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Home My WebLink AboutMiscellaneous - 54 STERLING LANE 4/30/2018 (2) :.� I I i C L i i'�� 6 �/ �� I - - Commonwealth of Massachusetts RECEIVED Title 5 Official Inspection Form NOV 172016 ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , TO EALTH DEPARTMENT lug ER 54 Sterling Lane evu Property Address Sean Kenney Owner Owner's Name information is required for every North Andover MA 01845 11/10/2016 page. Citylrown 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 filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Neil Bateson use the return Name of Inspector key. Bateson Enterprises Inc. Q Company Name 111 Argilla Road Company Address Andover MA 01810 City/Town State Zip Code 978-475-4786 SI-15 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 urther Evaluation by the Local Approving Authority //J- 1, -� 11/8/2016 InspectKes tignature 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 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.doc•rev.6/16 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 54 Sterling Lane Property Address Sean Kenney Owner Owner's Name information is required for every North Andover MA 01845 11/10/2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc•rev.6116 Title 5 Official Inspection Forth: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 54 Sterling Lane Property Address Sean Kenney Owner Owner's Name information is required for every North Andover MA 01845 11/10/2016 page. CityrFown 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 ❑I 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 16.303(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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System•Form-Not for Voluntary Assessments 54 Sterling Lane Property Address Sean Kenney Owner Owner's Name information is required for every North Andover MA 01845 11/10/2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No 0 ® 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 Y day flow t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "< 54 Sterling Lane Property Address Sean Kenney Owner Owner's Name information is required for every North Andover MA 01845 11/10/2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6116 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 54 Sterling Lane Property Address ISean Kenney Owner Owner's Name information is required for every North Andover MA 01845 11/10/2016 page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants.if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 54 Sterling Lane Property Address Sean Kenney Owner Owners Name information is required for every North Andover MA 01845 11/10/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d Yes 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: CurrentDate Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 54 Sterling Lane Property Address Sean Kenney Owner Owner's Name information is North Andover MA 01845 11/10/2016 required for every page. CityrTown 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 two years ago, owner Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Measured tank Reason for pumping: Inspect tank&tees 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts IVTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 54 Sterling Lane Property Address Sean Kenney Owner Owner's Name information is required for every North Andover MA 01845 11/10/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 16 years old, 11/16/2000, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.6 feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): 4" PVC through wall to septic tank, 3" PVC in house, no leaks visible Septic Tank(locate on site plan): Depth below grade: 0.6feet 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: 10'x 5'x 4' Sludge depth: 1" t5in5.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 9. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 54 Sterling Lane Property Address Sean Kenney Owner Owner's Name information is required for every North Andover MA 01845 11/10/2016 page. Cityfrown 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 32" 2" Scum thickness Distance from top of scum to top of outlet tee or baffle 8.1 Distance from bottom of scum to bottom of outlet tee or baffle 13" � How were dimensions determined? Tape measure Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. Center cover has riser to grade. Pumped septic tank. 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 I t5ins.doc•rev.6116 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 54 Sterling Lane Property Address Sean Kenney Owner Owner's Name information is North Andover MA 01845 11/10/2016 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal.System•Page 11 of 17 illl Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 54 Sterling Lane Property Address Sean Kenney Owner Owner's Name information is required for every North Andover MA 01845 11/10/2016 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box level &distribution equal. No evidence of carryover. No evidence of leakage Pump Chamber(locate on site plan): Pumps in working order: ® Yes ❑ No* Alarms in working order: ® Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Pump tank ok. Pump ok. Floats ok. Access cover to grade over pump&floats. Alarm has both audible&visual * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: i i t5ins.doc rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 54 Sterling Lane Property Address Sean Kenney Owner Owner's Name information is required for every North Andover MA 01845 11/10/2016 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2 trenches 70' long ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok.Vegetation ok. No sign of ponding to surface. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 54 Sterling Lane Property Address Sean Kenney Owner Owner's Name information is required for every North Andover MA 01845 11/10/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5ins.doc-rev.6/16 Title 5 ficial Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments 54 Sterling Lane Property Address Sean Kenney Owner Owner's Name information is required for every North Andover MA 01845 11/10/2016 page. City/rown 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 L O 5L r �jQ�(-�v�Gcna�. = f�a,► O plc PU o"PTa^�,t� I °v v � Y\?e t5ins.doc•rev.6116 We 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 54.Sterling Lane. Property Address Sean Kenney Owner Owner's Name information is required for every North Andover MA 01845 11/10/2016 page. Cityrrown 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: 4 feet 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: 5/30/1995 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: Design plan ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: As per test pit data on design plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5lns.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 54 Sterling Lane Property Address Sean Kenney Owner Owner's Name information is required for every North Andover MA 01845 11/10/2016 page. Cityrrown 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Town of North Andover Tax Map # 210-106.C-0022-0000.0 Parcel Id 17660 54 STERLING LANE SEAN &JESSICA KENNEY 54 STERLING LANE NORTH ANDOVER MA 01845 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 0.67 Acres FY 2017 U13-Mailing Index Name/Address Type Loan Number Active/Inact. From until SEAN&JESSICA KENNEY Owner 54 STERLING LANE NORTH ANDOVER MA 01845 SALTAMARTINI,ANTHONY Previous Customer Inactive 4/30/2004 SALTAMARTINI,LORRAINE 54 STERLING LANE NORTH ANDOVER,MA 01845 WILLIAM VANARSDALE Previous Customer Inactive 11/29/2011 JANET HYMAN 54 STERLING LANE NORTH ANDOVER, MA 01845 UB Account Maint, Account No Cycle Occupant Name Active/Inactive Bldg Id. 13868.01-54 STERLING LANE Last Billing Date 9/12/2016 2100713 02 Cycle 02 Active UB.Services Maint. Account No.2100713 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 797.50 A UB Meter.Maintenance Account No.2100713 Serial No Status Location Brand Type Size YTD Cons 16372379 a Active ERT METE METE w Water 0.63 0.63 2798 Date Reading Code Consumption Posted Date Variance 8/2/2016 4415 aActual 150 9/21/2016 650% 5/3/2016 4265 aActual 20 6/21/2016 -30% 2/2/2016 4245 a Actual 29 3/28/2016 -83% 11/2/2015 4216 aActual 165 12/30/2015 20% 8/4/2015 4051 a Actual 141 9/14/2015 626% 5/4/2015 3910 a Actual 19 6/22/2015 2% 2/3/2015 3891 a Actual 19 3/20/2015 -72% 11/3/2014 3872 aActual 69 12/15/2014 -42% 8/1/2014 3803 aActual 111 9/11/2014. 575% 5/5/2014 3692 a Actual 17 6/12/2014 11% 2/3/2014 3675 a Actual 16 3/17/2014 -93% 10/31/2013 3659 aActual 209 12/20/2013 7% 8/1/2013 3450 a Actual 198 9/18/2013 1176% 5/1/2013 3252 a Actual 14 6/18/2013 -81% 2/7/2013 3238 a Actual 90 3/13/2013 -68% 10/30/2012 3148 a Actual 247 12/13/2012 -6% 8/2/2012 2901 a Actual 273 9/26/2012 468% 5/2/2012 2628 a Actual 47 6/20/2012 266% 2/2/2012 2581 a Actual 11 3/14/2012 -89% 11/17/2011 2570 f Final Bill 135 11/17/2011 -23% ssachusetts Commonwealth of Ma City/Town of . System Pumping.Record Form 4 DE has.provided this form#or u§e-b local Boards of P Health.• th. Other forms P Y may be'used, but the information,must be substantially the same as that provided here. Before using.this form,check withY our local Board of Health to determine the form they use.The System Pumping Record must be submitted.to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left/Right front of house, Left i ht rear of hous , Left/right side of house, Left/ ? Right side of building, Left/Right front of buildilig, Left/Right rear of building, Under deck Address Citylrown State - Zip Code 2. System Owner. Name Address(if different from location) Citylfown State Zip Code �� Z3 Telephone Number .�> j . .6. Pumping t.Zecord 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type-ofsystem: ❑ Cesspool(s) ptic Tank . El Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? 0 Yes M'Mr' If yes,was it cleaned? ❑ Yes ❑ No, S. Condition of System: eLleA V` 1 _ ` 6. System Pumped By.- Nell y:Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Ina Company 7. Locatio where contentswere disposed: C.L S: Lowell Waste Water SignWe it Hiul Date t5form4.doc•06103 System Pumping Record•Page 1 of 1 � 4 t COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A \ CERTIFICATION Property Address 9 �' R Lc 1G /Y A'v VP( Owner's Name:.,ra Owner's Address: yu ®fPBfl{ . Date of Inspection:` Name of Inspector: (please print)� o f , -«� Company Name:( t Mailing Addressr� C) Y r 1 A :7;4J . Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority _,Fails Inspector's Signature: &jt,::7n Date: v The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I y m "-page 2 of 11� OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A . CERTIFICATION(continued) Property Address JJ -IFi c Owner ) �G�1 YIf 11. Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: - B. System Conditionally Passes: N One or more system components as described in the"Conditional Pass"section need to be replaced or repaired:The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): _ f _ broken pip4i)ane replaced " _ obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: " I 1 2 e Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address'1 ^ ( 1, 1 �v ` uc f Owner:`= G 1 N-Y)a( h i Date of Inspection: C. Further Evaluation is Required by the Board of Health: t/� 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 protecf public health,safety and the environment: — Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and. the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this fofiri. 3. Other: r. 3 } Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner:SG� }`C\n--\ Date of Inspection: 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 rt c/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''/Z day flow - 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 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)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• � F You must indicate either`yes"or"no"to each of the following: r (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply te _ the system is within 200 feet of a tributary to a surface drinking water supply _ _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone.II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 } Page 5 of I I dp OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: C v,(1 CI n . Lr 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 by the owner,occupant,or Board of Health 4,`W- ere any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? —F ave 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? G! _ Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? L� _ _ 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? 1 s The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no t - ff _ MExisting information.For example,'a planat the Board of Health. Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] } i 5 r = Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: CT CT G�1 ,C ,n Date of Inspection: – L1–j q FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMItr.115.203 (for example: 110 gpd x#of bedrooms): u Number of current residents: v Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):/,/,j [if yes separate inspection required] « Laundry system inspected(y6.or no): Seasonal use:(yes or no):_ V Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):�cJ ` Last date of occupancy: 4('G COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): `+ GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part 6f the inspection(yes or no): S If yes, volume pumped:/ �u gallons--How was quantity pumped determined? Reason for pumping: I 'i v tr r 4 1'L r= ( r zoe *, TYPE OF SYSTEM F A. Septic`tankadisti butiodb'ox,soil absmptian syst6in ` t _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) p_Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): 6 Page 7of11 ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address-"SLI _A/ _ i1c�01/P Owner:SOLI Xn )OH-, Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron t-"-40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): r tar /��(.�; �(°4•].�1,�� a {, rr " " a a t C SEPTIC TANK:_(locate on site plan) Depth below grade: y Material of construction:_cam' oncrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) r It s Dimensions: ° Sludge depth: Distance from top of slud a to bottom of outlet tee or baffle: 3 s 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: How were dimensions determined: D// Si 7-2f Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAP: 7(locate on site plan) Depth below grade:_ Material of construction: concrete` - metal_fiberglass _:polyethylene_other ' (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: J Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 , OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:S(4 LL /J'/1 /)rlvvf'r Owners—S(J l l _0' 1"' Date of Inspection: r 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: 1 1, Capacity: ''{z gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOJZ-5(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Af1?U'4,— 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.): 1 ' S . PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no):�/= 5 Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 4 . • wi 8 Page 9 of 11 e ' OFFICIAL-INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C fSYSTEM INFORMATION(continued) c'f=' Property Address: U., I ,/) ((Il F rte , OwnersDnki)Jnr L-h i Date of Inspection: -17-7t SOIL ABSORPTION SYSTEM(SAS):V�(locate on site plan,excavation not required) If SAS not located explain why: ' Type leaching pits,number:_ leaching chambers,number: _beaching galleries,number: leaching trenches,number,length: .2 U `� leaching fields,number,dimensions: 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.): Z,1 G,E %7W T/yi 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: 4 Indication of groundwater inflow(yes or no): 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.): 9 Page i � ! OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM'INFORMATION(continued) Property Address: Owner:-., )n I G hi Date of Inspection: —V—off Z 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. r t s G Ej A ,C D 20, % L W1 .. 10 s •. W� r 1 .� Commonwealth of Massachusetts it Title 5 Official Inspection Form y f; .d Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 71, a 54 Sterling Ln. sot _. Property Address - Janet Vanarsdale Owner Owner's ---.. _ -----— —.. _ wner's Name --- ---- information is required for every North Andover _— MA 01845 06/06/2011 page. Ciy/TownState Zip Code Date of Ins ection Inspection results must be submitted on this form. Inspection forms may not be all-tiered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your q cursor-do not John Som use the return — key. Name of Inspector k2A1.TM�plTIY16 .; Soucy's Sewer Service Company Name 78 N. Broadway Company Address - - -. Er�r� Salem _ NH _ _ 03079_ City/Town State Zip Code 603-898-9339 13397 __.. 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 ❑ N ds urther Evaluation by the Local Approving Authority f�'�-✓' 06/08/2011 nspe, or.' Signature Date r Th . ystem inspector shall submit'/copy of this inspection report to the Approving Aut"ority (Board of ' ealth or DEP) within 30 days of completing this inspection. If the system is a sharer system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shat; sL.omit 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. e t5ins•09/08 Title 5 Official Inspection Form:Subsurface P Sewage Disposal System Page i or 1- Commonwealth of Massachusetts a=1 Title 5 official Inspection Form �^ N Subsurface Sewage Disposal System Form Not for Voluntary Assessments 54 Sterling_Ln. Property Address Janet Vanarsdale Owner Owner's Name information is MA 01845 06/06/2011 required for every North Andover page. City/Town State Zip Code Date of Inspectiol B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria desc:'.oed in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health- * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 '>. Commonwealth of Massachusetts =1Wj- Title 5 Official Inspection Form ul Subsurface Sewage Disposal System Form Not for Voluntary Assessments 54 Sterling Ln. -- ---- — - ----- - Property Address Janet Vanarsdale -- --- — Owner Owner's Name ------- - —_-- - information is required for every North Andover _ _ MA 01845 06/06/2011 _ -- – - 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 obstructeu pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Title 5 Official Inspection Form:subsurface Sewage Disposal System•Page 3 of 17 t5ins 09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form ' 0 Subsurface Sewage Disposal System Form Not for Voluntary Assessments 54SterliaqLn Property Address JanetVonarm�a|e Owner Owner's Name information is required for every North Andover MA 01845 06/06C2011 »age City/Town --�� State Zip Code Date mInspection 5'' 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: R The system has a septic tank and soil absorption system (SAS) and the SAS is within 1OOfeet ofusurface water supply ortributary toasurface water supply. R The system has a septic tank and SAS and the SAS is within a Zone 1 of public water supply. R The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has eseptic tank and SAS and the SAS is less than 100feet but 5Ofeet or more from a private water supply we||°° � Method used todetermine distance. __—__.....' ._—_- ---__ — This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached tothis form. 3. Othec O) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No Backup ofsewage into facility orsystem component due tooverloaded or �� [� � �� clogged SAS orcesspool � Discharge or ponding of effluent to the surface of the ground or surface waters � due toanoverloaded orclogged SAS orcesspool 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 S^ below invert or available volume is less El [� �~ than 1/2dn flow `sns'oymn Title 5 official inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 ^' Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1-4 54 Sterling L Property Address � JanetVanarndale Owner Owner's Name information is required for every North Andover MA 01845 06X06/2011 page. Cuv[Tmmn State Zip Code Date ufInspection � B. Certification (cont.) Yea No Required pumping more than 4times inthe last year NOT due toclogged or obstructed pipe(s). Number oftimes pumped: _____ El E Any portion of the SAS, cesspool or privy is below high ground water elevation. FI �� Any po�ionofcesspool nrphvyinvvithin1OOfeet ofaau�ooewater supply or �� tributary toasurface water supply. Any portion ofacesspool orprivy iawithin aZone 1 ofapublic well. Any portion of cesspool or privy is within 50 feet ofa private w/a�ar supply well- Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet e||Anyportionofaceaspoo| orprivyiu |easthan10Ofeetbutgreaterthan5Ofeat i from a private water supply well with no acceptable water quality analysis. [This system passes ifthe well water analysis, performed otaDEP certified i laboratory,for fecal coliform bacteria indicates absent and the presence � � mfammonia nitrogen and nitrate nitrogen isequal toorless t�mn5ppm, � provided that no other failure criteria are triggered. A copy of the analysis � and chain ofcustody must beattached tothis fmrrn.] The system ioucesspool serving afacility with odesign flow of2OOOgpd 10.O0Ogpd The aystemnfa� . � | have determined that one ormore ofthe above failure �� ~~ criteria exist asdescribed in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board ofHealth todetermine what will be � necessary tocorrect the failure. E) Large Systems: Tobeconsidered alarge system the system must serve afacility with o design flow nf1O,OOOgpdto15,UOOgpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the � questions inSection D Yee No the system iswithin 4OOfeet ofasurface drinking water supply / the system inwithin 200feet ofatributary toasurface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— |VVPA) oramapped Zone || ufapublic water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, oranswered ^yes^ inSection Dabove the large system has failed. The owner oroperator nfany large system considered a significant threat under Section E or failed under Section O shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office ofthe Department. ��5omc�/msPem""p�m.s"�"�" Sewage o*�m/�v*°m-p��5m,, m/o^'n�ou | Commonwealth of Massachusetts 50 Title 5 Official Inspection Form 'i'i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e 54 Sterling Ln-_ Property Address Janet Vanarsdale Owner Owner's Name information is North Andover _ MA 01845 _ 06/06/2011 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 pF~od? ❑ ® 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 she site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: 4 Number of bedrooms (design): 4 — -- Number of bedrooms (actual): -- DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 - - t5ins•09/08 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System•Pace 6 of 17 °_. Commonwealth of Massachusetts Title 5 Official Inspection Form ISI Subsurface Sewage Disposal System Form Not for Voluntary Assessments 54 Sterlinq Ln. -- --- -- -.—.— - -- -- — Property Address Janet Vanarsdale Owner Owner's Name information is MA 01845 06/06/2011 required for every North Andover page. City/Town State Zip Code Date of Inspection D. System Information Description: 2 Number of current residents: -- Does residence have a garbage grinder? ❑ Yes ® No tem? if es separate inspection required] ❑ Yes ® No Is laundry on a separate sewage system? [ y p p q Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): --- — — Detail: See Attached Sump pump? © Yes ❑ No Current_ _ Last date of occupancy: 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? El 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: ------ - Sins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 1�j Subsurface Sewage Disposal System Form Not for Voluntary Assessments NO 54 Sterling n Property Address Janet Vanarsdale Owner Owner's Name information is North Andover MA 01845 06/06/2011 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: Owner Was system pumped as part of the inspection? Yes ❑ No If yes, volume pumped'. 1500 gallons Gauge on truck How was quantity pumped determined? Reason for pumping: Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy El Shared system (yes or no) (if yes, attach previous inspection records, if any) El 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 F-1 Tight tank- Attach a copy of the DEP approval. El Other(describe): t5ins-09/08 Title 5 Official inspection Form:Subsurface Sewage Disposa.System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 54 Sterling Ln. _ Property Address Janet Vanarsdale --—- -- Owner Owner's Name information is _ MA 01845 06/0_6_/20_11 North Andover required for every — page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 04/11/2000Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 36" Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): --- N/A Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade. 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 6'X11'- ---- Dimensions: Sludge depth: Title 5 Official Inspection Form:Subsurface Sewage Disposai System•Page 9 of 17 t5ins•09108 Commonwealth of Massachusetts Title 5 Official Inspection Form 1-1 Subsurface Sewage Disposal System Form Not for Voluntary Assessments 54 Sterling Property Address j2net Vanarsdale Owner Owner's Name information is MA 01845 06/06/2011 required for every North Andover page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont-) 37" Distance from top of sludge to bottom of outlet tee or baffle 2" Scum thickness 6" Distance from top of scum to top of outlet tee or baffle 14" Distance from bottom of scum to bottom of outlet tee or baffle - Tape& Sludge tool How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap (locate on site plan)., Depth below grade: feet Material of construction: F-1 concrete ❑ metal ❑ fiberglass ❑ polyethylene El 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 t51ns-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts i ls=i7y� Title 5 Official Inspection Form M t Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 SterlingLn Property Address Janet Vanarsdale Owner Owner's Name information is MA 01845 06/06/2011 required for every North Andover 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 play'.-: Depth below grade: Material of construction: ❑ concrete El metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per d"ay Alarm present: 7 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? El Yes ❑ No t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 I of 17 Commonwealth of Massachusetts ! Ii Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments � u 54 Sterling Property Address Janet Vanarsdale ._... —_--- - ------._.......--- Owner Owner's Name information is MA 01845 06/06/2011 required for every North Andover page. City/Town State Zip Code Date of Inspection D. System Information (cont.) I Distribution Box (if present must be opened) (locate on site plan): 0" - --- Depth of liquid level above outlet invert - - 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.): Flow checked ok. -- -- -- - I 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.): I Pump and alarm system working well. ----=--_ Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t51ns•090 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 ` ^ ^�� Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form Not for Voluntary Assessments 54SterlingLn`___________________�___'_-_'�____--_'_-__________________��.�____ _____ Property Address Janet Vanarsda|e______—__________ mwnor Owner's Name information is North Andover MA 01845 08/06/2011 roqu/oaumreve� --------'---------- - ------- --�- ��'-- �� i ---�-------- State Zip Inspection page. City/Town - Date of - D. System Information (cont.) � Type: � � 0 leaching pits number -----------��-- leaching chambers number: leaching galleries number - � CU4'X7O' �� leaching trenches number, length: ~-^-------- ---- � �� leaching fields number. dimensions: �------ ----- i �� F-1 overflow cesspool number -----------�' innovetive/altema�vesystem Type/name oftechnology: ----- ----'---- ---- � | Comments (note condition of soil, signs ofhydraulic failure, level of ponding, damp eni|, condition of vegatotion, etc.): No igof |ic failure � 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 - ---------�-------------- Depthofaoum |uyer ---------'----'--- - ---- Dimenoionsofoesspoo| Materials of ofounstruotion ---�---------------''- --- |ndioodonofgnoundvvoterinfluw El Yes | | No Commonwealth of Massachusetts Fr Title 5 Official Inspection Form r, Subsurface Sewage Disposal System Form Not for Voluntary Assessments 54 Sterling Ln__ _ Property Address .ianetVanarsdale __ ___ __— ___- _ --- -----_-- ----- Owner Owner's Name information is required for every North Andover _ MA 01845 06/06/2011 -- 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.) ------------ m Subsurface ossl System•Page 14 of 17 Sewage Dis Title 5 Oficial Inspection Form:S 9 P t51ns•09108 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ° 54 Sterling Ln. Property Address Janet Vanarsdale Owner Owner's Name information is MA 01845 06/06/2011 required for every North Andover State Zip Code Date of Inspection page. City/Town 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 a STERLING LtANE� � 22k DRIVEWAY EASEMENT EXISTING FOUNDATION, 'b0)•'' 00'GALLON SEQ.T/C LANK l ` ..'1'ODO CACLON>. DRIVEWAY / EASEMENT LOT:: 2 : \\9Ke AREA Lor s o / I zl I 0 &G N ¢LI 3WIDf o, lil I I fok ING OHES H IWI I I E5' ':1 H. op 41-1 1 . P 92-2 • s: I 1 I I .OP 9212 1 I .. 1 1 r•VERT 30 Title 5 Official Inspection Form:Subsurface Sewage Disposal Sys.:.,i•Page 15 of 17 t5ins•09/08 " . Commonwealth of Massachusetts , Title 5 Official Inspection Form Subsu�aceSevvageDisposal SyotomnFormn ' NotforVo|untoryAseeasmonto � 544 Sterling Ln. Property Address JanetVanorsdale______________________-_- Owner Owner's Name information is North [NA 01845 06/08/2011 mnu/roumrc,e� -_---_'--- ----'- --------- ---�---------'----�-----� — ------------�� State �pCode D�eof|nope�ion City/Town D. System Information (cont.) Paoo� Site Exam: Check Slope Surface water Check cellar Shallow wells 0' Estimated depth tohigh ground water: fee Please indicate all methods used to determine the high ground water elevation.. Obtained from system design plans on record O4/2OOO |fchecked, date ofdesign plan reviewed'. 6a�---- ---------'--- Observed site (abutting property/observation hole within 15Ofeet ofSAS) El Checked with local Board ofHealth exp|aini Checked with local excavators, installers (attach documentation) F� Accessed USGSdatabase 'explain: You must describe how you established the high ground water elevation: Duqho| Ath auger in low dro offanaa,�N Before filing this Inspection Report, please see Report Completeness Checklist on next page. a ' Commonwealth of Massachusetts r- z _- Title 5 Official Inspection Form VTli! Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �� E_ 54 Sterling Ln. — — _—_ --- --- Property Address Janet Vanarsdale -- Owner Owner's Name information is MA 01845 06/06/2011 required for every North Andover _--_--_ -- — - — 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 separaie file t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 FILE COMMENTS Name: Janet Hyman Comments: Date: December 7`", 2004 On December 7, 2004 I spoke to Janet Hyman and discussed the addition to 54 Sterling Lane. Janet has confirmed that there are 9 rooms in the existing dwelling, therefore maxxing out the home and leaving no room for any additions until a License Engineer can be consulted by the homeowners to consider a Septic System upgrade. I also asked if she'd like us to come out to the house and re-evaluate the home be to be certain about the number of rooms. She declined. Michele E. Grant 12/9/2004 Both Susan and I spoke to Bill Barrett on 12/9/04 explaining the situation, (above). We also offered to Bill a re-evaluation of the home by doing a walk thru. Bill was under the impression the permit was denied because of the 3- season porch. I indicated to him that I had discussed regarding this room with the homeownerr and the 3-season porch was not a consideration in the plan. The form was denied because the existing dwelling has 5 rooms on the first floor, and 4 rooms on the second floor, totaling 9 rooms; therefore requiring a Passing Title 5 inspection to insure security with the Septic System to the homeowner. Michele E. Grant i i T Town of North AndoverNORTH OFFICE OF 3?Of t"" •��0 L COMMUNITY DEVELOPMENT AND SERVICES p 30 School Street WII LIAM J. SCOTT North Andover,Massachusetts 01845 ss A. .9�`t5 9 ACHUS Director April 16, 1998 Mr. Steven D'Urso. 22 Lilly Pond Rd. Boxford, MA 01 9 21 Re: Lot 2 Sterling Lane. N. Andover, MA 01845 Dear Mr. D'Urso: This is to inform you that the proposed plans for the site referenced above have been approved. If you have any questions, please do not hesitate to call the Board of Health Office at the number below. Sincerely, � Sandra Starr, R.S. Health Administrator S S/rel cc: George Farr File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 . Y ` 1 STEVEN J. D'URSO �-9 ILIEV`l IEM ( [F lT[ USEO lU GILL �. Environmental Designs 22 Lilly Pond Road W. Boxford, MA 101921 DATE (508) 352-9872 ATTENTION TOalRE 1ad 4�1 �� > WE ARE SENDING YOU Attached ❑ Under separate cover via the following items: ❑ Shop drawings Pefrints ❑ Plans ❑ Samples ❑ Specifications ❑ Copy of letter ❑ Change order ❑ COPIES DATE NO. DESCRIPTION r I THESE ARE TRANSMITTED as checked below: ff For approval ❑ Approved as submitted ❑ Resubmit copies for approval ❑ For your use ❑ Approved as noted ❑ Submit copies for distribution > ❑ As requested ❑ Returned for corrections ❑ Return corrected prints ❑ For review and comment ❑ ❑ FOR BIDS DUE 19 ❑ PRINTS RETURNED AFTER LOAN TO US REMARKS f �� 24by,2,C 2 , ee� /% LA 'Aazo, � DPY TO I SIGNED: i It enclosures are not as noted. kindly nntlty un nt ^. Town of North Andover N0RTM OFFICE OF r o?o,'``" COMMUNITY DEVELOPMENT AND SERVICES p 30 School Street North Andover,Massachusetts 01845ss,-' I.00"�y WILLIAM J.SCOTT Director Decemberl0, 1997 -Steve D'Urso 22 Lilly Pond Dr. Boxford, MA 01921 Re: Lot 42 Sterling Lane Dear Steve: -� This is to inform you that the proposed plans for the site referenced above have been disapproved for the following reasons: —L No benchmark(3 10 CMR 15.220(q)). -2. Missing foundation drain(N.A. 02y). 3. No map and parcel (N.A.8.02a) 4. Note 43 to agree with 310CMR 15.255. 5. Please calculate emergency storage of pump chamber. 6. No manual operating switch specified (N.A.8.02x) 7. Missing complete pump specs (N.A.8.02x). 8. Please specify number of doses per day (310CMR 15,254(1)(d). If you have any questions, please do not hesitate to call the Board of Health Office at the number listed below. Sincerely, Sandra Starr, R.S. Health Administrator S S/cjp cc: George Farr William Scott, Director, P&CD File CONSERVATION-(978)688 9530 • HEALTH-(978)688-9540 • PLANNING-(978)688-9535 *BUILDINGOFFICE-(978)688-9545 0 *ZONING BOARD OF APPEALS-(978)688-9541 • *146 MAIN STREET NORTH ANDOVER BOARD OF HEALTH DESIGN REVIEW REPORT DATE n �} FEE: U PERMIT # % -3 DATE RECEIVEDD ��71 APPLICANT Co MAP PARCEL ADDRESS LOT ##_ STREET ## ENG. 7&-V9- D"" )R56 STREET ENGINEER' S ADD D. L/GG �/ P�,�A PLAN DATE REV. DATE CONDITIONS OF APPROVAL APPROVED DISAPPROVED REASONS FOR DISAPPROVAL: PA 41 112 70 U Hip 5,0e,6- 5-. C &�a5,6 i i a� 3 / PLAN REVIEW CHECKLIST ADDRESS o67- ENGINEER st GENERAL , / / 3 COPIES STAMP LOCUS // NORTH ARROW SCALE CONTOURS (/ PROFILEef (Sc) SECTION v BENCHMARK SOIL & PERCS -/ ELEVATIONS WETS . DISCLAIMER WELLS & WETS WATERSHED? AO DRIVEWAY" WATER LINE C/ FDN DRAIN M&P X SCH40 TESTS CURRENT? ()Ir_ SOIL EVAL .D U es 6 SEPTIC TANK MIN 150OG . 17 INVERT DROP L""'- GARB. GRINDER io (2 comps +200) 10 ' TO FDN L,"� MANHOLE L,,'� ELEV GW ## COMPS. / GB D-BOX SIZE ## LINES C�, FIRST 2 ' LEVEL STATEMENT INLET - OUTLET 17 (2" OR . 17 FT) TEE REQ'D? CS LEACHING MIN 440 GPD? RESERVE AREA 4 ' FROM PRIMARY? " 2% SLOPE `' 100 ' TO WETLANDS 100 ' TO WELLS a_-- - 4 ' TO S .H.GW e`� (5 ' >2M/IN) 20 ' TO FND & INTRCPTR DRAINS L-' 400 ' TO SURFACE H2 `f 0 SUPP 4 ' PERM. SOIL BELOW FACILITY, MIN 12" COVER FILL? x(15 ' ) BREAKOUT MET? bl� TRENCHES MIN 440 gpd SLOPE (min . 005 or 6"/100 ' ) SIDEWALL DIST. 3X EFF. W OR D (MIN 61 ) ✓ RESERVE BETWEEN TRENCHES? 4-� IN FILL?e--- MUST I BE 10 ' MIN. " PEA STONE? L--- VENT? ✓ ( >3 ' COVER; LINES >50 ' ) BOT �� + SIDE -9t6 = � d X LDNG = TOT 'T'S S7 `fes (L x W x #) (DxLx2x#) (G/ft2 Copyright @ 1996 by S.L. Starr /JD TE #3 To 1 E PITS MIN 440 LEACHING MIN 1 ( 13 ' x16 ' ) PIT MANHOLE/PIT GW MIN 4 ' BELOW BOTTOM EXC 2x EFF W OR D 12"-48" STONE BOT + SIDE x LOAD = TOTAL. (L x W x #) ( 2x( L+W)xD x #) (G/ft2) CHAMBERS MIN 440 LEACHING GW MIN 4" BELOW- COVER >3 FT - VENT' MANHOLES 12"-48" STONE SPLASH- PADS SLOPE ._005` BED/TRENCH (Bed max. 60 ' X 60 ' ) MIN 13 '' X 16.' PIT` _ BOT + SIDE' X.:.LOAD = TOTAL (L x W x. #)' (.2 x (L+W)xD. x: #:) (G/ft2), FIELDS.: - MIN 440 GPD X90'0 ft2 BED �GW MIN. 4 ' BELOW: BOTTOMOF FIELD- PIPE ENDS JOINED? ' 4" PEA STONE?. DIST LINE SLOPE' ._0.05? >3.' COVER-VENT. j i' SCH 40 4--- MIN 1211 COVER RATE ( g . ) X = TOTAL L W LDG �\ DOSING. TANKS AND PUMPS DIMENSIONS X. X = PUMP CAPACITY ` `gptct..: L W D i Vol . DISCHARGE SIZE C6 DISCHARGE RA TE DISCHARGE, TIME gPm MANHOLES TO GRADE (/ ALARM SEP .. CIRC. �GW v (Min. L" below inlet). HWL/C9 4: LWL �Z CHECK.. VALVE: BLEEDER HOLE MANUAL OP . W S ITC ENUF STORAGE . F}1 u 7-&-�1)}OCL S SEC 5 . 7--6),e 710/Lf X05 .Copyright ® 1996 by S.L. Starr I TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE 11/27/00 This is to certify that the individual subsurface Y disposal system p constructed ( X) or repaired ( ) by Dave Maynard at Lot 2 Sterling Lane has been installed in accordance with the provisions of Title V of the State Sanitary Code and with the North Andover Board of Health regulations. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. Board of Health Inspector i TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM INSTALLATION CERTIFICATION The undersigned hereby certify that the Sewage Disposal System constructed; ( )repaired; by '22" �c located at c was installed in conformance with the North Andover Board of Health approved plan, System Design Permit#_�LF3 , dated �- �2l O , with an approved design flow of//D gallons per day. The materials used were in conformance with those specified on the approved plan; the system was installed in accordance with the provisions of 310 CMR 15.000, Title 5 and local regulations, and the final grading agrees substantially with the approved plan. All work is accurately represented on the As-built which has been submitted to the Board of Health. Bed inspection date: ngine Representative Final inspection date: J/ v?2 (Z4 gineer Representative Installer: Lic. Date: Design Engineer: Date: / ,�/o J I 27 i INSPECTION CHECKLIST FOR SEPTIC SYSTEMS Yes NO Initials A. Bottom of Bed 1. Excavation to proper depth ✓ 2. With trenches,sides of excavation are beneath B horizon ,✓ 3. Edge of excavation specified distance from foundation,etc. Comments: JV� �o J�...�'D-T"i Cr^'� ��✓... '�v�` ". /."S��P )L�'c�..V J'!�� ✓"i�"^ �� rw[�► r�'.�''t+M�A B. Retaining Wall 1. Wall height and width as specified 2. Waterproofed 3. Wall minimum 10'to leaching facility 4. Wall meets specifications of plan Comments: C. Building Sewer 1. Pipe diameter minimum 4" 2. Schedule 40 pipe t/ 3. Watertight joints 4. Inlet to tank cemented 5. Slope minimum 0.01 or 1/8"per foot minimum 6. Pipe properly set on compact firm base 7. Pipe laid on continuous grade in straight line c/ 8. Cleanouts precede all change in alignment and grade 9. Manholes at any 90°change �---� 10. 10'minimum offset to water line Comments: D. Septic Tank 1. Level ' 2. 1,500 gal minimum 3. Gas baffle present on outlet 4. Manhole to grade 5. Manholes over center and each tee 6. 3-20"manholes -� 7. Inlet tee minimum 12"under invert ✓ 8. Outlet tee minimum 14"under invert 9. Outlet line cemented 10. Air space 3"above tees -� 11. 2"-3"drop from inlet to outlet 12. Pipe set ✓ 13. Compact base with 6"of 1/4"crushed stone under tank 14. Tank is watertight Comments: i Yes NO E. Pump Chamber 1. If separate from tank,compact base with 6"of 3/4"stone underneath ✓ 2. Minimum 2"pipe to d-box if gravity system ✓ . 3. 20"access manhole 4. Tank level ZL- eA�, 5. Watertight 6. Tank size agrees with plan specification ✓- ��` " 7. Manhole to grade 8. Check valve and bleeder hole presentovs� 9. Alarm in building on separate circuit 10. Alarm functions 11. Manual operating switch 12. Pump delivers liquid to d-box f Comments: l F. Distribution Box z/�3 1. D-box level 2. Minimum 0.IT'(2")drop from inlet to outlet ✓ 3. Minimum 6"sump ✓ 4. Outlet pipes show equal distribution 5. Compact base with 6"of stone beneath box 6. Box is watertight 7. All lines cemented with hydraulic cement 8. Schedule 40 pipe Comments: G. Soil Absorption system 1. All stone double-washed-'/4"- 1 ''/z" -pea stone Bucket test done? 2. Minimum 2".of pea stone above distribution lines 3. Minimum 6"stone beneath pipe 4. Distribution lines capped or connected together 5. Grading meets 3:1 slope 6. Minimum of 9"of fill graded over system 7. Toe of slope stops minimum 5' from edge of property; if not,then swale. Comments: H. Leach Trenches 1. Minimum 2 trenches 2. Length of trenches agree with plan. (Max. length 100') 3. Width of trenches agree with plan-Minimum 2';maximum-4'. ✓ 4. Vent present if�50 feet or specified ✓ 5. Distance between trenches minimum 4' and maximum of 6' ✓ 6. Minimum distance between trenches 10' ,/ 7. Pipe slope minimum 0.005 or 6"per 100' ✓ 8. Depth of trenches below outlet invert minimum of 6". y I Yes NO 9. Pipes set on stable base. Comments: I. Leach Field 1. Maximum length of field 100 2. Pipe slope minimum 0.005 or 6" �r 100' 3. Separation between pipe 6'maximum 4. Pipes connected at end 5. Separation between adjacent fields 10' um 6. Pipes set on stable base 7. Maximum 4' separation from edge of fiZeldt trst line 8. Minimum two distribution lines 9. Maximum perc rate 20 mpi Comments: I Leaching Pits 1. Minimum inlet pipe 4" 2. Pits of concrete 3. Sidewall between 12"azid,4,8"wide 4. Access manholes on each pit 5. Pipes cemented with hydraulic cement Comments: \ ' K. Final Grade !G 1. Slope over soil absorption system minimum 0.02 2. All system components covered by at least 9"soil 3. Cover soil free of stones larger than 6" 4. Grading slopes away from dwelling 5. No areas over system that may pond 1-4-7L AS-BUILT CHECKLIST LOT NUMBER, STREET NAME ASSESSORS MAP & PARCEL NUMBER LOT LINES & LOCATION OF DWELLINGS i- - LOCATIONS & DIMENSIONS OF SYSTEM, INCLUDING RESERVE �S • rJ�- �^^_"S r' �f TIES TO LOT LINES &DWELLING, WELLS a. FROM SEPTIC TANK b. FROM LEACH AREA LOCATIONS OF DEEP HOLES &PERC TESTS ELEVATIONS OF DISPOSAL SYSTEM +� TOP OF FDN ELEVATION LOCATIONS OF WELLS, DRAINS, WATERCOURSES WITHIN 150' OF SYSTEM LOCATION OF WATER, GAS, ELECTRIC LINES, CABLE DISTANCES FROM CORNERS OF HOUSE TO CENTER OF TANK& D-BOX ORIGINAL STAMP & SIGNATURE IMPERVIOUS AREAS - DRIVEWAYS, ETC. NORTH ARROW LOCATION& ELEVATIONS OF BENCHMARK USED Form No.3 Town of North Andover, Massachusetts BOARD OF HEALTH 2U�U NORT" LJ / Ot «ao a°1�0 3a ,•`. of o " •y'-o,-„;�.••�.� DISPOSAL WORKS CONSTRUCTION PERMIT ,,SAGHUSEt Applicant DRESS TELEPHONE NAM A If Site Location Permission is hereby granted to Construct ( ) or Repair ("'.) an Individual Soil Absorption Sewage Disposal System as shown on the Desi n Approval S.S. No. At ”' CHAIRMAN,BOARD OF HEALTH • Fee D.W.C. No. APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: CURRENT INSTALLER'S LICENSER LOCATION:��o� LICENSED INSTALLER. _:j)AJ)F_ pt-q a E�- SIGNATURE: TELEPHONER CHECK ONE: f-131 ION� C)n,t l REPAIR: NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUILT. Administrative Use Only 575.00 Fee Attached? Yes No Foundation As-Built? Yes No Floor Plans? Yes No Approval Date: INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction s coon of the septic system for the property at L2 46"elative to the application of dated a2c for plans by �CrO and dated with revisions dated _:z&1Af I understand and agreeto the following obligations for management of this project: 1. As the installer I am obligated to call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system is not ready then item two shall be applicable . 2. As the installer I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against my company. a) Bottom of Bed—generally first inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. b) Final Inspection—Engineer must first do their inspection for elevations,ties,etc. As-built or verbal OK from " engineer must be submitted to BOH,after which installer calls for inspection time. Installer must be present for this inspection. With pump system all electrical work must be ready and able to cause pump to work and alarm to function. c) Final Grade—Installer must request inspection when all grading is complete. Does not have to be on site. 3. As the installer I understand that persons or companies not associated with my company may not perform the work required by my company to complete the installation of the system identified in the attached application for installation. I further understand that work by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system, and/or revocation or suspension of my license in the Town of North Andover plus significant fines to all persons involved. 4. As the Installer I understand that I must be on site during the performance of the following construction steps: a) Determination that the proper elevation of the excavation has been reached b) Inspection of the sand and stone to be used. c) Final inspection by Board of Health staff. d) Installation of tank,D-box,pipes,stone,vent,pump chamber,retaining wall and other components. 5. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer Date: —"v C14 Town of North Andover, Massachusetts Form No.2 ` gORTry BOARD OF HEALTH �o 19— — s ti w t A DESIGN APPROVAL FOR t SSACMUSEt SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM i i Applicant �v i Test No. Site Location Reference Plans and Specs. ENGINEER DES IGN DATE } Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. a w CHAIRMAN,BOARD OF HEALTH i r. Site System Permit No. Fee_ r a FORM 11 -SOIL EVALUATOR FORM Page 1 of 3 No. Date: Commonwealth of Massachusetts lVd ANov✓e1Z , Massachusetts &abiUV Assessment for (Incite&Me D�snosal Performed By: �L � � Date: �' ye Witnessed By: � 5�� Location Address or Owner's Name Lot# � Address and Telephone# / j� � �✓�, New Construction ' Repair a Office Review Published Soil Survev Available: No F Yes Year Published Publication Scale —/4�6 Soil Map Unit Drainage Class RSoil Limitations Surficial Geologic Report Available: No Yes Year Published. Publication Scale Geologic Material(Map Unit) Landform Flood Insurance Rate Map: Above 500 year flood boundary No Yes Within 500 year flood boundary No Yes Within 100 year flood boundary No Yes Wetland Area: National Wetland Inventory Map(map unit) Wetlands Conservancy Program Map(map unit) Current Water Resource Conditions(USGS): Month Range: Above Normal Normal Below Normal Other References Reviewed: -- DEP APPROVED FORM-12M7!95—_ wilevel.esm FORM 11 -SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No. Z On - Site Review Deep Hole Number 9<7-2 Date Time `t'30 Weather Location(identify on site plan) Land Use Slope(%) Surface Stones VegetationW i�G2 J `)1 ap9t Landform v Position on landscape(sketch on the back) Distances from: Open Water Body �;r feet Drainage way ;;�Ipa feet -Possible Wet Area. fit. Property Line feet Drinking Water Well ��f/ feet Other _ DEEP OBSERVATION HOLE LOG* Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(Inches) (USDA) (Munsell) Mottling (Structure,Stones,Boulders,Consistency,% Gravel) 3Z._')/VS Z 2-SA 30 -MINIMUM OF 2 HOLES REQUIRED AT EVERY PROPOSED DISPOSAL AREA Parent Material(geologic) _Z2 L�— Depth to Bedrock: /'94/ 120th to Groundwater. Standing Water in the Hole: Weeping from Pit Face: Estimated Seasonal High Ground Water: 32 // DEP APPROVED FORM-12/07/95 �oilev�l.um i FORM 11 -SOIL EVALUATOR FORM Page 31 of 3, Location Address orLot No.. Z Determination for Seasons tet- 7'afite Method Used: aDepth observed standing in observation hole inches Depth.weeping fiom side ofobservation hole inches r, Depth.to soil mottles 32- inches j Ground water adjustment feet Index Well.Number Reading Date Index well level Adjustment factor Adjusted ground water-level Depth of Naturally Occumng Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the-depth of naturally occuring pervious material? Certification I certify that on /1�� date I have. passed. thesoil evaluator examination approved by the Department of Environmental Protection and that-the. above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. r Signature DatedII7l�7 f i DEP APPROVED FORM-17107)95 wilwd sam FORM 12 -PERCOLATION TEST Location Address or Lot No. COMMONWEALTH OF MASSACHUSETTS A A(Ilb• , Massachusetts Perealation Test* Date: Time: Observation Hole# 3 Depth of Perc g�`y �0 Start Pre-soak 10 d -r& End Pre-soak Time at 12" ,- 13 Time at 9" Time at 6" Time9"-6" ` 1 ��7 1� Rate Min./inch *Minimum of 1 percolation test must be performed in both the primary area AND reserve area. Site Passed F3�l Site FailedF__1 Performed By: Witnessed By: Comments: ,r DEP APPROVED FORM-12/07/95 PerdwtSAM 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 APPLICANT(C/�1Li0<'E" PHONE 97�—�¢�� LOCATION: Assessor's Map Number/ok- 00d,5"2, PARCEL SUBDIVISION LOT (S) STREET 5 �4//(/G ST. NUMBER �¢ **** *** ********* USE ONLY RECOMMENDATIONS OF TONIN AGENTS: 1& CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS X TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS y FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED. DATE REJECTED COMMENTS .,E PUBLIC WORKS - WER/WATER CONNECTIONS C l DRIVEWAY PERMIT r FIRE DEPARTMENT P RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm U LV l L'Ll'.t1�7L' i'Vl[1V1 G, A C .� INSTRUCTIONS: This form is used to verify that all-necessary approval/permits from 13 i Boards and Departments having Jurisdiction have been obtained.This does not relieve the l i licant and or landowner from compliance with any applicable requirements. ............................................................................ -r: PHONE �� Lr°�r=- �7 7 APPLICANT Y ASSESSORS MAP NUMBER SUBDIVISION LOT NUMBER S S `/ . � T �o - STREETSTREET NUMBER ...........................OFFIC L USE ONLY........................... RECOMMENDATIONS OF TOWN AGENTS . DATE APPROVED CONSERVATION AD STRATOR DATE REJECTED CONIMII�s DATE APPROVED TOWN PLANNER DATE REJECTED COI�IIv1EI`TTS DATE APPROVED FOODIN E R-HEALTH DATE REJECTED DATE APPROVED e P OR- TH DATE REJECTED col�N'TS ` PUBLIC WORKS-SEWER WATER CONNECTIONS I! DRIVEWAY PERMIT DATE APPROVED L� FIRE DEPARTMENT DATE REJECTED COMMENTS DATE RECEIVED BY BUILDING INSPECTOR '0 YC B R iIJ 1 TD'?�1 C L:E3A 14�DA ADt� �E33 FORM B MAR 15 3 C4 PM a APPLICATION FOR APPROVAL OF A PRELIMINARY PLAN March. 4 19_L6_ To the Planning Board of the Town of North Andover: The undersigned, being the applicant as defined under Chapter 41, Section 81—L, for approval of a proposed subdivision shown on a plan entitled "Preliminary Subdivision of Salem Forest IV" in North Andover, Mass. By Hancock Survey Associates, Inc. dated March 4 1996 being land bounded as follows: Bounded to the north and south by Commonwealth of Massachusetts State Forest; to the east by Granville Lane; to the west by Raleigh Tavern Lane. hereby submits said plan as a PRELIMINARY subdivision plan in accordance with the Rules and Regulations of the North Andover Planning Board and makes application to the Board for approval of said plan. 1087 314 Title reference: North Essex Deeds, Book_ 20 .$ Page 269 or Certificate of Title No. , Registration Book , Page ; or Other: Town of North Andover Assessor's Map 106C, Lots 22,23, 37, 38, 103. Applicant's signature: Received by Town Clerk: Date: Applicant's address c/o Farr Better Homes, Inc. 216 Raleigh Tavern Lane Time: North Andover, Ma. 01845 Signature: Owner's signature and address if not the applicant: 6. The following plans are included as part of this decision: Plan titled: Conventional Subdivision(Proof Plan) of Salem Forest IV in North Andover, MA Owner& Applicant: Fan Better Homes, Inc., George Farr, President 216 Raleigh Tavern Lane,North Andover, MA Scale: 1" =40' Date: March 4, 1996 Prepared by: Hancock Survey Associates, Inc. 235 Newbury Street, Danvers, MA 01923 Sheets: 1 & 2 Plan titled: Preliminary Subdivision of Salem Forest IV in North Andover, Massachusetts Owner& Applicant: Farr Better Homes, Inc., George Farr, President 216 Raleigh Tavern Lane, North Andover, MA Scale: 1" = 40' Date: March 4, 1996 Prepared by: Hancock Survey Associates, Inc. 235 Newbury Street, Danvers, MA 01923 Sheets: 1 & 2 Decision Given the above Findings of Fact, the Planning Board herein denies this Preliminary Subdivision plan. Hancock Engineering Associates #4980 To�tfNOF 1 0 AriOWER March 27, 1996 BOARD��: 1 02819 � Town of North Andover Board of Health 146 Main Street North Andover, MA 01845 Attn: Ms. Sandra Starr, Health Administrator RE: Salem Forest IV-Percolation Tests Dear Ms. Starr: With reference to your memorandum dated March 19, 1996 to the Town Planner regarding the status of soil testing for the Salem Forest IV subdivision, we hereby request time on your schedule to perform the required percolation tests at your earliest convenience. Based on our conversation on March 19, 1996, you anticipated being available in approximately three (3) weeks. Since the submission of the Definitive Plans for the subdivision completion depends on the of this testing, your p anticipated-attention to this matter is greatly anticipated. Should you have any questions or require further information concerning this matter, please do not hesitate to call. Very truly yours, 7OCK ENGINEERING ASSOCIATES seph J. Serwatka, P.E. JJS/wag cc: George Farr Planning Board HEA File 4980JJS I. I 235 Newbury Street•Route 1 North•Danvers,MA 01923•(508)777-3050•(508)352-7590•(508)283-2200•(617)662-9659•FAX(508)774-7816 Division of Hancock Survey Associates,Inc. k DAMARC DESIGN & DEVELOPMENT 41 Chestnut Street North Andover,MA 01845 ��L 1997 1 July 24, 1997 Ms. Sandra Starr,R.S. Town of North Andover Division of Community Development&Services 146 Main Street North Andover, MA 01845 Dear Sandra: Thank you for your time yesterday to discuss the proposed subdivision off Raleigh Tavern Way. At this time I would like to request a copy of the perculation test of record (form#12) as well as r soil evaluator(form#11)for the sub division known as Salem Forest IV. We are currently evaluating this project and the requested information is critical to our analysis. Thank you for your prompt attention and cooperation in this matter. If you any additional information please don't hesitate to contact me at(508)725-3630. Sincerely. 1 JJ-- David Mermelstein I