HomeMy WebLinkAboutMiscellaneous - 507 SALEM STREET 4/30/2018 (2) 567 SALEM STREET _
210/038.0-0107-0000.0
qS Dia
PUBLIC HEALTH DEPARTMENT
Town of North Andover
Community and Economic Development Division
CERTIFICATE OF.
COMPLIANCE
As of: 10/12/16
This is to certify that the individual subsurface disposal system received a
SATISFACTORY INSPECTION of the:
Replacement of Septic Tank
By: Todd Bateson
At:
507 Salem Street
Map 038.0 Lot 0107
N9r)th An over, MA 01845
I" suance of this ce i ia�ate hail not be construed as a guarantee that the system will function satisfactorily.
Grant
Public Health Agent �J
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
• TPI, j,
c,E.,z., .,fie •
North Andover Health Department
Community and Economic Development Division
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: 507 Salem St. MAP: 038.0 LOT: 0107
INSTALLER: Todd Bateson
DESIGNER:
PLAN DATE:
BOH APPROVAL DATE ON PLAN:
INSPECTIONS S N
TANK INSPECTION: 10�
DATE OF BED BOTTOM IN tTION:
DATE OF FINAL CONSTRUCTION INSPEC
DATE OF FINAL GRADE INSPECTION-
SITE CONDITIONS
4
Contractor r
[Existing se'
,n/1
❑ Internal plun U I
❑ Topography
Comments: --— Y
SEPTIC TANK
❑ Building severer in continuous grade, on
compacted firm base
❑ Cleanouts per plan
Bottom of tank hole has 6" stone base
/ Weep hole plugged
1500 gallon tank has been installed
H-10 loading
Monolithic tank construction
❑ Water tightness of tank has been achieved by
visual testing
❑ Inlet tee installed, centered under access port
�r
North Andover Health Department
Community and Economic Development Division
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: 507 Salem St. MAP: 038.0 LOT: 0107
INSTALLER: Todd Bateson
DESIGNER:
PLAN DATE:
BOH APPROVAL DATE ON PLAN:
INSPECTIONS
TANK INSPECTION: v>>
DATE OF BED BOTTOM IN PECTION:
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
Contractor reports any changes to design plan
Existing septic tank properly abandoned'
❑ Internal plumbing all to one building sewer
❑ Topography not appreciably altered
Comments:
SEPTIC TANK
❑ Building sewer in continuous grade, on
compacted firm base
❑ Cleanouts per plan
Bottom of tank hole has 6" stone base
Weep hole plugged
[ 1500 gallon tank has been installed
H-10 loading
Monolithic tank construction
❑ Watertightness of tank has been achieved by
visual testing
❑ Inlet tee installed, centered under access port
❑ Outlet tee installed, centered under access port
(gas baffle/effluent filter)
❑ inch cover to within 6" of finish grade
installed over one access port
Hydraulic cement around inlet & outlet
Comments:
PUMP CHAMBER
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ 1500 gallon Pump Chamber installed
❑ H-10 loading
❑ Monolithic tank construction
❑ Inlet tee installed, centered under access port
❑ Pump(s) installed on stable base
❑ Alarm float working
❑ Pump On/Off floats working
❑ Separate on/off floats
❑ Drain hole in pressure line
❑ cover at final grade installed over pump
access port
❑ Water tightness of tank has been achieved by
testing
❑ Hydraulic cement around inlet & outlet
Comments:
CONTROLPANEL
❑ Alarm & Pump are on separate circuits
❑ Alarm sounds when float is tripped
❑ Location of control panel: basement
❑ Alarm signal located inside: basement
Comments:
DISTRIBUTION-BOX
❑ Installed on stable stone base
❑ H-20 D-Box
❑ Inlet tee (if pumped or >0.08'/foot)
❑ Hydraulic cement around inlet & outlets
❑ Observed even distribution
❑ Speed levelers provided (not required)
❑ Schedule 40 PVC Pipe
Comments:
a ITDJ Commonwealth of Massachusetts Map-Block-Lot
038.00107
BOARD OF HEALTH Permit No
North Andover BHP-2016-0298
-
P.I. - ---------------
FEE
F.I. $175.00
-----------------------
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Todd-Bateson
to(Repair)an Individual Sewage Disposal System.
at No 507 SALEM STREET
as shown on the application for Disposal Works Construction Permit No. BHP-2016-029 d September 29,2016
---------------
----------------------------
FILE COPY
Issued On: Sep-29-2016 BOARD OF HEALTH
-----------------------------------------------------
E
r.k,• i
,
Application for Septic �isposai S�stero TODAY'S DATE
Construction Permit — TOWN OF goo'-Full Repair
NORTH ANDOVER MA 01845 cornponent
17�
Important: Application is hereby made for a permit to:
When filling out F1 Construct a new on-site sewage disposal system;
forms on the Repair or replace an existing.on-site sewage disposal'system"
computer,use El�p 7
only the tab key a air or replace an existing system component–Mat?? la
to move your
cursor-do not A. Facility Information
use the return So 17
key. .S�i� ��• � �►
Address or Lot#
SEP 2 9 2016
cityrrown �� ,
2.-*TYPE OF SEPTIC SYSTEM*: TOWN OF NORTH ANDOVER
➢ ump ❑Gravity(choose one) HEALTH DEPARTMENT
—if pump Sy ,attach copy of electrical permit to application"`
➢ Conventional System (pipe and stone system) •J
➢ E] Infiltrator or Biodiffuser(Gravel-Less)(Attach a copy of your certification to insta 1 this pe of system.)
➢ ❑Pressure Distribution S.A.S.(No D-Box)
➢ ❑Pressure Dosed(D-Box Present)S.A.S. / No
➢ [-] Does the system require an effluent filter? yes V
!f yes, does plan specify make and model of filter? YES=(no further info. needed)
NO=(installer must specify brand of filter before DWC issuance)
What is the Make? What is the 1fMode2e
2. Owner Information
Mame
S'�`7 S�L��--
Address(if different from above) Al + Q iY S
�� f•�-�U` State Zip Code
City/Town q 780 $-4 At
Telephone Number
3. Installer Information
Name of C mpany
Name BATMON ENT
/I/ ��y' 'g ARGILLA ROAD
Address ANDOVER, MA 01810
State Zip Code
Cityrr own F/3--,Y 7,0
y Telephone Number(Cell Phone#if possible please)
4. Desi Iner'lnforMLtion
Name of Company
7NameStateZip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
t
dRTN.. Ap;pliCation..for Septic Disposal_ys#ern
o 0 : ' TODAY'S DATE
a Construction Pg.
.rrnit TONT O
�'� ORTH :NDbY. MA $:250.60 T Full Repair
01845
'=A�,a, ° '� $1200.-Component
PAGE 2O 2
A. Facility.Information continued.,.,
S. Type-of Building: esidential Dwelling or(3Commercial
B. Agreement
The underslgned agrees to ensure the construction and maintenance of the afore-described
on-site sewage disposal system.ln accordance with the provls/ons of Title 5 of the
Environmental Code,as well as the Local Subsurface Disposal Regulations for the Town of
.North Andover, and not to place.the system 1n operation.until a Certificate of Compliance has
been Issued ,V this Board of Health.
9-A.
•-��
Name Date
i
Applicati Appro B : (Board of Health Representative)
Name Date
Applicat n DN pproved.for the following reasons:
For OM6.Use OnJV:
1 Pee Attached. Yes _
No
2. ProjectManager Obligation Form Atta Yes No
3.: Puma System? Ifso) b f 1 1 P it'. Yes No
4. Foundation As-Built?(new construction•ronly), Yes• No
(Same scale as approved plan) —
A FloorPLws?(hew construction-only); Ye
No
Applfcatfon{or•p�sppsai ystem: onMrudton permR Race 2 if
s
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
507 Salem Street
Property Address
Mark Perry
Owner Owner's Name
information is North Andover MA 01845 10/12/2016
required for
every page. Cityrrown 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.
m oiren flMgout A. General InformationRECEIVED
forms on the OCT 18 2016
computer,use 1. Inspector:
onlythe tab key
Y
to move yourNeil J. Bateson TOWN OF NORTH ANDOVER
cursor-do not
�
use the return
Name of Inspector
key. Bateson Enterprises Inc.
Company Name
111 Argilla Road
Company Address
Andover MA 01810
City/Town State Zip Code
978-475-4786 S115
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
10/12/2016
Inspecto s S nature 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
507 Salem Street
Property Address
Mark Perry
Owner Owner's Name
information is
required for North Andover MA 01845 10/12/2016
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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:
After permit from B.O.H., install new septic tank, inspection from B.O.H., septic system now passes
Title 5 Inspection.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins•3113 Title 5(Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments j
507 Salem Street
Property Address
Mark Perry
Owner Owners Name
information is
required for North Andover MA 01845 10/12/2016
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
-IV b = X116 Ir
it
it
-o A-aI t 9 3 u vuoi-e
a_ �6'e'n
P_
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
507 Salem Street
Property Address .
Mark Perry
Owner Owner's Name
information is
required for North Andover MA 01845 8/22/2016
every page. City(rown 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.
RECEIVED
Important: A. General Information
When filling out
forms on the AUG 2 9 2016
computer,use 1. Inspector:
only the tab key TOWN OF NORTH ANDOVER
to move your Neil J. Bateson HEALTH DEPARTMENT
cursor-do not Name of Inspector
use the return
key. Bateson Enterprises Inc. �53T
Company Name
VQ 111 Argilla Road
Company Address
Andover MA 01810
Cityrrown State Zip Code
978-475-4786 S115
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. 1 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 urther Evaluat' n by the Local Approving Authority
/ 8/22/2016
Inspedtort 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 conditio s at the time of inspection and under the conditions of use
at that time.This inspection does n t address how the system will perform in the future under
the same or different conditions of dse.
1 A.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
507 Salem Street
Property Address
Mark Perry
Owner Owner's Name
information is
required for North Andover MA 01845 8/22/2016
every 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):
Septic tank 6"from outlet invert, tank leaking
t5ins-3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
507 Salem Street
Property Address
Mark Perry
Owner Owner's Name
information is
required for North Andover MA 01845 8/22/2016
every page. Citylrown 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
a
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
507 Salem Street
Property Address
Mark Perry
Owner Owner's Name
information is
required for North Andover MA 01845 8/22/2016
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 17
J
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
507 Salem Street
Property Address
Mark Perry
Owner Owner's Name
information is
required for North Andover MA 01845 8/22/2016
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13
Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Tithe 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
507 Salem Street
Property Address
Mark Perry
Owner Owner's Name
information is
required for North Andover MA 01845 8/22/2016
every page. Cityrrown 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): N/A Number of bedrooms(actual): 5
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): N/A
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
V \ VVIIIIIIVIIwCQI�II VI 1T14*.74W1U*1ULW
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
507 Salem Street
Property Address
Mark Perry
Owner Owners Name
information is
required for North Andover MA 01845 8/22/2016
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
i
5
Number of current residents:
Does residence have a e a garbage gander? ® Yes ❑ No
Is laundry ona 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 years usage(gpd)): Yes
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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
507 Salem Street
Property Address
Mark Perry
Owner Owners Name
information is
required for North Andover MA 01845 8/22/2016
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Last month, owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
® Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
16
507 Salem Street
Property Address
Mark Perry
Owner Owner's Name
information is
required for North Andover MA 01845 8/22/2016
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:
Tank original, pump tank, d-box&leach area replaced 4/29/1989, as built plan
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 4
feet
Material of construction:
® cast iron ❑40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
4"Cast Iron through floor
Septic Tank(locate on site plan):
Depth below grade: 3
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: Tx 5'x 4'
Sludge depth: 0
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
507 Salem Street
Property Address
Mark Perry
Owner Owner's Name
information is
required for North Andover MA 01845 8/22/2016
every page. CitylTown 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 N/A
Scum thickness
Distance from top of scum to top of outlet tee or baffle N/A=Tank leaking
Distance from bottom of scum to bottom of outlet tee or baffle N/A
How were dimensions determined? Tape Measure
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Inlet baffle ok. Outlet baffle ok. Outlet tee ok. Depth of liquid 6"below outlet invert, evidence of
leakage. Center cover has riser 3"deep.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
507 Salem Street
Property Address
Mark Perry
Owner Owner's Name
information is
required for North Andover MA 01845 8/22/2016
every page. City/rown 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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
507 Salem Street
,p
Property Address
Mark Perry
Owner Owner's Name
information is
required for North Andover MA 01845 8/22/2016
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
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box level &distribution equal. No evidence of leakage. No evidence of carryover.
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.):
Pump tank ok. Pump ok.Alarm ok. Alarm has both audible&visual.
*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:
I
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Titre 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
507 Salem Street
Property Address
Mark Perry
Owner Owner's Name
information is
required for North Andover MA 01845 8/22/2016
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions: 1 field 25'x 40'
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soil ok. Vegetaion ok. No sign of ponding to surface.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 official inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
II
• <fCommonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
507 Salem Street
Property Address
Mark Perry
Owner Owner's Name
information is
required for North Andover MA 01845 8/22/2016
every 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,
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
l
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
507 Salem Street
Property Address
Mark Perry
Owner Owner's Name
information is
required for North Andover MA 01845 8/22/2016
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch,Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
hand-sketch in the area below
❑ drawing attached separately
CP
9W4) 0 _H
0
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
507 Salem Street
Property Address
Mark Perry
Owner owner's Name
information is
required for North Andover MA 01845 8/22/2016
every page. Citylrown 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: >4feet
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:
Essex County Soil Map.
You must describe how you established the high ground water elevation:
Essex County Soil Map, Sheet#30, Canton Soil,Water>6'deep.
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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
507 Salem Street
Property Address
Mark Perry
Owner Owner's Name
information is
required for North Andover MA 01845 8/22/2016
every page. Citylrown State Zip Code Date of Inspection
E. Report Completeness Checklist
I
E Inspection Summary: A, B, C, D, or E checked
E Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
E System Information—Estimated depth to high groundwater
E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
i
I
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Summary Record Card generated on 8116/2016 2:54:39 PM by Karen Hanlon Page 1
Town of North Andover
Tax Map # 210-038.0-0107-0000.0
Parcel Id 10410
507 SALEM STREET
MARC & LAUREN PERRY
507 SALEM STREET
NORTH ANDOVER, MA 01845
I
Class 101 Single Family Property Type j 1 Residential
Zoning2 1 Residential Zoning3 1 Residential
Size Total 1.09.Acres
FY 2017
UB Mailing Index
Name/Address Type Loan Number Active/inact. From Until
MARC&LAUREN PERRY Owner
507.SALEM STREET
NORTH ANDOVER,MA 01845
KEVIN McDONALD Previous Customer Inactive 10/3/2011
507 SALEM STREET
NORTH ANDOVER,MA
01845
UB Account Maint.
Account No Cycle Occupant Name Active/Inactive
Bldg Id. 16089.0-507 SALEM STREET Last Billing Date 7/26/2016
3160131 03 Cycle 03 Active
UB Services'Maint.
Account No.3160131
Service CodeRate Charge Multiplier/Users
MISCFEE ADMIN FEE 0.635/8 7.82 1/
WTR WATER. 01'ALL METER SIZE 140.68 /1
UB Meter Maintenance
Account No.3160131
Serial No' Status Location Brand Type Size YTD Cons
1633703.0 a Active 00 METE METE w Water 0.63 0.63 986
Date Reading Code Consumption Posted Date Variance
6/6/2016 1981 a Actual 32 8/2/2016 7%
3/2/2016 1949 a Actual 28 4/22/2016 -12%
12/3/2015 1921 a Actual 32 1/20/2016 -61%
9/3/2015 1889 a Actual. 83 10/16/2015 71%
6/3/2015 1806 a Actual 48 7/24/2015 42%
3/4/2015 1758 a Actual 33 4/28/2015 -3%
12/5/2014 1725 a Actual 35 1/15/2015 -37%
9/4/2014 1690 a Actual 56 10/15/2014 50%
644/2014. 1634 a Actual 37 7/16/2014 37%
3/5/2014 1597 a Actual 27 4/11/2014 -1%
12/4/2013 1570 aActual 27 1/17/2014 -7%
9/5/2013 1543 a Actual 29 10/15/2013 24%
6/7/2013 1514 a Actual 24 7/24/2013 9%
3/7/2013 1490 a Actual 22 4/22/2013 -20%
12/5/2012 1468 aActual 27 1/9/2013 -24%
9/6/2012 1441 a Actual 36 10/15/2012
6/7/2012 1405 a Actual 38 7/16/2012 -5%
3/8/2012 1367 a Actual 40 4/14/2012 52%
12/8/2011 1327 aActual 20 1/17/2012 58%
9/30/2011 1307 f Final Bill 22 9/30/2011 -3%
6/2/2011 1285 a Actual 17 7/20/2011 3%
3/4/2011 1268 a Actual 16 4/13/2011 16%
12/7/2010 1252 a Actual 15 1/12/2011 -23%
9/3/2010 1237 a Actual 19 10/15/2010 -20%
6/2/2010 1218 a Actual 23 7/15/2010 -4%
3/.4/2610 1195 a Actual 24 4/14/2010 -5%
07
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F 44 Flea St. SKET NO. AnA. - or• --NO—ANDOVER, MA 01845
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,Commonwealth of Massachusetts
Title 5 Official Inspection Form RECEIVED
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
507 Salem St. NOV 2 4 2009
Property Address
TOWN OF
McDonald HEALTH DEPARTMENTER
Owner Owner's Name
information is
required for every North Andover MA 01845 11/10/2009
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:
key to move your
cursor-do not Chad Jablonski
use the return Name of Inspector
key.
Jablonski & Sons Inc.
� Company Name
167 Willow Ave.
Company Address
Haverhill MA 01835
City/Town State Zip Code
978-360-9358 4574
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
'I
h 3AP917
I pector's, ;atreThe systempect shall submit a copy of this inspection report to the Approving Authority (Board
of Health orwithin 30 days of completing this inspection. If the system is a shared system or
has a desigw of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o ,Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
507 Salem St.
Property Address
McDonald
Owner Owner's Name
information is
required for every North Andover MA 01845 11/10/2009
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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:
SAS and all components in good working order.
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):
I
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�w 507 Salem St.
Property Address
McDonald
Owner Owner's Name
information is
required for every North Andover MA 01845 11/10/2009
page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
I
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w . ' 507 Salem St.
Property Address
McDonald
Owner Owner's Name
information is
required for every North Andover MA 01845 11/10/2009
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ 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 I well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
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 ors stem component due to overloaded or
❑ ® clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/day flow
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
507 Salem St.
Property Address
McDonald
Owner Owner's Name
information is
required for every North Andover MA 01845 11/10/2009
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
E] ® 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
E] ® 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.
15ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
b
Commonwealth of Massachusetts
PT Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 507 Salem St.
Property Address
McDonald
Owner Owner's Name
information is
required for every North Andover MA 01845 11/10/2009
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.
® El approximation
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): n tk Number of bedrooms (actual): 5
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): J1
I
l5ins-09/08 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
507 Salem St.
Property Address
McDonald
Owner Owner's Name
information is
required for every North Andover MA 01845 11/10/2009
page. CitylTown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 6
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d Attached
9 ( Y 9 (gp ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Occupied
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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 507 Salem St.
Property Address
McDonald
Owner Owner's Name
information is
required for every North Andover MA 01845 11/10/2009
'
page. CityTTown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
i
General Information
Pumping Records:
North Andover BoH
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: na
gallons
How was quantity pumped determined?
na
Reason for pumping: na
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•09/08 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w.4 507 Salem St.
Property Address
McDonald
Owner Owner's Name
information is
required for every North Andover MA 01845 11/10/2009
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed if known and source of information:
PP 9 P ( )
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 3.5'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.):
Sewer runs under footing
Septic Tank(locate on site plan):
3'
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
I
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ® Yes ❑ No
Dimensions:
8.5' x 5.5' x 5.5'
"
Sludge depth: 3 — —
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
�. Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
507 Salem St.
Property Address
McDonald
Owner Owner's Name
information is
required for every North Andover MA 01845 11/10/2009
page. CitylTown 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
24"
Scum thickness.
1"
5..
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? measuring tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank structurally sound inlet and outlet baffles in good working order
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
j Scum thickness
Distance from top of scum to top of outlet tee or baffle
I
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•09/08 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
507 Salem St.
Property Address
McDonald
Owner Owner's Name
information is
required for every North Andover MA 01845 11/10/2009
page. Cityfrown 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
t51ns•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
- .Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
507 Salem St.
Property Address
McDonald
Owner Owner's Name
information is North Andover MA 01845 11/10/2009
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on siteplan):
0"
Depth of liquid level above outlet invert
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.):
Box is level and distributing equally
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.):
Pump Chamber structurally sound, pump and alarm in good working order
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
I
i
i
t5ins•09/08 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
wM 507 Salem St.
Property Address
McDonald
Owner Owner's Name
information is North Andover MA 01845 11/10/2009
required for every
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:
1-25' x 40'
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
no sign of hydraulic failure or ponding
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-09/08 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
507 Salem St.
Property Address
McDonald
Owner Owner's Name
information is North Andover MA 01845 11/10/2009
required for every y
page. Cit crown 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,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
I
Commonwealth of Massachusetts
ANI - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
507 Salem St.
Property Address
McDonald
Owner Owner's Name
information is North Andover MA 01845 11/10/2009
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
56
o�
Anz,
i000,5�
A _ Z3 `
ia� C_ fgi�r
A p 2-3
c,
>
I
E
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
_ W Title 5 Official Inspection Form
,Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
507 Salem St.
Property Address
McDonald
Owner Owner's Name
information is North Andover MA 01845 11/10/2009
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
4' under leach field
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
�� Cda
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:
'Fob
1. a "� t, L e�G.►a F t CL'i7 i� APC'�o>< , 2. �' r1 r3v✓
C C-LL A 2
�,E�iy �� •a j ;,�M.t� QU M t�
— i
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
507 Salem St.
Property Address
McDonald
Owner Owner's Name
information is
required for every North Andover MA 01845 11/10/2009
page. Cityfrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
Summary Record Card generated on 11/13/2009 12:25:16 PM by Karen Hanlon Page 1
Town of North Andover
• Tax Map # 210-038.0-0107-0000.0
Parcel Id 10410
507 SALEM STREET
KEVIN McDONALD
507 SALEM STREET
NORTH ANDOVER, MA
01845
Class 101 Single Family Property Type 1 Residential
Size Total 1.09 Acres
FY 2010
UB Mailing Index
Name/Address Type Loan Number Active/Inact. From Until
KEVIN McDONALD Payor
507 SALEM STREET
NORTH ANDOVER,MA
01845
UB Account Maint.
Account No Cycle Occupant Name Active/Inactive
Bldg Id. 16089.0-507 SALEM STREET Last Billing Date 10/7/2009
3160131 03 Cycle 03 Active
UB Services Maint.
Account No.3160131
Service Code Rate Charge Multiplier/Users
MISCFEE ADMIN FEE 0.635/8 7.82 1/
WTR WATER 01 ALL METER SIZE 97.82 /1
UB Meter Maintenance
Account No.3160131
Serial No Status Location Brand Type Size YTD Cons
16337030 a Active 00 METE METE w Water 0.63 0.63 150
Date Reading Code Consumption Posted Date Variance
9/2/2009 1145 a Actual 24 10/15/2009 4%
6/2/2009 1121 a Actual 22 7/20/2009 1%
3/6/2009 1099 a Actual 23 4/29/2009 -3%
12/3/2008 1076 a Actual 23 1/20/2009 -26%
9/4/2008 1053 a Actual 32 10/10/2008 19%
6/3/2008 1021 a Actual 26 7/16/2008 1%
3/5/2008 995 a Actual 26 4/11/2008 9%
12/5/2007 969 a Actual 22 1/22/2008 16%
9/12/2007 947 a Actual 21 10/12/2007 -17%
6/11/2007 926 a Actual 26 7/20/2007 -20%
3/8/2007 900 a Actual 32 4/16/2007 13%
12/5/2006 868 a Actual 27 1/19/2007 -22%
9/7/2006 841 a Actual 35 10/20/2006 -12%
6/9/2006 806 a Actual 35 7/10/2006 14%
3/22/2006 771 a Actual 39 4/17/2006 -1%
12/12/2005 732 a Actual 36 1/17/2006 -25%
9/12/2005 696 a Actual 53 10/14/2005 3%
6/3/2005 643 a Actual 46 7/15/2005 38%
3/5/2005 597 m Manual estimate 33 4/5/2005 -1%
12/6/2004 564 aActual 33 1/14/2005 -11%
9/9/2004 531 a Actual 41 10/8/2004 10%
6/4/2004 490 a Actual 20 7/30/2004 -17%
---�^• TO F NORTH ANDOVL W
$OARD OF HEALTH
COMMONWEALTH OF MASSACHUSETTS
�- EXECUTIVE OFFICE OF ENVIRONMENTAL AFF RS
IA DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: ra-7 moi'=�+'� �T Name of Owner Lc:cr nrSt rQ- n I �}
�c:•"Ar&uf'ft 01CY. Address of Owner: � (E'Kxu..ct r� 1 rC�P . odcue
Date of Inspection: ;I ouewt
Name of Inspector.(Please Print) rvtnetLX C-) •. ����
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: t _
Making Address: 44 r1 —
Telephone Number:
CERTIFICATION STATEMENT
certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
r• _ Fails
r
Inspector's Signature: Date: Jit,
41 _[K8
The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30) days of
completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of•Environmemal Protection. The original should be sent to'Ttm
system owner.and copies sent to the buyer, if applicable, and the approving authority. .
NOTES AND COMMENTS
� ISI
revised 9/2/98 Pagel of 11
A
4 Printed on Recycled Paper
m '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
�f -. Qp /(�� CERTIFICATION (continued)
Property Address:v� �JG� ric,. 1„14Cuer
Owner: �GL(vy ar`A Ky
Date of Inspection: i i to 6
INSPECTION SUMMARY: Check A, B, C, o/ A
A. SYSTEM PASSES:
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 more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes, no, or not determined (Y, N, or 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 inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
e Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructedi e s
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with a P f ( )
approval P
Health). of the Board of
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumPhIg-more than fourtimes a year-due to broken or obstructed pipe(s). The-system wilhpess-•
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
I �
r
revised 9/2/98 Page 2of11
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(contirxred)
` Property Address:50-7,3 (k
F
k'1� S C• �lJJ.1�lr1C5ci�l�f r (k
Owner:
Date of Inspecow:
C. FURTHER EVALUATION LIST 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.PRQTECT THE PUBLIC HEALTH.AND SAFETY AND.THE ENVJBONMENT:
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 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
D. SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for 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)ntofecility ousystem component•duetto an overloaded orclegged-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.
li
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 lastear NOT due to clogged gged or obstructed pipe(s).
Number of times pumped_.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
I
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.
I
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
-coliform bacteria,volatile organic-compounds, ammonia nitrogen-and nitrate nitrogen. _
E. LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
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 witbin•200 feet of a ifibutary to a eurfsos 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
i
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 9/2/98 Page 4of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
«- CHECKLIST
Property Address:SCR
Owner: I..aroy irt:
Date of Inspection: ([l a I l
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
_ Pumping in was provided by the owner, occupant, or Board of Health.
--Non
— _ e of the system compoaents baww.abeen
Pua►pe"rat J
eas
rates during that period. Large volumes of water have not beentintroduced8ntoithessystemstem hecently or aspart of this
ws flow
inspection.
_ As built plans have been obtained and examined. Note if they are not available with NIA.
The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
✓ All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior o
f the septic or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth o ank was inspected for condition of baffles
The size 9 p f scum.
and locatiQ[�of,the Soil A sorption System on-the site has been .
} Y►ty�Kc l ry„ determined based on:
Existing information. For example, Plan at B.O.H.
_ Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
[15.302(3)(b))
The facility owner.(and.occu
laaats,if different from-o.wnethwere.provided.with inf=ation-on.tha4uzper4naintanaucs of
SubSurface Disposal Systems.
I I
revised 9/2/98
Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property address:E07 Sa(om S; eT, (06. 0. r
Owner: harry Arjiro
Date of Inspection:
RESIDENTIAL: FLOW CONDITIONS
Design flow: g.p.d./bedroom.
Number of bedrooms(design):_ Number of bedrooms(actual):
Total DESIGN flow
Number of current residents:
Garbage grinder jyes or no): y��,
Laundry(separate system) (yes or no):1 O;- If yes,separateinspection,required _
Laundry system inspected (yes or no)
Seasonal use(yes or no): AL
Water meter readings,if available(last two year's usage(gpd): ,o
Sump Pump(yes or no):�.,
Last date of occupancy: (% 7/90
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: gpd ( 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
f PUMPING RECOR S and source of' formation_:
Vis: - - .
System pumped as part of inspection: (yes or no) z
If yes, volume pumped- '•cam gallons -
Reasonforum in
P P 9�
TYPE OF SYSTEM
L/_ 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 �� `►.� c �Sy�
APPROXIMATE AGE of all components, date installed{if known)-and source of,iwformation:
Sewage odors detected when arriving at the site: (yes or no)1 rub
revised 9/2/98 Page 6of11
s: ;44ii(
SMUU604A/CS/UO5/LO04 TORN OF NORTH ANDOUER DATE: 11/16/'x"
TERMINAL NO: 000 CONSUMER METER F/M TIME: 10: 18:t._'`.
Acct : 01 -4367000-0 GIROUD CLAUDE 507 SALEM ST:
Meter No: 001 Rev Mtr/#: N 000 Book: 16 Page: 43670.00000 Meter Flg: 0 ['
Connector: ] Digits: 4] Dim Cd: A] Multiplier: ] Arb #:
Manf Cd: ] Units: Pipe Size: ] Len: ] Type:
Req: 00/00/00 Inst : 00/00/00 Cnct : 00/00/00 Disc: 00/00/00 Cd: t ,
kirk Cd: ] Mt Code: ] Met Loc: ] In/Out :
Notes: 5/8 TRY ] Serial #: 0020590603
Bgn: Cur: 3025 C Prev: 3025 E 2nd Prev: 3018 A [2
From: 05/12/98 To: 08/05/98 Cur2: Prev2:
Next : 00/00/00 Cns. Cr: 20-Mth Bill : 03 User: ]
-------------------------- Consumption Information -------------------------
--- First 12 Billing Months ------[3] 1 ------ Last 12 Billing Months -------[4; '
09/98 C 03/97 20 E 109/95 17 E 03/94 17 E
06/98 7 E 12/96 339-A 106/95 16 E 12/93 15 E
03/98 A 09/96 16 E 103/95 16 E' 09/93 20 E
12/97 27-E 06/96 16 E 112/94 16 E 06/93 9 A
09/97 20 E 03/96 16 -E 109/94 17 E 03/93 17 A
06/97 20 E 12/95 16 E 106/94 16 E 12/92 18 A
First 12 Total: 235- 1 Last 12 Total : 194
<ESC> to Enter New Meter Number
<M>odify, <D>elete or <N>ext _
�,,:,,. .
„ ..'
.:: ..::::.. _..:.:::-_. -
#ot�Eic�c t+[� rns Ess: TOtt t>F NORTH TQ F OF iETH 1�k 9 Aks
.......:...:............
..............
_...................................................................:.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
�{ PART C
SYSTEM INFORMATION(continued)
Property Address: `rj 7 SStH Yt� � E ;
Owner: �arry 11rck1At
:F Date of Inspection: Tai�CIFi
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 3S
Material of construction: X cast iron_40 PVC_other(explain)
Distance from Private water supply well or suction line
Diameter-AL -�-+
C mments: (condition of jo'nts, venting,evidence of leakage,-etc.) ,
SEPTIC TANK:_
(locate on site plan)
Depth below grade:3
Material of construction: concrete_metal_Fiberglass _Polyethylene—other(explain)
If tank is metal,list age_ 1s.age-confirmed by Certificate of Compliance_(Yes/No)
Dimensions- P'L 5 5`
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:_ _-
Distance from top of scum to top of outlet tee or baffle: G f
Distance from bottom of scum to bolt m of outlet tee or baffle:
` How dimensions were determined:
Comments:
(recommendation for pumpin , condition of inlet and outlet tees or-baffles, dept of liquid level in relation to outlet invert, 'tructuralln egri y,
evidence of le ge,etc.)
all i '{ 1 e c r ,r, r
C�t' •t
GREASE TRAP:
(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.)
revised 9/2/98
Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:Sb7&t k-:VIA S T1-ee7-/ (lac..11ASC,:A-,
Owner: fy
Date of Inspection: !(/
:z
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order:Yes_ No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert: c 13w'U-4.ou'r{pr
f
Comments:
(note:if level and distributio is equal, e4idenee of solids carryover, evidence of leakage into or out of box, etc.)
X11
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No)l
Comments:
( ote ccoonndition of pu p chamber,condition of pump and appu enances
1 , etc.)
r 11'14
revised 9/2/98
Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
'
SYSTEM INFORMATION(continued)
Property Address: S07 �!iC'Ef✓i� 'W•1')`'IC�LiLI`
Owner: "P('y Ara 1 L0
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS):_
(locate on site plan,if possible:excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
I
Type:
leaching pits, number:_
leaching chambers,number:_
leaching galleries,number:_
leaching trenches,number, length:
leaching fields, number, dimensions
i overflow cesspool,number:_
Alternative system:
j Name of Technology:
I
Comments:
j (note c ndition of soil, signs of hydraulic failure, level of po ding, damp soil, condition of vegetation, etc.)
Sbl t P (,*t( (v r•7 Si ' � 1 001' 4.141
C'
yd
CESSPOOLS:_
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensiods of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
0
Comments:
(note condition of soil, signs.of hydraulic failure, level of-ponding,condition of,vegetation, etc.)
PRIVY:_
(locate on site plan)
Materjals of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation;etc.)
revised 9/2/98 Page 9of11
I
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
+ r n SYSTEM INFORMATION(continued)
Property Address:rl�6�
Owner:
Y
Date of Inspection: i t�a(l
YI
C
............. te 1'u
Qc .
:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:55;7 SOJE'It Smec
Owner: �a;cy Arskvo
Date of Inspection:
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 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed.Site(Abutting property, observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators, installers
Used USGS Data .
Describe how you established the High Groundwater Elevation. (Must be completed)
II ��- S n� S��s;�-.�-� t s S�rr��c�� t� �l •�c•-�r cl Eu�:�zt��, c�•. Y :� ,�•r
QC).
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revised 9/2/98 page 11 of 11
i
i
Commonwealth of Massachusetts RECEIVED
City/Town of 2014
System Pumping Record JUL '
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use--by local Boards of Health. Other forms may be'used, but the
information must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. Information
1. System LocatioOing., Left
/Right ont of hous Left/Right rear of house, Left/right side of house, Left/
Right side of bu /Rig on o uilding, Left/Right rear of building, Under deck
Address /11% 7
city/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
Citylrown State Code
Telephone Number
_ t
B. Pumping Record
Lf
1.1. Date of Pumpinggate 2. Quantity Pumped:
Gallons i?
3. Type of system- ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yeas No If yes, was it cleaned? ❑ Yes ❑ No.
5. Condition of SystemV�
6. System Pumped By.-
Nell
y:Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Lowell Waste Water
Sig a 9t Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
RECEIVE®
Commonwealth of Massachusetts
u
City/Town of jil 29 ?013
System Pumping Record TOWN OF NORTH ANDOVER
� Form 4 IHEALTH DEPARTMENT
DEP has provided this form for use-by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house, Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town State u� Zip Code
2. System Owner.
Name
Address(if different from location)
Citylrown State � L Zip Code
4
Telephone Number
B. Pumping Record _
r7 -- -C3
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) ET Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes D-9-0 If yes, was it cleaned? ❑ Yes ❑ No
S. Condition of System:
i •
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locationere contents were disposed:
Lowell Waste Water
signAtufe I Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts RECERE�D
N W City/Town of North AndoverOCT 10 X011
} System Pumping Record
Form 4 TOWN NORTH ANpt�V(wR
�M
HEALTH DEPARTMENT
SV
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:
When filling out 1. System Location:forms on the
computer,use
only the tab key Address
to move your No.Andover ma 01845
cursor-do not
use the return City/Town State Zip Code
key. 2. System Owner:
: �
Name
" Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date ( 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) optic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
CDna/
6. stem Pumped-P
1e
Name Vehicle License Number
Stewart's Septic Service j
Company
7. Location where contents were disposed:
nTewart's
Pre-treatment ant, 20 So. Mill Bradford, Ma 01835
I
nature of Haul r Date
�j
Signature a eiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
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], {` th or other approving authority,
A Facility lnforl 'ation '
;"�tmjZortant::' i ;,':' .:;? ,`•`','.' ::., :`;;•'�;' ' '1 TOWN OF NORTH ANDOVER
J,;.Wherf(]tilr]Q out' System l.ocatlon;` ! HEALTH DEPARTMENT
only the tab key Address
to move your
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p� �r I� p Coda.
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'' ' " • ' Gallons
�+ TYp,e P(system;; Q. Cesspool(s) Septic Tank
C3 Tight Tank
•, __ _ __r r�%Other(descrlbej;�� .
4;;: Effluent Tee FlIta�pr$sent?.❑ Yes o. If
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System Pnpin9 Record Pale 1
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" monwealth of ass.'c usetts � _ °
Com .
it °/Town';off•NORTH ANDOVER MAS AC T
v
System Pumping Record
TOWN CJr NORTH ANDOVER
. Form 4 HEALTH DEPARTMENT
DEP,has provided this form for use by local Boards of Health. The System Pumping Record must
local Board of Health or other approving be submitted to the pp 9 authority.
A. Facility Information
Important:
when fining out .1 System Location:
forms on the
computer,use
only the tab key Address
to move your
cursor-do not City/Town State Zip Code
Use the return
key..
2. . System Owner:
MC 1)4n
Name 5�.
5"a.? leen
AOJD Address(if different from to tion)
CitylTown State Zip Code
Telephone Number
B. Pumping Record -
i z o64SJ
;,,, • 1. Date of Pumping 2. Quantity Pumped: eons
Date
3. Type of system: ElCesspool(s) Septic Tank ❑ Tight Tank
❑'Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:`
6. Sy em Pumped By: - - - -
Name ,VehicleOrd License Number
. • 5�. �;. i�ccc:Q, ��-. ac� J Ana
Company
7. . Location where contents were disposed:
X4Cccnc� , �
Signature of Hauler . Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5forrn4.doc•06/03 System Pumping Record•Page 1 of 1
TO OF NORTH ANDOVISP, JAN 0 6 2005
U^I I SY M PUMPINQ UCOftL
SYSTEM OWNER dt ADDRE S SYSTEM LOGATIQN
-7
DATE OF PUMPINQ,_,. �- l _QUANTITY PUMPED;
Sa c Tank: NO YES
P� ,
NA rVRE ON SERVICE: ROUTINE„ �M RUIrNC'1'
ObSBRVA't'IUNS:
GOOD CONDITIUN�PULL'f'U WVER �y
AV ORWE BAFFLES 1N PLACE.
ROOTMUMS SOLIDS ..._.. FLOODED LWH]qD RUNBACK
SOLID CARRYOYER_.,__OnfER EXPLAIN
System Pumpod by _ ... ...... (./.G... '
rvice-)
. .. . �`. . ,Qraa�r� rrra.
VUMMENTS.
�:VN PEN'I'S fKANSt'EKRBp I't� ,,..�
I
cj�
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.g 1jr 12
Bo ' s
TOWN OF`NO$TH ANDOVER w
'`SYSTEM PUMPING RECORD
DATE C• IDD 3 " - ...�— �.
SYSTEM OWNER&ADDRESS SYSTEM LOCATION
MC DON.a)61
DATE OF PUMPING QUANTITY PUMPED
CESSPOOL NO�_YES 77777 SEPTIC TANK NO YES
NATURE OF SERVICE;:,RO[JTINE EMERGENCY
OBSERVATIONS: / e
GOOD CONDITION FULL TO COVER
HEAVY GREASE ,T BAFFLES IN LACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLID CARRYOVERT
0 HER EXPLAIN ,
SYSTEM PUMPED BY �I
COMMENTS:
CONTENTS TRANSFERRED TO )e U v/x
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: I LO
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
Lo
DATE OF PUMPING: / - U I QUANTITY PUMPED aoo GALLONS
CESSPOOL: NO . YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN) i
II' SYSTEM PUMPED BY:
i
COMMENTS:
CONTENTS TRANSFERRED TO:
JUbr6 Alvwver 12.4 I- •, STIIMT's SEPTIC TANK SERVICE
��G Nlo,n Sf 47 RAILROAD STREET
Na f4h A BRADFORD, Ih 01835
Won v I L,f- )G1-0614 978-372-7471
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MONTH
OF ®c(a ber �96co
M0NTHLY REPORT FOR TOWN OF
DATE ADDRESS
ADDRESS GALLONS 00 '3
ern
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U JWN OF NORTH ANDOVER
TOWN OF/jANDOVER BOARD OF HFALTH
SEPTIC SYSTEM SERVICING DEC 9199s
REPORT {
Date:_ 3L-�9-�= -
Homeowner:_ (.IJwJ�C� Pumper
Street :_ -7s�a-� -, Address:—/14,6
Phone �}, _ Phone
Nature of S-arvice: Routine
Emergency
Observations: Good Condition
Full to Cover
Baffles in Place
Leachfield Runback
Excessive Solids
Heavy Grease
Roots
Other (Explain)
Description of Work:
Comments ::
Town of North Andover, MA TOWN OF NORTH ANDOVER/
Wate:rshed Septic System BOARD OF HEALTH
servicing Report
Date:. Mr, I lQ--(q,/,g
Homeowner: Re;c,�, (.0 Pumper
Street S(N-1 I �. , Address:
Phone Phone
Nature of Service: Routine
Emergency
Observations: Good Condition
Full to Cover _
Baffles in Place
Leachfield Runback ]
Excessive Solids
Heavy .Grease
Roots
Other (Explain)
Descr:_pt.ion of Work :
Comments:
s
Town of North Andover, MA
Watershed SeRtic Sys tc-m NORTH EP�
F H
Servicing I:eport IOW gpPR00F
Date. ` N
Homeowner:_ � � Pt roper :_I -4 Lpol—I AIV
Street _ Ac dress:
Phone _ �Q��- p`� (� PI one
Nature of Service: Routine
Emergency _
Observations: Good Condition
Full to Cover
Baffles in Place
Leachfield RunbEck
Excessive SolidE 1�U0
Heavy Grease Nd
Roots
Ka
Other (Explain)
Description of Work:
Comments :
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INTER AGENCY REFERRAL Q
Report from Date: _
Community Agency
From: To:
Tel. No. : Tel, No. :
Attention
Patient Age
Address Date of next clinic; app't.
Ho sp. BID„
Content of Report to Hospital:
Division of Tuberculosis, MDPH
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In Mar - vi I V�j LJ -,P-LIS
Page 2 :
Tom Neve stated that in a R-3 Zoning District a cluster
development was not allowed. Changes in the Bylaw since 1985 regarding
contiguous building area, upland and a zoning freeze on property' as to
use . The common driveways will be 15 feet wide with a 6 . foot wide.
island with post and rail fence between. Four common driveways
accessing 11 dwellings. Paul Hedstrom stated that the standards of the
Special Permit have to be met as well as the safety issues being
addressed. Tom Neve stated that the driveways have been placed 125 feet
to 200 feet apart, all are straight and with grades of 5% normal
curvature . A water looped system around the property, hydrants,
sprinklers in each home, a sewer system from Route 114 . Paul Hedstrom
stated that due to the freeze on the property that the Board has to live
up to the Bylaw obligation but factorally the Board can control,
minimize and reduce the number of dwelling units accessed of common`.
driveways . George Perna asked why the applicant has not submitted a
subdivision plan originally. Tom Neve stated that he had a choice. Tom .
stated that he would like to set up a workshop to make modifications.
A motion was made by John Burke to take the matter under
advisement and continue the public hearing. The motion was seconded by
George Perna and voted unanimous by those present.
On January 7 , 1988 the Planning Board held a meeting in the Town
Hall Selectmen' s Meeting Room. The meeting was called to order at 7 : 40
p. m. by Vice-Chairman, George Perna. Also present and voting were John
Simons, Clerk and Erich Nitzsche . John Burke arrived at 7 : 45 p. m. Paul
Hedstrom was absent.
Ben Osgood presented the Board with the proposed driveways .
George Perna questioned the applicant about a possible cluster as an
alternative and/or subdivision. Ben Osgood stated that due to limited
land area and the Towns new CBA Requirements , he could not subdivide the
property and obtain 11 lots . Cluster is not currently allowed in R-3
Zoning District. Erich Nitzsche questioned the design of 11 lots on 1
driveway. The Board asked for a cluster development plan, a scale
drawing of the 1 driveway proposal, asked for the easement documents,
and water and sewer design.
A motion was made by Erich Nitzsche to continue the public
hearing to February 4 , 1988. There was no second. John Simons made a
motion to continue the public hearing until January 21-, 1988. The
motion was seconded by Erich Nitzsche and voted unanimous by those
present.
The Planning Board held a regular meeting on Thursday evening,
January 21,1988 in the Town Hall , Selectmen ' s Meeting Room. The
meeting was called to order at 8 : 25 p. m. by the Chairman, Paul
Hedstrom. Also present were John Simons, Clerk and John Burke . George
Perna and Erich Nitzsche were absent. Because there was not quorum, the
Planning Board could not hear the application on the Chestnut Street,
Common Driveways.
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Page -4-
Order of Conditions Lots 7 and 11 Chestnut Street & Turnpike DEQE X1242-447
14. The NACC does not agree with the applicant's delineation of the wetland
resource areas at the site, particularly at the area of the crossing.
Accordingly the wetlands shall be redelineated and revised plans sub-
mitted to NACC for review under Condition 1119, prior to the start of
construction. Since a breakdown by type of the resource areas affected
by the proposed crossing has not been provided, the NACC has assumed
that all of the resource areas affected are bordering vegetated wetland
areas and has evaluated this project accordingly.
PERFORMANCE/DESIGN STANDARDS/CIIANGES:
15. The NACC finds that intensive use of the upland areas and buffer zone
proposed on this site may cause alteration of the wetland resource areas
during the construction activities, particularly the housing unit construc-
tion. In order to prevent any alteration of wetland resource areas beyond
those proposed in the Notice of Intent and approved herein, a ten (10)
foot no-cut zone and a twenty-five (25) foot no-construction zone shall
be established from the edge of the bordering wetland resource areas.
These zones shall be shown on the plans discussed in Condition 1121 below.
16. No earthen embankment in the buffer zone shall have a slope steeper than
2: 1. Any slopes of steeper grade shall be rip-rapped to provide permanent
stabilization.
17 . Prior to the start of construction, a detailed Construction Sequence
Schedule and Erosion Control Plan shall be submitted to .the NACC fc.ir
review and approval. Said sequence or schedule shall integrate the
erosion control measures in the construction program.
18. No further Notices of Intent or Requests for Determination shall be
required of this project if it conforms to the requirements of this
Order of Conditions. Any changes shall be handled as specified in
Condition 1119 below.
19• Any changes in the submitted plans, Notice of Intent, or resulting from
the aforementioned Conditions must be submitted to the NACC for approval
prior to implementation. if the NACC finds, by majority vote, said
changes to be significant and/or to deviate from the original plans,
Notice of Intent, or this Order of Condition , to such an extent that the
interests of the Act and Bylaw cannot be protected by this Order of
Conditions and would best be served by the issuance of additional Conditions,
then the NACC will call for another public hearing within 21 days, at the
expense of the applicant, in order to take testimony from all interested
parties. Within 21 days of the close of said public hearing, the NACC
will issue an amended or new Order of Conditions.
GILBERT REA JOB
44 Rea St. SHEET NO. • OF
NO. ANDOVER, MA 01845
Phone 682-9864 CALCULATED BY DATE
CHECKED BY DATE
SCALE
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PRODUCT 204-1Ees Inc..Groton,Mass.01471.