF WATER BEARING ROCK: WATER ANALYSIS DATE: HIGH MANGANESE: Y N HIGH IRON: Y N OTHER CONTAMINANTS: Y N '1 ;.i �l 1 —. rrvF '• :;i.Li'.i;vv.t?.Ilcl4o Ct'nr' jlyI tc1Ut — f e r\, rn IS(f�/i,yn9 �L �'� l�?��t �J�4 j),r11�'����'(�tf( r�'•. t ` .'j I/ J/i t. ----'- -� ,—- 1��"�I Ilk ���t{' /;I, (�i,� a-�ijr �)I�I tv ���,,, y r � •�,�� " - . may;,'.t)C�{ /j`•�l(I�J/y���lll�l�r 1 a', I ,i NO S.ysTrM PUMP1N >> > �M .U:WNR'& hU01ZCSSSYSTCM x°78 �osj-�N ST. &Ice I � I i(( , .—•--�__- ,.__..... � � ,. ' ctrl l��l ' td d t r"r ' i 1 , �•;TVKE..OF:SER`:Y.ICE; ROUTIN I ll.irliY: l '�P,.� CU CX'CESEY.,E49OroS Fi 0.00 0 jr ('''i �l1rrlhr �Jul�rl,,(� .I rj S,S ,,i tlt'c l.:lt { } v': ------------ I/ ----'- l;f (!111.�i';' l'vlif�.`fjS�.l'!tJ•���('}r'1Nj((.y`j ,� ^_ .. � ... •: . it J.r'.:.1 Mot 1.......... .:.. .'. n ,r;�,�r � �r�^:G z �c 6Dly�{.rl^r���,x:4�;i `, F i • 1 1 , • r r;r , ' Record A USE ! r Irl °�'�I�1 ��r ;'r��� �{��� • , 1',� r '� r Ian,•' r. "�r:r Y Irll 1 , IIL•., NOV 1 0 200 9 • ,'411.1•,lrvi''�•ger ,lr O oe vvmlPtovldf0 lhl# loan ror LT1 hQERAR T• A, Faclllty In(orm�(lon r v''�ll 'I(i,1i�Yr,r,��.'I:�/'ll•''ml,r` ,11„i��,:�y�,.' `� • '1,C`'��'•�ri''Y I,err{L•Irl;r'11,,ri'r�l'rr��;�lr, ''" '' ''rrr ���' 1 1� ' 111����I,I�Mr x �rl,irl I r.'• , '';�'�ar�'++ 1 4 lrinl rcrn buVon) Tpng' a�ord . ' �I• Oa10 of Pumpinp,�• � �.� •� " ', r„ 01;1 � n':a�'.'' r ;8 �.. r� yilem; ens ,ypC9))�001O) S80!!C T ,I• ,1;`,,,r'{. '►'�"•:c�• � '-1 SIS• l '• ,�Q%.Qthe/(describe'• �• "I a• . yon it FIII10('(� OI'aenr7 C Yo) , IfY ", '•'�, ';`, I Ir r,17 r)� ,Irl:, ';' � ,., r� s ',/II,•',,(,,1 I,`'r,Yr 11,,, , „1 i�,4 �1%r; V_ O • r rr l"1 ,�nu'11'��;tinr,I1+,;Nlr'i\' 4,�e 1)cz' I� 11 ' �� r Ylrticll Uc4nlr n'','��lr _ . rr''� ,,:�h'�i,•:!Vly 1 I�IS��iY 1�1 7 lir,, 1 � / I It i I•'•S'.'%'1,�' '�;l y�V;iu hl►�Iti�ll�1�,1lf �;1i�1;;,1?�?If',1�,:' ..� •., r,�lr.t,o� -%poAlenla' �'� .•� tiff190 ya�e dl�posea; T�AIVl 9/h'IV4('�,�r,fr,,.',,,r,l or/d e �.,rr�nr.me ! 'D , e�erlbpprvYilallblorm�,r:'naln��ocl �r , Commonwealth of Massachusetts W City/Town of North Andover NOV 212012 a System Pumping Record TOWN OFNORTH ANDOVEiR H Form 4 FAUN DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. I A. Facility Information I Important:When filling out forms 1. System Location: on the computer, use only the tab key to move your Address cursor-do not North Andover Ma 01845 use the return key. City/Town State Zip Code 2. System Owner: Name ienan Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record Lo 0 f 1. Date of Pumping Date 2. Quantity Pumped: A Gallons � 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. tem, P�ped Name V� Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: art's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 `d Si ture of�Haule Date Signature of Receiving Facility Date / t5form4.doc•03/06 System Pumping Record•Page 1 of 1 RECEI` ED _ NOV 3 2004 TOWN U '' NORTH ANDOVER SYSTE PUMPINQ RECORi) T HF L�.i',OR " Art OVOER UA t'I: SYSTEM OWNER & ADDRESS SYSTEM LOCATION DATE OF PIiMPtN( ;_ _OI.IANTiTY PUMAED: �-:LSSPOOL: NO YES SOPUC Tank: NO YE NA PUKE OF SERVICE: KUU'fl.NE EMERU>~N�'1' (MSERVA CIONS: GOOD CONDITION FULL TO COVER � HEAVY ORF-ASE BAFFLES IN PLACE. ROOTS _ LEACHFIEL,D RUNBACK _ 6XCESSIVE SOLIDS _ FLOODED SOLID CARR YQVER.. ^_OTHER EXPLAIN System Pumpcd by 715..... . 7G. rUice� .rlQ. �:UMMENTS. CUN I EN I'S fKANSFW(R.ED 1-0