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Miscellaneous - 50 HAY MEADOW ROAD 4/30/2018
50 HAY MEADOW ROAD F - 210/1043-0102000:0 "! I wi� r i Jam// JG` 1 `§ S -_ -_ North Andover Board of Assessors Public Access Page 1 of 1 t ; µoR7y IDoa*d of TOW>N2 Q 1�©F AOP. ssors - r�. z �g8es t�' Property Record Card Return to the Home page click on lona Parcel ID:210/104.13-0102-0000.0 Community:North Andover SKETCH PHOTO New Search Click on Sketch to Enlarge Click on Photo to Enlarge Sales Summary Residence Detached Structure - - Condo s `� Commercial Comparable Sales =- 50 HAY MEADOW ROAD Location: 50 HAY MEADOW ROAD Owner Name: RICCIARDELLI,GINO&FELTZ,LISA Owner Address: 50 HAY MEADOW ROAD City:NORTH ANDOVER State:MA ZIP:01845 Neighborhood: 7-7 Land Area: 1 acres Use Code: 101-SNGL-FAM-RES Total Finished Area:3348 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 773,800 804,800 Building Value: 549,000 568,300 Land Value: 224,800 236,500 Market Land Value:224,800 Chapter Land Value: LATEST SALE Sale Price: I Sale Date:08/18/2005 Arms Length Sale Code:A-NO-FAMILY Grantor:RICCIARDELLI,GINO Cert Doc: Book:9714 Page:271 http://csc-ma.us/NandoverPubAcc/jsp/Home.jsp?Page=3&Linkld=1180293 6/11/2008 f Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form Not for Voluntary Assessments 50 Hay Meadow Rd. Property Address , n v Gino Ricciardelli cV Owner Owner's Name information is North Andover Ma 01845 10/8/13 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: ��` 1 203 key to move your cursor-do not Mike Graham TOWN OF NORTH ANDOVER use the return Name of Inspector key. Windriver r� Company Name 163 Western ave Company Address Gloucester Ma 01930 City/Town State Zip Code 978-282-7315 13560 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 ❑ Needs Further Evaluation by the Local Approving Authority Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 50 Hay Meadow Rd Property Address Gino Ricciardelli Owner Owner's Name information is required for every North Andover Ma 01845 10/8/13 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: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ one or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Hay Meadow Rd. Property Address Gino Ricciardelli Owner Owner's Name information is North Andover Ma 01845 10/8/13 required for every 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): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Hay Meadow Rd Property Address Gino Ricciardelli Owner Owner's Name information is re 1845 10/8/13 wired for eve North Andover Ma 0 � every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ 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 El ® 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 'h day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments (C�M 50 Hay Meadow Rd Property Address Gino Ricciardelli Owner Owner's Name information is North Andover Ma 01845 10/8/13 required for every 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 t ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 50 Hay Meadow Rd Property Address Gino Ricciardelli Owner Owner's Name information is North Andover Ma 01845 10/8/13 required for every 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): 440 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 50 Hay Meadow Rd. Property Address Gino Ricciardelli Owner Owner's Name information is required for every North Andover Ma 01845 10/8/13 page. Cityrrown 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 81.68 gpd 9 ( y 9 (gp ))� Detail Sump pump? ❑ Yes ® No Last date of occupancy: Current Date 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments °� 50 Hay Meadow Rd Property Address Gino Ricciardelli Owner Owner's Name information is North Andover Ma 01845 10/8/13 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) i Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner/WRE Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Pump truck/tape measure Reason for pumping: Check structural intergrity Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 50 Hay Meadow Rd. Property Address Gino Ricciardelli Owner Owner's Name information is North Andover Ma 01845 10/8/13 required for every 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: 4/8/80 On file at the board of health. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 27..,. feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): All joints are in good condition, the venting is fine. There is no evidence of leakage. Septic Tank (locate on site plan): Depth below grade: 11" feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: L 10'6"w 5' h 63" Sludge depth: 4" t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 i Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 50 Hay Meadow Rd. Property Address Gino Ricciardelli Owner Owner's Name information is North Andover Ma 01845 10/8/13 required for every 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 31" Scum thickness 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 14" How were dimensions determined? Tape measure/sludge judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Recommend yearly pumping. The inlet, outlet baffles are in place. The structural integrity is good. The liquid level is good and there is no evidence of leakage. 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 W Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 50 Hay Meadow Rd. Property Address Gino Ricciardelli Owner Owner's Name information is required for every North Andover Ma 01845 10/8/13 page. City/Town 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, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments f,M 50 Hay Meadow Rd. Property Address Gino Ricciardelli Owner Owner's Name information is North Andover Ma 01845 10/8/13 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" I Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The d-box is level and the distribution to outlets are equal. There is no evidence of carry over or leakage into or out of the d-box. The d-box is 30"deep. 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Hay Meadow Rd. Property Address Gino Ricciardelli Owner Owner's Name information is required for every North Andover Ma 01845 10/8/13 page. City/Town 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: 4x20x60 ❑ 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.): The condition of the soil is good. There is no sign of hydraulic failure or ponding. The vegetation is good. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 50 Hay Meadow Rd Property Address Gino Ricciardelli _ Owner Owner's Name information is Ma 01845 10/8/13 required for every North Andover page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments note condition of soil signs of hydraulic failure, level of ponding, condition of vegetation, ( 9 Y P 9 etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Hay Meadow Rd Property Address Gino Ricciardelli Owner Owner's Name information is North Andover Ma 01845 10/8/13 required for every 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 [] drawinq attached separately "L ..... f Uig i I '6 3 f5in -3/13 Tido 5 Official Inspoc5or,Form:Subcurf3co So—go Disposal Syc[om-Pago 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 50 Hay Meadow Rd Property Address Gino Ricciardelli Owner Owner's Name information is North Andover Ma 01845 10/8/13 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 78 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Plans on file at board of health, Sam Sousa 4/9/03. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 16 of 17 I Commonwealth of Massachusetts - Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 50 Hay Meadow Rd. Property Address Gino Ricciardelli Owner Owner's Name information is required for every North Andover Ma 01845 10/8/13 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 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS mw_ME DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS_ SUBSURFACE SEWAGE DISPOSAL SYSTEM,-F-O � �,i PART A •���; � CERTIFICATION 77 — i! s92293 Property Address , d ,�/mss• ��iC/��//r_'.'-�. .�./''r`'/ � ! ..._._...� ..�-,,.,=,13 Owner's Name: Owner's Address: -- Date of Inspection: &!:Z Name of Inspector: (please print) �/,�/ ol Company Name• ^._` � Mailing Addres, zMj 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: 4-5Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: !` ��� �'�c..� Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. 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 1 Page 2 of 11 c- OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) ` Property Address: J10 Owner:/- , Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes:��-s 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: /k/ B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired:The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipes)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 " '"page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1-:�D /� /�" /✓11� Owner: Date of I spection: hi C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: — Cesspool or privy is within 50 feet of a surface water" } _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria-,are triggered.A copyof the analysis-must lie attached to this form. 3. Other: 3 „,,Page 4 of 11 T OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address• : h` , 1/O, . Owner• Date of Inspection: 1223 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 r _ A 1 _'"'`Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow <<-4equired 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. 0.4 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.] to (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303.therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd: .. You must indicate either"yes"or"no"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 I 1 C OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: * Owner: /r/ Date of Idspection: /r Check if the following have been done.You must indicate"yes"or"no"as to each of the following: PumY�gs�No ping 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: Yes - o _ 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)[3 10 CMR 15.302(3)(b)] 5 •a ,Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL / r Number of bedrooms(design): / Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): o v Number of current residents: Does residence have a garbage grinder(yes or no): P S Is laundry on a separate sewage system(yes or no)::'Wo[if yes separate inspection required] Laundry system inspected(yes o r no):_ Seasonal use:(yes or no): f 1 r Water meter readings,;if availabli!tlast 2,yeSrs usage(gpd)): e Sump pump(yes or no): f c1 / Y Last date of occupancy: (�v� -COMMERCIAL/INDUSTRIAL / r ` 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: (/ /2 PS t let, Was system pumped as part of the Inspection(yes or no):_ If yes, volume pumped: f0J gallons--How was quantity pumped determined? TQ UCIC Reason for pumping: C11 P t^✓L ZA f 2-lL s 4•– 13 s TYP)t`ur^OF SYSTEM L Z- Septic tank;distribution box,soil absofptiam System _Single cesspool Overflow cesspool —ivy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information. Were sewage odors detected when arriving at the site(yes or no): 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Add ess:cJo Owner: Date of fispection: 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:". fs Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:�3(locate on site plan) It Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene _other explain) If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: Sludge depth: W Distance from top of sludge to bottom of outlet tee or baffle: 5s- Scum teScum thickness: / '' Distance from top of scum to top of outlet tee or baffle: _ Distance from bottom of scum to bottom of outlet tee or baffle: / How were dimensions determined: S'/ )— C Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_conciete Fmetal fiberglass_polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:,-, Owner: Date of Inspection: 11 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day t ss e Alarm present(yes or no): ' ' F Alarm level: Alarm in working order(yes or no): ; Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX) S (if present must be oplened)(locate on site plan) Depth of liquid level above outlet invert: "Cf od / 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.): G .0 6c; C"Q 7- PUMP PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 1 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: do Owner: Date of Idspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: w Type leaching pits,number:_ ¢ leaching chamber's,number.1 leaching galleries,number: 1 Ching trenches,number,length: t/leaching fields,number,dimensions: ,:�0 j 6-.3 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.): 46 f/Q/ T/u i/ G rj!J / t.1 �L/o r2�j CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): t � PRIVY: (locate(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 sr .o OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM'INFORMATION(continued) Property Address,,-10 Owner: f i /'r�' Date of Inspection: 11 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. t f /rl d 4V 10 'r-Page 11 of 11 ,�.. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:✓� �!.c �� f� l Owner: . r'f/f Date of Ii6spection: _ 6 X SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground w.1ter?levation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked.with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: iV v . 11 Town of North Andover, Massachusetts Form No.3 BOARD OF HEALTH tt`co ,6T � O 19 ! L O 9 P DISPOSAL WORKS CONSTRUCTION PERMIT 9SSwcHUS Applicant NAM ADDRESS �j TELEPHONE Site Location - � C;/ Permission is hereby granted to Construct ( ) or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. Z) CHAIRMAN, BOARD OF HEALTH Fee D.W.C. No. 994 APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: 2 Z/ 8 CURRENT INSTALLER'S LICENSE# LOCATION: 6,0 &,/, 4" LICENSED INSTALLER: SIGNATURE: Y 'TELEPHONE# 917Y z175-1Z_37 CHECK ONE: REPAIR: V NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUILT. - Administrative Use Only $75.00 Fee Attached? Yes V No Foundation As-Built? Yes No Floor Plans? Yes No Approval Date: 50 Haymeadow ■ 2/9/98 Phoned Mike Riley to get an update on the status of the D-Box repair ■ 2/10/98 Peter Riley returned call and stated the work had been completed ■ Please note that the permit to repair the system component was applied for, but never picked up by Riley. Work was certified by the installer. It was not observed by this department. r 107 Forest St. FILE# Middleton,MA 01949 (508)774-27,72 ummicSEPTIC & DRAIN SERVICE JIV � -yo \ti�0. ` FEB 3 kc ofd '?gl98 Deck golgc SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PROPERTY OWNER'S NAME: r 1e PROPERTY ADDRESS: , mv 4 dow a A1-4ubq 9K 0 ADDRESS OF OWNER: (if different) DATE OF INSPECTION: 1,7 O I �O NAME OF INSPECTOR: •THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY j 107 Forest St. Middleton,MA 01949 (508) 774-2772 SEPTIC.& DRAIN SERVICE SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: *,/LVu1V4:qS Address of Owner: Date of Inspection: CO i wig `ho �. (If different) '.•, Name of Inspector:• I am a DEP app system I c or pursuant t Sectio15.34015.340 of Title 5 (310 CMR 15.000) Company Name: C r @ C JV 1� Mailing Address: H Telephone Number. CERTIFICATION:STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: -asses K Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fail Q4,m_ Inspector's Signature: Date: I. The Svstem Inspector shall sGbmit a copy ofihis 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 floes• 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 Environmenta? Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Chec{{ A)B, C, Or D: W-K W0�5 / r � p�� �/f}S /n_,�� AJ SYSTEM PASSES: t GN NfRG�(a/!GW A 97$ y7u��(237 e5 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. COMMENTS: BJ SYSTEM CONDITIONALLY PASSES: j?&x 9ep14ce_b fIze P L �ONS7,�NG— v One or mores stem m TTe' m u 2 y components as described in the "Conditional Pass" section need to be replaced or repaired. The sysf�m, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 069 Indicate yes, no, or not determined (Y, N, or ND). Describe determination all'instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the.existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web http./Avww.mapnet.state ma.us/det: 0 Printed on Recycied Paper F I L E# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: C7 � Owner- Date Date of Inspection: � � � �!'�����+ �• 117-1/4 122 PR BJ SYSTEM CONDITIONALLY PASSES !continued �e�r���Ll��oNsTRuc- Sewage backup or breakout or high static water level observed in the distri ution box is due to broken or obstr�u�tt����� 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). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled orplaced 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 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, safe hand the environment. ent. 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 pri�� is within 50 feet of a surface water 441, r Cesspool or pmy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) 5 SWILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM 15 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 to a surface water supply I 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 supr)!v'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) WER (revised 04/25/97) Paye 2 of 20 FILE# / 2-1 TAF- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO\ FORM PART A CERTIFICATION (continued) Property Address: +' .. Owner. Lip /��fa+",' � Date of Inspection: lJ DI SYSTEM FAILS: Iq8 Y'ou s; indicate either "Yes" or "No' as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The oas for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to corre^. the failure. Yes No b 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 c• cesspool. _ Stant liquid level in the distribution boa 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 flov.. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe!sj. Number of times pumped— Any portion of the.Soil Absorption System, cesspool or privy is below the high groundwater elevation. Anv porton of a cesspool or privy is within 100 feet of a surface water supply or tributan• to a surface water supply. Any porton of a cesspool or privy is within a Zone I of a public well. An} portion of a cesspool or privy is within 50 feet of a private water supply well. Anv portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with ro acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis foe coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. EI LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: 1777 The system serves a facility with a design flow o 0,000 gpd or greater (Large System) and the system is a significant threat to public health and safe and the environment cause one or more of the following conditions exist: Yes No the system is within 400 f o surface drinking water supply the system is within 2 feet of a tributa a surface drinking water supply the system is located in a nitrogen sensitive area ( erim Wellhead Protection Area'-IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Paye 3 of 10 p � FILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Date of Inspection:s0 / ��a� fg8 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Ye No / Pumping information was provided by the owner, occupant, or Board of Health. V — None of the system components have been um for at least two week n h pumped s and the has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or / as part of this inspection. ✓ — As built plans have been obtained and examined. Note if they are not available with N/A. The facilih or dwelling vas inspected for signs of sewage back-up. P —/_ The system does not receive non-sanitary or industrial waste flow. ✓ The site �%as inspected for signs of breakout. — All system components, excluding the Soil Absorption System, have been located on the site. —•. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of / baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge,depth of scum. / The size and location of the Soil Absorption System on the site has been determined based on: The facilm• owner tand occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. E . Plan)t B.O.H. e, Determined.in the field iif anv of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302i3)(b)) (revised 01/25/97) Page 4 of 10 FILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Properh Address: Owner: Date of Inspection: RESIDENTIAL: FLOW CONDITIONS Design fiov% .p. ,/bedroom for S.A.S. Number of bedrooms: Number of current residents: Garbage g•.:der(Yes r no!: Laundry co -ected t systemthe or no,: Seasonal use the . s oro Water meter rea ;n d if available a table (last two (2) year usage (gpd): Sump Pump (yes no)' f Last date of occupancy: COMMERCI kUINDUSTRIAL- Type of establishment. Design flog+. allons/da% Grease trap pr ent: lyes or n _ Industria! blaste ding Ta present: lyes or no;_ Non-sanitan waste d; r to the T;tle S system: Lyes or no) Water meter readings, if ble Las(,fate of o cupancv OTHER: (Describe Last date of occuoancv GENERAL INFORMATION PUMPING RECORDS and source of informal .�W System pumped as part of inspection: (Yes or not If yes, volume pumped: gallons Reason for pumping TYPE YSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) VA Technology etc. Copy of up to date contract? Other t APPROXIMATE AGE of all components, date installed (if known) and source of information: �ll+h S OCl� Sewage odors detected when arriving at the site: (yes or �0 >_ ad (revised 04/25/97) Page 5 of 10 ' FILE# -j O/ ZO1?8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) -MA 17 Property Address: �ncr� - Owner: Date of Inspection: kza(,WW/r-d,�iQOx,dY'v" BUILDING SEWER: q (/ (Locate on site plan) Depth below grade: Material of construction: _cast iron _40 PVC_other (explain) Distance from private water supply well or suction Irt Diameter t'# Comments: (condition of joinU, venting, evidence of leak ge,-et SEPTIC TANK:_ (locate on site plan) Depth below grade: Material of construction: /concrete _metal _Fiberglass _Polyethylene other(explain) If tank is metal, Inst age _ Is age confirmed by Certificate of Compliance _ (Yes/No; Dimensions: t- (f ,��W • Y. 4f Ili iwe '/fit Sludge depth 'f Distance from top of sludge to bottom of outlet tee or baffle: Z�f Scum thickness:___AZON'Lr �f Distance from top of scum to top of outlet tee or baffle: (O ff Distance from bottom of scum to bottom of outl t tee or ba"le: How dimensions were determined: k / Sjc� r�L Comments: (recommendation for pumping, condition of inlet o lett or baffl s epth f liquid level n relati n to o flet invert,it ct}�ral integrity, evidence of leaka , etc.) '00V— '# — . . it 9z lk GREASE TRAP: (locate on site plan) Depth below grade: Material of constr ion: _concrete _metal _Fiberglass _Polyethylene _other(explain) D nsions: Scu hickne s: Distance top of scum to top of outlet tee or baffle: Distance o nom of scum to bottom of outlet tee or baffle: Date of t pum Co nts: n (ro ommendation for pumping, conditio f<inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 04/25/97) Page is of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C Property Address: SYSTEM INFORMATION (continued) �f/f,��j ON ner: Date of Inspection: �' v TIGHT OR HOLDING TANK: (locate on site plan; WEdank must be pumped prior to, or at time, of inspection) Depth below grade: y� Material of constru o OQncrete _metal _Fiber lass —Polyethylene g _,other(explain) Dimensions: Capacin,:_____. g Ions Design floes•: ga s%da Alarm level._ Alarm in orking order_ Yes; No Date of previous pumping — Comments: (condition of inlet tee, conditi of alarm an loat switches, etc.) --------------- DISTRIBUTION BOX: 'CS, N#W (locate on site plan: N 16 X 16)DAOX, 6�eEL Depth of liquid level above outlet invert: Q�W � _ gam•��ii3 Co encs: (no e if lev�Otel and distribu i iual Kiden �bf6l se of so i r over evid ce f I kage into or ou box, eu•.�/` �� J O PUMP CHAMBER (locate on site pla ; v • CL Am Pumps in king order. (Y or Not Alarms in w order es or Nor Comments: (note condition of p p c >er, condition of pumps and appurtenances, etc.) _ l (revised 04/25/97) Pa96 7 of 10 FILE# Ot20!O SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) OwnedProperty Address: po'IeV4 Date of Lnspection. 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 prese t, explain: "&" o 9 V4 Type: � leaching pits, number:_ leaching chambers, number: leaching galleries, number: leaching trenches, number,length:�s-�— leaching fields, number, dimensions:_ -t L/11�j 20' X (i.3Zp��Pe overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ondin condition f P g, o vegetation, etc.) CESSPOOLS: (locate on site plan) Number and configuration Depth op of liquid to i et invert: Depth cilids layer- Depth of scu v Dimensions of c sp Materials of co struction: Indication of groundwater: inflow (cesspool must be pum d as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) B �- J PRIVY: (locat on site plan) Materia f con ruction: Depth of s Dimensions: Comments: (note condition of so' igns of hydraulic failure, level ofponding, condition of vegetation, etc.) (revised 04/25/97) Page a of 10 �• FILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: /�Gr OH ner: Date of Inspection: l SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent refnchmarks locate all wells within 100' (Locat wh� p blic ater supply comes ' house) 74 WA/ / "/cam Ale-LL. ,� i •.� zo' ti �pN tSop�A� pPkK 1L CA+,,N b/Y� �� �NC� aa6j..S sw�M TbOL ren ISS Slops Ce �D 1 -T (revised 04/75/97) ?aye 9 of 10 FILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: Depth to Groundwater /,S Feet 7- Please indicate all the methods used to determine High Groundwater Elevation: Owained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health l Check FEMA maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how`ou established the High Groundwater Elevation. Must be completed) log/ wo-b" 4&ea ez �s S�.r (revised 01/25/97) Page 10 01 10 FILE# Z,Q� 107 Forest St. Middleton,MA 01949 i (508)774-2772 SEPTIC & DRAIN SERVICE SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PROPERTY OWNER'S NAME: rGf PROPERTY ADDRESS: ADDRESS OF OWNER: (if different) DATE OF INSPECTION: NAME OF INSPECTOR: 1)1 r 1 •THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY.• FILE#' •Z,Q - 107 Forest St. , A` Middleton,MA 01949 -' (508)774-2772 SEPTIC & DRAIN SERVICE SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM " PART A CERTIFICATION Property Address: lY�/VVOW Address of Owner: Date of Inspection:J�—Oi� (If different) Name of Inspector: I am a DEP app664crifft i o;-pursuant t Section 15.340 of Title 5 (310 CMR 15.000) Company Name: C t; Awh /Y 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The s•stem: Passes . T Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fail Inspector's Signature: Q4- wm5w G. g Date: The Svstem Inspector shall s•Gbmit a copy 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 Environmenta! 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, C, Or D: Y Aj 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. ,.r; COMMENTS: Bj 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. P 06YC Ad d-ani Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination stances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator'has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 0{/25/97) Page 1 of 10 DEP on the world wide Web: http.Uwww mapnet.state ma.us/dep 0 Printed on Recycled Paper i� pppppw* } FILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: f rD Date of Inspection: •J 4 Bj 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). Describe observations: ; broken pipe(s)are replaced T ' obaruction 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 wiltP ass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed iEConditions HER EVALUATION I5 REQUIRED BY THE BOARD OF HEALTH: exist which require further evaluation nation 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 MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: CZ5500 .ar gacv rs w thm So fim cii.a.usirfack wows C Or PRO-i;.s.ad as 50%w-1 cii a botemM nem r.Gtassd ct a sak wwdii,. -2j aA 11t7lLLT•1►11.111111IT�5Zifi1:�UA� i'il 11L'titl(At1D�i381lL iNATEt ,'� � Tf�tV11`Jt?SZIiA1 THE SYSTEM IS FUNCTIONING INA MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: NThe system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a'surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supoiy'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) WER (revised 04/25/97) Page 2 of 20 000,00 FILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO\ FORM PART A CERTIFICATION (continued) Property Address: Owned Date of Inspection: D) SYSTEM FAILS: 1 14S Y'ou s: indicate either "Yes" or "No"as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The oas s for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to corre ci 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 c• cesspool. Static liquid levet 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 flov.. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipels;. Number of times pumped_. Any portion of the.Soil Absorption System, cesspool or privy is below the high groundwater elevation. Anv 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. Anv portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with rJ acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copv of well water analysis fo• coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: NO You must indicate either "Yes" or"No"as to each of the following: The following criteria apply to large systerps in addition to the criteria above: The system serves acility with a design flow o 0,000 gpd or greater(Large System) and the system is a significant threat to public health and safe and thAenvironment e one or more of the following conditions exist: Yes No the system is within 4inking water supply the system is within 2a surface drinking water supply the system is located in a nitrogen sensitive area ( erim Wellhead Protection Area-IWPA) or a mapped Zone 11 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 04/25/97) Page 3 of 10 r.. FILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Date of Inspection:] • �iaIr Check if the following have been done: You must indicate either "Yes" or "No"as to each of the following: Ye No / Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or / as part of this inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility• or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. The site was inspected forsigns pe of breakout. All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, matehal 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: The facility owner land occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. _ Existing information. E . Plat B.O.H. yes Determined-in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)) s (revised 04/25/97) Page 4 of 10 FILE# D�Zo9� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: Date of Inspection: RESIDENTIAL: � FLOW CONDITIONS Design flow 2%8 �/bedroom for S.A.S. dr Number of bedrooms:' Number of current residents: Garbage g,.:der(Yes r no!: Laundry cor•-ected t systemlye or no): Seasonal use !yes orC_ _ Water meter read In tf available (last two (2)year usage (gpd): Sump Pump Ives no) Last date of occupanc}:Z"e&4 COMMERCI AUINDUSTRIAL• Type of establ!shment: Design floe,•. allons/da% Grease trap pr ent: lues or n _ Industria! Wasie ding Ta oresent: ryes or nog Non-sanitary Haste di r to the Title 5 system: ryes or no) beater meter.readings, if ble — Last Pate of o•cupancv OTHER: (Describe! Last date of occuoanc-%, GENERAL INFORMATION PUMPING RECORDS and source of!nformat -- Systemum q P Ped as part of inspection: lyes or&a If yes, volume pumped: _ gallons Reason for Pumping TYPE *STEM 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) VA Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, t date installed (if known)and source of information: "--�— 1 A.hS OGI� Sewage odors detected when arriving at the site: (yes or (Vsvi,.d 04/2s/97) Page 3 of 10 ' LFILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C Property Address: SYSTEM INFORMATION (continued) Owner: /y� ' Date of Inspection; BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: cast iron 40 PVC •_other (explain) Distance from Private water supply well or suction list Diameter Comments: (condition of join venting, evidence of leak ge,-4t ) SEPTIC TANK:_ (locate on site plan) Depth below grade:-0 r r Material of construction: "/Concrete_metal_Fiberglass _polyethylene If tank is metal, list a e _other(expla,n) 8 Is age confirmed by Cen�ficate of Com Dance p -_ (Yes/ho; Dimensions: r_ I( W. '�l' Sludge dept �ut �`t'ffh Distance from �i top of sludge to bottom of outlet tee or baffle:_ Scum thickness:•__ t9-01 Distance from top of scum to top of outlet tee or baffle:_( Distance from bottom of scum to bottom of outl t tee or ba"'le:_ How dimensions were determined: `` Comments: W144a�44 Y17C4-_ —40L../ Q�� (recommendation forPumping, / A&A integrity, evidence of eaka condition of t or baffl e t inlet o let • etc.) Pth liquid level "n relati n to o flet invert, t cty�ral GREASE TRAP:_ (locate on site plan) Depth below grade: Material of constr ion: _Concrete _metal_Fiberglass _.poiyethylerie nsions: —other(explain) D Scu hickn s: Distance top of scum Disto top of outlet tee or baffle: tance o Date of t ptee ttom of scum to bottom of outlet or urn baffle: Co nts: (ro ommendatiPumping, conditio on for m ' ante ri l inlet and outlet tees or baffles, depth of liquid level in relation to outlet g ry, nclati ce of leakage, etc.) invert, structural ti revised 04/2t/97) Papa 6 of 20 FILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: �G1! Owner: Date of Inspection: TIGHT OR HOLDING TANK: "Tank must be pumped prior to, or at time, of inspection) (locate on site plan; Depth below grade: e—a Material of constru ncrete _metal _fiberglass _Polyethylene _other(explain) Dimensions: Capacity: g Ions Design flow: ga s d Alarm level. Alarm •orking order_ Yes; _ No Date of previous pumping- Comments: - - - - -- (condition of inlet tee.'conditi of alarm an oat switches, etc.) DISTRIBUTION BOXI-es, . (locate on site plan; Depth'of liquid level above outlet invert: Comments: (note if level and distribu ion i�q al e4idenw of so i r over evid ce of I kage into or out of box, efc.l lS O 9 OWL Ow-d-3. � Gtr f"�-�� a� � •���• _ PUMP CHAMBER Z1lIX21 (locate on site pla ; Pumps in in4(Yor Alarms in wor Comments: (note condition ondition of pumps and appurtenances, etc.) \ (revised 04/2S/97) Page 7 of 10 FILE# 'Q�1�p�j¢-- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C r, SYSTEM INFORMATION (continued) Property Address: �j���fiv� `� Owner; Date of Inspection: SOIL ABSORPTION SYSTE&SAAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be prese t, explain: ze rrrr„b,er_ - leaching galleries, number: leaching trenches, number,length. leaching fields, number, dimensions: overflow cesspool, number: X G 3 , Gy= cGc Zp��pe Alternative system: Name of Technology.. Comments: (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.) . CESSPOOLS: /v (locate on site plan) Number and configuration- Depth p of liquid to i et invert: Depth o lids layer- Depth of scu v Dimensions of c sp Materials of co struction: Indication of groundwater: inflow (cesspool must be pum d as part of inspection) :omments: cote condition of soil, signs of hydraulic failure, level of ponding,g condition of vegetation, etc.) 'IVY- .41 .at on site plan) eria f co ruction: >th of s iments: Dimensions: condition,of s igns of hydraulic failure, leve!of Ponding, Condition of vegetation, etc.) P•Q• 8 of,10 FILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: OKner. Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent refnchmarks TOWAI locate all wells within 100' (Locate wh� p blic ater supply comes ' house) Na wctL �y w S .TSN N(s Co wr s `�• 2-0 13ma zf toojA A( tTNIC ftiGlaJtS -t'AN Ctftre lb SWI►" y6oL IS slope, Ce Z)A., w'J 4jlNblo . i(reviaed 0{/25/97) Page 9 of 10 " FILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: Depth to Groundwater /V Feet , Please indicate all the methods used to determine High Groundwater Elevation: O ained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) V Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) Jou/ Wit y (revised 01/25/97) Page 10 of 10 r Board of Wealth North An&versMass jZ V' J WBMRFACE DISPOSAL DESIGN CHECK LISP LOT DISAPPROOED DATE PPRWED DATE 'rovideds Reasons, Utle V VrjLLJU tag 2.5 e submitted plan must show as a mi ni mum2 the lot to be served-area dimensions lot fpsabutters location and log deep observation hoes-distance to ties location and results percolation tests-distance es leaching area design calculations & calculations showing required location and dimensions of system-including reserve area ✓ existing and proposed contours (g) location any wet areas within 100' of sewage disposal system or disclaimer-check wetlands mapping h) surface and subsurface drains within 100' of sewage disposal system or disclaimer (i) location any drainage easements within 100' of sew disposal system or disclaimer-Planning Board files (3) knos= sources of water supply within 200' of sewage disposal system or disclaimer location of any proposed well to serve lot-1001 from leaching facility 1) location of water lines on from leaching facility jlocation of benchmark driveways garbage disposals no PVC to be used in construction lamb pipes septic tank q profile of system-elevations of basements p s P P s s distribution box inlets and outletesdistribution field piping and Omer elevations ) maximum ground water elevation in area sewage disposal system (s) plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Reg 6 SeDtie Tanks (a) cac t es- 5016 of flows water tables tees., depth of tees, ap access, pumping b) cleanout ✓ (%) 10' from cellar wall or inground sulmmi.ng Pool (d) 25' from subsurface drains Reg 10.2 Distribution Boxes, j (a slope greater than 0.08 Reg 10.4 1b) �� Subsurf�:�e Design Check List P& FAIL 0K Leaching Pits Leaching pits a preferred Where the installation is possible Reg 11.2 a) calculati s of leaching area-rdni rmm 500 eq ft 11.4 b) spec - 11.10 c anrfa a drainage lid 11.11, dj cov material e) 21 I x4" splash pad f) a at elbow g) bends in pipe from d-box to pipe Leaching Fields Reg 15.1 .a no greater than 20 minutes/inch area-minimum 900 s4 ft 15.4 construction of field i5.8 d) surface drainage 2 % 3.7 e) 201 from cellar call or inground mxLmidng pool Leaching�Ii M&s Reg 14.1 a) calculateons'orZeaching area-min 500 sq ft 14.3 b spacing-4 t min 6 ft. with reserve between 1,4.4 c) dimensio 14.6 d) const tion 1,4.7 e) stone 14.10 f surface drainage 2% Downhill) Slo e a slope y x a be shown bj y/x x 50 a (to be shown] Reg 9.1 a) vel 9.6 b) s d- power �ard of Health BF,PTIC SIETEH North An Yer tea• INS'TAI.1-ATIGK CHEcK LIST LOT '�5L - AVATI(N OK FAIL ppm DATE Eff FRI011i — - - eaeonst r FAIL 0K 1. Distance Tot (/ a. Wetlands b. gains c. Wen ✓ 2. Water Line Location 3. No PPC Pipe �. Septic Tank S., -Tees --Length & To Clean Out Covers. b. Cement Pipe to Tank -- On Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Lines Flowing Equal Amvtmts c. No Back Flow 6. Leach Field or Trench a. Dimensions b. Stone Depth Capped maids Clean Double Washed Stone 7. Leach Pits a. Dimensio s b. Stone epi .; C. 8pla Pads d, T e. C t Pipe to Pit - Both Sides. . f. can Double Washed Stone v 8. No Garbage Disposal 9. Final Grading Inspection 10. Barricading Covered System 11. As Built Submitted- -_ a. Lot Location . b. Dixuensions of System - c. Location with Regard-to Perc Test i d. Elevations /' e: Water Table PLA 1c1 LVV40 444? AeOPos64o SUBSu�e FAGS SL Ae*E b1sp►s4e_ SyS TEM Awv t. a P,eOPOSE� LOT �7RAd/NG 5147 ' �'CAC,E = ��` ATE - ��fc ' I Q % !7 7 IAO"C�Cal, o-zle"oe /0,0 '00 rGlY- -'- /�h d Gam•., \ dT i . t DIES/U�t/ER DIES/Caa! 4DATA i ',--r TYPE OF BU/[D/NG: * I r ' ; \ (3ARA�� ¢� CELLAR PCUMe3/A14 FAlC/e:/TAE'S= 4,49,t/E i cd; SEtUA!aE FLOW F.ST/MA rE : 6 C.� �,cJ SEPT/e- TANK ABSORPT/ON AREA : �C)o . 11 ,� OPERGDLATL r/oA1 srs t TVP ELE!/AT/ON -/SCo . 3 'R_T Ver_` o A&Or_ro y ECC✓A rha v /5 3 3 SArL/R,4T/DA/ _/'S ff/ M/N MIA-1M/N. /2"ro 9" DROP z--- 9- roc." DRoP -_ --- ^, CW PERcaCA r/oAl RATE � ryiv7ir. - -�y..,.��N -- /NDN//N Mir Av. NOTA V �, 4 (l TEST PITS at/ 46,10 DATE TDP EL,EVAT/OIV_ -- /�/ T,yE• �/2000SEZ� � Y ' - T s7WEG.C. 1N6• - -- - -_ �' - — z ' Tai _Uc SO/C TYPES _- WATER TABLE 00 LOcA rio A/ b0rrOM CLE'VAr/o�v �r T _ J � 4 ' _ f-• l -._ _) �' _C�f.t_ TESTS t.�/ C(GTE� gY .�::, = : *-i ��f it_��'tr..l. .�._i 1? r• TESTS W1 rNESSEo BY PLAN DF.S/G,v 6R/rer7e/A CY"EE"T / OF 2 i I � i' I � I i � I �I E I ' f' � I i ' r J hLL 11.1 V G'i tom.D r[ 1LLL�.PLP ILjTf�D.�a�J.' . i I I' { [v j y • 151. 00, Zo. li LO T °3 o 4 � Q i O J s Isoo G TANK. �y. f• 3 :-7 � s 1 4, 02 r4_00, I WV PIPE OUT OP NSE t 3 C90 A� E5ulL-T IKIV P PE 1410M V.4 15 3.2 5 I61y PIPED1t,/ 152.78 c V 1NV PIPE INTO D P50X 152, 14 B.. Ju�'���� i NV, PI PE nt JT D PjnX 152. 05 ir,1V. ENI 0 op- P1 vE 151 . 910 i 1\1 0 T_ A N MA . IZ -4Awovizz FAzm s NoR!T� I7ATE;q-IS•80 �,?�• .,,_ . F 2A1�1 k G ELI N AS A S5vG1 T ES Ef1�1NE.fa-Qs ALzr_ tITEGTS