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HomeMy WebLinkAboutMiscellaneous - 543 FOREST STREET 4/30/2018 + 543 FOREST STREET _I 210/106.6-0045-0000.0 - i Commonwealth of Massachusetts ftcle H W Title 5 official Inspection FormTo <'ozo Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wNp� �� y�cTyo pRgHgNop II M 543 Forest Street RTMF Property Address Douglas & Patricia Saal Owner Owner's Name information is required for every. North Andover MA 01845 November 4, 2017 page. CityfTown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered •n any way. Please see completeness checklist at the end of the form. Important:When i filling out forms A. General Information Lpa; on the computer, v 1 0 use only the tab 1, Inspector: key to move your cursor-do not Peter F. Reilly use the return Name of Inspector key. Peter F. Reilly ISI Company Name --- ! 136 Andover Street �I Company Address Andover MA 01810 City/Town State Zip Code 978-375-3750 HE-033221 Telephone Number License Number B. Certification 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 i i ❑ Needs Further valuation by the Local Approving Authority November 4, 2017 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing.this inspection. If the system has a design flow of j 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 W Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 543 Forest Street Property Address .Douglas & Patricia Saal Owner Owner's Name information is North Andover MA 01845 November 4, 2017 required for every page. Cityrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair; as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. 0. Y ❑ N ❑ ND (Explain below): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 543 Forest Street Property Address Douglas & Patricia Saal Owner Owner's Name information is requited for every North Andover MA 01845 November 4, 2017 page. City/Town State Zip Code Date of Inspection B..Certification (cont.) ❑ Pump Chamber pumps/alarms not operational.System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ 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 saltmarsh t5ins.doc•rev.6/16 . Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 • Commonwealth of Massachusetts W Title- 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 543 Forest Street Property Address Douglas & Patricia Saal Owner Owner's Name information is North Andover MA 01845 November 4, 2017 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: i i D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ElBackup of sewage into facility or system component due to overloaded or El clogged SAS or cesspool El 1-1Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El 1:1 or liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El El than depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 543 Forest Street Property Address Douglas & Patricia Saal Owner Owner's Name information is required for every North Andover MA 01845 November 4, 2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ N 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.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 543 Forest Street Property Address Douglas & Patricia Saal Owner Owner's Name information is required for every North Andover MA 01845 November 4, 2017 page. CitylTown 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): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 450 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 543 Forest Street Property Address Douglas& Patricia Saal Owner Owner's Name information is required for every North Andover MA 01845 November 4, 2017 page. City/Town State Zip Code Date of Inspection D. System Information Description: This is an original system that includes a 1000 gallon septic tank, with two plastic access covers at the surface. There is a d-box and a 4 line SAS (field)that is 25'x 40' (per design plan) located in the rear yard. According to the notes on the design plan provided by the owner, the system was installed in 1977. The design plan is dated 1976. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: not applicable-the house has a well for domestic water. It is in the front yard >100'from the SAS. Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: n/a 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: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 543 Forest Street Property Address Douglas& Patricia Saal Owner Owner's Name information is required for every North Andover MA 01845 November 4, 2017 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-pumped on 5/8/2017 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason r pumping: easo o pu p ng: 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 co of the DEP approval. 9 copy pP ❑ Other(describe): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 543 Forest Street Property Address Douglas & Patricia Saal Owner Owner's Name information is required for every North Andover MA 01845 November 4, 2017 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: System is about 40 years old, installed in 1977. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet 26" 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.): Watertight, no evidence of leakage. I i . Septic Tank(locate on site plan): Depth below grade: 18" -20"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) Top of tank is 18"-20" below the surface. Two plastic covers on risers at the surface. I If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: rectangular approx. U x 12' <1,, Sludge depth: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 543 Forest Street Property Address Douglas & Patricia Saal Owner Owner's Name requinform r on is North Andover MA 01845 November 4, 2017 requireddfor every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet,tee or baffle 2111 -22" <1„ Scum thickness 6.._7.. Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 8"'_g How were dimensions determined? design plan Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Original cross-tank baffles appear to be in good condition. Tank was observed to be water tight and functioning property. Tank was pumped more than.two weeks prior to the inspection. Grease Trap(locate on site plan): Depth below grader Net Material of construction: ❑ concrete ❑metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top.of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date .t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts rz Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,N 543 Forest Street Property Address Douglas & Patricia Saal Owner Owner's Name information is North Andover MA 01845 November 4, 2017 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: N/A 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 r rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface,Sewage Disposal System Form -Not for Voluntary Assessments c,M 543 Forest Street Property Address Douglas & Patricia Saal Owner Owner's Name information is North Andover MA 01845 November 4, 2017 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): 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.): Four lines, all level and accepting effluent about evenly. Minimal solids carryover evident. The box cover was between 3 and 4 inches below the surface. Therefore no riser is needed per town regs. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* i Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances,etc.): N/A * 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: The 4 line, 900 s.f. SAS (field) is shown on the design plan provided by the owner. t5ins.doc-rev.6/16 Title 5 ofricial Inspection.Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts mx 1 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 543 Forest Street Property Address Douglas & Patricia Saal Owner Owner's Name information is required for every North Andover MA 01845 November 4, 2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: 1 field, 4 lines, ® leaching fields number, dimensions: 20' x 45' ❑ 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.): Soils in the area of the SAS appeared normal, no evidence of breakout. I Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration N/A Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer. Dimensions of cesspool i 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 N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c�M 543 Forest Street Property Address Douglas & Patricia Saal Owner Owner's Name information is required for every North Andover MA 01845 November 4, 2017 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: N/A Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): j t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 543 Forest Street Property Address Douglas & Patricia Saal owner Owner's Name information is required for every North Andover MA 01845 November 4, 2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately ® wed �Prorn SRS A � Porch 0 , p 4-o Tnle4 32-1-0"* 54-o _rnde-1- IS, P"' Q %L* 00-/e4° 33•x°' + D®l6Ce 72.0' bOX 70, ®• SPS p_6o�c t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 • Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 543 Forest Street Property Address Douglas & Patricia Saal Owner Owner's Name information is required for every North Andover MA 01845 November 4 2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: >4'feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 1976 Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: plans on file ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database-explain: USGS data non-specific to the site. Testing data more reliable. You must describe how you established the high ground water elevation: 1976 Design plan indicated no ground water in the SAS. Dry soils and grade changes in the area indicate that ground water elevation should be well below the SAS. No surface water observed. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts H W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 543 Forest Street Property Address Douglas & Patricia Saal Owner Owner's Name information is required for every North Andover MA 01845 November 4, 2017 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 Z Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I I i t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 DISCLAIMER This passing septic inspection under Massachusetts Title V is in no way a guaranty or warranty of the inspected septic system. The inspection is a "snapshot in time" and does not constitute a complete assessment of the quality or potential longevity of the septic system. The pass/fail criteria are specific and outlined in detail in this report. Under the limited criteria of a Title V inspection, it is impossible to determine how long any septic system will last. The inspector made a diligent effort to certify the septic system based on the criteria required under Title V. Under Massachusetts Title V, soil evaluation is the accepted method of determining the high groundwater elevation. This inspector is not a certified soil evaluator and is therefore not qualified under Title V to determine or establish the high groundwater elevation. The method used to estimate the high groundwaterfor this inspection was based on the public records and methods of observation described on the previous page. Groundwater levels can vary greatly from season to season, year to year and soil evaluation is considered the most reliable method of groundwater determination under Title V. Peter F. Reilly Inspector November 4, 2017 o Town of North Andover HEALTH DEPARTMENT S�CHUSt CHECK DATE: LOCATION: .5<-/3 zLo`c :54 a+ H/O NAME: CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type. $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5Inspector $ Illi Title 5 Report /dA.5 5 ❑ Other:(Indicate) $ i He Agent Initials White-Applicant Yellow-Health Pink- Treasurer _ Commonwealth of Massachusetts u W City/Town of North Andover System Pumping Record Form 4 M DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Location: �.. fc�on the computer, use only the tab L��� keyDEIVED to move your Address cursor-do not North Andover use the return ------ -- ------------ -JUN.� � key. City/Town State 11pFC d 2. System Owner: TOWN OF NORTH ANDOVER � ��� ------------------ ---HEALTH DEPARTMENT Name iehon I Address(if different from location) City/Town ------- --- ------ State -- ---- Zip Code Telephone Number B. Pumping Record 5LDI- 157' 1. Date of Pumping Date 2. Quantity Pumped: Ga Ions 3. Type of system: ❑ Cesspool(s) �eptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): ------------- ----- -- —-- - 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Name Vehicle License Number Stewart's Se ice Company — ----------- -- 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 I System Pumping Record•Page 1 of 1 i. RECOVED Commonwealth of Massachusetts Cityjown of No Andover JUN 10 2013 System Pumping Record TOWN OFNORTH ANDOVER HEALTH DEPARTMENT Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form,check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Importarit!Mhen filling out forms 1. System Location: on the computer, ,, // C use only the tab .545 );C-e-5- key to move your Address cursor-do not No andover Ma use the return City/Town State Zip Code key. 2. System Owner:. Name rears Address(if different from location) City/Town State Zip Code * - TelephoneNumber B. Pumping Record 1. Date of Pumping YI I 2. Quantity Pumped: a Date Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: . SteVd re-treatment Plant, 20 So. Mill Bradford, Ma 01835 natu of Hauler ate i y Date t5form4.doc•03/0 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts W City/Town of North Andover a W° System Pumping Record Form 4 �M DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Eta .. Important: When filling out 1. System Location: � � _ �� forms on the4j t computer, use 543 Forest St only the tab key Address I VVVN OF NORTH ANDOVC-R to moveour HEALTH . cursor-do not North Andover Ma TMENT use the return City/Town State Zip Code key. 2. System Owner: r� Saal Name fe"0/ Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 5/2/11 2. Quantity Pumped: 1000 DateGallons 3. Type of system: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Grease Trap El Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: Good Condition I 6. System Pumped By: Mike Snow Name Vehicle License Number Stewart's Septic Service j Company 7. Lo, �)'s where content ere disposed: to Pre-treat Plant, 20 So. Mill Bradford, Ma 01835 ^natuu Date Signature f R Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 TOWN OF NORTH ANDOV&F,, UA 11 SYSTEM PUMPINQ REC®}�b YS em OWNER& ADDRESS SYSTEM Lt?CATynN DATE OF PNQ' 7m _QuANTT Y PJaFE�; en NA PvKjh OF 3ERv,cE: ROU'riNk V �h4�f$U�NC 1 RECEIVED U�s��vArlONs: OOOo CONDITION •_..••_.• Puw, 'W COVbR JUN 0 3 2005 Kuyy ®I�AgB BAFYLBS IN PLACL Rom _ _. LBACKPIEL ? RUNBACK to- WN OF NORTH ANDOVER W3381VE SOLIDS....e_. FLOODED HEALTH DEPARTMENT �L�CAI RY®VER, 0TH'ER EXPLAIN 'y•t�m PturtPzJ by __ ,C.(C `7 �...... • `•ur���Nrs. �:ury P'BN'I'� rK�elv��"lrt�>�it� rtr z � TO: NORTH ANDOVER, MASS 2` 19 77 j ARD OF HEALTH FROM: DESIGN ENGINEER Re: Soil Absorption Sewage System Inspection Y p This is to certify that I have inspected the construction of the said disposal system at L67- 3 /ca PL-"S T 574- 1 North Andover, Mass. SITE LOCATION The grades and construction are as specified in my plans and specifications dated 19 —( �H 0 F M4S. JOSEP yG Reg. �/ e y\ rtarian o 'A G G d �oF F � � o5Ti c- S3 �' SOIL PROFILE & PERCOLATION TEST DATA Town/City l/Ud.&Street_ Lot No. Loc./Subdiv. Plan Owner (3COh9 eQ-e,� Investigator --�C c7��� Observer SOIL. PROFILES-DATE e 2' Elv. 01" Elev. 3° Elev. 0 J3- 1--Elev. •` 2 2 2 2 v 3 3 3 3 4 4 4 4 � 5 , 5 5 5 O6 6 6 6 7 7' 7 7 8 g 8 8 9 9 9 9 10 1010 10 Benchmark Location Elevation_ Datum Percolation Tests-Date ?it Number /f`'/ 1 2 3 4 5 Start Saturation ; Soak-Mins. Start Test-Time ' UU r'op of_...3"-Time ' p Dro of me ' .3 Mins'.'Ist` ;3"Dro ._ ..,_ . ..:. ,:. `• ' Minse2nd 3"Dro Notes &_Sketched on Back' Frank C.. Gelinas & Associates, , North And. a' . ...._..... , , r wry /��/^ f ire i rq y �.f.� (( r+a•..., �.' V x f'�y�r ,.J�. ��Gf Kw�w�t(J 4! /�.�U�lJl!�'+1.� *u"� e (}` ...' Jl {{ ?.. ..... +"•�.. J � wit, ., � 3 ,.�....._�,r_..._,�.,t. .� .....—►...j. 61 . 01 l ✓/ i�cr�+^r,^r.�^...-�.4i�.a..w— Gi f�� j r:�� '�C'L 5!.O 1'i 1 � ` r r-..4..:»„:t*-"""f.d. ...ate. ii a°•«'�""`.` y � �t 1. .-........,_ ti ... ��+.r�++.+.•.�...«.r.� �� a..r...+r. �1..-r.�.-.moi..� .- ...,r.•>.,..._ „�.. _ - .-. - . r „rr,.. . «.,.,,...,.+e.+w..r+�• 1 .' RZA I1 c 7AOW1wC PROPOSED S'UBSl1�2FADE S'ErvAc,E h/5P0.54L 6�sTEM 0 1�(t ,Awo �/. PROPOSED ZDT aIe'.4b//l/G l LOCA T/O N: LOT . . AI . 78 S+a DES/CT it/ER ,6 tTO.SEPq cT 23A�2BA47i�ILC , /Ps• M(10 C.- Rl�C3AC.�c• !�/SP�SAG � -1.. "'` � J I WESTG(/Ai2d Cl,2C« /t/o . .QE.ao��vG , MASS./Wu Y t36 l�STAGLQ) — -- -- / -92 DES/GAJ DATA = OF BU/LD/it/G: & OOA4 l�lt�ELG/�flG 6Q .� J GARAGE ` CEGL.4� PcUMB/Mt/C, FAC/G/riES= 96 G 46;E SLOW ESTIMATE : / SEPT/c rA�K /DDo G'ALS 4t/ f�BSOePT/ON AREA : 900 :s',r, .9L�.So.�;or/o.0 .B ¢�, �PERcoLAT/ow TESTS / #Z `3 #4 `gam_ \ eoT A471F y �a TDP E�EI/AT/oN Bz.O `r �40TTOitJ ELE!/AT/dN 79. D t f 57-• Sao 35 - P SArv�eA r/OA/ /S AL1/,i/. M/N. 0/".. M/N. } (4�K -••,. .. F2 V . / /Z"ro 9" DROP ZQ /l�//N. �t�l/�c% iYliv Miter DROP .34?- IV IA/. N/1w. AAAA T/ON RATE /D.7 Miv//N. _7` �. -_ - B.M. Cl TEST PITS -#/ z #3 #4 cow DA TE 9a -g` EC. 100.00 /• TDP ELE!/AT/O" dZ,o �¢,. . �`'. � - . - `�`` �i. _. `�— ' -`' // � �. / SO/C TYPES 7L.. on/E✓ AAJD GOCA T/.ON L5'&3-We 46E i `o `- r--- f/ SEK�A6E IySPl�SAG 5 Y--5 rEMvl a BOTTOM ELEUATioN 75;D PLAA/ kSHAGG du $� �tfOT f3E CD•VST.2LlCTEd TE5TS COO/DaC TEI� BY = JO5E,oy T. 54RBAGAC.L 0 , R.S. UMC/T-/G Th/E lf//ATEA TABLE TESTS W/Tti/ESSEI� .BY MtID Ati/l�Of/E,2 !-�EALTN DEPT EC�U�]T�O�c! /S ESrA t3 GI�S//ED C cS' 2 //t! TyE cSF�.2l N� f /9'7 7 /PCAAI e 651e7�c/ e/7 Ee/A /BEETyOF <SEAGED 75-mlr, 5oz-/o P. ll(f. - Cole EQVA(-'NT) .m. , .o_ • e. oe� o e e •o .Q - � V o -e �� •. s o o CAPPED �e(!�S o v 6 V <69 � ��E,eFoeATE� P/PE Cope EG?tJ/vAGE�tIr") DART/AL BED EA-1D ECT/D til - SCALE �2' =l -0" (F0.2 SPEC/F/CAT/D/l/S — S'EE SECT/D/l/ AT LOWER RA/ ;A17-, D��T,eiBUr�o�v �x � h ti I000 44L. COAICZET,� SEPT/C TA�t/K 45 �z r E., .5EALE.O . (D/NTS ¢'� PE,eF. P�. � s=.oas �BSO.ePT/OlU 8E� LAN �� /t/or To cScALE 45" I)V) t / pu)E1- t C-)Z,O SEAQ ED �S'EL EG T Q 61.@ a C,QU/v, S� o 0 0 0 wBo 4i Ile- j STONE •tea e v o Seo B" 7-0 8 W,45 HE'D o : � aao J . EQc//,%•SILENT //Z" Wf}SNED N \ al- � � G�USNE27 STONE Q L/ �voc/BGE WAS �Q TO MEET A.A. a L S.N.O• � D LL P,5ou. .. _ OUE ^ jtsU6sorL JAI 86.0 H�SD�'PT/D/t1 &EZ) cSECT/DA/ �� � �� � � $. � AREA• REPLrt cE cc�r rH 70 a L cs P.eOF/G E PLA" ANt3 SECT/DIMS SAAEE-T o� Z SCALE f-x'0.2. l' 4�O T �� ��, i I _ _ _ -: �(� � r l� ,� Y .. � � - �\ r- � Y� f AS��C � •�� .,,, , �' � '' F� fir';c���'R e c o rd ��1`7 ,. ,'. il,n�l.�,.p.,; �.��'' JUL 0 8 2009 G/ovlr• ded )hlaYlor,n for Sao 00 mlllod`lo thr loch BCarf: o^or oc,I orLQ�lw—� asOlfftllTH ANDOVERF a C I I I ty � ®EWARTMENT In(orMr Hon "•'ill v/ I. u/•�i;'',Y•�`'f•;;y �" �'i;'l�.i�li(+�u�•�" �'' ,��',. ,' 51111 -------__.. .,) I 'i�;,,ti1, •r y318m Own@�r,���.;,,�. .. ,R . , . f. 1 . ti '�; 4,µa (II OVf�rinl'rcvn buVcn) ---------------- c� / 70 — tal fl— •1 Y,Il�npn, n,mp„ -- (' P,umpin8'Ra'yord ' ! a o, Pompin9• VVI �. Typo 91 ►ys►om; $99oc Tan,, ` , .�•�%O�J�ar (doscrlblj' �' _ ls�, la. . ht�en,► Too Fllle� „sons? Yos�o II y %' %,:• �?�^�'!'`�'�r,�'�i,(r�l,i'� I;�„ �I�I,.t ,,. 69 n'61 II C'eane � '"1 1 ' `6 �,C•o�dlyon P(„.9y ' m,: v res — ^ '�� �,' I i 1'��j�.�lr,��'/,1�1�I.1'1���5�} ✓'.5:'Y 1(/,''' J (J(,J �. G un i •. rr,�,,' � ��%1�i , �' .Y!!'' lI�1 V • I• 1 YI111y L' I,J�n v '�•'((1'.r..�l.`•;.,�Vlv{•i`' y;%I,�Y it' i �1 'I',�u' ) •l r� ''"rG� ,j . '.�,, ,1�� '•r.,.;l,i,'' ;illy .�.'@r@ d19pOS@0: r' .masa.gorld8 e1erlepproy8jv(l lorm�.n main oll, 1 •`! t. y 1 1q Y,1.1 (,t ` 1�(� ,11� i �iiL 1 -�'.Y 1 f - .. .. I TbWN-o,V.N0RT�1 'AIi1�OVR SYSTEM PUMPING RRcop, 7-4 �1 I'EM UWNFR & ADDRESS SYSTEM LOCATION. .��� (ez�m�le: Icf'l�(ron� of housr) ( OF RvM,PINC '' � ` zti3QUaNTITY !'UM1'CD C,� L L��.11 ;c r , YES SEPTIC TANK: NO Y ES v VwaTURE,O.F:SERYLCE;:' ROUTINE. EM ERCEN•CY : Wi•r..:RYATlONS; ' CUO:D: CQNUITION FULL TO C0YCIZ fII'XVY GR ;rtSC:'! .8AFFLLS IN I'I,ACI, ;RU.O,TS ' LEACHFI)~LD ItUNl3AC'K.., ---� GXCESSIY SQ1�1DS FLOODED S0LI CARRYOVER ' ;p HFft (EXr'LA.INj woy -Y • C'u:YI NI rNTS, 1 ON,I ANs'�CIZIZLD '1'U r vniv) U ,- LU I RELEASE FORM _ TRUCTIONS: This form is used to verify y that all necessarya Boards and Departments having jurisdiction have been obtaine , .This does from This does not relieve the applicant and/or landowner from compliance with any applicable or re quirem ents. *****************************APPLICANT FILLS OUT THIS SECTION APPLICANT PHONE_ ( LOCATION: Assessor's Map Number 0 L6 PARCEL SUBDIVISION LOT (S) STREET ST. NUMBER__ CIAL USE ONLY*********************************** RECO MENDATIONS O TOWN AGENTS: CONSERVATION ADMINIST TOR DATE APPROVED / O DATE REJECTED COMMENTS 1Lds L �� /�q"� / TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED '' SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT i FIRE DEPARTMENT i RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm —'-'---- .Address 2t3 'r—O ,Title of File Page of Date File Open: Date file closed: Doc Document/Action Title Date of Refer to other Purpose of Document/Action and notes action Document/ document/ Num. Action Department Board of Appeals — Board of Health — Planning Board — Conservation Commission — Building Department �y TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD '� � DATE• c� Y 1 {, 1 �tl ii�l�a,I. t, ,I I • �.w�l���� t it 1p wr�IA�.I�� I II I.• " ' SYSTEM OWNER& ADDRESS SYSTEM LOCATION A . i I = (example: left front of house) fn t� j r A k �'�If�it,ar99�'��1�';.,1 i jfr rt � '�z�1 �'i ry' +°:Y,•,,r P ,� .,.,.._.. .. _ .... .. .. t F l = I T 1 DATE.OF PUMPING: QUANTITY PUMPED I_GALLONS F. 1 4 , CESSPOOL: NO YES_ SEPTIC TANK: NO YES 1 C/ ..I • �� ji k l I ¢g NATURE OF SERVICE: ROUTINE .EMERGENCY - ar,� = Q$SERVATIONS. } aN} YI I i �� ;, _ . };: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE _ ROOTSLEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED y SOLIDS CARRYOVER_ OTHER(EXPLAIN) I , 41 l ,•VVS'XSTEM PUMPED BY: c .. - hf 7 ! x CUMMENTS: � wv� � �o�` ANL HEAH i wl I ab •A. Y _ _ +Way, CONTENTS TRANSFERRED TO: ,,11 r }I ikl'W'4�ig4� #h"9��f�p } `�V la t{ n�j.s�,♦;74 t,zL�Ttgt,:. a,,y . .A� y L FI I j I i f•} �..