HomeMy WebLinkAboutMiscellaneous - 520 SHARPNERS POND ROAD 4/30/2018 (2) i 520 SHARPNERS POND ROAD
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Town of North Andover
HEALTH DEPARTMENT
,SSACNUSt�
CHECK#: DATE:
LOCATION.
H/0 NAME:
CONTRACTOR NA
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 $
❑ TrashlSolid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
Title 5 Report $i�, A.Z
❑ Other. (Indicate) $
Health Agent Initials
White-Applicant Yellow-Health Pink-Treasurer
Commonwealth of Massachusetts FOFNORTH
l -
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessment94
520 Shar Hers and road DOV R
Property Address ART N
Barry & Karen Fitzgerald
Owner Owner's Name
information is North Andover Ma Aril 3,2014
required for every �
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When
A. General Information
fillip f
g out forms
s
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not John DiVincenzo
use the return Name of Inspector
key.
Stewarts Septic Serive
r� Company Name
58 South Kimball street
Company Address
R Bradford MA 01835
State Zip p Code
978-372-7471 S113386
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
eed FuVEvalun by the Local Approving Authority
r I l I L1
I ector's Signature Date
The system inspector shall su mit 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 Oficial 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
,M 520 Sharpners pond road
Property Address
Barry & Karen Fitzgerald
Owner Owner's Name
information is
required for every North Andover Ma April 3,2014
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Check A B C D or E/always complete Inspection Summa C all of Section D y
P Summary:
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
I
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.
I
Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
520 Sharpners pond road
Property Address
Barry & Karen Fitzgerald
Owner Owner's Name
information is North Andover Ma April 3,2014
required for every
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
Pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
❑ Y q p p 9 Y
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 520 Sharpners pond road
Property Address
Barry & Karen Fitzgerald
Owner Owner's Name
information is
required for every North Andover Ma April 3,2014
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
i
i
I
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 Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
_ W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
520 Sharpners pond road
Property Address
Barry & Karen Fitzgerald
Owner Owner's Name
information is
required for every North Andover Ma April 3,2014
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
520 Sharpners pond road
Property Address
Barry & Karen Fitzgerald
Owner Owner's Name
information is North Andover Ma April 3,2014
required for every
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
i
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 GPD
t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
a
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 520 Sharpners pond road
Property Address
Barry & Karen Fitzgerald
Owner Owner's Name
information is
required for every North Andover Ma April 3,2014
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2 people
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage (gpd)): N/A
Detail:
Well
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 trapresent? Yes No
P ❑ ❑
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
520 Sharpners pond road
Property Address
Barry & Karen Fitzgerald
Owner Owner's Name
information is North Andover Ma April 3,2014
required for 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: Andover Septic
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1500
gallons
How was quantity pumped determined? Site guage on truck
Reason for pumping: inspect tank
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 520 Sharpners pond road
Property Address
Barry & Karen Fitzgerald
Owner Owner's Name
information is
required for every North Andover Ma April 3,2014
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
25 Years approx
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
24"
Depth below grade: feet
Material of construction:
® cast iron ❑40 PVC ❑ other(explain):
Distance from private water supply well or suction line. 125'
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 12
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:
Sludge depth:
t5ins•3/13 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
°M 520 Sharpners pond road
Property Address
Barry & Karen Fitzgerald
Owner Owner's Name
information is
required for every North Andover Ma April 3,2014
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 27
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle
20"
How were dimensions determined? Tape measure&sludge judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Both baffles good, no leakage, liquid levels good.
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
;M 520 Sharpners pond road
Property Address
Barry & Karen Fitzgerald
Owner Owner's Name
information is North Andover Ma April 3,2014
required for 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):
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
�M 520 Sharpners pond road
Property Address
Barry & Karen Fitzgerald
Owner Owner's Name
information is North Andover Ma April 3,2014
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
liquid levels good no solids carryover. no leakage.
Pum
Chamber(locate on siteplan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ElYes E] No*
Comments (note condition of pump chamber, condition of pumps and 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):
If SAS not located, explain why:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
520 Sharpners pond road
Property Address
Barry & Karen Fitzgerald
Owner Owner's Name
information is
required for every North Andover Ma April 3,2014
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: 2-48
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
T e/name of technology:
'Y:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
no hydraulic failure no ponding. solids good
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 520 Sharpners pond road
Property Address
Barry & Karen Fitzgerald
Owner Owner's Name
information is
required for every North Andover Ma April 3,2014
page. City/Town 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
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 520 Sharpners pond road
Property Address
Bar & Karen Fitzgerald
Barry 9
Owner Owner's Name
information is North Andover Ma
required for every
page. City[Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
Xnd-sketch in the area below
drawing attached separately
�0
j,1
G
t5ins•3/13 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
520 Sharpners pond road
Property Address
Barry & Karen Fitzgerald
Owner Owner's Name
information is
required for every North Andover Ma April 3,2014
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
❑ Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: no plans#492 water @ 132"#542 water
@ 8'
Please indicate all methods used to determine the high groundwater elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: #492 date 1984
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
Pulled file
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Took water elevations from house beafore. After water @#542 96" Bottom of system raised above
original ground system Aprox T to 4' above water table.
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
°M 520 Sharpners pond road
Property Address
Barry & Karen Fitzgerald
Owner Owner's Name
information is North Andover Ma April 3,2014
required for 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
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Commonwealth of Massachusetts RECEIVED
City/Town ®f No Andover APR �U ?014
System Pumping Record TOWN OF NORTH ANDOVER
Form 4 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 you
local Board of Health to determine the form they use. The System Pumping Record must be submitted tc
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 Informati®n
Important:When
filling out forms 1. System Location-
on the computer,
j
c� ^C � �
use only the tab �j
key to move your Address ' �,(
Ponj.
cmor-do not No Andover
use the return Ma
key. Citylrown State Zip Code
2. System Owner:
1F 1i
Name
ieavn
Address(if different from location)
City/Town State
. Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ate 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. Stem Pumped By:
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Si Hauler Date
Signatur eceiving Fa I' Date
t5form4.doc-03/06
System Pumping Record•Page 1 of 1
�7 FORM U — LOT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
*****************************APPLICANT FILLS OUT THIS SECTION***********************
APPLICANTF)AIRPs,/A, �,/ ECJ L F(-f-7 c�i✓.�.d � PHONE `7 Ll`(c)4—
LOCATION: Assessors Map Number 0765 PARCEL
SUBDIVISION C AA RE�JLp` lbkl) RQAi? LOT (S)
STREET can 61V QRPAVC25 —264)Z> ED ST. NUMBER C�
* **** * * ***** ******OFFICIAL USE ONLY********************�* * *
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RECOMMENDATIONS OF TOWN AGENTS:
CONSERVATION ADMINISTRATOR DATE APPROVED
DATE REJECTED
COMMENTS
TOWN PLANNER DATE APPROVED
DATE REJECTED
COMMENTS
FOOD INSPECTOR-HEALTH DATE APPROVED
DATE REJECTED
SEPTIC INSPECTOR-HEALTH DATE APPROVED 9 �l
DATE REJECTED
COMMENTS 6K G/9 TED d 42
PUBLIC WORKS - SEWERIWATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR DATE
Revised 9197 jm
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-' TOWN OF NORTH ANDOVER t NOR*M
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT }
400 OSGOOD STREET ►
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NORTH ANDOVER, MASSACHUSETTS 01845 'Ss��o U
978.688.9540—Phone
Susan Y.Sawyer,REHS/RS 978.688.9542—FAX
Public Health Director E-MAIL: healthdept@townofnortliandover.com
WEBSITE:hqp://www.townofnorthandover.com
April 11, 2005
To all Sharpeners Pond Road Residents:
Please note that it has come to the attention of the Health Department that many residents are
leaving their trash barrels and trash bags out at the curbside for days, or weeks at a time.
Empty trash barrels blowing about in the road are a safety hazard, and trash and debris along the
roadway is a health hazard. Please be mindful of this, as the Health Department will conduct
periodic inspections of the area to determine who is in violation, and fines will be issued if
protocol is not followed.
The Board of Health follows the State Sanitary Code regarding Human Habitation,
j 105.CMR.410, Section 1:
410.600
(A): Garbage or mixed garbage and rubbish shall be stored in watertight receptacles with tight-
fitting covers. Said receptacles and covers shall be of metal or other durable, rodent-proof
material. Rubbish shall be stored in receptacles of metal or other durable,rodent-proof material.
Garbage and rubbish shall be put out for collection no earlier than the day of collection.
(B): Plastic bags shall be used to store garbage or mixed rubbish and garbage only if used as a
liner in watertight receptacles with tight-fitting covers as required in 105 CMR 410.600(A),
provided that the plastic bags may be put out for collection except in those places where such
practice is prohibited by local rule or ordinance or except in those cases where the Department of
Public Health determines that such practice constitutes a health problem. For purposes of the
preceding sentence in making its determination the Department shall consider, among other
things, evidence of strewn garbage, torn garbage bags, or evidence of rodents.
410.602
(A) Land. The owner of any parcel of land, vacant or otherwise, shall be responsible for
maintaining such parcel of land in a clean and sanitary condition and free from garbage, rubbish
or other refuse. The owner of such parcel of land shall correct any condition caused by or on
such parcel or its appurtenance which affects the health or safety, and well-being of the
occupants of any dwelling or of the general public.
(D) Common Areas. The owner of any dwelling abutting a private passageway or right-of-way
owned or used in common with other dwellings or which the owner or occupants under his
control have the right to use or are in fact using shall be responsible for maintaining in a clean
and sanitary condition free of garbage, rubbish, other filth or causes of sickness that part of the'
passageway or right-of-way which abuts his property and which he or the occupants under his
control have the right to use, or are in fact using, or which he owns.
.� Residents should know the following:
• The Town has a mandatory paper and cardboard recycling ordinance that requires
residents to separate these items from their household trash. Paper and cardboard are
collected every other week on the same day as the household's normal trash. Residents
can call the DPW at 978.685.0950 to get their recycling schedule.
4
• Residents are responsible for picking up loose trash left at the curb after collection.
Banned Items and Recycling Requirements:
Please refer to the DPW website for a complete list of all the recycling requirements:
http://www.northandoverrecycles.com.
Please contact the Health Department if you have any additional questions. Thank you.
Sincere
" an Y. Sawyer, REHS/RS
Public Health Director
File
PAW
ORTH�ANDOVER MASSACHUSETTS
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System Pumping Record
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DEP has provided this form for use by local Boards of Health. The System Pump1ng Record must
be submitted to the local Board of Health or other approving authority.
A: Facility Information
Important: `
When"i out 1. System Location: i`i +
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Name
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O/Town State Zip Code
Telephone Number
B. Pumping Record
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1. Date of Pumping p /S ~/ Quantity Pumped: Gallons
3. Type of system: [] Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe)
4. Effluent Tee Filter present? ❑ Yes nNo If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System
e. System Pumped By:
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4pany Vehicle Ucense NumberiL
er
7. Location wh re contents were disposed:
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