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HomeMy WebLinkAboutMiscellaneous - 545 BOXFORD STREET 4/30/2018 545 BOXFORO STREET at 2]U1105.C-00260000.0 i i I Commonwealth of Massachusetts City/Town of NORTH ANDOVER MASSAC tJ§ - ;�-S" System Pumping Record �`'� ED Form 4 OCT - g 2009 DEP has provided this form for use by local Boards of Health. T ystpup PumpiHng9�ve�Ck must be submitted to the local Board of Health or other approving aALIOr �ALTH,.EPARTMENT A. Facility Information Important: When filling out 1. System Location: forms on the �1 computer,use "5q C>J only the tab key Address to move your q ��� �� 7, cursor-do not C—it Irown use the return y State Zip Code key. 2. System Owner: 1,roen L:) Name — — Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping. Record 1. Date of Pumping Date A 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) LKSeptic Tank ❑ Tight Tank t� ❑ Other(describe): 4. Effluent Tee Filter present? Yes ❑ No If yes,was it cleaned? Yes ❑ No 5. Condition of Syytem:. ` . AcU 6. System Pumped B ame - Vehicle License NumbbT Law" '- Company -- 7. Location where contents were disposed: Signature of Hauler Date http:/Iwww.mass.gov/dep/water/approvals/t5forms,htm#inspect t5form4.doc•06/03 System Pumping Record•Page 1 of 1 DelleChiaie, Pamela From: DelleChiaie, Pamela Sent: Thursday, September 03, 2009 4:08 PM To: 'ivank@comcast.net' Subject: FW: I.R. -Septic-545 Boxford Street Attachments: SKMBT_60009090315590.pdf Attached is the information you requested yesterday afternoon. Please call the office if you have any further questions. Pamela DelleChiaie Health Department Assistant TOWN OF NORTH ANDOVER Health Department 1600 Osgood Street Building 20;Suite 2-36 North Andover,MA 01845 978.688.9540-Phone 978.688.8476-Fax pdelleehiaie@townofnorthandover.com-E-mail http://www.townofnorthandover.com-Website Notes: ff copied to BOH Members-Reference Copy Only-no response requested at this time From: noreply@townofnorthandover.com [mailto:noreply@townofnorthandover.com] Sent:Thursday, September 03, 2009 5:00 PM To: DelleChiaie, Pamela Subject: I.R. - Septic- 545 Boxford Street Town' of North Andover NQ�7y O"CE'OF COMMUNITY DEVELOPMENT AND SERVICES:: ,.-.. ., 146 Main Street North Andover Massachusetts 01845 ` WILLIAM P.SCOTT �SSACHUS�� Director. TOWN"OF� NORTH ANDC)VER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE This is fi0 certif}z that tfie septic flank contracted O ox repaired (Xy. by. Mme:REILL�E: installer at .:545::$.OXFORD:-STREET has beeninstalled in accordance with the provisionsF of TITLE 5 of the State Sanitary Code and with the NOrth Andover Board of Health regulatioils. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A: GUARANTEE:THAT THE SYSTEM WILL;FUNCTION SATISFACTORILY. Board of�3ealthjiRspect©r BOARD OF APPEALS 688-9541. BUEDATG 688-9345 CONSERVATION,688-9530 HEALTH 688-9540" PL NN D46 6$8-9533 rte" APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERM DATE: -q L., CURRENT INSTALLER'S LICENSE# LOCATION:— y nX !f - - LICENSED INSTALLER.--f::-- SIGNATURE: NSTALLER SIGNATURE: � , Q5_TELEPRONE4_ '} CHECK ONE: REPAIR: & NEW CONSTRUCTION: IF NEW CONSTUCTION,PLEASE ATTACH FOUNDATION AS-BUILT. fSrocz Administrative Use Only $75.00 Fee Attached? Yes V No Foundation As-Built? Yes - No Approval l! fL _% Date: % / Z r i Form No.3 Town of North Andover, Massachusetts' s. BOARD OF HEALTH N6RTM e 19 pt ,rao;e'�'Yp Lz 1p 3�i e.f' •' .e OL 0 p , # ���,;;,;:•°t�� DISPOSAL WORKS CONSTRUCTION PERMIT SSACMU y i Applicant NAME ADDRESS TELEPHONE Site Location Permission is hereby granted to Construct( or Repair (4an Individual Soil Absorption Sewage Disposal System as shown on the. Design Approval S.S. No. CHik-MMAN,BOARD OF HEALTH a� D.W.C. No. ..... Fee MERRIMACkrENGINEERING SERVICES Professional Engineem•Land Surveyors•Planners 66 PARK STREET ANDOVER, MASSACHUSETTS 01810 (508)475,3555 SEPTIC SYSTEM-q AS-BUILT FORM Us-rA L{_. 1 t.-- 'W✓e Lli 1;; ^rsrZ ��1. (� .:�� L=tIon/Addl'ess: Date: BUILDING TIES INVERT.ELEVATIONS �Ipllp�p 13!a Comer A B, C D 4'pipe(M Fdtn. Septic Tank Se 'c Tank In 3Purnp Tank Septic Tank Out Dist. Box Pump Tank In Cam.Lead Feld#1 Pump Tank Out Com.Leach Feld#2 Cist. Box in Can.Leach Field#3 Dist. Box Out Can.Leach Field#4 End Leach Line#1 i End Leach Line#2 Benchmark( ) Elev. _? End Leach Line#3 R.R. + End Leach Lane#4 ' i H.I. = i i - / 4-o i i 5u �AkA 1, � • Sketch 107 Forest St. FILE#A�� Middleton,MA 01848 0� (508)774-2772 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PROPERTY OWNER'S NAME: PROPERTY ADDRESS: obi� D �!4- k-1 A aA Oye r /Mat ADDRESS OF OWNER: of different) DATE OF INSPECTION: _ a 4[.i_ -- � ' , 19M Ifo NAME OF INSPECTOR: •THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY• FILE# 9� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION �`1�d�ress ��/lkfta Property Address: _j q,5- &,C&,.1 S� IVB o n•er: Date of Inspection: f Qlmst NO /9?4 (if different) ���✓ Name of Inspector:7hpwAr 0 %W Company Name,Address and Telephone Number: Currier Septic&Drain Service,Inc. 107 Forest Street,Middleton, MA 01949 (506)7742772 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails > QQ Inspectors Signature: Amar0 Lf Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system 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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B,C, or D: A) SYSTEM PASSES: _ I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.Any failure criteria not evaluated are Indicated below. B) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no,or not determined(Y,N,or ND). Describe basis of dtermination in all instances. If"not determined", explain w.hy not The septic tank is metal, cracked stru___qumlly unsound, shows substantial infiltration or exb1tration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. I i (revised 8115/95) it FILE# F SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (COOinuEd) 8) SYSTEM CONDITIONALLY PASSES(continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health); broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health), broken pipe(s)are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if t e s stem i failing to protect the publig health, safety and the environment.'r5 '6e�U&c-TA K +:� lea C�h ctf„ sear/ Po��#is Se"e IM6 VM&4 -, . _ 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING INA MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone i of a public water supply well. (1( The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D) SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. (revised 8115195) 2 ' FILE# 919 ~ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) D) SYSTEM FAILS(continued) Static liquid level in the distribution box above owlet invert due to an overloaded or clogged SAS or cesspool. iA Liquid depth in cesspool is less than 6"below invert or available volume is less than 112 day flow. Required pumping more than 4 times in the last year ALAI due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwatere I levation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. MAAny portion of a cesspool or privy is within a Zone I of a public well. i Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. RGE SYSTEM FAILS: The o . ' criteria apply to large systems in addition to the criteria above: The design flow of system 0 gpd or greater(Large System)and the system is a significant threat to.public health and safety and the environmen se one or more of the following conditions exist: the system is within 400 feet of a surface drinkin r supply — the system is within 200 feet of a tributary to a surface drinkin ply the system is located in a nitrogen sensitiv ,a nterim Wellhead Protection Are PA)or a mapped Zone II of a public water suppl The owner or operator of an system shall bring the system and facility into full compliance with the groundwater treatment program ments of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department far .. further Of on. (revised 8/55/95) 3 [-FILU �� f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: +pumping information was requested of the owner,occupant,and Board of Health Zone of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this Inspection. f As built plans have been obtained and examined. Note if they are not available with N/A. ✓The facility or dwelling was inspected for signs of sewage back-up. ✓The system does not receive non-sanitary or industrial waste flow. _ZThe site was inspected for signs of breakout. ,/All system components,excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid,depth of sludge, depth of scum. _✓The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. ✓The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of SubSurface Disposal System. (revised 8115195) 4 LFILE# 7 �j SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS ES� Design flaw: "gallons Number of bedrooms: Number of current residents: Garbage grindereor no): Laundry connecte o s ste a or no):�S Seasonal use(yes or/n-6): qq Water meter readings, if available: 1,042 M1 S,fs—, Last date of occupancy: Type of estabriViment Design flow:_gallo Grease trap present: (yes or not) Industrial Waste Holding Tank present:(yes or n Non-sanitary waste discharged to the Title stem: (yes or n Water meter readings, if avialble: Last date of oc cy: 0TH : (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECIDIRDS and source of lnformation; h System pumped dd p rt of inspection: (yes or no)_,,,_„ If yes,volume pumped: gallons Reason for pumping; � &441nfaLng TV,Pf 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) Other(explain) AP ROXIMATE AGE of all components, date installed (if known)and source of information: Q .V _En d Sewage odors detected when arriving at the site: (yes or no).4. (revised 8/15!95) $ FILE# ej"ffbiq SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) . SEPTIC TANK: (locate on site*pan Depth below grader Material of construction: concrete_Metal FRP—other(explain) Dimensions: L XF _ Baffle Depth Below Outlet Invert: t�8 '�— Sludge depth: 5 �� Distance from top of sludge to bottom of outlet tee or baffle: Z5 Scum thickness:_�H Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffler Comments: (recommendation for pumping, condition of inl and outlet tees or baffles depth of liquid level in relation to outlet invert, structural integrity,evidence of le e,etc.) A " v 5 GREASE TRAP:00 on site p an Depth below gra , Material of construction: �Crete _metal_FRP—other(explain) Dimensions: Baffle Depth Below Outlet Invert: 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 b Comments: (recommendation for ,condition of inlet and outlet tees or baffles,depth of liquid level in n to outlet invert, structural int idence of leakage, etc.) (revised 8115/95) 6 FILE# + 9� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) TIGHT OR HOLDING TANK.-Na (loca ite plan) Depth below grade: Material of construction:_cone metal„ FRP_other(explain) �Y Dimensions: Capacity:_ gallons Design flow: gallons/day Alarm level: Comments (condition of inlet tee,co of alarm and float switches,etc.) DISTRIBUTION BOX: (locate on site plan) Depth below grader Depth of liquid level above outlet invert:—<.I Dimensions of D-Box: 9.9pth of Sump:_ �X'�D Comments: e if I vel and distribution is ectual evidence of solids carryover, vidence of leakage into or out of pox, etc. ce Dvr � ncQ a r e PUMP CHAMBER: (lo on site plan Depth below grade: Pumps in working grder:(yes or n Comments: (note conditions of pump chamber, condition and appu s, etc.) (revised 8/15/95) 7 FILE# 0 7 SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SOIL ABSORPTION SYSTEM (SAS)- (locate(locate on site plan,if pass a ex�,afion not required,but may be approximately b non- e �i Y PP Y Y intrusive methods) Depth to bottom of SAS: (Stone or Pit) X• If not determined o be p e t, a plain: !Gl Y r f" r. FC Type. leaching pits, number leaching chambers, number: leaching galleries,number: INI leaching trenches, number, length: leaching fields, number,dimensions: tj Ll UnILS Commen ate Tridition fail, signs of hydraulic re, level of ponding, di ion f ve etati tc.) �. L�.��i7 �Q 1 �} Gth Sl � d'rJ V, CES LS*e (locate sits p an) Depth belo rade:_ Number and co oration: Depth-top of liquid to' let invert Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwa : inflow(cess 1 must be pumped a art of inspection) Comm ts: (note condition of soil, signs of hydraulic iIure, level of ponding, condition of vegetation,etc.) PRIVY: {locate on site p Materials of construction: Dimensions: Depth of solids: Comments: (note conditio oil, signs f 1Xdraulic failure, level of ponding,condition of vegetation, etc.) (revised 8/15/95) $ i1 • FILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM'INSPECTION FORM PART C SYSTEM INFORMATION(continued) SKETCH OF SEW E UISPO LAL WSTEM. include tie t49; twc Fnent references landmarks or benchmarks locate all ells"'thin 100 L .-54!5 E c=x rd ST A 1B 094 c, CI o -ray)>< V D' DI 45`,i= '.each p. IES n �7 8�c c '� a DEPTH OF GROUNDWATER Depth to groundwater:_j_f->__feet me od of etermin 'on or app ximation: 06ar * ' r er-- n © S ' 'A }o Tt =3s' 6 �o T1 = t9 Ao � t j (revised 8115/95) WELL DATABASE �- ADDRESS: � yr AGE OFW rr:� WELL DRILLER. x< WELL PEPUN4I T m: WELL LOCATION: -WELL PElUvrL DATE:- —DE 7a OF WELL: . TYPE OF WELL: a.. DRrr.r_Fn _'� b. DUG c. T:YEE.OF WAT'ERBE4RINCz ROCKr WATFA?LNTALYSTS DAA HIGFitifANGANESE. Y N' HTG IRON: y N OT= NTAi�BNANTS: N WELL DATABASE ADDRESS: AGE OF WELL: w WELL.DRILLER: WELL PERMIT�: Iqz=L OCA „ WELL PERIv1I17DATE: DE OF WELL. TYPE OF WELL: a. DRIZLED bU TYPE OF WATER BEARING ROCK: WATER ANALYSIS DATE. HIGH NL .NGA14-Esl Y N HIGH IRON: Y N O'IT£Er""t CONTAINMNAIYTS: Y N Town of North Andover f NORTH OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES � 9 x - '' 146 Main Street North Andover,Massachusetts 01845 WILLIAM J.SCOTT Ssgc�us� Director TOWN OF NORTH ANDOVER q ��6 BOARD OF HEALTH CERTIFICATE OF COMPLIANCE This is to certify that the septic tank constructed () or repaired (X) by MIKE REILLY installer at 545.BOXFORD^STREET has been installed in accordance with the provisions of TITLE 5 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 BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERM DATE: q- ( (1-g CURRENT INSTALLER'S LICENSE# LOCATION: Si L-{ 4 r-A :f2� - LICENSED INSTALLER: -E7 � `\ -�, SIGNATURE: A TELEPHONE# �f D5.J�3� CHECK ONE: REPAIR: NEW CONSTRUCTION: IF NEW CONSTUCTION,PLEASE ATTACH FOUNDATION AS-BUILT. Administrative Use Only $75.00 Fee Attached? Yes No Foundation As-Built? Yes No Approval Date: q 1,/o J. r Form No.3 Town of North Andover, Massachusetts BOARD OF HEALTH OE PORT a 1h - . O 19— M 9—M 9 'v DISPOSAL WORKS CONSTRUCTION PERMIT =:. ,'SSACSUSE< Applicant ADDRESS TELEPHONE NAME Site Location Permission is hereby granted to Construct ( ) or Repair (4an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S.No. t _ CHAIRMAN,`BOARD Of HEALTH Fee D.W.C. No. 1 MERMWCK=ENGINEERING SERVICES Professional Engineers.Land Surveyors•Planners 66 PARK STREET ANDOVER,MASSACHUSETTS 01810 (508)4754555 SEPTIC SYSTEM AS-BUILT FORM Z415TA LLFJZ �-- 1�• �'t�� -�-5®(`i_� r�C� Location/Address: Date: _' — BUILDING TIES INVERT ELEVATIONS Bldg.Comer A B, C D 4'pipe @ Fdtn. Tank Septc Tank In Pump Tank Se 'c Tank Out Dist. Box Pump Tank In Cam.Leach Field 41 Pump Tank Out Com.Leach Feld#2 Dist. Box In Com.Leach Field#3 Dist. Box Out Com.Leach Field#4 End Leach Line#1 End Leach Line#2 Benchmark O Elev. = End Leach Line#:i R.R. + End Leach Line#4 H.I. _ ; r A- 444 -I 4o AA k Q4la�` �: 0 Sketch M1 (� FILE# 107 Forest St. aP�r1 Middleton, 9 �608)774-2772 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PROPERTY OWNER'S NAME: Rnc/f-)!�3a - U PROPERTY ADDRESS: 51- Q, ifl nA O VC r �. i ADDRESS OF OWNER: (if different) DATE OF INSPECTION: Lg NAME OF INSPECTOR: TCS •THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY• FILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: -5 45— �x f /d St �), Mff=ot Uw ner: Date of Inspection: f 01d4s� He 1996 (If different) Name of Inspector: r�N w Company Name,Address and Telephone Number: Currier Septic&Drain Service, Inc. 107 Forest Street, Middleton, MA 01949 (508) 774-2772 CERTIFICATION STATEMENT I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: � �o Date: /574 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30)days of completing this inspection. If the system 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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N,or ND). Describe basis of dtermination in all instances. If"not determined", explain w.hy not The septic tank is metal, cracked§tucturall unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8115/95) I FILE# (?1 f 961q SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (coerinuEd) B) SYSTEM CONDITIONALLY PASSES(continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health); broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: _ Conditions exist which require further evaluation by the Board of Health in order to determine if t e system i failing to protect the publig health, safety and the environmVt.'f5 —tecau&c ranK Let Th�'c's Po�en�is SeeP�2 /neo sew��� � . 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. V The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D) SYSTEM FAILS: _ I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. (revised 8/15/95) 2 i FILE# 919 q SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) D) SYSTEM FAILS(continued) Static liquid level in the distribution box above oulet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NQJ due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. AAny portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. EARGE SYSTEM FAILS: ��The o criteria apply to large systems in addition to the criteria above: The design flow of system 0 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environmen se one or more of the following conditions exist: the system is within 400 feet of a surface drinkin r supply the system is within 200 feet of a tributary to a surface drinkin ply the system is located in a nitrogen sensitiv nterim Wellhead Protection Are PA)or a mapped Zone II of a public water suppl The owner or operator of an system shall bring the system and facility into full compliance with the groundwater treatment program ements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further info on. (revised 8/15/95) 3 FILE# V SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: ✓Pumping information was requested of the owner, occupant, and Board of Health ZNone of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. f As built plans have been obtained and examined. Note if they are not available with N/A. ✓The facility or dwelling was inspected for signs of sewage back-up. ✓The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. _�./AII system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. _✓The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. _✓The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of SubSurface Disposal System. (revised 8/15/95) 4 LFILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS Design flow: allons Number of bedrooms: Number of current residents: Garbage grinder(y7e)or no): Laundry connectedo s ste ye or no):�$ Seasonal use(yes or no Water meter readings, if available: 00--tA tw) Last date of occupancy: L/INDUSTRIAL: Type of esta i t: Design flow:_gallo Grease trap present: (yes or not) Industrial Waste Holding Tank present: (yes or n Non-sanitary waste discharged to the Title stem: (yes or n Water meter readings, if avialble: Last date of occy: 0TH . (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: 4 Vr_S ag©, t Q9z. System pumped a p rt of inspection: (yes or no)_ If yes,volume pumped: gallons Reason for pumping: flfnki29 "40LSF,11 Typf 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) Other(explain) AP ROXIMATE AGE of all components, dr ate i stalled(if known)and source of information: 147 r' �r�' 'O��. S" In io /o�� Sewage odors detected when arriving at the site: (yes or nou,!— (revised 8/15/95) 5 LFILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) , SEPTIC TANK: (locate on site*pan Depth below grader Material of construction:iconcrete Metal FRP other(explain) caST ?,ecTca.r,g I —��t< t oe�c� Dimensions_s LX ; i,�1 '_S' N Baffle Depth Below Outlet Invert; ►S Sludge depth: 5 /1 Distance from top of sludge to bottom of outlet tee or baffle: Z5 Scum thickness:_0_ Distance from top of scum to top of outlet tee or baffle: �! ` Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inl and outlet tees or baffles depth of liquid level in relation to outlet invert, structural integrity, evidence of le a e,etc.) p , ►J �¢ !A1 41�he �a ams GREASE TRAP:GD e on site pan) Depth below gra Material of construction:_ crete_metal_FRP—other(explain) Dimensions: Baffle Depth Below Outlet Invert: 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 ba Comments: (recommendation for p condition of inlet and outlet tees or baffles, depth of liquid level in r n to outlet invert, structural inte idence of leakage, etc.) (revised 8/15/95) 6 FILE# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) TIGtiT OR HOLDING TANK: ,00 (loca ite plan) Depth below grade: Material of construction:_concr metal_FRP—other(explain) Dimensions: Capacity: -gallons Design flow: gallons/day Alarm level: Comments (condition of inlet tee, con ' ` of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth below grader f L/nom hwes ®vr, Depth of liquid level above outlet invert: r, /"V, Dimensions of D-Box: Qepth of Sump:_ c2p 2 1 '7xD0"H Comments: e if level and distribution is a al, evidence of solids carryover, evidence of leakage into or out of ox, etis or /'.7 / r t) s ce So rtt4 Cif, loo� ence nItax, The —is &16ezrl �- PUMP CHAMBER: (lo on site plan Depth below grade: Pumps in working order.(yes or n Comments: (note conditions of pump chamber, condition s and appu s, etc.) (revised 8/15/95) 7 FILE# 0 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if pos�s��e exca a ion not required, but may be approximately by non-intrusive methods) Depth to bottom of SAS: f (Stone or Pit) 4 �X- If not determined o be pr se t, a plain: r ter- rin a�4a r. r_346h Type: leaching pits, number: N leaching chambers, number:f leaching galleries, number: leaching trenches, number, length: leaching fields, number, dimensions: Ll Comment ote c ndition of oil, signs ofdraulic f etatt ' re, level of ponding, co di ion f ve i c.) >~3,Tn� r� t t4 l Gib p r r � , CES OOLS: (locate site p an) Depth belo rade: / Number and co uration: �f Depth-top of liquid to"A Depth of solids layer: Depth of scum layer: Dimensions of cessp Materials of construct Indication of groundw inflow(cess art of inspection) Comm ts: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) it PRIVY: b (locate on site p Materials of construction: / Dimensions: Depth of solids: Comments: (note conditio oil, signs 1411 draulic failure, level of ponding, condition of vegetation, etc.) it \ (revised 8/15/95) 8 FILE# 91Y96 R SUBSURFACE SEWAGE DISPOSAL SYSTEM'INSPECTION FORM PART C SYSTEM INFORMATION(continued) SKETCH OF SEW EPO AL YSTEM: include tie tows tw p rmanent references landmarks or benchmarks locate all ellUhin 100 U ?aoL a� A � O� SEP41 c- -Tay)Y,Tau'1k V 8Nt 45�L Leach Linf ST DEPTH OF GROUNDWATER Depth to groundwater:_f r> feet me hod of&termingion or appr ximation: Oar1- a qS If2:L;( anj ! �!— �, er � sJAI © s �s, der: A k> T1 =mss' B �oTt = 1q ' A +0 -t) l '3C 1I = 125 ►, (revised 8115/95) 9 t0 ) WELL DATABASE ADDRESS: c� AGE OF War r. WELL DRILLER: ' WELL PES I tf"1.T: WELL LOCATION: — V- TELL.PERNIC DATE. --DEPTH OF WELL: w =OF WELL: a._ DRIL.= b. DUG c. ui Fl2i 0 WN —_ TYPE OF WATE BE:4RING ROCK_ WATER ANALYSIS DATA HIGH MA1vGANESE .Y N' _ HIGHIIZON: Y N 0= NTAMLNANI'S: f WELL DATABASE r ADDRESS: �f AGE OF WELL: WELL DRILLER: r ' -.WELL PERMIT : WELL LOCATLON: WELL PER�WTDATE: DEPS OF WELL: TYPE OF WF-.LL: a. DRILLED b. DLTG' c. L'N �i0�7,rN TYPE OF WATER BEAR "-TG ROCK. WATER 4.NA.LYSIS DATE: HIGH N ANGA.NESE: Y N HIGH IRON: Y N OTN=R CONTAIYE TANTS: Y N