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HomeMy WebLinkAboutMiscellaneous - 51 BANNAN DRIVE 4/30/2018 (2) 51 8DRIVE i 210/038.D-0110-011 4D000.0 ! =I I I I A r Of NOR7:,� 6564 Town of North Andover 5 HEALTH DEPARTMENT $,q USt CHECK#: DATE: LOCATION: H/O NAME: CONTRACTOR NAME: c- Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DW0 $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ )� Title 5 Report $ Sj j"�V ❑ Other. (Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer 6564 of �� • Town of North Andover �ti'•�,;;o:: � HEALTH DEPARTMENT 1SSgCHUS�� CHECK#:'�) DATE: 211 10 k LOCATION: I POO nown I r- H/O NAME: 6 1) - CONTRACTOR NAME: hp . 6 11�hyyb Type of Permit or License:(Check box) 0 Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DW() $ ❑ Title 5 Inspector i$ )� Title 5 Report $ ❑ Other. (Indicate) $ Health Agent Initials White-Applicant , Yellow-Health Pink-Treasurer r IZ RECEIVED 14 ,013 SLE# �1ndRCoI3 TOWN 0�NORTi!ANDOVER HEALTH DEPARTMENT f `\ Dean G.Luscomb II&Sons / i• P.O.Box 135 Middleton,MA 01949 078-774-4065 Licensed Plumber#20285 " SUBSURFACE SEWAGE DISPOSAL SYSTEM INPSECTION FORM a PROPERTY OWNERS NAME L e D u C PROPERTYADDRESS Q Y) bc)1� 1r. N . Andover MA ADDRESS OF OWNER(if differew) - DATE OF INSPECTION - A ii-a ar NAME OF INSPECTOR G�11 l ) L ©I'� QUALITY IS NUMBER ONE TO US_ Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form Not for Voluntary Assessments `a wM 51 Bannon Dr. Property Address Leduc Owner Owner's Name information is required for Northover g AndMA 01845 August 6, 2013 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer, use 1. Inspector: only the tab key to move your Dean G. Luscomb II cursor-do not Name of Inspector use the return key. Dean G. Luscomb If &Sons Company Name P.O. Box 135 Company Address Middleton MA 01949 renin Cityrrown State Zip Code 978-774-4065 S1848 Telephone Number License Number B. Certification I certify that 1 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 z /9 AJ . August 6, 2013 Inspe or's signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 51 Bannon Dr. Property Address Leduc Owner Owner's Name information is required for North Andover MA 01845 August 6, 2013 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Checl 131C,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 `0 determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts N . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM a''V 51 Bannon Dr. Property Address Leduc Owner Owner's Name information is required for North Andover MA 01845 August 6, 2013 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): O ❑ 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 51 Bannon Dr. Property Address Leduc Owner Owner's Name information is required for North Andover MA 01845 August 6, 2013 — every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, Dsafety 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 El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 51 Bannon Dr. Property Address Leduc Owner Owner's Name information is North Andover MA 01845 August 6, 2013 required for every page. Cityfrown 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, yoLriTwst indicate either"yes"or"no"to each of the followi , in addition to the questions in Section D. Yes No , ❑ ❑ the system is within 400 e f urface drinking water supply ❑ ❑ the system is within feet of a trib to a surface drinking water supply ❑ ❑ the system ' cated in a nitrogen sensitive ar Interim Wellhead Protection Area— A) or a mapped Zone II of a public wate upply well If you have answere ` es"to any question in Section E the system is considered a significant threat, or answered "yes in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 ' t N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 51 Bannon Dr. Property Address Leduc Owner Owner's Name information is required for North Andover MA 01845 August 6, 2013 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 ® 1:1 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): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t5ins•3113 Title 5 Official Inspection Forth: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 wM 51 Bannon Dr. Property Address Leduc Owner Owner's Name information is required for Northg Andover MA 01845 August 6, 2013 every page. City/Town State Zip Code Date of Inspection D. System Information Description: owner and town Number of current residents: 4 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ®1No� Water meter readings, if available(last 2 years usage (gpd)): Detail: / J � G"F, ar / Z► S(� 1. s R� 40,n40,n� Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Com— cial/Industrial Flow Conditions: Type of Establishm Design flow(based on 310 CMR 03): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., et . Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste disch to the Title 5 system? Yes ❑ No Water meter ings, if available: _ t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 51 Bannon Dr. Property Address Leduc Owner Owner's Name information is required for ort g h Andover MA 01845 August 6, 2013 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date upancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pumped on average every yr-owner and town. Last pumped 6-10-13 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: 0 gallons How was quantity pumped determined? Reason for pumping: No need at this time Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 51 Bannon Dr. Property Address Leduc Owner Owner's Name information is g required for North Andover MA 01845 August 6, 2013 every 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: System was installed in 1981 -32 years old-town records Were sewage odors detected when arriving at the site? ❑ Yes ® No C� Building Sewer(locate on site plan): 13tDepth below grade: feet Material of construction: ®cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Main line and joints appear to be in good condition, as they are in the slab of the floor. Septic Tank(locate on site plan): 3.. Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) Precast rectangular- 1000 gallons If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 5'x 5'x 8'- 1000 gallons Sludge depth: 1" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 . Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 51 Bannon Dr. Property Address Leduc Owner Owner's Name information is North Andover MA 01845 August 6, 2013 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) 5 Distance from top of sludge to bottom of outlet tee or baffle 34 1" Scum thickness Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? sticks and 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.): The septic tank and baffles are in very good condition. The liquid in the tank is running at it's correct working heigth. The solids in the tank are very light and do not require pumping at this time. Grease Trap(locate on site plan): Deptl 'beow grade: feet Material of constr n: ❑ concrete ❑ meta ❑ fiberglass ❑ p hylene ❑ other(explain): Dimensions: Scum thickness. - Distance from top of scu o top of outlet tee or baffle Distance from om of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 ?iUe 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 51 Bannon Dr. _ Property Address Leduc Owner Owners Name information is North Andover MA 01845 August 6, 2013 required for 9 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): 0Depth below grade: — Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: awe Capacity: ° gallons rr., Design Flow: gallons per day Alarm present: ❑ Yes E. No Alarm level: Alar' "In working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and floatswifches, etc.): lee •,' ` .r *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 A Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 51 Bannon Dr. Property Address Leduc Owner Owner's Name information is required for Northover g AndMA 01845 August 6 2013 every page. City1rown State Zip Code Date of Inspection D. System Information (cont.) SDistribution Box(if present must be opened) (locate on site plan): / Depth of liquid level above outlet invert Zero Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The d-box is 11" below grade and is 20"x 20"square. The d-box is level and in good general condition. The liquid in the d-box is running at it's correct working heigth. The soil in this area is clean and dry with no signs of any problems. The d-box has had repairs done to it, but it looks solid and shows no signs of any problems. Pump Chamber(locate on site plan): t� Pumps in work) der: Yes ❑ No ,V Alarms in working order: ❑ Y ❑ No" Comments(note condition of pump chamber, c ion of pum appurtenances, etc.): * If pumps or alarms are not in working orders stem is a conditional ass. P P 9 Y P Soil Absorption System (SAS) (locate on site plan, excavation not required): 7 If SAS not located, explain why: The SAS was located by asbuilt drawings. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Bannon Dr. Property Address Leduc _ Owner Owner's Name information is North Andover MA 01845 . August 6 2013 required for 9 , every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: 1 -20'x45'- ® leaching fields number, dimensions: 900sf total ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The SAS is in good general condition with no signs of any problems. The soil in this area is clean and dry with no signs of ponding or breakout. This area is covered with well maintained green grass. i Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Numb e d configuration Depth—top of liqui let invert Depth of solids layer Depth of scum layer j Dimensions of cesspool / Materials of construoti'on Indication-o1'groundwater inflow ❑ Yes No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Bannon Dr. Property Address Leduc Owner Owner's Name information is North Andover MA 01845 August 6, 2013 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont:) ents (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 'vy(locate on site plan): U Materials of onstruction: Dimensions �-J Depth of solids Comments(note condition of soil, signs of by c failure, level of ponding, condition of vegetation, etc:): I t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 . res L Conmnaawealth of Massachusetts Title 5 O ial Inspection Form Subsurface Sewage Dispo I System Form -Not for Voluntary Assessments 51 Bannon Dr. Property Address Leduc Owner Owner's Name information is North Andover MA 01845 August 6, 2013 required for every page. City/Town State Zip Code Date of Inspection D. System Information (coni.) Sketch Of Sewage Disposal Syste : Provide a view of the sewage disposal system, including ties to at least two permanent reference I ndmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters he building. Check one of the boxes below: ® hand-sketch in the area b ow ❑ drawing attached sepa tely F,-c-4 o f 1644 Oav� ikry 57 BG^116h DC_; A��a3S� rg 40-T z 9`` A pt, 7-�36"1 a a Pjvko3?'3," 0 stag m X APO D Irk,9,� DD ��! t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 51 Bannon Dr. Property Address Leduc Owner Owner's Name information is North Andover MA 01845 August 6, 2013 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water NDS ® Check cellar ® Shallow wells 5' Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 4-25-81Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: Proposed previous Title V and pumping records on file. ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: Deep hole test done 4-25-81 by Merrimack Eng. Services showed ground water at 5' below grade. The basement is dry with no sump pump. Bannon Drive sits 5' plus below the grade of the yard where the system is located 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Bannon Dr. Property Address Leduc Owner Owner's Name information is required for North9 Andover MA 01845 August 6, 2013 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 16 h to s E SACHUS PUBLIC HEALTH DEPARTMENT 21 1. `� I Community Development Division To: All North Andover Residents with Septic Systems and Garba a Grinders a v � Please note that due to recent reviews of Title 5 Reports, your property has been identified as maintaining a working garbage grinder that is being used in conjunction with a septic system. The Health Department is concerned for the longevity of your septic system. Garbage grinders are never recommended where septic systems are used, but if they are installed, the system must be specifically designed to handle the waste from them; your system can not handle the waste as designed. Please note that continued use of this grinder could quickly cause a pre-mature failure of your septic system, resulting in a large expenditure to replace it. The North Andover Health Department recommends that you remove it from your home as soon as possible. Some information regarding regular maintenance of your septic system is attached. Please call the Health Department-at 978.688.9540 if you have any questions, or e-mail your questions to: healthdept(2townofnorthandover.com. Thank you for taking the time to consider the impact that your current setup has on your septic system and'the environment. Sincerely, Susan Y. Sawyer, RENS/ Public Health Director /pfd Enc: Septic System Information: http://www.mass.gov/deD/water/wastewater/dodont.htm 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web http://www.townofnorthohdover.com d Commonwealth of Massachusetts _ W City/Town of North Andover System Pumping Record c, Form 4 GSM 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 -mom RECEIVEImportant: When filling out 1. System Locatio r�nn forms on the nn pp��,/� �1�� 18 G U computer,use l J ! �c only the tab key Address TOWN OF NORTH ANDOVER - to move your No.Andover Ma HEAtO?h305PARTMENT cursor-do not City/Town State Zip Code use the return key. 2. System Owner: Ifd Uc Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date Gallons 2. Quantity Pumped: f 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. tem Pumped BNA i 1 Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: . Ste rt's Pre-treat e t Plant, 20 So. Mill Bradford, Ma 01835 Signature of Ha ler Date �j 3 0 ► Signature of ceiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 rO 4CC,0A,?RANK?4M H SvBSv�e�"�rCL_ j �j 21"m At a� 24 MH ' ,aE. SCgGE 2/ M,-C—R e/MAC/ ENI, IW ?IM SeRVI C£S I 1 �+roovER,1-0AsS,461.Yvs&-rrS, Oielo �9tiG I (LING RNA Goat. T � - ,� a. '�• ` ' 4 o-'• b•' p' ' +' O i 'Q ' + � 6p' 4.4: ?d a. - .1 � 6p4. . Op` v 0• -�� ..�0, 4 4 . e, da � d C� � C� ° 'QQ. '6 r d Q o 0 CUntrete — Icu e o a� •Q S T d /3 `v . o yao" G1 /000 (,ct#O,u rn 61 a ' Q cj. d0 a a 6'• ' ao c �• O a -o` ca � ' - - -COQ o a SE's r1OA1 A -A b e r it ., '� *•tet ' ' 44 r rMY� •�'�`�� etm7'� .. t ✓.^ � ! ', r e TO: NORTH ANDOVER, MASS ^- ! 19 BOARD OF HEALTH FROM: DESIGN ENGINEER Re: Soil Absorption Sewage System Inspection This is to certify that I have inspectedthethe construction of the said disposal system at �a-� 3 ��vii -yc. o `.�i�L-�-t North Andover, Mass. SITE LOCATION The grades and construction are as specified in my plans and specifications dated i 19 . eg. Pr f. E Ineer/Reg. S,a,6itarian Ov } ,. �.�d !s_1. 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Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM � PART A• CERTIFICATION ! fYy1i� ( G .. !'+• ,Al 40 0 V- '1. e .- Property Address: c� ;, Address of Owner: Date of Inspection: 1�7(' ''�'`� (If different) Name of Inspector: 5 ,j/A 190s4 Company Name, Address and Telephone Number: J4 N00-0 Pv ��" o f c.. t f 12-o !G (�4 1 a� r C ��'! !� r►eY7r X4 fit— +/._- 71 t CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage-disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails r Inspector's Signature: Dater.s ¢ The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this. inspection. If the system i� a shared system or has a design flo" of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent !c ihr, system owner and copies sent to the buyer, if applicable and the approving duthotit�. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: l f e� I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR F5.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: /\_/4 One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 a Telephone(617)292-5500 0 Printed on Recycled Paper �r r Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: J Owner: 0 J .t./'.t- Date of Inspection: B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced sThe system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ the system nay a septic tank and soil absorption system and is witiiiU '100 feei 'LU a SUriaLe water supp!'y or tributary to a surface water supply. _ The system.has a septic,tank andsoil absorption system and is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and is within 50"feet of a private water supply well.. _ The systen, hay a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm• D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. (revised 8/15/95) 2 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued)t Property Address: Owner: Date of Inspection: Y - D) SYSTEM FAILS (continued): Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times.pumped 4 e Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: 1y'A The following criteria apply to large systems in addition to the criteria above: The design floe of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet,of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply _the system is located'm a nitrogen''sensitive area (I'nterim Wellhead.Protection Area(IWPA) or a'mapped Zone II of a public water supply well' 4, The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 .m SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 13 Owner: Date of Inspection: ! dzz� Check if the following have been done: `"Pumping information was, req nested gf,the owner, occupant Viand Bpardr.of.Health: i , , _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates ,,, ing that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _, As built plans have been obtained and examined. Note if they are not available with N/A. ""AsThe 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. "fAll'system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or ,t�e'es, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. +rThe size and location of the Soil Absorption System on the site has been determined based on existing information or roximated by non-intrusive methods. _The facility o,,;cr (and occupants, if diffcrent from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. tF 7 (revised 8/15/95) 4 r x SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART C SYSTEM INFORMATION �yy� ,R Property Address: Owner: ( o p (Z- Date of Inspection: it: l FLOW CONDITIONS RESIDENTIAL: Design flow: gallon Number of bedrooms: Number of current residents: Garbage grinder(yes or no)::---/-/ Laundry connected to system (yes or no); Seasonal use (yes or no):_ A-/' - S ;, Water meter readingst if available: Last date of occupancy: V C V COMMERCIAUINDUSTRIAL• } Type of establishment: Design flow: rtallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no) Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: l7 System pumped as part of inspection: (yes or no) /P S If.yes,volume,pLimpe',. + / gal o.n<., . . '. .. i Reason for-pumping. n(ti a c�.rL $ R r-r Lcs <# l�C�K S TYPE OF JYSfE—M Septic tank/distribution box/soil.absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: tl P?v 3 � F 9 Sewage odors detected when arriving at the site: (yes or no) f,' (revised 8/15/95) $ i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION (continued) Property Address: Owner.: d-O Date of Inspection: SEPTIC TANK:VPS (locate on site plan) lr Depth below grade: Material of construction: concrete _metal FRP—other(explain) i a Dimensions: .t .C_ ,:3 x ff r, t. Sludge depth: rl! Distance from top ofs tidgeto bottom of outlet tee or baffle: 3 Scum thickness: I �` Distance from top of scum to top of outlet tee or baffle: v•/ Distance from bottom of scum to bottom of outlet tee or baffle: 1 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.) 5 r ,C"a o .0 *Ie p Tip ,�/u .S'f 5,�- a� G e ��c�.r z O ✓ S T 2-�� Ty�• f u�� �tr,� GREASE TRAP: . (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Scum thickness. Distance from top of scum to top of outlet tee or baffle: Distance from hottom n, shim t- ho"om of outlet tee or battle Comments ... , i .+ (recommendation for pumping;'conditi - of'inlet'arid outlet tees or baffles,`depth of ligi)id level in±relation to outlei invert, structural integrity, evidence of leakage, etc.i a~ (revised 8/15/95) 6 V SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: �f � rd!//� �-✓ ��'' M �.R-JQ t� d c°,r/ Owner: 0 a_ Date of Inspection: F . f/ TIGHT OR HOLDING TANK:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP—other(explain) 1 Dimensions: r Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: PS (locate on site plan) Depth of liquid level above outlet invert: U� Comments: (note if le.cl and.dstrib;a: c:,,;;', e•.idence of sc!id ca n-r rPr evidence of leakage into or out of box, etc.) 96 )E– .T'2uc ru.1 /4 �tde e 11 u a 1 , PUMP CHAMBER:_ t (locate on site plan) Pumps in working order.(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 i. i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):_ La,� (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type I6aching pits(;number. leaching chambers, number: 4 leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: !90a overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) -a H/? /Jy 4 0 C. CESSPOOLS: { (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs`of hydraulic failure, level'of ponding, condition"of vegetation etc.) s a PRIVY:_ � ) (locate on site plan) Materials of construction: Dimensions: Depth-of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) (revised 8/15/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM { PART C SYSTEM INFORMATION (continued) a.'-/ Property Address: ` Owner. Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' i3 a �C , 0— 6 co t t d' DEPTH TO GROUNDWATER Depth to groundwater: 4 feet .� method of determination or approximation: 4,T "0 /a/ 4'.e/1, U S +4 b G � U A/C+Y A64 a! (revised 8/15/95) 9 Board of Health j North AncpverjK.ass. BE,MC SYSTEM INSTALLATICK CHWK LIST Lar IONNID_ PEY DI FtiOVED AQATICN OK FAIL FAM € 1. Distance Tos a. Wetlands ,j b. Drains • 77. c. Well y 2. Water Line Location - 0 PVC Pipe t { 7Septic Tank' ' a. --Tees --Length & To Clean Oat Covers - b. Cement Pipe to Tank On Both Sides of Tank 5. Distribution Boa a. Covers & Box - No Cracks b. All Lines Flowing Rima Amounts c. No Back Flow 6. ' Leach Field or Trench ; a. Dimeasions b. Stone Dearth c. Capped 'Ends'- d: nds d. Clem Double-Washed Stone'" - 7. Leach Pitsy - a. Dimensions b. Stone Depth c. Splash Pads d. Tees e. Cement Pipe to Pit - Both Sides. f. Clean Double Washed Stone 8. No Garbage Disposal 9. Final Grading Inspection _ 10. Barricading Covered System - As Built Submitted a. Lot Location b. Dimensions of System -- --- , c. Location -4th Regard_to Pere Test d. Elevations e: Water Table r Merrimack Engineering Services Inc. [LIEUTEIM OF URROOM UZU Engineers - Surveyors - Planners 66 Maim t Stre Suite 13 ANDOVER, MSSACHUSETTS 01810 DATE, JOB NO. (617) 175-3555 ATTEN ION 11 RE: iJJo Irl P - . TO �O/�3 �/�a 2Ai!Y TeP� e r 7 Y AOT-11'all It QE OUR NEW ADDRESS Effective March 15. 1981 66 Park Street GENTLEMEN: ANDOVER, MASSACHH'5ETTS WE ARE SENDING YOU ❑ Attached ❑ Under separate cover via the following items: ❑ Shop drawings ❑ Prints ❑ Plans ❑ Samples ❑ Specifications ❑ Copy of letter ❑ Change order ❑ COPIES DATE NO. yy DESCRIPTION ^ t THESE ARE TRANSMITTED as checked below: ❑ For approval ❑ Approved as submitted ❑ Resubmit copies for approval ❑ For your use ❑ Approved as noted ❑ Submit copies for distribution ❑ As requested ❑ Returned for corrections ❑ Return corrected prints ❑ For review and comment ❑ ❑ FOR BIDS DUE 19 ❑ PRINTS RETURNED AFTER LOAN TO US REMARKS A Q19� EltARlcs -T-)I .E Lc /�(r F:I.)ntj COPY TO SIGNED: FORM 240-2-Available from Groton,Mass.01450 If enclosures are not as noted, kindly notify us at once. t 2 Tri:..;(7, s ;;;',1 :;1" it) 4139 flvst ac-? -.04 Town of North Andover, Massachusetts Form No. 1 NORTH A BOARD OF HEALTH Q��1.ED Ib�,YO 0� 19 0 p 7 APPLICATION FOR SITE TESTING/INSPECTION ��SSACHU5���h Applicant NAME� ADDRESS TELEPHONE Site Location Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time CHAIRMAN,BOARD OF HEALTH Fee r Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts Form No. 1 BOARD OF HEALTH tY ORT' / � Y19 s t 1— APRILM :z kA��ssa'ciiuS��KA APPLICATION FOR SITE TESTING/INSPECTION jos /� �� fP►TV q, U 1 Applicant . ✓_ecC .^ OJ �v NAME ADDRESS TELEPHONE Site Location 3 /1,4- Engineer NAME ADDRESS TELEPHONE Test/I nspection Date and Time /' 7 CHAIRMAN,BOARD OF HEALTH Fee �� O Test No. 72- S.S. S.S. PermitNo. D.W.C. No. C.C. D e Plbg. Permit No.