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HomeMy WebLinkAboutMiscellaneous - 479 SALEM STREET 4/30/2018 (2) 479 SALEM STREET C - 210/038.0-0009-0000.0 . :� , • , k S WERERAGE DISPOS /�L .h . SYST_E AS - BUILT C�tN .E .. a_.4AYGO CONSTRUCTION bA (;Qo LOT B - SALEM ST. N ANDOVER MASS. t` DATE o 12-I2—,80 PREPARED BYo J.J.FLYNN INC. 1. 41 SECOND ST. LOT B NORTH ANDOVER, MASS. v 100-37 ( 01 ) GRAVEL � s 00 \ �r of rn 00 ao vW. _ - i 4 +•. - Y a - a �., ,.n. N M - : -,.G 1,•. '. F' : s �, y S� K , � �, ��`7•�.''. z..�` ;- :: E° Cf? ap cD -_. w. ..s,x.a r..s.r>. :fir^ '., i.,...... ;a..« .y,•-,.ai, r - r. �... .r.3.,k. <.. .., .. A ..% ... # r r = - `,y;. S• e - �`e .ar.'...�"iA�M.�.��� _•x _ y _ ,� - Lf' _ - ♦ '♦ '* 2. t bt a ra r'. 7"14 RIZORTALTSCALE. r = 40 -_ VERTICAL SCALE 1,�_ 4� ( X ) DENOTES DESIGN ELEV. .W� i SCALE 1�= 30� } f IL 1 - i r l� 4 f E I y TT r - 17� 46 7 r f- vU1�R [A G DISPOS ;�-�� SYS TEM - AS - BUILT _ OWNER - JAYGO CONSTRUCTION OC/TION o LOT B — SALEM ST. N. ANDOVERa MASS. DATE o 12-12—.8o PREPARED 8Yo J.J.FLYNN INC. 41 SECOND ST. LOT B NORTH ANDOVER_, MASS. v i 2O\Q w GRAVEL Ln 00 \ p00 00 x M1- _...�,:.,,. :ire a.s . rx?r ''.. i7 tT a?'�.t„ . OF 1LE, co °a IfOP,IZOiYTALRSCALE I _ 40� VERTICAL SCALE Its 4� � N ( XDEN SIG ELEV. ) DE , e.:.^:p.r, 'sa . . r,n_a.:A In».Y. -.�. ... � w. _. .a _ ... 4»K-+Rb.LT./d^ v tw....a}9P]9�Ce9j..SC!.'+WiYRN-..'�+JP1.1.iks+s uC4 ww.r.... �a+. a+SYT.MTk.wD.S Jsf'..MNCtC... .4t1'�++.>M.wWw.fK•+..M'�S"A�'✓.d•'+'.�..wr�^M.4.w P .M.J .. ✓ 'ti �`�''� � s ? ice• O'r o4 SCALE I = 30 j } � f Board of Health North Andover Septic Management Summary Report-Sorted by Builder's Lot Printed On:Tue Mar 14,2006 SQL Statement:Street No.like"479#"AND Street="SALEM STREET" NUMBER OF SEPTIC SYSTEMS THAT MEET YOUR CRITERIA:I System ID: BHS-2002-1381 GIS#. 1994 District. Bedrooms: Compliance? Yes Comments: Address: 479 SALEM STREET Map: 038.0 State Code: 101 Residents: Shared? No Builder's Lot. Block: 0009 Water. Calc.Design Flow: Seasonal? No Subdivision: Lot: Sewer. Design Flow: Grinder? No Lot Area: Zoning: Total Flow: Laundry? No Septic Inspections Status Inspector Pumped? Date Inspected Expires On Meter Odors Volume Depth Comment - - - - - - - - - - - - - - - - - - - - - - - - • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - - - - - - . . . . . . . . . . . . . . . . . . - - - - - - - - Passes John DiVincenzo No 11/29/2002 No Title V-Received 12/18/02 Passes Benjamin C.Osgoo No 3/3/2006 No Title 5 GeoTMS®2006 Des Lauriers Municipal Solutions, Inc. Page 1 of 1 F .3 To_*n of North Andover Health Department Date: ti Location: (Indicate Address,if Residential,or Name of Business) ;= Check#• Type of Permit or License:(Circle) ➢ Animal $ ➢ Dumpster $ ➢ Food Service-Type: $ ➢ Funeral Directors $ �v ➢ .Massage Establishment $ - ➢ Massage Practice $ ➢ Offal(Septic)Hauler $ k' > Recreational Camp $ ➢ SEPTIC PERMITS: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ r ❑ Septic Disposal Works Construction(DWC)$ ❑ Septic Disposal Works Installers(DWI) $ ➢ Sun tanning $ ➢ Swimming Pool $ ➢ Tobacco $ ➢ Tras4lSolid Waste Hauler $ ➢ Well Construction $ ➢ OTHER:(Indicate) �n r Health Agent Initials i 454 White-Applicant Yellow-Health Pink-Treasurer T '} NEW ENGLAND ENGINEERING SERVICES INC RECEIVED MAR 1 3 2006 March 9, 2006 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Ms. Susan Sawyer North Andover Board of Health 400 Osgood Street North Andover, MA 01845 RE: TITLE V REPORT: 479 Salem Street,No.Andover,MA Dear Ms. Sawyer: Enclosed is the Title 5 Report for the above referenced property. The system PASSES the inspection. If there are any questions please call me at my office, 686-1768. Sincerely, c Benjamin C. Osgood, Jr. Certified Title 5 Inspector 60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 j 10f 11 1 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 479 Salem Street No Andover,MA 01845 Owner's Name: Kris Alexander Owner's Address: 479 Salem Street No Andover,MA 01845 Date of Inspection: 3 March 2006 Name of Ynspector:(please print) Benjamin C.Osgood,Jr.Certified Title 5 Inspector Company Name: New England Engineering Services Inc. Mailing Address: 60 Beechwood Drive North Andover,MA 01845 Telephone Number. 978-686-1768 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of the on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15340 of Title 5(3 10 CMR 15.000).The system: _1,�fftsses Conditionaily Passes Needs Further Evaluation by the Local Approving Authority -Fails Inspector's Signature: C_ C�42 Date: 3) The system inspection shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. J 2oft I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 479 Salem Street No Andover,MA 01845 Owner's Name: Kris Alexander Date of Inspection: 3 March 2006 Inspection Sununary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: &t O 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 exfiltrahon 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; e i3 orl1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 479 Salem Street No Andover,MA 01845 Owner's Name: Kris Alexander Date of Inspection: 3 March 2006 C. Further Evaluation is Required by the Board of Health: 90 Conditions exist which require finther evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and (SAS)Soil Absorption System and the(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is-within a Zone 1 of a public water supply. The system has a septic tank and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organize compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 4of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 479 Salem Street No Andover,MA 01845 Owner's Name: Kris Alexander Date of Inspection: 3 March 2006 D. System Criteria applicable to all systems: You mu indicate"yes or No"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overload or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overload or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than''/2 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times Pumper Any Portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (this system passes if the well water analysis,performed at a DEP certified laboratory for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrogen is equal to or less than 5ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form,) N (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 nmIst indicate either`yes"or"no"to each of the following. (The folio criteria apply to large systems in addition to the criteria above) Yes No The system is wi 400 feet of a surface drinking water The system is within 200 fee a tributary to a ace drinking water supply The system is located in a nitro ns i' area(Interim Wellhead Protection Area—IWPA)or a mapped Zone H of a public water supply If you answered"yes"to uestion in Section E the system is consid significant threat,or answered"yes"in Section D above the large system ed The owner or operator of any large system conside significant threat under Section E or failed under Secti upgrade the system in accordance with 310 CMR 15.304. The system o er should contact the appropriate regional office of the Department. 5of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 479 Salem Street No Andover,MA 01845 Owner's Name: Kris Alexander Date of Inspection: 3 March 2006 Check if the following have been done. You must indicate``ves"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? / f Have large volumes of water been introduced to the system recently or as part of an inspection? '✓ Were as built plans of the system obtained and examined? (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for sign of break out? Were all system components,excluding the SAS,located on site? Were all the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if difference from owner)provided with information on the proper maintenance of the subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No /Existing information.For example,a plan at the Board of Health- Determined ealthDetermined 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)] 6of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 479 Salem Street No Andover,MA 01845 Owner's Name: Kris Alexander Date of Inspection: 3 March 2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design)_Number of bedrooms(actual)— DESIGN flow based in 310 CMR 15.203(for example: 110 gpd x #of bedrooms): 4 JI 0 . Number of current residents:_ Does residence have a garbage grinder(yes or no): i Is laundry on a separate sewage system(yes or no): X� 0, [if yes separate inspection required] Laundry system inspected(yes or no): — Seasonal use:(yes or no): A)o . Water meter readings,if available(last 2 years usage(gpd): s i 9 Sump Pump (yes or no):,�` Last date of occupancy a Lt y, r COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/personstsgft,etc Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no) Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: /o 3©/b Was system pumped as part of the inspection(yes or no): N O If yes,volume pumped: eallons–How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank, distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank Attached a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected wen arriving at the site(yes or no): 4) . 7of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 479 Salem Street No Andover,MA 01845 Owner's Name: Kris Alexander Date of Inspection: 3 March 2006 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: cast iron 40 PVC other(explain) Distance from private water supply well or suction line:_ Comments(on condition of joints,venting,evidence of leakage,etc.): A/cy—I a ir"3LF e(oft A/C5 N1sHc- A� L SEPTIC TANK: (locate on site plan) Depth below grade: 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:_ .L t�—n v 6�r L-L Q,,-- Sludge i.!Sludge depth: 41 Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 4 1 , Distance from top of scum to top of outlet tee or baffle: 6 Distance from bottom of scum to bottom of outlet tee or baffle_f J How were dimensions determined: ,A ec s v I?e- -&-23L-rG Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): !'r7 NO it O tJ. GREASE TRAP: AJ -(locate on site plan) Depth below grade: Materials of construction:. . concrete metal fiberglass polyethylene other (eXPlainl Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of sludge to bottom of outlet tee or baffie: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc. 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 479 Salem Street No Andover,MA 01845 Owner's Name: Kris Alexander Date of Inspection: 3 March 2006 TIGHT OR HOLDING TANK:—YJ-6 —(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Materials of construction: concrete metal fiberglass polyethylene other (explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level:,. Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: d Comments(note if box is levet and distribution to outlets equal,any evidnence of solids carryover,any evidence of leakage into or out of box,etc.): y S Dn I ti oft, c_o rri 9\-n 6 A T2 CLAY-[C--1%4 r PUMP CHAMBER N j j - (locate on sire plan) Pumps in working order(yes or no) Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 9of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 479 Salem Street No Andover,MA 01845 Owner's Name: Kris Alexander Date of Inspection: 3 March 2006 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not.required If SAS not located explain why TYPE leaching pits number leaching chambers, number leaching galleries number leaching trenches,number in length X leaching fields,number,dimensions: overflow cesspool,number: innovative/aiternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure.Level of ponding,damp soil,condition of vegetation,etc) I _ �Gr}- d� 1=[F•L� L-Ac'�/� /�-/ /Z NLAL, /t/J Ec,�r!J�ti' C f- C�%' FO nl 9 P ys U CESSPOOLS:A_ (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of Construction Indication of groundwater inflow(yes or no) Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: ,,,, ,,II4 (locate on site plan) Material of construction: Dimensions: Depth of solids Comments(note condition of soil signs of hydraulic failure,level of ponding,condition of vegetation,etc. 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 479 Salem Street No Andover,MA 01845 Owner's Name: Kris Alexander Date of Inspection: 3 March 2006 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmadcs. Locate all wells within 100 feet. Locate where public water supply enters the building. 13.9 �53' � I C D � L eac K a e " 1foh1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 479 Salem Street No Andover,MA 01845 Owner's Name: Kris Alexander Date of Inspection: 3 March 2006 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water y feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavator,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Sets i e iS �� ►4+'Les4 TKt f-�r BGS='^/ `� "7 `� 577 Main Street,Suite 110, Hudson, Massachusetts 01749 E-Mail: "� E N V I R O N MENTAL Telephone 978.562.4500 Facsimile 978.562.7255 I wrenvironmental.com L0MA2`-016March 16, 2006 Wind River Environmental 163 Western Ave. Gloucester, MA 01930 Board of Health Administrator, This package contains the dump slips for the Board of Health from the field office located in Gloucester, MA. This is the work we have completed. If you have any questions, please feel free to contact our Branch Manager, Dave Martin at 978-282-7315. Thank you, s Jillia . L lam COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS r DEPARTMENT OF ENVIRONMENTAL PROTECTION or iE� Kol� DEC 18 2002 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY AS ESSMENTS— � SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Owner's Name: /2-7 � Owner's Address: Date of Inspection: Name of Inspector: (please print)�mn Company Name: ,�0�///�S'SP/► SFj�U/C Mailing Address: ? Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Condit'onally Passes Ne ds "er Ev luation by the Local Approving Authority F "s Inspector's Signature: v mate: �Z f The system inspector shall s mit a copy of this inspection report to a pproving Authority(Board of Health or DEP)within 30 days of co leting this inspection.If the system is a ed 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. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 'f OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: /9 Owner: Date of Inspection: d� Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: have not found any information which indicates that any of the failure criteria described in 310 CMR T4315303 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).^ _ I bro'kea pipes)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 v . Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: ./F,//oi Owner:'9/ Date of Inspiction. 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 areviggered"A copy of the analysis must be ittache8 to`this form. � 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: ! /9/T P - v0 it✓Q Owner: "1 Date of Inspection: / t-O Z 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 k 4. l a r liquid level ifi the6tribution box abbve outlet invest due to an.overloaded or clogged SAS or cesspool co�Liquid depth in cesspool is less than 6"below invert or available volume is.less than 1/2 day flow equired 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. t-* Any portion of.a cesspool or privy is within a Zone 1 of a public well. 6110,�1ny portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as �^ described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Boafd of Health to determine what will be necessary to correct the failure. E. Large Systems: t To be considered a lame system the system.mustEserve a facility,with a desigdflow of 10,000 gpolo 15,000 gpd: You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST r. Property Address: � QSam, 4 Date of inspection: Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes o Pumping information was provided by the owner,occupant,or Board of Health (/ Were any of the system components pumped&t in the,previdus two�,weeks?, Has thePsystem received normal flows in the previous two week period? l/ 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 determmed based on: ., Yes no _ a ESusting inforniation:For exairiple,a plan at the Board of Health. zDetermined 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)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner•,'/>°,�� F, ' Date of Inspection:_ jam✓`jG� / FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 C- .203 (for example: I 10 gpd x#of bedrooms): Number of current residents: j Does residence have a garbage grinder(yes or no):Xt",5 f 2e GDI'�'UN t%( m UIs laundry on a separate sewage system(yes or no): V4if yes separate inspection required] Laundry system inspected(yes or no) Seasonal use: Qes,or no): " AW Water meter readinks,if availabO(last 2years usage�19A):' 3 { Sump pump(yes or)ho): Ve.1 Last date of occupancy: C,v p j -e COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5,system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION �. Pumping Records Source of information: Was system pumped as part of the inspgftion(yes or no): . If yes,volume pumped/-0, b gallons--How was quantity pumped determined? ro Reason for pumping: . TYPE OF SYSTEM t t r _i8eptic tank,'distribution box,soil absorptiam 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): _ f Approximate ae f all comp � onents,da installed(if known)and source of information: l � �a r. t Were sewage odors detected when arriving at the site(yes or no):/W 6 Page 7ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2 'S Owner: �liyT Date of Inspection: BUILDING SEWER(locate on site plan) Ga Depth below grade: Materials of construction:_cast iron _ 0 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: k5ocate on site plan) c � Depth below grade: oL Material of construction:_(,,.dncrete_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 cert Dimensions: Lo Sludge depth: (172 Distance from top of udge to bottom of outlet tee or baffle: y Scum thickness: Distance from top of scum to top of outlet tee or baffle: �l Distance from bottom of scum to bottomoutlet tee or baffle: How were dimensions determined: _e OL e Comments(on pumping recommendations,inlet and outlet tee-or baffle condition,stn 1 integrity,fi id t�vels as related tlet invert,evidence o leaka tc.): .. Ail< voo:wl - �f A y,� GREASE TRAP:_(locate on site plan) Depth below grade:-_, Matenal'of construction:_concrete metal_fiberglass polyethylene_other r (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels. as related to outlet invert,evidence of leakage,etc.): 7 Page8ofll OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: r�./r bL-' .Date of Inspection: / r " 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 f G� JN Design Flow: ;,. gallons/day '. Alarm present(yes o ;no): t Alarm level: ; Alarminworking order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakee into or out of box, tc.) S -- ooJ G�l D 6.11 PUMP CHAMBER: (locate on site plan) a Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): a p. .w . 8 • Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: ,ey p ' Date of Inspection: i SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching leaching chaml3e s,number: r' leaching galleries,number: le ping trenches,number,length: eaching fields,number,dimensions (-/ overflow cesspool,number: r 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.)6 ,D oAjot ' 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: ,� z 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.): a PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEMINFORMATION(continued) Property Address: �� iP/1/.S . Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. r� . � a _ I , e - w m a .� s 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: .57e-, Owner• Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 7 feet Please indicate(check)01 methods dsed to determine th6 high ground water elevation: C/Obtained from sysiem design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked.with local excavators,installers-(attach documentation) Accessed USGS database-explain: You t describe how you establis d the hi h ground water elevation: l / o a m - Sgs7- 1� a� G��c roc/" Q d ze .., or � a i 11 Board of Health 3Fj> O,'SISTEK Norah Anc�o•verztiaaa. INSTATT ATIU1 CHCS LIST LOT 1 DATE DI SAVATI5 OK FAIL OVID APPt70PID easunst 1 r, 1 FML OK 1. Distance Tos- a. Wetlands b. Drains c. Well / 2. Water Line Location ' 3• No PPC Pipe Septic Tank a. . _Tess -_Length do To Clea Out Covers. b. Cement Pipe to Tank On Both Sides of Tank 5. Distribution Box j a. Covers & Box - No Cracks b. All Lines Flowing Equal Amounts C. No Back Flow 6. Leach Field or Trench a. Dimensions b. Stone Depth c. Capped Inds d. Clean Double Washed Stone' 7. Leach Pits a. Dimensions b. Stone/Depth c. S014sh Pads d. gens Carseat Pipe to Pit - Both Sides. / Clean Double Washed Stone 8. No Garbage Disposal 9. Yinal. Grading Inspection 14. Barricading Covered System 11. As Built Submitted. _ a. Lot Location . b. Dimensions of System c. Location with Regard-to Perc Test d. Elevations / e: Water Table V*dreg a-f-HeAlth J North Andover,Mass ! SUBSURFACE DISPOSAL DESIGN CHECK LIST LOT # 13 APPROVED DATE DISAPPROVED DATE_____, Provided: Reasons: Title V FAIL AK _. Reg 2.5 -The submitted plan must show as a mini=m: 'the lot to be served-area..dimensions lot #,abutters location and log deep observation hoes-distance to ties V ,'location and results percolation tests-distance to ties design calculations & calculations showing required leaching area j location and dimensions of system-including reserve area existing and proposed contours (g) location any wet areas within 1001 of sewage disposal system or disclaimer-check wetlands mapping (h) .surface and subsurface drains within 1001 of sewage disposal system or disclaimer (i) location any drainage easements vithin 1001 of.sevage disposal system or disclaimer-Planning Hoard Piles �) wa sources of water supply within 2001 of sewage disposal Sys tem or disclaimer location of a prop®sed well to serve lot-100 from leaching facility 1)flocation of water lines on property-101 from leaching facility ) `location of benchmark 4 -driveways L0100garbage disposals no PVC to be used in construction 77(q) profile of system-elutions of basement, plumb, pipe, , septic tank distribution box inlets and outlets, distribution field piping and � ether elevations maxima�m ground water elevation in area sewage disposal system 4e I(s) plan :east be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Reg 6 1-11 S tic Tanks (a) capacc t.s- % of flow, water table, tees, depth of tees, access, pumping cleanout ✓ LOI from cellar wall, or inground sul=dng pool (d) 25+ from subsurface drains Reg 10.2 Distribution Boxes (a) slope greater thea 0.08 Reg 10.4 b) sump ub�e•XI3esJ! Check List Pae 2 a FAIL OK Leachin, Pit/ Leaching p its are preferred where the installation is possible eg 11.2 a) calculat ons of leaching area-minimum 500 sq ft 3.1.4 b) spac j 11.10 c) surfac drainage 2% 11.11 d) cover material e) 2 o x2 xl�p splash pad f) tee. at elbow 1 g) notbends in pipe from d-bog to pipe LeachingFields eg 15.1 no greater n 20 mdnutes/inch area-mini=x 900 sq ft 15.4 - construction of field 15.8 / surface drainage 2 % ` 3.7 e) 202 from cellar wall or inground swan dng pool i Leachin men s eg 1}x.1 a) c`alc calculations o eaching area-min 500 eq ft 3 14.3 b) spacing-4 m n 6 ft with reserve between 14.t, c) dimensio ; 14.6 d) construc on 14.7 e) stone ! 3le.10 f) surf drainage 2% " Dowilhill Slope a) s ope y xtm be shown] b) y/x X 150 (to be shown) qg 9.1 a) Val , 9.6 b) s d-by power i t s - i i I , I � l I f! � Commonwealth ,of,Massachusetts, , W City/Town of. NORTHANDOVER, MASSACHUSETTS System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. The System Pumping Record must be submitted to the local Board of Health or other approving aut ar' i; RECEIVED A. Facility Information Important: APR 0 7 2009 When filling out 1. System Location: forms to the �� TOWN OF NORTH ANDOVER computer, use HEALTH DEPARTMENT only the tab key Addre s to move your J� � cursor-do not Cit /Town l�V�t M use the return y State Zip Code key. 2' Syste Owner: sr.. h e Al. Name Address(if different from location) CitylTown State Zip Code b Telephone Number i. B. Pumpnga Record r 1. Date of Pumping PSDo p g Date--_. 2. Quantity Pumped:_ Gallons 3. Type'of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ 'Other(describe): 4. Effluent Tee Filter present? Rj'<es ❑ No If yes, was it cleaned? Yes ❑ No 5. Condition of System:. C1rl� 6. ystem Pumped By: _\ " o I Name(� Vehicle License Numbe I INA -�C ci t Yt,S Company 7. Location where contents were disposed: v Signature.of Hauler Date r http://www.mass.gov/dep/water/approvals/t5forms,htm#inspect -- - - ---- - - t5form4.doc•06/03 ,System Pumping Record•Page 1 of 1 C;:NORT-H ANDOVER/ B(l A OF HEALrj TOWN/OF NORTH ANDOVER NOV4 2002 SYSTEM PUMPING RECORD ti'l OWNER & ADDRESS TTFS—TCMLOCA-T-10—r, (MIMPIe. left from of h0L�(: , X4 0 E OF PUMPINC: /0-30 -0"-7 QUANTITY PUMPED_/ NO —, YES SEPTIC TANK : NO YE- -Cl* U RE OF SERVICE: ROUTINE L-----EN, c R C E",C Y COOD CONDITION FULL TO CO "[ HEAVY CREASC l AF17LLS IN ROOTS LEACHFIELD RUN!3AC'K , CXCESSIVE SOLIDSFLOODED SOLIDS CARRYOVER/ � O,�H E R (E X P L.)a, I N) 1 L'E'I PUMPED B Y ----------- lItiLFNTS: L Ile v j I I:'N 1'J TI A N S F C I Z I ED TO: Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection William F.Weld Governor Trudy Coxe Secretary,EOEA David B. Strults Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ) � p� Q,, q CERTIFICATION Property Address: `'"f " 1 q �.Jt-CJ`QAJA, ` V> � ` A At Address of Owner: Date of Inspection: t Q 1— — •�,., (If different) Name of Inspector: �jQ�L��•��C7 Company Name, Address and Telephone Number: CERTIFICATION STATEMENT `<� Cf • (����0 I certify that I have personally inspected the sewage di.posal system at this laddress 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: asses Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: � Date: l/ The Systern Inspector shall s omit a c of this inspection report to the Approving Authority 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. INSPECTION SUMMARY: Check A, B, C, or D: Al SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or riot determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) 1 One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATI (continued) Property Address: L1q ���" � ( (U2 Owner: Date of Inspection: lo— a t _ �S B] SYSTEM CONDITIONALLY PASSES (continued) _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within f in 5 0 feet of a surface water _ g vegetated wetland or a salt marsh. within 50 feet of a borderin _ Cesspool or privy is g 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: �, .f, n 2r st! nl„ r✓ r , 5'r'S:CC; �lnj IS within 100 CCI tC .. _..� surface water supply. — The wstem has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ the sy'sti:in hay a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. (revised 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (c nti'nueed,)� Property Address: 1" �Q� vsvV n y ��, �j Owner: �\ • �� �� v -4 Date of Inspection. t CD- DI SYSTEM FAILS (continued): 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 rol"on of a rbemi-ol ar rrl-y is logia than 100 font hit aroplar than go foot f nni a privatd WOW OlPrIv wall WIIIt na 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. FJ LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: the design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the syslem is located in a nitrogen sensitive area (Interim Wellhead Protection Area 0WPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: �'1J` "v `'�• - ���`"�-VvQ/� Owner: C• ��"��t "+�-- M w/`'v` rU Date of Inspection: CCS a -t' Check if the (oil o Ing have been done: Pumping information was requested of the owner, occupant, and Board of Health. 6<_"' of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates Burin that period. Large volumes of water have not been introduced into the system recently or as pan of this inspection. _As built plans have been obtained and examined. Note if they are not available with N/A. _ ,e facilit or dwelling was inspected for signs of sewage back-up. �e system does not receive non-sanitary or industrial waste flow e site was inspected for signs of breakout. I system components, excluding the Soil Absorption System, have been located on the site. ,e septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. _Lfhe size and location of the Soil Absorption System on the site has been determined based on existing information or approximate b� non-inUUsive methods. _ ie facility o..ne. ull '. l occupants, if diff(,rnn! from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. I v' 15 95 `3 (revised 8/ / 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION � Property Address: q Owner: /� Date of Inspection: {�" \C m�-, "uf>c-qA o Co- V t—q,�- FLOW CONDITIONS RESIDENTIAL: Design flow: gallons Number of bedrooms: Number of current residents: Garbage grinder (yes or no): C'j Laundry connected to system (yes or no):YL / Seasonal use (yes g �U L 55013" Waterx ater meter readings, if if available: (1 Last date of occupancy: COMMERCIAUINDUSTRIAL: Type of establishment: Design flow: ga►►ons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: YU -+Uc) c o - 0-UP1I System pumped as part of inspection: (yes or no)� If yes, volume pumped. �Jr� gallons t Reason for pumping: _ TYPE_OFJ STEM (/ Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared systern (yes or no) (if yes, attach previous inspection records, if any) Other (explain) APPRO 1MAT AGE f all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) 0 (revised 8/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: q < C_)"QJ, 0" Owner: C� ULkiq �' [ 0 Date of Inspection: SEPTIC TANK:�^ (locate on site plan) Depth below grade: to Material of construction: —concrete _metal _FRP _other(explain) Dimensions: 10' x S n 7• = ISop O`�S Sludge depth: Distance from top of lodge to bottom of outlet tee or baffle: Scum thickness: 11? �t Distance from top of scum to top of outlet tee or baffle: ti Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, cond' ' n of inlet a d outlet tees or baf les, depth of Ilquid level in elation to o�rtlet it© structural integrity evidence o leak ge, tcJ v L tC 1 ckz ' h Of GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP _other(explain) Dimensions: Sunn llwknes;. Distance from top of scum to top of outlet tee or baffle: [_) ctanCn from hotl(.", „ .rn.,� I Inllun (a (,Iliiw lrl' O� Iralll(•' Comments irecommendation for pumping. condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural Integrity, evidence of leat.,lyc• el(.) �"• I Irevised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATIO (continued) Property Address: ( 419 Owner: [4C MnWA-�� �UJ� Date of Inspection: C. (�L (0 - 31— TIGHT 0" 31 TIGHT OR HOLDING TANQ[\DVje (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_✓ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note ifIr el an dimii nr(�rn i ey 1I, e�idence of solid, c n} r, ev once of leakage into or out of pox, e .) fi l Gcix C dV. �? - _ PUMP CHAMBER:Vi���— (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ��� ` "`-� s "W4— Owner: Date of Inspection: , / SOIL ABSORPTION SYSTEM (SAS):✓ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions overflow cesspool, number: Comments: (note condi ion of soil igns of hdraulic lure vel of po in , condition of vegetation,etc.) ut�c CESSPOOLS: NONP_ (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 grou1)d�%3tc": inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: - (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 8/15/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Lt V1 q �� N Owner: r Date of Inspection: a qs SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' A- \4 F A- l3 S �t✓ t t , L{o` ---� DEPTH TO GROUNDWATER Depth to groundwater: Lt feet t a.0 method of determination or approximation: (revised 8/15/95) 9 FORM 4 - SYSTEM PLNIPLIG RECORD Commonwealth of Massachusetts NU Massachusetts a 'mak system Pumping Record vstem Uwner _ •stem Location <JV - Date of Pumping (�� ` V —qS Quantity Pumped: ��CJ t Cesspool: No ,17 Yes ❑ Sentir, TanILL- N,I Yes System Pumped bv: License #: Contents transferred to: Date Inspector �Cfomm nwe lth ofnM,�assachusetts `� ` �"�lassachusetls Svstem Pumping Record System Owner System Location Date of Pumping: �� � � Quantity Pumped: gallons Cesspool: No Yes L) Septic Tank: No U Yes Ll System Pumped by: vareQo.-t gitrvB flaw License# Contents transferrred to : Greater Lawrence Sanitary District Date: Inspector: TGAd OF NORTH AN(?0!;`�R OARL OF HEA:[TBi f "� 31999 i 1 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WRMR STREET,BOSTON MA 02108 (617)292-5500 TRUDY COXE Semvtw ARGEO PAUL CELLUCCI DAVID B.STRUHS Commissioner - Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM IllISPECTION FORM PART A CERT RIMATION Property Address: 479 Salem Street North Andover Name of Owner: Eric Lindsay Address of Owner:479 Salem Street North Andover MA 01845 Date of Inspection:08/25/1999 Name of Inspector:Neil J.Bateson 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name:Bateson Enterprises Inc. Mailing Address:111 Argilla Road Andover MA 01810 Telephone Number:(978)475-4786 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of 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: X Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: fsVit 4 .,J Date:08/2511999 The System Inspector shco of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of Ys 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 C' rl/�r14 LSEP, 9-3 X99 revised 9/2/98Page I of 11 � Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:479 Salem Street North Andover Owner:Lindsay Date of Inspection:08/25/1999 INSPECTION SUMMARY: Check A, B, C,or D: A.SYSTEM PASSES: _X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: B.SYSTEM CONDITIONALLY PASSES: One or move 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 NO).Describe basis of determination in all instances.If"not determined",explain why not. _ The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspecrfion if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised 912198 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 479 Salem Street North Andover Owner:Lindsay Data of Inspection:08125H999 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: 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: 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 revised 912198 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:479 Salem Street North Andover Owner:Lindsay Date of Inspection:0812511999 D.SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No _ Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6'below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E.LARGE SYSTEM FAILS- You must indicate efther"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area @ IWPA)or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2).Please consult the local regional office of the Department for further information. revised 912/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:479 Salem Street North Andover Owner:Lindsay Date of Inspection:08/25/1999 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No _X Pumping information was provided by the owner,occupant,or Board of Health. _X None of the system components have been pumped for at least two weeks and the system has been receiving normal flaw rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _X As built plans have been obtained and examined.Note if they are not available with NIA _X_ The facility or dwelling was inspected for signs of sewage back-up. _X The system does not receive non-sanitary or industrial waste flow.The site was inspected for signs of breakout. X All system components,excluding the Soil Absorption System,have been located on the site. The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _X Existing information.For example,Plan at B.O.H. X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [I 5.302(3)(b)) X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 912/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 479 Salem Street North Andover Owner:Lindsay Date of Inspection:08/25/1999 FLOW CONDITIONS RESIDENTIAL: Design flow::_110_..g.p.d./bedroom. Number of bedrooms(design): 4_ Number of bedrooms(actual):-4— Total actual): 4_,Total DESIGN flow_440_ Number of current residents: 4_ Garbage grinder(yes or no):_Yes_ Laundry(separate system)(yes or no):_No ;If yes,separate inspection required Laundry system inspected(yes or no) Seasonal use(yes or no):_No Water meter readings,If available Jun 96 to Jun 99=70,900ft3 x 7.5=531,750 Gals/1095 Days=485 Gals./Day Sump Pump(yes or no): Yes_ Last date of occupancy:—Current— COMM urrentCOMM ERCIALIINDUSTRIAL: Type of establishment: Design flow: gQd(Based on 15.203) Basis of design flow Grease trap present:(yes or no) Industrial Waste Holding Tank present:(yes or no) Non-sanitary waste discharged to the Title 5 system:(yes or no) Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information:Pumped last year owner. System pumped as part of inspection:(yes or no)_Yes_ If yes,volume pumped:_1500_gallons Reason for pumping:Inspect tank&tees. TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) 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 known)and source of information:19 Years Installed 12/12/80 As built plan Sewage odors detected when arriving at the site:(yes or no)_Nc_ revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 479 Salem Street North Andover Owner:Lindsay Date of Inspection:08/25/1999 BUILDING SEWER:x (Locate on site plan) Depth below grade:22" Material of construction: cast iron_X 40 PVC — other(explain) Distance from private water supply well or suction line: Diameter:4" Comments:Unable to see pipe leaving foundation,behind wall. 3"PVC in house. SEPTIC TANK:X (locate on site plan) Depth below grade:10" Material of construction_X concrete_metal_Fiberglass_Polyethylene_other(explain) If tank is metal,list age_Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions:10'x 5'x 4' x 7.5=1500 Gallons. Sludge depth:6" Distance from top of sludge to bottom of outlet tee or baffle:21" Scum thickness:10" Distance from top of scum to top of outlet tee or baffle:8" Distance from bottom of scum to bottom of outlet tee or baffle:11" How dimensions were determined: Subtract sum&sludge depths to tee length. Comments:Pumped septic tank.Inlet tee&baffle ok.Outlet tee corroded on top.Depth of liquid at outlet invert.No evidence of leakage. GREASE TRAP: None (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: revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 479 Salem Street North Andover Owner:Lindsay Date of Inspection:08/25/1999 TIGHT OR HOLDING TANK:_None (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: Material of construction: concrete—metal_Fiberglass Polyethylene_other(explain) Dimensions: Capacity:_ allons Design flow:gallons/day Alarm present Alarm level: Alarm in working order:Yes_No Date of previous pumping: Comments: DISTRIBUTION BOX.:_X (locate on site plan) Depth of liquid level above outlet invert:0 Comments:D-box level&distribution equal.No sign Of leakage.No solid carryover. PUMP CHAMBER:–None,gravity system_ (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: revised 912/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued)) Property Address:479 Salem Street North Andover Owner: Lindsay Date of Inspection:08/25/1999 SOIL ABSORPTION SYSTEM(SAS):X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: Type: leaching pits,number leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions:One field 20'x 40' overflow cesspool,number: Alternative system: Name of Technology: Comments:Soil ok.Vegetation ok.No sign of ponding to surface. CESSPOOLS: None (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: PRIVY:None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: revised 912198 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:479 Salem Street North Andover Owner:Lindsay Date of Inspection:08/2511999 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) House Garage Water Meter Drive Way Septic Tank 3 2 1 D-box 20' 40' 'I AtoI = 17' Ato2= 14'6" A to 3= 13'5" A to D-box=26' B to 1 =31'4" Bto2=35' Bto3=38'6" B to D-box=53'3" revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 479 Salem Street North Andover Owner:Lindsay Date of Inspection:08125/1999 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 4 Feet Please indicate all the methods used to determine High Groundwater Elevation: _X Obtained from Design Plans on record _X Observed Site(Abutting property,observation hole,basement sump etc.) —X—Determined from local conditions —X—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.CMust be completed)As per design plan. revised 912198 Page 11 of 11 Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating-Water.& Sewer Lines-Septic Systems&Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 479 Salem Street North Andover Owner: Lindsay Date of Inspection: 08/25/1999 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. eil J. B eson Bateson Enterprises, Inc.