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Home My WebLink AboutMiscellaneous - 537 BOXFORD STREET 4/30/2018 / 537 BOXFORD STREET JJ 210/105.C-0025-0000.0 t t f NEW ENGLAND CLAIMS SERVICE, INC. Incorporated❑ P ❑ Reply To . Reply To Mansfield, MA 02048 `" 131 Dodge Street, Suite 6 P.O. Box 345 Beverly, MA 01915 SURA TEL. (5081337-8058 NSURA#Xt TEL. {978}927-3000 FAX{508)339-5835 snc m r FAX{978}927-3002 wrandall@newenlandclaims.com Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec 3B January 17, 2015. To: Building Commissioner or Inspector of Buildings i City Hall North Andover, MA 01845 - RE: Insured: Cramer,Lauren&Baptiste, James ` Property Address: 537 Boxford Street Cause of Loss/Date: Freeze 1/8/2015 F' o Claim o• B 0 201 File r C N OS 53 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER 143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Section 3B. No insurer shall pay any claims (1) covering the loss, damage, or destruction to a building or other structure, amounting to one thousand dollars or more, or(2) covering any loss, damage or destruction of any amount,which causes the condition of a building or other structure to render section six of chapter one hundred and forty-three applicable, without having at least ten days previously given written notice to the building commissioner or inspector of buildings appointed pursuant to the state building code, to the fire department or arson squad of the city or town and to the board of health or board of selectmen of the city or town in which the same is located. If at any time prior to payment the said city or town notifies the insurer by certified mail of its intent to initiate proceedings designed to perfect a lien pursuant to section three A, or to section nine of chapter one hundred and forty-three, or section one hundred and twenty-seven B of chapter one hundred and eleven, the said payment shall not be made while the said proceedings are pending; provided, however, that said proceedings are initiated within thirty days of receipt of such notification. Any lien perfected pursuant to section three A, or to section nine of chapter one hundred and forty-three or section one hundred and twenty-seven B of chapter one hundred and eleven, shall extend to and may be enforced by the city or town against any casualty insurance policy or policies covering any loss, damage, or destruction pursuant to which the proceedings to perfect the lien were initiated. No insurer shall be liable to any insured owner, mortgagee, assignee, city or town, or other interested party for amounts disbursed to a city or town under the provisions of this section, or for amounts not disbursed to a city or town under the provisions of this section. Paul A. Dionne General Adjuster On this date, I caused copies of this Notice to be sent to the persons named above at the addresses indicated above by First Class Mail. Signature Date Commonwealth of Massachusetts City/Town of North Andover SystemPumping Record Form 4 wy DEP has provided this form for use by local Boards of Health. Other forms may be used butthe t be substantially the same as that provided her :Before,using this fora t be submitted to kwithyour information mus Record local Board of Health to determine the form they use. The Syste: Pumping the local Board of Health or other approving authority within 14 flays from`the pumping date in accordance with 310 CMR 15.351. u A. Facility information -T Important:When filling out forms 1. System Loca�ion: on the computer, 3 use only the tab key to move your Address Ma 01886 cursor-do not North Andover State Zip Code use the return Cityf-own key. 2. System Owner: a Name rmcm Address(if different from location) State Zip Code City/Town Telephone Number B. Pumping Record ALV 1. Date of Pumping Date 2. Quantity Pumped: Gallons Ti ht Tank ❑ Grease Trap Se tic Tank ❑ 9 3. Type of system: ❑ Cesspool(s) P ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No if.yes, was it cleaned? E] Yes ❑ No 5. Condition of System: 6. System Pumped By: Dmy�&, - Vehicle License Number ame Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signatur f er Date Signature of Receiving Facility Date System Pumping Record•Page 1 o t5form4.doc•03/06 ommonwealth of Massachusetts J's SEPTIC & DRAIN /Title 5 Oficial ' s eictio For IVII131 Forest street dDDLETON, MA01949 l' (978) 774-6685 Not for Voluntary Assessments ..Y Subsurface Sewage Disposal System Form C. System Information (cont.) 537 BOXFORD ST. Property Address NO. ANDOVER MA 01845 CitylTown State Zip Code NEAL SENIOR 11/5/07 Owner's Name Date of Inspection Sketch Of.Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet_ Locate where public water supply enters the building. ' y Title V.doc.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 16 ��qyy y/. ,y�.�y�y ()M .I'�+ ',,.J Oi'?�yF+—y6-yr�s'd.NO ¢�4y R.,,T .S.SM AySyJi-dy�(�'; rYM ��ACE MWA DMPOSAL PAT C !'�Yuperty Address, `F a*—Mh Ufa she ds ' eswM cam. -Locaft an-veem vndwm I00 ftt LOCLU whm-lm tFLIC tt� 3i sSuMl ' buffd E. f NORTH ;7 F O 9 � w 11 a Town of North Andover E TH DEPARTMENT S4CHUS�t CHECK#: DATE: _ f LOCATION: , H/O NAM CONTRACTOR NAM 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 $ SEPTICS stems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑. Title 5 Inspector $ Title 5 Report / }, $ rl ❑ Other:(Indicate) $ k Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer Commonwealth of Massachusetts F City/Town of No Andover RECEIVED System Pumping Record OCT '181012 ^M Form 4 TOWN OF NORTH ANDD„!ER DEP has provided this form for use by local Boards of Health. Other form �+ T 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 forms 1. System Location: on the computer, 7 use only the tab _ � / t .x460 r S1 key to move your Address cursor-do not No andoyer ._ _Ma . "sp the return -- key. City/Town —- --— - State — � Zip Code t� 2. System Owner: Name sewn Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: InCY3I Date ____ // Gallons 3. Type of system: F1Cesspool(s) �eptic 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: I 6. System 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 natuf f-H � / Date II Sig ature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 it Commonwealth of Massachusetts City/Town of NORTH ANDOVER, MASSACHUSETTS System Pumping Record Form 4 DEP has provided this form for use by local Boards of Hea h. The yst umping ecord must be submitted to the local Board of Health or other approvi aut�i��tyRo�n A. Facility Information TOWN OF NOM ANDOVER Important HEALTH DEPART When filling out 1. System Location.- forms ocation:forms on the X computer,use �1 onlythe e tab key Address to move your cursor-do not City/Town State use the return Zip Code key. . 2. System Owner. � % , � fP Name law Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record invh� �l/ 1/ 1. Date of Pum l p 9 Dat 2. Quantity Pumped: 000 Gallons 3. :Type of system: . ❑ Cesspool(s) Cj"Septic Tank ❑ Tight Tank {] Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes'was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. S stem Pumped By: e Vehicle License Number Company 7. Location wh a contents were disposed: . m -trete rr� �%� • Signat of Hauler a e http:/twww.mass.gov/dep/.water/approvalstt5forms.htm#inspect i t5form4.doa 06/03 System Pumping Record•Page 1 of 1 x i FROM : PHONE NO. Dec. 13 2007 09:44AM P1 ttORIN JTACKU FUgjic KLAtTN DIPARTPAINT Community Development Divisipn Demmbe r 4,2007 / Jamcs Currier "Pre, %' �• . Re.Title V Inspection at 537 Boxford Street Dear Mr.Currier, This correspondencc is a follow--up regarding the Title V in..pcction report,dated November 5, 2007,submitted to the Healib Department for the address noted above.The Inrpeot:ion Mort was found to be Lacoraplate in section C.reprdix►.g the distribution.box.According to the report,this important component of the septic sysim was not exposed duritxg the inspection,rather viewed with a video camera,because,"box,is uxtder the bade walk''. Unfortunately,thin is why it is impomtat for bomeowmers to be very aware ofthe location of all. their septic cojnponents,and one reason Title tin does not allow permanent shucturtz to be constructed over system components.Altbougb the walk is not permanent,its prestmee has bindemd the general inupection ofthc septic system.'1` e MA DEP regu,la on 310 CMR 1,5.302{ requires that,the distribution box be opened and itaspected.Health Depariment files show that the last inspection in 2003 revealed the same condition,however at that time there was no regulation requirilne this vfFCcc to review the inspection_form for completeness. Due to problarns with inadequate inspections,the North.Andover Health Depaxtnaont approved a local regulation that now requires a tall.review.As the ago of tl:as system is approaching 30 years,it is very important that this be checked and made accessible for J.uftrc obscivation as requmi d, please complete the impection and resubmit the report for review.Thtt&you for your effort W.eimring a properly functioning subsurface disposal,iystcm. Thank , you W � • 4 Susan sager,z;�EHS/RS Public Health Director Cc:Neil Senior or Current Resident, 537 Boxford Street 1600 Osgood Street,North Andover,Massachusetts 01845 Phom 978.688.9540 For 918.688.8476 Web wwvAnwnohorthandover.com FROM PHONE HO. Dec. 13 22©0? 01:59PM P1 S P'TIC&. RAIN -septic Tanks•Ccsgpools•Drywells Leaching Melds Installed, Cleaned or Repaired 131 Forest Street Jay Carrier Middleton, MA 01949 978-774-6685 To: /y, ! Pages including cover sheet: Comments: e FF'011 PHOHE HO. Dec. 13 2007 01:59PM P2 Commonwealth of Massachusetts "s, -SEPTIC & DRAIN 131 Forest StrPet DLETON, MA 0.1949 Title 5 Official Inspection Form MID(978) 774-668� Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 537 BOXFORD ST. Property Ai:Wr�— NO- ANDOVER MA City/Town state Zip Gode NEAL SENIOR 1-1115./07 Owner's Name Date of Inspection Tight or Holdinlj,,Tank(Cont.) Dimensions- Capacity: 1--- -n Design Flow- gallons per day Alarm present: Yes No Alarm level" order: El Yes L1 No Alarm in W Alarm in Date of last pumping; es. etc.)_ z rm and Zfloatswitch te Comments(condition of rm and float switches, etc.): .❑.......... 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.): TUNNELLED UNDER BRICK WALKWAY AND EVERYTHING LOOKS FINE. Pump Chamber(locate 0 ite plan): Pumps in working order: Ll Yes ❑ No Alarms in working order: < El Yes E] No DocurvientlAot,-11!2004 Tido 5 Official inspection rorm-,Subsurfam Sewage Oispoaal System- Page 12 of 15 [`Rnr�j PHf--iHE Hf-1 Dec. 13 2007 02:0OPM P3 J's SEPTIC & DRAIN Commonwealth of Massachusetts 131 Fof-(-.,-t Street MIDDLETON, MA 01949 Title 5 OT'Llficial Inspection Form Not for Voluntary Assessments .0 Subsurface Sewage Disposal System Form C. System Information (cont.) 537 BOXFORD ST- "15-PD-P4ty Address NO.ANDOVER MA cityrrpwn State A01845 Zip Code NEAL SENIOR 11/5/07..-, —...... ....... Owner's NWe Date of Inspeotion Comments(note condition of pump chamber, nditOn of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan,excavation not required): If SAS not located, explain why: ---------- Type'. ❑ leaching pits number, ............................. leaching chambers number: ❑ leaching galleries number, F1 leaching trenches number, length: 0 leaching fields number, dimensions: N/A 1-1 overflow cesspool number: 13 innovative/alternative system Typefname of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,etc.): ALL VEGETATION Is NORMAL, No siGN5 OF HYDRAULIC, FAILURE. Documentl.doc-11!2004 Title 5 Official Inspection Form;Subsurface Sewage Disposal System- Page 13 of 16 TRANSMISSION '',iERIFIC.ATION REPORT TIME 12x'05/2007 08:47 NAME HEALTH FA X 9786888476 TEL 9786888476 SER.# 000B4J120960 DATE,TIME 12,''05 08:46 FA;; FJO.Ih�lAAE 819787746685 DURATION 00:00:45 PAGE"4'S;' 01 RESULT OK MCIDE STANDARD �,raRr� e+� [Mwi2Ni NtM L�, 4aRArso ►lA,,�g ACHU PUBLIC HEALTH DEPARTMENT Community Development Division December 4, 2007 James Currier ' 7• roto Re: Title V Inspection at 537 Boxford Street Dear Mr. Currier, This correspondence is a.follow-up regarding the Title V inspection report, dated November 5, 2007, submitted to the Health Department for the address noted above. The Inspection report was found to be incomplete in section C,regarding the distribution box. According to the report, this important component of the septic system was not exposed during the inspection,rattier viewed with a video camera, because,"box is under the back wall~:". Unfortunately, this is why itis inlpoytant foa.-homeowners to be very aware of the location of alt. their septic components, and.one reason Title V does not allow permanent structures to be constructed over system components. Although the walk is not permanent, its presence has hindered the general,inspection of the septic system.. Tlie MA.DEP regulation 310 CMR 3.5.302(f) requires that the disb.'ibution box be opened and inspected. Health Department files show that the last inspection in 2005 revealed the same condition,however at that time there was no regulation requiring this office to review the inspection form for completeness. Dire to problems with inadequate inspections, the North Andover Health Department approved a local regulation that now requires a ftil,l review. As the age of this system is approaching 30 years, it is very important that this be checked and rna.de accessible for future observation as ., 110RTF/ q • O (Iuso 06 ti 'e O O t� b T ° COCMiC.9re 7' ��SSAC HUS�� PUBLIC HEALTH DEPARTMENT Community Development Division December 4, 2007 James Currier .' �' ��7• �i�g� Re: Title V Inspection at 537 Boxford Street Dear Mr. Currier, This correspondence is a follow-up regarding the Title V inspection report, dated November 5, 2007, submitted to the Health Department for the address noted above. The Inspection report was found to be incomplete in section C,regarding the distribution box. According to the report,this important component of the septic system was not exposed during the inspection, rather viewed with a video camera, because, "box is under the back walk". Unfortunately,this is why it is important for homeowners to be very aware of the location of all their septic components, and one reason Title V does not allow permanent structures to be constructed over system components. Although the walk is not permanent, its presence has hindered the general inspection of the septic system. The MA DEP regulation 310 CMR 15.302(f) requires that the distribution box be opened and inspected. Health Department files show that the last inspection in 2005 revealed the same condition, however at that time there was no regulation requiring this office to review the inspection form for completeness. Due to problems with inadequate inspections,the North Andover Health Department approved a local regulation that now requires a full review. As the age of this system is approaching 30 years, it is very important that this be checked and made accessible for future observation as required. Please complete the inspection and resubmit the report for review. Thank you for your effort in ensuring a properly functioning subsurface disposal system. Thank you, .��< •_ cel Susan Sawyer, REHS/RS Public Health Director Cc: Neil Senior or Current Resident, 537 Boxford Street 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com Page 1 of 1 DelleChiaie, Pamela From: Sawyer, Susan Sent: Tuesday, December 04, 2007 4:12 PM To: DelleChiaie, Pamela Subject: 537 Boxford St Pam, There is a problem with this Title V. I left a message for James Currier to call me. If he calls tomorrow tell him I am sending a letter to him and the homeowner. Maybe he would rather have it faxed. Please check and print out. I wanted to give him a heads up before the homeowner gets it. Thanks S Susan Sawyer, REHS/RS Public Health Director 978 688-9540 12/4/2007 �L\ Commonwealth of Massachusetts City/Town of NO. AND System Pumping Record Form 4 M 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 Important: FEB 0 S 2007 When filling out 1. System Location: forms on the computer,use 537 BOXFORD ST. TOWN OF NORM' only the tab key Address L h HL I M ULPAi,<., , to move your NO.ANDOVER MA 01845 cursor-do not use the return City/Town State Zip Code key. 2 System Owner: tQ TERRY PALISIN tL Name Address(if different from location) City town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date/07 2. Quantity Pumped: 1000ns 3. Type of system: ❑ Cesspool(s) ] Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes Lo No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Benjamin Shute H79 406 Name Vehicle License Number J's Septic& Drain Company 7. Location where contents were disposed: GLSD wat1/22/07 a ure a er Date t5form4.doc•06/03 System Pumping Record.Page 1 of 1 i FORM 4-SYSTEm PUNFi NG RECORD CommonweaNi o,f Massachwe& Massachusetts . ms em Pwn�ing Record er Y n FH � JUL 1 ► 200 I Type: Emergency ❑ Routine Cesspool: No Yes ❑ Septic Tank: No ❑ Yes Date of Pumping: (o 03 Quantity Pumped: J OU gallons System Pumped by (Company): Permit : Contents transferred to: .Contents disposed at C � s � Date Pumper Signature Condition of system/other comments: DFP APPMVM FORM-I7WMS FORM 4-SYSTEM P[31viPING RECORD ommonwealth of Massachusetts Massachusetts RECEIVED System System owner v System Location TOWN OF NORTH ANDOVER HEALTH DEPARTMENT fSCi 7 Type: Emergency ❑ Routine 9 Cesspool: No LO Yes ❑ Septic Tank: No ❑ Yes Date of Pumping: v�- l�„� Quantity Pumped: 0 gallons System Pumped by (Company): �- Permit #t: Contents transferred to: Contents disposed at: Date 9-2-dV Pumper Signatu Condition of system/other/comments: DEP APPROVED FORM-12107195 THE PROrE56IU14AL EXHEhl5 IN THE SEPTIC AND DRAIN INDUSTRY FORM - SYSTEI\1 PUl1fP1I�G RECORD Commonwealth of Massachusetts Massachusetts stem lum ire ystem %Amer System Location Date of Pumping: fQ-J —�S Quantity Pumped: gallons Cesspool: No/Q Yes ❑ Septic Tank: No ❑ Yes SystemPumped by: ........................... .. ................................................... License,#: ................................................................... Qontents transferred to: Date Inspector Address �3? �3o x Fp2o. S7- Title of File Page of Date File Open: Date file closed: Doc Document/Action Title Date of Refer to other Purpose of Document/Action and notes action Document/ document/ Num. Action Department Board of Appeals - Board of Health - Planning Board _ Conservation Commission - Building Department d FORM 4- SYSTEM PUMPING RECORD Commonwealth of Massachusetts -j.xFI'd , Massachusetts System Pumping Record System Owner System Location ( J —)aald 70v NED R LU M TUNN OF B-, .XFORD Type: Emergency ❑ Routine ' BOARD OF HE;,LTH Cesspool: No ❑ Yes ❑ S(-ptic Tank: No ❑ Yes Date of Pumping:. Z' c'` Quantity Pumped: gallons System Pumped by (Company): r•e9 2 ��5 S e �.yz Permit r: Contents transferred to: Contents disposed at: Date Pumper Signature ? Condition.of system/other comments: pp ��'(�CiC/, lS��a�'l'1•�1�to 0 12 2001 DEP APPROVED FORSt-12/07/95 i FORM 4-SYSTEM PUMPING RECORD JRRIER SEPTIC & DRAIN SERVICE FOREST STREET;MIDDLETON,MA 01949 (978)774-2772 CO MONWEALTH OF MASSACHUSETTS MASSACHUSETTS SYSTEM PUMPING RECORD SYSTEM OWNER: SYSTEM LOCATION: S , Ivav--e v- e-�-e V-v �DL 3 �0C-')cl-- DATE OF PUMPING: a QUANTITY PUMPED: GALLONS CESSPOOL: NO E2� YES 0 SEPTIC TANK: NO YES SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE CONTENTS TRANSFERRED TO: DATE: INSPECTOR: tiv iL r� Commonwealth of Massachusetts Title 5 Official Inspection Form y Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 537 Boxford St d l Property Address Cramer _ Owner Owner's Name information is required for every North Andover MA 01845 4/22/2013 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. RECEIVED Important:When ms A. General Information on the computer, MAY 0 7 2013 } use only the tab 1. Inspector: key to move your TOWN OF NORTH ANDOVER cursor-do not Chad Jablonski HEALTH DEPARTMENT use the return Name of Inspector key. CJ Jablonski Septic Inspection & Repair r� Company Name 237 Merrimac St. Company Address Newbu!yport MA 01950 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 Furt valuation by the Local Approving Authority inspector Signatu Date The system inspe or shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP witlin 30 days of completing this inspection. If the system is 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 ap r riate 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. t5ms•11/10 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 537 Boxford St Property Address Cramer Owner Owner's Name information is required for every North Andover MA 01845 4/22/2013 _ 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: ® 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: 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): i5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 ,L-\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 537 Boxford St Property Address Cramer Owner Owner's Name information is required for every North Andover MA 01845 4/22/2013 page. City/Town 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: El 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 t51ns•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 537 Boxford St Property Address Cramer__ Owner Owner's Name information is required for every North Andover MA 01845 4/22/2013 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. El 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 ❑ Z 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 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts ,10 Title 5 Official Inspection Form $ -- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 537 Boxford St _ Property Address Cramer Owner Owner's Name information is required for every North Andover MA 01845 4/22/2013 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. ❑ 2 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 „1 Commonwealth of Massachusetts Title 5 official Inspection Form 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 537 Boxford St Property Address Cramer Owner Owner's Name information is required for every North Andover MA 01845 4/22/2013 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. ® EJ 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: no Number of bedrooms(design): avaidlab en Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): no design 151ns•11/10 Title 5 Official Inspedon 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 537 Boxford St Property Address Cramer Owner Owner's Name information is required for every North Andover MA 01845 4/22/2013 _ page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? (if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d Private Well 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: 151ns-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 7 of 17 Commonwealth of Massachusetts -r Title 5 official Inspection Form ut Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °tiu 'r 537 Boxford St Property Address Cramer Owner Owner's Name information is required for every North Andover MA 01845 4/22/2013 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: Pumped 9/18/2012 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 stem P p y ❑ 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): t51ns•11/10 Title 5 Official Inspection Form:Subsudace Sewage Disposal system•Page 8 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form =1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 537 Boxford St Property Address Cramer Owner Owner's Name information is required for every North Andover MA 01845 4/22/2013 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: Over 25 years, current and previous home owners. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 37" below foundation feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10'+ feet Comments(on condition of joints, venting, evidence of leakage, etc.): Watertight at foundation Septic Tank(locate on site plan): 12" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) na 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: 2" t5ins•11110 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 < 537 Boxford St Property Address Cramer Owner Owner's Name information is required for every North Andover MA 01845 4/22/2013 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 28" Scum thickness minimal 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 18 How were dimensions determined? measuring stick 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 is structurally sound, inlet and outlet baffle in good working order. 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•11/10 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 «„ 537 Boxford St Property Address Cramer Owner Owner's Name information is required for every North Andover MA 01845 4/22/2013 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 15ins•11/10 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 537 Boxford St Property Address Cramer Owner Owner's Name information is required for every North Andover MA 01845 4/22/2013 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.): Box is level and distributing equally. Distribution box is under the brick walkway, bricks need to be removed to inspect. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form a1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 537 Boxford St Property Address Cramer Owner Owner's Name information is required for every North Andover MA 01845 4/22/2013 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: 20'x 30' ❑ 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 orponding. 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 15ms•11/10 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 - 537 Boxford St Property Address Cramer Owner Owner's Name information is North Andover MA 01845 4/22/2013 required for every 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.): i I ;Sins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 01 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 537 Boxford St Property Address Cramer Owner Owner's Name information is North Andover MA 01845 4/22/2013 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately -a � r cr I 3.?-1 - c. ITS , Z t5ins-tin 0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 i i i i i I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 537 Boxford St Property Address Cramer Owner Owner's Name information is North Andover MA 01845 4/22/2013 required for every page. City/Town SatetZip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water i ® Check cellar ® Shallow wells Estimated depth to high ground water: eet/ Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Wetland in rear of the property. No sump pump Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 i Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 537 Boxford St Property Address Cramer Owner Owner's Name information is North Andover MA 01845 4/22/2013 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 ;Sins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Septic System Information 537 BOXFORD STREET Printed On: Tuesday,December 04, 20 System ID: BHS-2004-0104 General System Information Latest Permit Information Calcaluted Design Flow: Test Pits Septic Tank Disposal Trench Design Flow: One Two Capacity: Number.- Design umber.Design Flow Provided: Minutes per inch: Width: Width: Total Flow: Depth: Length: Length: Seasonal: No No Depth to Water: Diameter: Leaching: Grinder: No No Soil Type: Depth: Laundry: No No Haulinp/Pumping Listing Quantity Type System Type Pumped Pumped By Transferred To Disposed At Date Pumped allons Routine Septic Tank J'S Septic&Drain 09/07/2004 1000 Routine Septic Tank J'S Septic&Drain GLSD 12/22/2007 1000 Inspections: Inspected: Expires: Inspector: Status: 11/05/2007 James H. Currier Passes Comments: Title 5 GeoTMS®2007 Des Lauriers Municipal Solutions, Inc. Page 1 of 1 �-._�� w> 1 1i l% Of AORT.,�O# a 3j•�` o �• Oc 0 x • Town of North Andover `ti'•=.... :. HEALTH DEPARTMENT �.,S,% Us�� -f CHECK#: DATE: LOCATION: 171 H/O.N-AME CONTRACTOR NAME: 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 Const action SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ 0 Title 5 Report $ ❑ Other:(Indicate) $ x. 689 Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer ` - Commonwealth of M « Official' Title 5 -- - -- 0- -- ~~t~ ~~ ~ ~ Form � W. Not for Voluntary Assessments '7 RE Subsurface Sewage Disposal System Form 7:7CE1V7E:D Ila Inspection -esults must be submitted on this foml or o"V cffitii?0jVle 5 Inspection F6rm-dated 6/15/2000. Inspection forms may not be altered in ny way. JR rV1 -- A. Certification TM T ,-yl-NORTH ANDOVER Important: HLALTH DEPARTMENT When filling out 1Property Information: w~ ' forms on the computer,use 537 BOXFORD ST., NO. ANDOVER, MA 01845 only the tab key Pmpertyxuurens to move your NEALSEN|OR � cursor do not ---------- � use the return Owner's Name key. 537BOXFOROST. � ' "==~°"=°°u /U� U NO� ANO{JVE�� | »»* 01846 City/Town State Zip Code � Date ofInspection: 11/5/07Date � 2. Inspector: JAMES H. CURR|ERU wam --- � evv� � --------'----------- J'sSEPT|C& ORA/N _Eompany-Name 131FOREST ST. Company Address K8|DDLETON -E-ity/Town State Code MA 01849 078'774-8085 Telephone Number --'-----~^ ~~^~-^~~^^' | certify that | have personally inspected the sewage disposal ayotann at this address and that the information reported below istrue, accurate and Complete aso{the time ofthe inspect/on The inspection was pedbnnedbased onnmytraining and oxpehenneinthe proper function and nnaintano'^ceofonsite sewage disposal systems. Y am m DEP approved system imm�emtmx�urmmanttm Section �� 340 of Title (31D ��K8nn� � YS.�Q�)' Thesyota � ' | 0 Posamn 171 Conditionally Passes Fails El ds Furthe Ev tion by the Local Approving Authority 11/5/07 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 repert only describes conditions at the time mfinspection amdandmr the conditions ofuse mm atthat tie' This inspection does not address how the system will perform in the future under the same or different conditions of use. Title Kmm.uoc`11/2on4 � Title 5Official inspection Form:Subsurface Sewage Disposal Gystam^ Pagel of i a ` Commonwealth of Massachusetts Title 5 Official inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 537 BOXFORD ST. Property Address NO. ANDOVER_ MA gin`'— 01845 City/Town r State ``tom Zip Code NEAL SENIOR 11/5/07 VER _ Owner's Name �ARTMENT Inspection Summary: Check A,B,C,D or E/always complete all of Section D 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: SYSTEM WORKING PROPERLY. B) System Conditionally Passes: ❑ One or mo4,system components as described in the"Conditional Pass" sect' need to be replaced or repaired. The system, upon completion of the replacement o pair, as approved by the Board of HeaJfh, will pass. Answer yes, no or not diatermined (Y, N, ND) in the❑ for the folio ' g statements. If"not determined," please expla . ❑ The septic tank is metal a over 20 years old*or th eptic tank (whether metal or not) is structurally unsound, exhibit substantial infiltratio or exfiltration or tank failure is imminent. System will pass inspection if t e existing tan ' replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspec if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the nk is ss than 20 years old is available. ND Explain: Title V.doc.doc-11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts MT Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) , 537 BOXFORD ST. Property Address NO. ANDOVER M Nov �0�� 01 45 Citylrown Sta aode NEAL SENIOR Owner's Name Dat tf i B) System Conditionally Passes (cont.): ❑ Obse • ation of sewage backup or break out or high static water level in the distributio ox due to brok n or obstructed pipe(s) or due to a broken, settled or uneven distribution bo . System will pass ins ction if(with approval of Board of Health): ❑ brok n pipe(s) are replaced ❑ obstruction is removed Z ❑ distribution b x is leveled or replaced r; ND Explain: .r r ❑ The system required pumping more an 4 timesra ear due to broken or obstructedpipe(s). The Y 4 P P� 9 Y system will pass inspection if(with ap oval o �ie Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: ,r f' C) Further Evaluation iso Required by the Board of Health: ❑ Conditions exist vetch require further evaluation by the Boa\ptect order to determine if the system is failing to protect public health, safety or the en i 1. System w pass unless Board of Health determines with 310 CMR 15.303(1)(bj that the system is not functioning in a mannp tett public health, safety and`the environment: ❑ Cesspool or privy is within 50 feet of a surface wate❑ Cesspool or privy is within 50 feet of a bordering vegd or a salt mar h s Title V.doc.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 eel\ Commonwealth of Massachusetts J Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 537 BOXFORD ST. Property Address NO. ANDOVER 01845 City/Town aVate Zip Code NEAL SENIOR 11/5/07 "Ool Owner's Name J'�Intpekw 4 JVER of- C) Furthervaluation is Required by the B (cont.).: 2. System will it unless the Board of Health (and Public Water Supplier, if any determines that t system is functioning in a manner that protects the publi ealth, safety and environ nt: El The system has septic tank and soil absorption system (SAS) and e SAS is within 100 feet of a surfa water supply or tributary to a surface waters ply. ❑ The system has a septic nk and SAS and the SAS is wi n a Zone 1 of a public water supply. El The system has a septic tank and AS and the AS is within 50 feet of a private water supply well. ❑ The system has a septic tank and S an he SAS is less than 100 feet but 50 feet or more from a private water supply ll**. Method used to determine dist ce: This system passes if the well ter analysis, performed at DEP Certified laboratory, for coliform bacteria and volatile or nic compounds indicates that well is free from pollution from that facility and the presence ammonia nitrogen and nitrate nitro en is equal to or less than 5 ppm, provided that no othe ailure criteria are triggered. A copy of th analysis must be attached to this form. 3. Other: Title V.doc.doc-11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 537 BOXFORD ST. Property Address NO. ANDOVER MA 01845 City/Town te, ZipCode NEAL SENIOR 11/5/07 ate ,/5/07 Date of� n Owner's Name Date of InweeW D) System Failure Criteria Applicable to All A 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 EJ Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow El 0 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: El 0 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 1:1 El tributary to a surface water supply. ❑ F71 Ai� 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 E:] n well. Ej E] Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet it from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] Yes No El 0 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. Title V.doc.doc-11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 5 of 16 Commonwealth of Massachusetts ` Title 5 Official Inspection Foran ��l l978)7s�,-C63� r Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 537 BOXFORD ST. Property Address NO. ANDOVER LiF-8�� 1845 City/Town ED ip Code NEAL SENIOR Owner's Name ate of nspection NAV 14 2007 E) Large Systems: To be considered a large syst the sysN4�rve a facility with a design flow of 10,0 pd to 15,000 gpd. TOWS OTH OEPARI For large systems, you m t indicate either"yes" or"no o the fo ing, in addition to the questions in Section D. YES NO ❑ ❑ the system is within 4 feet of a rface drinking water supply ❑ ❑ the system is within 200 f a tributary to a surface drinking water supply ❑ ❑ the system is located ' a nitrogen nsitive area (interim Wellhead Protection Area—IWPA) or apped Zone 11 o ublic water supply well If you have answered "yes"to any estion in Section E the syste ' considered a significant threat, or answered "yes" in Section D ove the large system has failed. The ner or operator of any large system considered a signific t threat under Section E or failed under Sect D shall upgrade the system in accordance wi 10 CMR 15.304.The system owner should contact appropriate regional office of the partment. Title V.doc.doc•11/2004 Title 6 Official inspection Form:Subsurface Sewage Disposal System Page 6 of 16 i I Commonwealth of Massachusetts n-*Street Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Checklist 537 BOXFORD ST. Property Address NO. ANDOVER MA 01845 '&iity117own State Zip Code NEAL SENIOR 11/5/07 Owner's Name Date of Inspection 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 wnlr, occ pant, or Board of Health El Z Were any of the system ponents pumpedoo in t previous two weeks? AHas the system received no al wlinith4e prelvio o week period? i. el"10 El 0 Have large volumes of wate be&a9a d8o em recently or as part of this inspection? T "E vi El N Were as built plans of the Sys obtained and examined? (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? El Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? El 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 SGUM? El 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: EJ El 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(3)(b)] Title V.doc.doc-11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 7 of 16 J Commonwealth of Massachusetts 11 Irare�;l 3Street A17(A O.T949 1978'!' 6,? Title 5 Official Inspection Form 274.61F Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information 537 BOXFORD ST. Property Address --- NO. ANDOVER MA 01845 City/Town State Zip Code NEAL SENIOR 11/5107 Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms (design): N/A Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms)- 440 GPD Number of current residents: 3 Does residence have a garbage grinder? R Yes 0 No I laundry on a separate sewage system? [if yes separate inspection required] 0 Yes 0 No Laundry system inspected? i4l! El Yes [:1 No Seasonal use? F1 Yes 0 No Water meter readings, if available (last 2 years usage (gpd)): WELL Sump pump? D Yes 0 No Last date of occupancy: CURRENT Date - Commercial/industrial Flow Conditions: Type of Establis nt: Design flow(based on 31 MR 15.203): Gallons per day(gpd) Basis of design flow (seats/perso sq.ft., etc.): Grease trap present? El Yes [:1 No Industrial waste holding tank present? 1771 Yes El No Non-sanitary waste discharged to the Title 5 sy m? EJ Yes 171 No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): Title V.doc.doc-11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 8 of 16 . . . . , K� �� ]~� �� ' --- ^ lJ7l�F)o�e7si4'S�t5e�e�t ^80DLETON, il,�-&S19 4,; Title 5 Official Inspection Form � Not for Voluntary Assessments subsurface SeVYa�e []ispDS�l ��VSt�0FD[0 � C. System Information (cont.) BJ8OXFORDST. Property Address NO. /\NOOVER MA 01846 Cityrrown State Zip Code NEALGEN|C>R 11/5/ 7 � ~~.~.~..""= Date mInspection � KSmnemml Information Pumping Records: Source of information: REGULAR MAINTENANCE - LPD 1/2207 � Was system pumped eapart ofthe inspection? El Yes Z No Ifyes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: ype of System: Septic tank, distribution box, soil absorption system � Single cesspool El Overflow cesspool / Phvy � � Fl Shared system (yes urno) (if yes, attach previous inspection nocunde. if ally) �l InnovativelAlternative technology. Attach a copy of the current operation and -- maintenance contract (to be obtained from system owner) El Tight tank. Attach acopy nfthe DEP approval. Fl Other(describe): Approximate age of all components, date installed (if known) and source of information: 28YEARS - 1979 � Were sewage odors detected when arriving sdthe site? El Yeo Z No � Tule Kdnndo:'11�oo4 � Title sOfficial Inspection Form:Subsurface Sewage Disposal System' � Page 9m10 � Commonwealth of Massachusetts ` ' `'} "C DRAW.3.3". Forest Street Title 5 Official Inspection Form Not for Voluntary Assessments _ Subsurface Sewage Disposal System Form C. System Information (cont.) 537 BOXFORD ST. Property Address — -- — NO. ANDOVER MA 01845 Cityrrown State Zip Code NEAL SENIOR 11/5/07 Owner's Name Date of Inspection Building Sewer(locate on site plan): 37" Depth below grade: feet Material of construction: ® cast iron ❑ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 26 feet Comments(on condition of joints, venting, evidence of leakage, etc.): ALL PLUMBING LOOKED GOOD ttO S tic Tank (locate on site plan): Jv O,fept below grade: 14" 0 feet N, PN�a f construction: concrete ❑ metal ❑ fibergiass EJ polyethylene ❑ other(explain) P F O ( ) O If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 GAL. Sludge depth: 10_12" Distance from top of sludge to bottom of outlet tee or baffle 13" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 8.. Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? SLUDGE JUDGE &TAPE MEASURE. Title V.doc.doc•11/2004 Title 5 Official inspection Form:Subsurface Sewage Disposal System Page 10 of 16 Commonwealth of Massachusetts `�' S=� ` t., 1 1 For �' � Title 5 �ffi »I, 11 T �f ti` l,a_ - -- cia�l Inspection Form f ,,. ��_�:. Not for Voluntary Assessments >„ Subsurface Sewage Disposal System Form C. System Information (cont.) 537 BOXFORD ST. Property Address NO. ANDOVER MA 01845 City/Town State Zip Code NEAL SENIOR 11/5/07 Owner's Name Date of Inspection Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): MIDDLE COVER HAS RISER TO GRADE, OUTLET COVER 14" BELOW WITH TWO ELECTRIC LINES OVER COVERS. Grease Trap (locate on site plan): Depth elow grade: feet Material of onstruction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene other(explain): Dimensions: Scum thickness Distance from top of scum to top of o et tee or baffle tanc from bottom of scum to bottom of tlet tee baffle Datplof la pumping: DiC�U1 Date mmer� n pumping recommendations,), le# and o et tee or baffle condition, structural integrity, liqu*��t I related to outlet invert, evfd'ence of leakag etc.): N Tight or Holding Tank (tanX must be pumped at time of inspection) (loc on siteIan p ) Depth below grade: Material of constru ion: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ othe explain}: Title V.doc.doc-11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form 131 �-_orest S-u-eet Not for Voluntary Assessments C) Subsurface Sewage Disposal System Form C. System Information (cont.) 537 BOXFORD ST. Property Address NO. ANDOVER _MA 01845 Cityrrown State -zip Code NEAL SENIOR 11/5/07 Owner'sNameDate of Inspection Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: allons per day Alarm present: 0 Yes ❑ No Alarm level: - A in working order: El Yes El No Date of last pumping: Date pumping: Comments (condition Zalarm and float switches, etc-): ast', rib Box (if present must be opened) (locate on site plan): PN ENS 0 OF No liquid level above outlet invert '�o 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.): INSPECTED BOX WITH VIDEO CAMERA, BOX IS UNDER BACK WALK. LIQUID LEVEL AT INVERT OF PIPE. Pump Chamber(locate on s plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: El Yes El No Title V.doc.doc-11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal system- Page 12 of 16 BRAIN Commonwealth of Massachusetts treel A r - 0 1 -6, Title 5 Official Inspection Form M9 Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 537 BOXFORD ST. Property Address NO. ANDOVER MA 01845 City/Town State Zip Code NEAL SENIOR 11/5/07 Owner's Name Date of Inspection Comments (note condition of pump chambe' 7 of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: leaching trenches number, length: leaching fields number, dimensions: N/A overflow cesspool number: innovative/altemative system 10 ;1z Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): ALL VEGETATION IS NORMAL, NO SIGNS OF HYDRAULIC FAILURE. USED CAMERA TO INSPECT D-BOX. Title V.doc.doc-11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 13 of 16 Commonwealth of Massachusetts - - - Title 5 Official Inspection Form IMIDDLETO�J A0194S, _ — _ c;�;'�'� a-•4-05£35 Not for Voluntary Assessments iVnM Subsurface Sewage Disposal System Form C. System information (cont.) 537 BOXFORD ST. Property Address NO. ANDOVER MA 01845_ _ City/Town State Zip Code NEAL SENIOR 11/5/07 Owner's Name Date of Inspection Cess ools (cesspool must be pumped as part of inspection) (locate on site plan): Number a configuration Depth–top of I id to inlet invert - Depth of solids layer -- -- Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydra 'c ilure, level of ponding, condition of vegetation, etc.): Privy (locate on site pian): Materials of construction: — Dimensions -- De of s ids --- ------ - – ---------..-- ents ( e condition of soil, signs of hydraulic failure, level of ponding, condition of ve tation, tc.): 01 v 0 _ OFF-��pFz Title V.doc.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 . � . Commonwealth of Massachusetts .i's SEPTIC & DRAIN _ Title 5 Official inspection Form 131 Forest street MI 7 , -6 01949 {978) 774-6685 Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System information (cont.) 537 BOXFORD ST. — Property Address NO. ANDOVER MA 01845 Cityfrown State Zip Code NEAL SENIOR 11/5/07 Owner's Name Date of Inspection Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 2 32, b z 00� ti 2 O oc � ID _ z/l- _3 Ind 4 Title V.doc.doc•11/2004 Tale 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 16 N � T . w Commonwealth of Massachusetts e.,4 N T,C & DRAIN ---- 1:31 Forest Street Tele 5 Official Inspection Form �;i.T�1<�, t�PA©194 Not for Voluntary Assessments {�� 'r4-668F Subsurface Sewage Disposal System Form C. System Information (cont.) 537 BOXFORD ST. Property Address NO. ANDOVER MA 01845 City/Town State Zip Code NEAL SENIOR 11/5/07 Owner's Name Date of Inspection Site Exam: Slope i Surface water Check cellar Shallow wells Estimated depth to ground water: Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record I If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) i ❑ Checked with local Board of Health- explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database - explain: You must describe ow you established the high ground water elevation: STANDIN TER 00+ FROM SYSTEM AND COMPARED ELEVATIONS. _ — _G�� . --� . --- ---- -----_---------— 1N WJ � P I Title V.doc.doc w 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 r � I COMMONWEALTH OF MASS CRUSETM -RMCUTM 0MCE OF AFFAIRS AL PROT-Umoji - RECEIVED APR 2 6 2005 M E 5 TOWN OF NORTH ANDOVER OMC i 3sp=nm Fay-�N Fob T SUBS A E SE 'AGE-DI" SAL SYS'T'EM J OMI PAR'S'A Property Address:. � Q ` - ��_�_-z- Owner's Owner's Naum Owner's Address: Bate of Inspection:...__ J's SEPTIC & DRAIN Name of Inspector:(please print) 131 Forest Street companyName: MIDDLETON, MA 01949 X12 iing Address: (978)774-6685 Telephone l'�utt mer. I f =fit Z have personally inspected the savvax�e disposal system at this address and that the infamalion reported below is tme,aoctnate and conWlete as of the tuneof tete zz�, zQn.1"$a inspection.was permed based on my training and experience in the proper Enaction and ice of oti site sewage disposal system.it am a DEP approvedsystem inspector pursuant to Section 15.340 of Title 5(310 CMR:15-004 The system: _ZPasses Conditionally Passes Needs Further Evaluadon by the Local Approvmg-An#torgy Fails Itspeefoes S he Date.- The system inspector shall . a copy of this inspoction report t o the Approving Au&miLy ofRealth or DID P)within 30 days of coinp}etiug this unction.Ifthe sysWm is a shared system orbs a desip flow of 10,000 gpd or gr r,the inspector and the system owner shall s dm&the report to#te appropriate regional office of the DEP.The original should be sent to the systems owner and copies sent to*e buyer,3f applicable,and the approves -totes and Comments **'This re-oort ouly describes conditions at the time of inspection and ander the conditions oftree at that time.This�IJe cfitrn does not add how them swill[Perform ut the fhb under the s �+� o ante or different conditions of n5e. Page 2 of I I £)YnCaAL S?j�CD -F()t ' — D FOS$. OLUNTARY ASSE'SgMENT _ PART A. -CERTMACA ION(confmued) P , , ate Qft� � - 41 Inspection summary: Check A,B C,D or E l. kLW YS complete sit afsectlon D A. System-Passes: I havemot(bund any inforzm=on which indicates that any of the failure criteria described.in 3 10 CUR 15.303 or in 310 00-15.304 exist.Any failure criftnia.not evaluated are indicated below- Comments- B. elow-Comments:B. stem Conditionally Passes: 11 Zk- One more system components as described in the"Conditional Pass"section need to be replaced or i acct The upoar completion of the-ropj=meL--or repair,as approved by the Board of I�ealt�i, ass. p Answer yes,-no or not Bete (Y,N ND)in the for the following statemert� of determined"-please e)Mlaun- ..� The septic tank is metal and over 2 old*or the septic�Irefbzr metal or nut)is structurally unsound,e)Nbits substantial mon or Nation or tank is MMMCM Sygm Will pass inspeMort if the ea-is6ng tank is replaced vhffi a complying septic pts by the Board of Realft *A-neral septic tank will pass inspection if it is sound,not lig and if Cerdficabc of Compliance indicating that the tank is less than 20 years old is . `able. lD explain: Observation of sewage backup�or break out v r-Mgh static wau rlam, the distribution box clue to broken or obstructed pipe(s)or due-to a p`` settled or uneven.distribution box System pass irsgection if( approval ofBoarti ofHealth' . brdicen pipe(s)a=xcpbced. obsttucticsn is.removed distn'iiudoribor islevLied orreplaced---' ND explain„ _ e m eel Ing-more than 4 tunas a year due-to broken'€rrobst acted pipe(s).The s will system pumping- � ISP y p f ection.if(with approval of the Board of Health)- broken-spe(s)are replaced obstruction is removed ND exDlain: -Page 3 of I I 0YMCJALS2iCn0PY6JiM=NOT FOR VOLUMt Y AS&VMrVMTS PART A -CTRT ` CA' ON(continued) prtapeM Address: �€ers J's SEPTIC & DRAIN Bate ufrspaction• 134. #rarest Street IDDLEI"ON, IMA 02949 (��8 74-6685 C. Farther Fvaluation is Required by the Board ofHealtho tie�ns exist which requi€e fr€rrther eva noxi by tlzc Board c}fl ealth order s die if the system is fading to prti public health,safety car tate envituuineut, 1. Systeyn will pass ess Board of Health determines in accordance with 310 CMR (1)(b)that the system is not funetio ' in a manner which will protect pubrrc health,sat d the environment: Cesspool or privy is Vi tl fact of a sure water Cesspool orprxvy is Within S!i ofa bordering Vege d w or a salt marsh 2e stem will fail uzdfm the Board of Health ablic ester Supplier,If=Y)determines that the system is functioning in a manner drat protects a public hes safety and euvirnnmeat: _ The system has a septic tank and so abscarpti8rt system.(SAS) 'the SAS is within 1€0 feet of a surface water supply or tributary to a water supply. The system has a sekotic d SAS and the SAS is within a Zme I of bIic water supply. The system has a septic and SAS and the SAS is witi int 50 feet of a pri stet supply well. The system Inas ass "e tank and SAS and the SAS is less than 100 feet but 50 feet €>re from a private water supply **.Method used to determine distance *.WS system p s if the wed,water analysis„wormed at aMP certified labomory,for to bacteria and va Z or ie campomds irtftaWs that the well is fift from pollution fivm 9M and the presence Qaia nitrogen arrd nitrate nitrogen is equal to or less than 5 ppm,Provided that umo failure am triggered.A copy of the analysis must be atbito this f 3. i or: r age 4 of I I Y .�•��y�/�s ....� :t. . ��y MOT TOR �gyq'� ..mss �t e�ss�x _ _ V.7l'�i'IC�IAL ,,te�aa ��sZ��'�+�rr��7TT F;O�eR6��°^"MO 3'O.1F.1 r1��7�4ti�GMARY L3R71.a�7FE�SSb"- 3S . SUBSU ..1 AQ. E R7$..+'XlAG DO&' S L-jSYS S� SPECUO FORM RM . PART 1Z- iQXRTMC i O1N(continued) Property Address; A t3wnrer: r r ' n Date OfJispection. � 131 i=ernst Shtrep* D. System'FailmmCriteiiaapplicable toallsystems: t9"8` rf-66335 You MW indicate"Yes"or`fro"to each of the following for alt I��spe�soas: Yes No Xaclarp of sewage Mta facility or system component due to overloaded or clogged SAS or cesspool Discharge or goading of effluent to the surface of the groundar surface waters due to an overloaded or logged.SAS or cesspool Siatie liquid level in the distribution box above outlet invert due to an overloaded or c3.agged SAS or cesspool �/ nqund depth is cesspool is less than f>'below invert or available volume is less than:4 clay flaw equired pumper more than 4 times in:the last year NOT due to clogged or obstructed pipe(s).Number -Aaf times pumped _/:buy portion of the SAS„cesspool or prier is below lie ground water elovcm. � Any portion of cesspool or privy is within.100 fes of a surface water supply or taInS ry to a s tcs _ /water supply V y portion of a cesspool or privy is widda a.Zone 1 of a public well. portion of a cesspool or privy is within 5t}feet of a private water supply well. Puy portion of a cesspool or privy is less Bran 100 bent greatertan 50 feet f .a private water supply well with no acceptable_wauw quaIiy analysis.rrhft System passes if the Well waftraaatsni =% performed at a DEP cartiffed.laboratM7,for calms bact+ersa and volatile or game goshpomnds indicates that tIte well is free&om-ponution from that facility and the presence of ammonia mtrogen and nitrate nitrogen is egxmtto or less than-3_ppws provided that no other fadrtae crderia are triggered.A copy of the analysis must he attOdW to this forMl fYes je�TTne sysXem€ads.I stave deDermiued that erste or more of the above fail=criteria exit as described in 31 a CMR 15-303,t fore tt systema fails.The slaAQM owner should contact the Board of 1lealdn to determine what will be necessary to correct the failure: E. targe Systems: Ta are considered a large system the systain mast serve.a bciW with.a desks fYow of 1Q,ifflt#gpd to 15,400 1pd- _. indicate either`'lees='or"no"to each ofthe followirng ('Me follo _ rte is apply to large systems ivaddition to the ) yes no the system is within 400 e . �e drinking water supply the system is QQ feet of a trib surface driving water mW!Y _ the cyst �I=Mted in anihmgan sensitive area VsTelllnead Protection Area—IMPA)or amapped Zone A of apublic water supply well IfyotLh ve answered"yes=`to any question in Section.E the system is capsid teat,or answered "yep"in Section D above the large systems bas Med.Tke owner or operator of considereda sit threat under Section E or fid under Setting sltali ups the in- with 31CWM 5.3a4.The system owner should contact the appropriate regional affhce of the Department Page of II �PARTB - PropertyAcdress:�. ' �" 'x. «:�� } i3:t Forest Street r} MIDDLETON, MA 01949 Owner. /'.o L.r`- (978) 774-6685 pats efluspet -OW. Check iftbn fella -.«have be=daM-you WMC "fle as to WCb Ofthe M � yIo Ptmapin� was pzt�� t std occupant,or Boaad.yeah. Were auy of the zySMM eoruponma wed out in the previous two weeks? _ Has the Wmar rmcrived mimal do _�;the w�ik�aex d?' ave large vobmes ofwauwbe=.. 10-the S-P3M c ret y as peat Offs nspe=ap_ }" Were as buMplMs0fthCsjrmmvbtWhed=d exammePtirtheyvmrenotavaflablenmasNI Was the&cHfty sr dellut . Yl - -Was the sits hmpected for eigns of break out? Were a)J SYSIM COMPORetury cWUwffiO&&SAS,iocared ou site? Wam the septic=*waxjh�Oksnwxvzrad Opanedam&awinuxkworlhet=kinspecforths conditi cl tai of a-d ufthc byes€�rser:s,ma�rial`of��tsuttcitou, _ _ ., _� � � � & was the facaky►owner(aud ncWpmgsif tfxom owner)provided with information an%be proper maintce tafsbsMfkW sc`wtym&SPdSal-SNUM o Thed= . S [ t l h d �t s aid aC AO �xCf + a i �istsu�mon:.moa p app ut the r �trh_=-_ ��xmiaedi�ttlSe:ticld(�'a�+c�'�xe��tet.xr3�ed to�?'a��us issue app!r+ a�r�a ofd Fage 6a of 1 I SUBSUWA4=1 .��iiTiG �i7te3,�R��LL�4�f.�- - PAIRT IC SYSTM RMATIO 1 Prow"Add re= Owner-.�f Date of - .? as r: st street respss#Q� 170,'V; 110A01949 Number r ofbr&ao%n (dedga):_ �o dmumbs(ate+_� � DESIGA7 how lamd cu 3IO (fDr WmWI�I IO jWd x x -7 7t0(;:t Naa�tnbrx of�reut tdpidemt� �- po r�c�ave Is humdrytau a sqxuaft sewacpSNM-mb DWYes5%mam kareWonrequhcdl Lmmdrysysreut� ors ✓„ - Scasonal use:{yes Orn o).T t 1Natermaztt gs,if pabk ) e'! sump Prof dacerin-r- c date o€o COASIVIERCMUMDUSTRIAL Type ofestab I�s #a sis Of Grease MW pr-c=t Indusub!waste holfing uu* Nina-sauftary Wain East dais o€acoyluse, Q Famglng Reeords Sour=ofinfa u; z1V-sss rystem PumPId as Part ef'tbe ar4o�- �Y�voIutac�, �- ►war q�* I �? Reason.forp �tScPtic taut detita�c I '- � - -Single ce f ' —Overflow cesspool- —PAVY S mmd s3 (yes arm a)ffycs,attache records,,ifmy) - Txutavarive-(Alt m3dve"4bPoTo9Y=Af ach a eogrof'the cmxmt operau-m and mabmw=m cmtmm(to be obtained from sysftm€►wads) _TIzbttank AifacA a copy e3fthc EW-TPWVRi Y �3ther(dlest�'I►e)- - - Appraximam �e of mss(jf]amwn3 and smur..e of dm lef9 Were;sr-wage oeiom do i+and vthm a=Mg Ute or nt Pgge7ofll .a UBWMAIM MWAG9 O 'er S M ° laMM1 C Address: _ .: .-5e pey & DRAIN t3 1 Forest Street ' TO.N',MA 01949 Ovmww - ✓ r t :. _6G Date of Inspew . BIDING SEWER{locate onsits = t)eplhbdow9V4dw Distmece fr+tmipttc swply vteIl oirs lam; Came(M CIMOiOn afjomis,ve eyidM= sEpnC TACTIC- �!Ctocate on hep ) belaly _ '-�- t (Yesarno)=._._.(anwh nCOPY of ftm be o�ofo it tee orb � 31Dk=ct /l - _fnatop of scum totnp of jidatic or baM- DkMn0efivmbOftMOfM=lb � - Ho +r ae s condhiM st�tacttsal hgagaty,lictuid levels Comments(on pm tee asxehftd-ta outletb v evideace,ofd ami: /'r df ;�>.•� CMIKA" =she Dept Vi=- other Matieud of Di ice fvnutop asfss�uto tee ori: _ csf s W b€tam tee+rarbaf$e: Daft oft ., _ . ari�ffit:+ ��''_�levWs Comments( �ofkdMZe7 - rage is of I I nakxr ot(Fq ,fig gyp` may* -Y ASE MIE��FT v SUB-51WACE BMWAGWIMPOSAL SYSTMW MWMCnON ORM PART C -Pragertg Address: Date of Im idiot.- L 13,t F-,-p, U 6�L f TIGHT or noLDING TANK:VhTTWk rust be P=4,---d at time of �oasj(Iacate oaa site plan) eprh below grade: 'of consmuctioaa: cotter c mcrtnl ___,_pol�yIeaae othet(escplaats : Dimensions: ac1t3'- Desiga Pow: Alarm preseut(yea or Alarm ieveL- Alarm in wuridng order Date of Co (couditiotx ofa3arm and floatswi€clacs, : DIST Z UTION BOX- II/ (xfxeseut must be o on site plan) Depth of liquid level above outlet mvv Comments(wrote if boat is level wd di,tdfbudon to trttticts eco emy evidence of solids leakage wto or ut of�ox eetc.)- fiver,any evidence of PI .l; 'i—(lcrc.,ate on site plan) umps in working Alarms in Woo r 3no); c.omtn condition of fiber,condition of pumps and appurtenancer,etr_). GMCL&L INSAMONFORNT-•-NOTRVOL 3W"Y,&& .,��F> SSUWACES"�AM DBTOER&L SYSTEMFF.CnON FOAM PW 4C WopertyAddress:Owner: J's SEPI` & N i 1.31 For,s, street 13�eofc s Out MIDDL"1ON. 0319,S' SOM ABSOItMON SYSTSM(SAS): zloo on sltea phix6 excavation not retlutred) if .S not locawd este why. Type l�ch�g pits,mti�er__ leachingmss,nuFuliczz. sd1ft1=6 number: leeg� ,hatters: leaddag Ids, zmber, p .. overflow cesspool,xumdhet: imuovwive,/hbuna ve systems T,+gef oftt3chnolog3r_ Comments{tom coed-ion.ofsoi,sqM ofhy&aullo bAme,level ofd damp soiL cmtdition of ve=etetioxi, etc.): CESSPOOLS: (cesspool bes of- `oq)aocaw on site plan) laer end an: l?epth— of liquid to Net invelt Depth ca€scrlic r. _ Depth of scum layer Dimensio Of �- l�:ials Indican dratmdr inflow(yes orxto. C+a (now C011c ioti ofso ,sag s ctfizy c �kvdof]c=ditn&cmdidon ofvegeWtion,etc.)_ PRr": -aocaxe on site pis.) Ma c€instructioa 3ZlhD�a0b_ �s: - - 17s dour=dht sod,sib ofhycmio hbar,Ie l ofpan&W.diem of vemetadw4 etc.)- rage to of l I =WWAM SMAIM DSLI %T�+:CnO PAff C SYSTIM MFORNUMN(c ontWued) ,r- I' ETI ' Prot a Address_. . �jt`" 131 hu sI treed n �s I�'i c� t Date of Inveeflon: "I SKETCH€F SZWAUE DISPOSAL SYSTM Fzsvide a sloe ofthe sewvkp dinm4 syxtc=jaclaftgti to atIem two pmummase Cc b dorsa t or loin LOc2ft Awe%WRb.ia.100 fut Locaft vibm pubbe MW m4*y ft ftg f-ro,%4 1- PART C SSM EWORMATION(=mfim:d) Property Address: . A— Y's SEPTI men Date of InVeeffout -D- Ors'"l .',•�—::.��. SM E X AM er Estimated depth to Wat and water � fejt Pi se indite(d=k)aU meth c&used to detunme the Ngh gmund water ele ion- t fromsystcm des*mpImsmm c ord-Wd m do 4 daft ofdes-Wm phn=&:wed: sft(abnnmg r af hole wi&150 fixt of SAS) O=kedwithtoed Board of He&W"Vfm= _.. wft kmnd cmmvauns,hmtmUcws-(att ix t) cursed USGS database - YOU d e how yaq established tlaefth around weer etev Pion: aled;G 'I