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Miscellaneous - 546 FOSTER STREET 4/30/2018 (2)
546 FOSTER STREET 210/104_B.0O07-0000:0 r c i Y r i i i� V' i 1 �i Iw � Pi � Lot.& Street '!LPA Map/Parcel CONSTRUCTION APPROVAL Has plan review fee been paid: YES . NO Permit# Plan Approval: Date: _: `-Approved by: - Designer:_ Conditions: Water_Supply:.�. -Town Well Permi#: Driller. -Well:Tests :Chemical Date A ppr9yqda Bacterial Date Approved: . `'Bacteria i- - DateA)r)roved:: - Plumbing Sign Off - _ WiTSign off Comments: : - Form "U"Approval:; Approval to Issue YES N0 Date Issued .- - s ._-` By: Conditions,.,- 7 Final onditions:-_.,.Final Approval. . All Permits Paid?. ,.' YES _'N w Well Construction Approval? >. : . :YES = :: r NO Septic System Construction Approval? YES NO Certification? = YES NO Other? \ =YES NO Any Variance Needed? y: YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: APPROVED BY: SEPTIC SYSTEM INSTALLATION §_ CONDITIONS: Is the"installer licensed? ` :YES NO : _ Type= of Construction: . _ NEW REPAIR NeW:Construction Cc Plot Plan Review `. 1. YES -' NO Floor Plan Review YES . NOS " Conditions of'Approval from Form tJ: YES N0_` - 1 „ Issuance^of D C permit _ x.. YES NO DWC Permit Paid YES NO I.DWC Permit# -Installer :BeginInspectlon: e YES 'Excavation=Inspection: - Needed.: - w P�ass&d y By - , - - Construction Finspection - .- - - " - -� . ,Needed:. r ' As~Bvuilt Pfan=Satisfactory � � � _ _ Approval.oftBackfill ,y ,Date By: - 'Final,GradKpproval Date r\ By .r Final Construction Approval Dafe By: Certificate of Compliance:- Approval: Date: Commonwealth of Massachusetts. City/Town of r f -_ - System Pumping Record NORTH ANDOVit'Rv8 2,01 Form 4 r Totti;av: 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 1. System Location: forms on the osT-i S computer,use —�_�—--- --- --- -..._.-.only the tab key Address to move your - cursor-do not CityfTown State Zip Code use the return key. 2. System Owner: �I Name -- ----•- -- - Address(if different from location) ----- --- ---- City/Town — .------ -- State -- - Zip Code — gjg-' 7e -7 ---- Telephone Number B. Pumping Record G� 1. Date of Pumping Date2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) [G�'Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): ---- - -- -- - — - — 4. Effluent Tee Filter present? ❑ Yes [4-No1 If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: O�C 6. System Pumped By: Name Vehicle License Number Company 7. Location where contents were disposed: --MAD.-- -NorthAndaW MA -- Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 1 REC CED Commonwealth of Massachusetts City/Town of P' 'v11)6 2 G __ System Pumping Record NORTH ANDOVER 00 j4-A,;'TV, �: }g 1�1 T Form 4 4 b�.. _ y 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 1. System Location: forms on the computer,useonly the tab key Address to move your cursor-do not City/Toown — State Zip Code use the return key. 2 System Owner: Name +�^ Address(if different from location) CityfTown - State Zip Code Telephone Number B. Pumping Record �.. / /-. .. 2. Quantity Pumped: ---- 1. Date of Pumping Date Gallons _ 3. Type of system: ❑ Cesspool(s) (Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? 0 Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: Ole-- --- - 6. System Pumped By: Name Vehicle License Number Company 7. Location where contents were disposed: —----------------... -- Date Signature of Hauler Signalure of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of t Commonwealth of Massachusetts - . City/Town of j; G - System Pumping Record NORTH ANDO TERFN0RTHAN;. R Form 4 HEALTH DEPARTMENT T h 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 1. System Location: forms on the SLiLo �vs�rG� 5� computer,use _ ----- --------- — -----------_..__.._.only the tab key Address to move your cursor-do not CitylTown State Zip Code use the return key. 2 System Owner: Name ------- — - ----- - Address(if different from location) ----- _-- - - -- - -- - -- ------- City/Town ------ ------------ -State ---- - Zip Code --° Telephone Number B. Pumping Record Quantity 1. Date of Pumping Date 2.` t� y Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap El Other(describe): ------- ------ . --------------------------__-.. 4. Effluent Tee Filter present? ❑ Yes P401 If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Name �C f� — Vehicle License Number VJs✓t f Company 7. Location where contents were d' posed: Signature of Hauler r A: Date Signature of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 ` r health Department utjn SC — Torwarded 6y(Pamela Tease return after review. qW ank Yom Date: RECEIVED JUN 3 0 2005 TOWN OF NORTH ANDOVER HEALTH DEPARTh�4" T RE: Susan: ➢mac ele );;- Debbie Health Calendar Updated? ❑ s ❑ No ❑ n/a RETURN TO PAMELA ❑ File: ❑ Dispose NOTE: SILLARI & GLINES ATTORNEYS-AT LAW CHARLES J.SILLARI,JR. 92 HIGHLAND AVENUE JOSEPH A.TORRA, SOMERVILLE,MASSACHUSETTS 02143 OF COUNSEL STEPHEN A.GLINES,JR. ------------------------------------- JEFFREY J.DIGREGORIO, TEL: 617.628.1110 FAX: 617.628.0880 OF COUNSEL www.SomerviUeLawFirm.com June 29, 2005 RECEIVED John J. Soucy JUN 3 p 2005 g 830 Livingston Street Tewksbury, MA 01876 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Benjamin C. Osgood, Jr. 164 Johnson Street North Andover, MA 01845 Deborah Moore 546 Foster Street North Andover, MA 01845 Susan Sawyer, Director Department of Public Health 400 Osgood Street North Andover, MA 01845 RE: Chiles, et al v. Barrett, et al, Essex Superior Court Docket No. ESCV2003-1266 Trial Scheduled July 7, 2005 at 9:00 A.M. Ladies and Gentlemen: Please be advised that the above-mentioned civil action is scheduled for trial on July 7, 2005 at 9:00 a.m. at the Essex County Superior Courthouse, Courtroom 2 Rear, 34 Federal Street, Sale,—,,, Massachusetts. You are hereby reminded that your presence is required and you are still under subpoena and are required to attend. I have enclosed a copy of the subpoena that has been previously served upon you. If there are any questions or concerns please do not hesitate to contact the undersigned. SiFphentA: Clines Jr. Commonwealth of Massachusetts County of Essex The Superior Court '; CIVIL DOCKET# ESCV2003-01266 rw RE: Chiles et al v Barrett et al TO:Charles J Sillari Jr, Esquire RECEIVED 92 Highland Ave Somerville, MA 02143 JUN 3 0 2005 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT TRIAL NOTICE The above entitled case has been called for TRIAL at the Essex Superior Court, Salem in the A session, ON: 07/07/2005 AT: 09:00 AM LOCATION: CtRm 2 -rear (Salem) A JOINT PRE-TRIAL MEMORANDUM shall be submitted at the time of the Pre-Trial conference or Screening, and in any event, shall be filed NO LATER THAN ONE WEEK PRIOR TO THE SCHEDULED TRIAL DATE. COUNSEL, OR PRO SE PARTIES, SHALL BRING THE FOLLOWING DOCUMENTS TO COURT ON THE DATE OF TRIAL, IF NOT ALREADY SUBMITTED AT THE TIME OF A PRE-TRIAL CONFERENCE OR SCREENING: 1. List of Witnesses 2. List of Exhibits 3. Any Pre-Trial Stipulations 4. Brief Agreed Statement of the Case to be read to Jurors 5. Proposed Jury Instructions and Proposed Verdict Slip or proposed Findings of Fact and Rulings of Law 6 ercpcsou Finding^s of Fact and Ru°ings of Lave SN;LL boe f lea' the Court on the FIRST day of Trial. a Please contact the Session Clerk prior to the trial date as to the trial status and also notify the Court promptly of any settlements. By the Court, David Lowy, Justice Judith Brennan Assistant Clerk Telephone: (978) 744-5500 ext. 414 Disabled individuals who need handicap accommodations should contact the Administrative Office of the Superior Court at(617)788-8130 Check website as to status of case:http://ma-trialcourts.org/tcic cvctria1notessex_2.wpd 77979 triju brennanj COMMONWEALTH OF MASSACHUSETTS Essex, ss Superior Court Department Civil Action No.: 3-1266 f CHRISTINE CHILES and JAMES ' CHILES, Plaintiff, SUBPOENA DUCES TECUM V. PER MASSACHUSETTS RULE OF CIVIL PROCEDURE JOHN BARRETT, MARCIA RULE 45 BARRETT, et al.,. Defendants TO: Susan Sawyer, Director JUN 3 0 2005 DEPARTMENT OF PUBLIC HEALTH TOWN OF NORTH ANDOVER Town Offices HEALTH DEPARTMENT 400 OSGOOD STREET N. Andover, MA 01845 YOU ARE HEREBY COMMANDED in accordance with the provisions of Rule 45 of the Massachusetts Rules of Civil Procedure to appear and give testimony, before the Superior Court Department of the Trial Court holden at 34 Federal Street in the City of Salem, within and for the County of Essex originally scheduled for the 14th day of February, 2005.This is an on -call trial. The new trial date has yet to be determined, likely your appearance will be required for testimony at a given date between February 16th and March 4th 2005, and from day to day thereafter until the action hereinafter named is heard by said Court, relating to Civil Action No. 3-1266 then and there to be heard and tried between Christine Chiles and James Chiles, Plaintiffs, and John Barrett, Marcia Barrett, et al., Defendants.. "You are further required to bring with you those documents listed on Appendix A attached hereto. Your failure, without adequate excuse, to obey this subpoena may be deemed in contempt of the Court in which this action is pending. PLEASE NOTE that you may quash or modify this subpoena as unreasonable or oppressive pursuant to Rule 45(b) of M.R.C.P. Furthermore, pursuant to Rule 45(d)(1) of M.R.C.P. you are afforded an opportunity to object, in writing, to inspection or copying of the materials designated herein as Appendix A. PLEASE ALSO NOTE that your presence at the deposition may not be required if you deliver the documents requested in Appendix A before the date of the deposition. HEREOF FAIL NOT, as failure,without adequate excuse,to obey this subpoena may be deemed in contempt of the Court in which this action is pending. C arler6jitari,A J , Esquire S 1 ines, orneys-at-Law 92 Highland Avenue Somerville, Massachusetts 02143 Tel: (617) 628-1110 BBO #649722 COMMONWEALTH OF MASSACHUSETTS Middlesex County, ss. February /S, 2005 On this�yIdayL[ of February, 2005 before me the undersigned notary public, personally appears C/IArlCJ T. S1'/1,1rj'jip, proved to me through satisfactory evidence of identification, which were, by Massachusetts Driver License, to be the person whose name is signed on the preceding or attached document, and acknowledgement to me that(he) signed it voluntarily for its stated pu e. ry Public: S f c l.`n ,�A, My commission expires:a/aj aoo? S MP"IIN A.010211,JN. wormy puux cwwaarw.�w a W COA0MMM EXPOU FEBRUARY 2,2007 r APPENDIX A 1. Any and all documents related to 154 Rea Street,North Andover, MA, including, but not limited to, all records,bills, plans, correspondence, submissions, complaints, particularly septic system designs, etc., with regard to the property located at 154 Rea Street,North Andover, MA currently owned by James Chiles and Christine Chiles formerly owned by Marcia.Barrett and John Barrett. i i :,:.,,. ;d� ,.., ; r:. . X911 t��#tt... �G :k ta•F��� ,'2,. <..F.p,r s ..afr,. I , , e±. �5.. „s@: ,[',.: .,r 3.y..c rEa•. I I;,,, t ,.,.w,• : i,+„! ,:. . . : +. r...,4: e F{{•aha. _ ., lk yy� . . >.,,. $” nti . z �y 3.,f..� r 's,. RN"!.u., `4 ,t .t, v ,. 'pE .a�.. � r '.g 'a: "'r,:.: 'Y�f<: $e,,,a .aewGf,,. . t,I ,,: ..,aYrl:».. r .._,t..,, � .• ��' krwr~ .. . �b c�^- , . :- , _..t. a,,➢.. 4F.,.a f r rk ,i, ',..f. i i , ,L" ,t rWl,r � �.E':°+tl,� �. .� }.{:;� .a{q. r�.rd�4° ,:°ttr ip�a, Exp, fet r'as''t .i1 • e, .>_, i ri } ti tfv.., x k e 'd f "�+�+•.s,,,:4ST•,.,,,.._ ? 7.Fr FY r�# 4 ¢:. � tsF R r l [. vRt �,$ E''�afx tt i t k f Town of North Andover, Massachusetts Form No. 3 of NooTe�ti BOARD OF HEALTH r f f , 3� ,a•R p"-r' s9 . . 3? 9t„':-'.:..• +e OCL (f 'A' ' 3,,i[r19 rl rtM1f *s Vie' 1 k x," � „rr"�ryr DISPOSAL WORKS CONSTRUCTION PERMIT }fF 47 CHU tit r(,< ; : t , aaa' t'!l rlr; f t 3 { 1f tx Ktz Applicant �6r S f r •. )) � I i : t7 k t (F R ' t NAME ADDRESS TELEPHONE Site Location --"7- Permission , Permission is hereby granted to Construct ( ) or Repair ( ) an Individual Soil Absorption I }� r • Sewage Disposal System as shown on the Design Approval S.S. 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'r-., ➢ .., :.A. .r A' [. ,•. ar .. ,.:.,. t f• ;.^„ . ii Gqqs..,.,.. 7a Y ,s.i� .:.. .. 1.'€.. N"t u43. .ss��z r, { >zj •q:;}, .. ..., j.. drrr,.n.. l;€ ,.�::.J. i.., it..,....1<.'0 c .:. �. 5 ,, .rtStS 7:a S, .t.,l.; .. ��1'Tt.., .::: .3i {;>. Form 4 -- System Pumping Record Commonwealth of Massachusetss I Massachusetts -e-—IVI System Pumping Record System Owner System Location )r Y Ir f) 3 CELL r,7`; Type: Emergency Routine Cesspool: No Yes Septic tank: No F]Y.S 0 Date of Pumping: Quantity Pumped: Gallons System Pumped By: Wind River Environmental, UC Permit#: Contents transferred to: 6F NORTH Bot_,,T)OF OEC,j' Contents Disposed at: Date: Pumper Signature: Condition of System/Other Comments Dep Approved Form - 12/07/95 Address 574 �- 57' Title of Fiile Page of Date File Open: Date file closed: Doc Document/Action Title Date of Refer to other Purpose of'Documeont/Action and notes T action Document/ document/ Num. Action Department Board of Appeals — Board of Health — Planning Board -, Conservation Commission -- Building Department �� FORK\l 1-SYSTEM PUMPING kFC'OPD CuIER. SEPTIC & BRAIN SERNICE - 107 FOREST STREF7- h11.DDL ETON,?%-JA 019,, �97 81 7!7 x7779 I a ENV IRONkiENTAL CM\ll0NW'EALTli OP 1�Z�SSACFiIJSETTS _____�/v- /�✓SCE'�l/P�; MASSACHUSETTS SYSTEM.ELYPI-NG RECORD SYSTEM z.ocATluti: I klmZ)0�-� q7o ^ 3? :l DATE OF VUl, 'ItiTG: `i) ���d QI JANTITY PURVFD: 1.56 3 —,-- GALLONS CESSPOOL: NO YES --� SFt?T(C TANK: NO YES SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE CONVENTS TRANSFERRED T0: c DATE - IN SP.ECTOR: `e 14 Gr 17 Form 4 -- System Pumping Record Commonwealth of Massachusetss : Massachusetts System Pumping Record OCT 2 5 2001 System Owner System Location C-3b, t. h lluure -.7 r for _ . `)': Frs.-.t ac :tiNet 1' f;,,rtli .adowr 1L4 for , An6»vr M 01u 047 0011 Type: Emergency Routine Cesspool: w Yes Septic tank: filo =Yes Date of Pumping: (C © -0 1 Quantity Pumped: f- �-�a Gallons System Pumped By: Wind River Environmental, LLC Permit#: Contents transferred to: Contents Disposed at: Date: Pumper Signature: Condition of System/Other Comments Dep Approved from - 12/07/95 I I 107 FOREST STREET FILE# 9999A MIDDLETON,MA 01949 (978)774-2772 SEPTIC & DRAIN CURRIEJE111--,SERVICE 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i PROPERTY OWNER'S NAME: MOORE PROPERTY ADDRESS: 546 FOSTER ST. N. ANDOVER.MA ADDRESS OF OWNER: SAME (IF DIFFERENT) DATE OF INSPECTION: 9 SEPT 1999 DEC 2199 NAME OF INSPECTOR: THOMAS CHIGAS * THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY 107 FOREST STREET FILE#9999A MIDDLETON,MA 01949 (978)774-2772 SEPTIC&DRAIN SERVICE SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION PROPERTY ADDRESS:546 FOSTER ST. NAME OF OWNER: MOORE N.ANDOVER,MA ADDRESS OF OWNER: SAME DATE OF INSPECTION: 9 SEPT 1999 NAME OF INSPECTOR: (PLEASE PRINT)THOMAS CHIGAS I AM A DEP APPROVED INSPECTOR PURSUANT TO SECTION 15.340 OF TITLE 5 (3 10 CMR 15.000) COMPANY NAME: CURRIER SEPTIC &DRAIN MAILING ADDRESS: 107 FOREST STREET: MIDDLETON, MA 01949 TELEPHONE NUMBER: 978 774-2772 CERTIFICATION STATEMENT I CERTIFY THAT I HAVE 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 PREFORMED BASED ON MY TRAINING AND EXPERIENCE IN THE PROPER FUNCTION AND MAINTENANCE OF ON-SITE SEWAGE DISPOSAL SYSTEM. THE SYSTEM: PASSES CONDITIONALLY PASSES NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY YES FAILS INSPECTOR'S SIGNATURE: DATE: 24 NOVEMBER 1999 THE SYSTEM INSPECTOR SHALL SUBMIT A COPY OF T IS INSPECTIO REPORT TO THE APPROVING AUTHORITY(BOARD OF HEALTH OR DEP) WITHIN THIRTY(30)DAYS OF COMPLETING THIS INSPECTION. IF THE SYSTEM IS A SHARED SYSTEM OR HAS A DESIGN FLOW OF 10,000 GALLON 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. NOTES AND COMMENTS: DURING THE TIME OF REPAIR ON 11/24/99 HAVE DETERMINED THE SYSTEM TO BE AT HYDULIC FAILURE AND POSSIBLY IN WATER TABLE. I REVISED 9/2/98 PAGE I OF 11 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) PROPERTY ADDRESS:546 FOSTER ST. OWNER:MOORE DATE OF INSPECTION:9 SEPT 1999 INSPECTION SUMMARY: CHECK A, B, C, OR lam' A. SYSTEM PASSES: N I HAVE NOT FOUND ANY INFORMATION,WHICH INDICATES THAT ANY OF THE FAILURE CONDITIONS DESCRIBED IN 310 CMR 15.303 EXIST. ANY FAILURE CRITERIA NOT EVALUATED ARE INDICATED BELOW. COMMENTS: B. SYSTEM CONIDTIONALLY PASSES: NONE 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. INDICATE YES,NO,OR NOT DETERMINED(Y,N,OR ND). DESCRIBE BASIS OF DETERMINATION IN ALL INSTANCES. IF"NOT DETERMINED",EXPLAIN WHY NOT. N THE SEPTIC TANK IS METAL,UNLESS THE OWNER OR OPERATOR HAS PROVIDED THE SYSTEM INSPECTOR WITH A COPY OF A CERTIFICATE OF COMPLIANCE(ATTACHED)INDICATING THAT THE TANK WAS INSTALLED WITHIN TWENTY(20)YEARS PRIOR TO THE DATE OF THE INSPECTION;OR THE SEPTIC TANK,WHETHER OR NOT METAL,IS CRACKED,STRUCTURALLY 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 COMPLYING SEPTIC TANK AS APPROVED BY THE BOARD OF HEALTH. N 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). N BROKEN PIPE(S)ARE REPLACED N OBSTRUCTION IS REMOVED N DISTRIBUTION BOX IS LEVELLED OR REPLACED N 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): N BROKEN PIPE(S)ARE REPLACED N OBSDTRUCTION IS REMOVED REVISED 9/2/98 PAGE 2 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) PROPERTY ADDRESS:546 FOSTER ST. OWNER:MOORE DATE OF INSPECTION:9 SEPT 1999 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N CONDITIONS EXIST WHICH REQUIRE FURTHER EVALUATION BY THE BOARD OF HEALTH IN ORDER TO DETERMINE IF THE SYSTEM IS FAILING TO PROTECT THE PUBLIC HEALTH, SAFETY AND 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRNONMENT: N/A CESSPOOL OR PRIVY IS WITHIN 50 FEET OF SURFACE WATER N/A 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 AND SAFETY AND THE ENVIRONMENT: N THE SYTEM 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. N THE SYTEM HAS A SEPTIC TANK AND SOIL ABSORPTION SYSTEM AND THE SAS IS WITHIN A ZONE I OF PUBLIC WATER SUPPLY WELL. N THE SYSTEM HAS A SEPTIC TANK AND SOIL ABSORPTION SYSYTEM AND THE SAS IS WITHIN 50 FEET OF A PRIVATE WATER SUPPLY WELL. N THE SYSTEM HAS A SEPTIC TANK AND SOIL ABSORPTION SYSYTEM AND THE SAS IS LESS THAN 100 FEET BUT 50 FEET MORE FROM A PRIVATE WATER SUPPLY WELL, UNLESS A WELL WATER ANALYSIS FOR COLIFORM BACTERIA AND VOLATILE ORGANIC COMPOUNDS NDICATES 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. METHOD USED TO DETERMINED DISTANCE (APPROXIMATION NOT VALID). 3) OTHER: N/A REVISED 9/2/98 PAGE 3 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) PROPERTY ADDRESS:546 FOSTER ST. OWNER:MOORE DATE OF INSEPCTION:9 SEPT 1999 D. SYSTEM FAILS: YOU MUST INDICATE EITHER"YES"OR"NO"TO EACH OF THE FOLLOWING: YES I HAVE DETERMINED THAT ONE OR MORE OF THE FOLLOWING FAILURE CONDITIONS EXIST AS DESCRIBED IN 310 CMR 15.303. THE BASIS FOR THIS DETERMINATION IS IDENTIFIED BELOW. THE BOARD OF HEALTH SHOULD BE CONTRACTED TO DERTERMINE WHAT WILL BE NECESSARY TO CORRECT THE FAILURE. YES NO YBA K _ CUP OF SEWAGE INTO FACILITY OR SYSTEM COMPONENT DUE TO AN OVERLOADED OR CLOGGED SAS OR CESSPOOL. N DISCHARGE OR PONDING OF EFFLUENT TO THE SURFACE OF THE GROUND OR SURFACE WATERS DUE TO AN OVERLOADED OR CLOGGED SAS OR CESSPOOL. N STATIC LIQUID LEVEL IN THE DISTRIBUTION BOX ABOVE OUTLET INVERT DUE TO AN OVERLOADED OR CLOGGED SAS OR CESSPOOL. N/A LIQUID DEPTH IN CESSPOOL IS LESS THAN 6'BELOW INVERT OR AVAILABLE VOLUME IS LESS THAN %DAY FLOW. N REQUIRED PUMPING MORE THAN 4 TIMES IN THE LAST YEAR NOT DUE TO CLOGGED OR OBSTRUCTED PIPE(S). NUMBER OF TIMES PUMPED Y ANY PORTION OF THE SOIL ABSORPTION SYSTEM,CESSPOOL OR PRIVY IS BELOW THE HIGH GROUNDWATER ELEVATION. N/A ANY PORTION OF A CESSPOOL OR PRIVY IS WITHIN 100 FEET OF A SURFACE WATER SUPPLY OR TRIBUTARY TO A SURFACE WATER SUPPLY. , N/A ANY PORTION OF A CESSPOOL OR PRIVY IS WITHIN A ZONE I OF A PUBLIC WELL. N/A ANY PORTION OF A CESSPOOL OR PRIVY IS WITHIN 50 FEET OF A PRIVATE WATER SUPPLY WELL. N/A ANY PORTION OF A CESSPOOL OR PRIVY IS LESS THAN 100 FEET BUT GREATER THAN 50 FEET FROM A PRIVATE WATER SUPPLLY 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. E. LARGE SYSTEM FAILS: YOU MUST INDICATES EITHER"YES"OR"NO"TO EACH OF THE FOLLOWING: THE FOLLOWING CRITRTIA APPLY TO LARGE SYSTEMS IN ADDITION TO THE CRTERIA ABOVE: N THE SYSTEM SERVES A FACILITY WITH A DESIGN FLOW OF 10,000 GPD OR GREATER(LARGE SYSTEM) AND THE SYSTEM IS A SIGNIFICANT THREAT TO PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT BECAUSE ONE OR MORE OF THE FOLLOWING CONDITIONS EXIST: 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 SYSEM IS LOCATED IN A NITROGEN SENSITIVE AREA(INTERIM WELLHEAD PROTECTION AREA-IWPA)OR A MAPPED ZONE II OF A PUBLIC WATER SUPPLY WELL THE OWNER OR OPERATOR OF ANY SUCH SYSTEM SHALL UPGRADE THE SYSTEM IN ACCORDANCE WITH 310 CMR 15.304(2).PLEASE CONSULT THE LOCAL REGIONAL OFFICE OF THE DEPARTMENT FOR FURTHER INFORMATION. REVISED 9/2/98 PAGE 4 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INPSECTION FORM PART B CHECKLIST PROPERTY ADDRESS:546 FOSTER ST. OWNER:MOORE DATE OF INSPECTION:9 SEPT 1999 CHECK IF THE FOLLOWING HAVE BEEN DONE: YOU MUST INDICATE EITHER"YES"OR"NO"AS TO EACH OF THE FOLLOWING: YES NO Y PUMPING INFORMATION WAS PROVIDED BY THE OWNER, OCCUPANT, OR BOARD OF HEALTH. Y NONE ON 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 SYTEM RECENTLY OR AS PART OF THIS INSPECTION. N/A AS BUILT PLANS HAVE BEEN OBTAINED AND EXAMINED.NOTE IF THEY ARE NOT AVAILABLE WITH N/A. Y THE FACILITY OR DWELLING WAS INSPECTED FOR SIGNS OF SEWAGE BACK-UP. Y THE SYSTEM DOES NOT RECEIVE NON-SANITARY OR INDUSTRIAL WASTE FLOW. Y THE SITE WAS INSPECTED FOR SIGNS OF BREAKOUT. Y ALL SYSTEM COMPONENTS,EXCLUDING THE SOIL ABSORPTION SYSTEM HAVE BEEN LOCATED ON THE SITE. Y 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: Y EXISTING INFORMATION. FOR EXAMPLE,PLAN AT B.O.H. Y DETERMINED IN THE FIELD(IF ANY OF THE FAILURE CRITERIA RELATED TO PART C IS AT ISSUE,APPROXIMATION OF DISTANCE IS UNACCEPTABLE) [15.302(3)(b)] Y THE FACILITY OWNER(AND OCCUPANTS,IF DIFFERENT FROM OWNER)WERE PROVIDED WITH INFORMATION ON THE PROPER MAINTENANCE OF SUBSURFACE DISPOSAL SYSTEMS. REVISED 9/2/98 PAGE 5 OF 11 • SUBURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION PROPERTY ADDRESS:546 FOSTER ST. OWNER:MOORE DATE OF INSPECTION:9 SEPT 1999 FLOW CONDITIONS RESIDENTIAL: DESIGN FLOW: 330G.P.D.BEDROOM. NUMBER OF BEDROOMS(DESIGN):3 NUMBER OF BEDROOMS(ACTUAL):3 TOTAL DESIGN FLOW: 330 NUMBER OF CURRENT RESIDENTS: 1 GARBAGE GRINDER(YES OR NO):NO LAUNDRY(SEPARATE SYSTEM)(YES OR NO):NO;IF YES,SEPARATE INSPECTION REQUIRED LAUNDRY SYSTEM INFECTED(YES OR NO):NO SEASONAL USE(YES OR NO):NO WATER METER READINGS,IF AVAILABLE(LAST TWO YEAR'S USAGE(GPD): 100 HCF FOR TWO YEARS USAUGE SUMP PUMP(YES OR NO):YES LAST DATE OF OCCUPANCY: CURRENT COMMERCIALANDUSTRIAL: TYPE OF ESTABLISHMENT: DESIGN FLOW: GPD(BAESED ON 15.203) BASIS OF DESIGN FLOW: GREASE TRAP PRESENT(YES OR NO): INDUSTRAIL WASTE HOLDING TANK PRESENT YES OR NO): NON-SANITARY WASTE DISCHARGED TO THE TITLE 5 SYSTEM(YES OR NO): WATER METER REDAINGS,IF AVAILABLE: LAST DATE OF OCCUPANCY: OTHER(DESCRIBE): LAST DATE OF OCCUPANCY: GENERAL INFORMATION PUMPING RECORDS AND SOURCE OF INFORMATION: SYSTEM PUMPED AS PART OF INSPECTION(YES OR NO):NO IF YES,VOLUME PUMPED:N/A GALLONS REASON FOR PUMPING:N/A TYPE OF SYSTEM YES SEPTIC TANK/DISTRIBUTION BOX/SOIL ABSORPTION SYSTEM N SINGLE CESSPOOL N OVERFLOW CESSPOOL N PRIVY N SHARED SYSTEM(YES OR NO)(IF YES,ATTACH PREVIOUS INSPECTION RECORDS,IF ANY) N UA TECHNOLOGY ETC. ATTACH COPY OF UP TO DATE OPERATION AND MAINTENANVE CONTRACT TIGHT TANK COPY OF DEP APPROVAL OTHER:N/A APPROXIMATE AGE OF ALL COMPONENTS,DATE INSTALLED(IF KNOWN)AND SOURCE OF INFORMATION: INSTALLED 8/82-,OWNER SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE(YES OR NO):N REVISED 9/2/98 PAGE 6 OF 11 • SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C SYSTEM INFORMATION(CONTINUED) PROPERTY ADDRESS:546 FOSTER ST. OWNER:MOORE DATE OF INSPECTION:9 SEPT 1999 BUILDING SEWER: (LOCATE ON THE SITE PLAN) DEPTH BELOW GRADE:9" MATERIAL OF CONSTRUCTION: CAST IRON YES 40 PVC OTHER(EXPLAIN) DISTANCE FROM PRIVATE WATER SUPPLY WELL OR SUCTION LINE:N/A DIAMETER:3" COMMENTS: (CONDITION OF JOINTS,VENTING,EVIDENCE OF LEAKAGE,ETC.) NO SIGNS OF LEAKAGE IN OR AROUND PIPE,SOILS ARE CLEAN AND DRY. SEPTIC TANK: YES (LOCATE ON SITE PLAN) DEPTH BELOW GARDE: 2"+ABOVE GRADE MATERIAL OF CONSTRUCTIOMYESCONCRETE METEL FIBERGLASS POLYETHYLENE OTHER (EXPLAIN): IF TANK IS METAL,LIST AGE N/A IS AGE CONFIRMED BY CERTIFICATE OF COMPLIANCE(YES/NO) DIMENSIONS: 81 X 5'W X 5'H OUTLET INVERT @,4'2"= 1000 GAL SLUDGE DEPH: 8" DISTANCE FROM TOP OF SLUDGE TO BOTTOM OF OUTLET TEE OR BAFFLE:N/A SCUM THICKNESS:<2" DISTANCE FROM TOP OF SCUM TO TOP OF OUTLET TEE OR BAFFLE:N/A DISTANCE FROM BOTTOM OF SCUM TO BOTTON OF OUTLET TEE OR BAFFLE:N/A HOW DIMENSIONS WERE DETERMINED: SLUDGE JUDGE,ROD,RULER COMMENTS: (RECOMMENDATION FOR PUMPING,CONDITION OF INLET AND OUTLET TEES OR BAFFLES,DEPTH OF LIQUID LEVEL IN REALTION TO OUTLET INVERT,STRUCTURAL INTEGRITY,EVIDENCE OF LEAKAGE,ETC.)THERE'S NO INLET OR OUTLET TEE BAFFLES.THE INLET PIPE IS 3"PIPE.THE OUTLET PIPE IS SCH2O 4"PIPE.SHOWS SIGNS OF PONDING IN LINE.THE TANK IS NOT LEVEL AND SHOW NO SIGNS OF LEAKAGE IN OR OUT,SOILS ARE CLEAN AND DRY. GREASE TRAP: N_ (LOCATE ON SITE PLAN) DEPTH BELOW GRADE: MATERIAL OF CONSTRUCTION: CONCRETE METAL FIBERGLASS POLYETHLENE OTHER (EXPLAIN) DIMENSIONS: SCUM THICKNESS: DISTANCE FROM TOP OF SCUM TO TOP OF OUTLET TEE OR BAFFLE: DISTANCE FROM BOTTOM OF SCUM TO BOTTON OF OUTLET TEE OR BAFFLE: DATE OF LAST PUMPING: COMMENTS: (RECOMMENDATION FOR PUMPING,CONDITION OF INLET AND OUTLET TEES OR BAFFLES,DEPTH OF LIQUID LEVEL IN REALTION TO OUTLET INVERT,STRUCTURAL INTEGRITY,EVIDENCE OF LEAKAGE,ETC.) REVISED 9/2/98 PAGE 7 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(CONTINUED) PROPERTY ADDRESS:546 FOSTER ST. OWNER:MOORE DATE OF INSPECTION:9 SEPT 1999 TIGHT OR HOLDING TANK:N(TANK MUST BE PUMPED PRIOR TO,OR 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/DAY ALARM PRESENT: ALARM LEVEL: ALARM IN WORKING ORDER: YES NO DATE OF PREVIOUS PUMPING: COMMENTS: (CONDITION OF INLET TEE, CONDITION OF ALRM AND FLOAT SWITCHES,ETC.) DISTRIBUTION BOX: YES (LOCATE ON SITE PLAN) DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT. 0 DEPTH BELOW GRADE;14" COMMENTS: (NOTE IF LEVEL AND DISTRIBUTION IS EQUAL,EVIDENCE OF SOLIDS CARRYOVER,EVIDENCE OF LEAKAGE INTO OR OUT OF BOX,ETC.) THE D-BOX IS IN POOR CONDITION.SHOWS SIGNS OF LEAKAGE AND DECAY.THERE'S ONE INLET AND THREE OUTLETS. DURING THE TIME OF REPAIR ON 11/24/99 THE D-BOX AREA WAS FULL OF LIQUID SHOWING SIGNS OF HYDRULIC FAILURE. PUMP CHAMBER: N_ (LOCATE ON SITE PLAN) PUMPS IN WORKING ORDER(YES OR NO): ALARMS IN WORKING ORDER(YES OR NO): COMMENTS: (NOTE CONDITIONS OF PUMP CHAMBER,CONDITION OF PUMPS AND APPURTENANCES,ETC.) REVISED 9/2/98 PAGE 8 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(CONTINUED) PROPERTY ADDRESS:546 FOSTER ST. OWNER:MOORE DATE OF INSPECTION:9 SEPT 1999 SOIL ABSORPTION SYSYEM(SAS): YES (LOCATE ON SITE PLAN,IF POSSIBLE;EXCAVATION NOT REQUIRED,LOCATION MAY BE APPROXIMATED BY NON-INTRUSIVE METHODS) IF NOT LOCATED,EXPLAIN: TYPE: LEACHING PITS,NUMBER: LEACHING CHAMBERS,NUMBER: LEACHING GALLERIES,NUMBER: LEACHING TRENCHES,NUMBER,LENGTH: LEACHING FIELDS,NUMBER,DIMENSIONS: ONE LEACHBED APPROX 20'X 40' OVERFLOW CESSPOOL,NUMBER: ALTERNATIVE SYSTEM: NAME OF TECHNOLOGY: COMMENTS: (NOTE CONDITION OF SOIL,SIGNS OF HYDRAULIC FAILURE,LEVEL OF PONDING,DAMP SOIL,CONDITION OF VEGETATION,ETC.) DURING THE TIME OF REPAIR ON 11/24/99 OF D-BOX HAVE DETERMINE THE SYSTEM TO BE UNDER HYDULIC FAILURE,SOILS ARE WET AND DIRTY.THE ORENGEBERG PIPE AND THERE IN FAIR CONDITION. CESSPOOL: N (LOCATE ON SITE PLAN) NUMBER AND CONFIGURATION: DEPTH-TOP OF LIQUID TO INLET INVERT: DEPTH OF SOILD LAYER: DEPTH OF SCUM LAYER: DIMENSIONS OF CESSPOOL: MATERIALS OF CONSTRUCTION: INDICATION OF GROUNDWATER: INFLOW(CESSPOOL MUST BE PUMPED AS PART OF INSPECTION) COMMENTS: (NOTE CONDITION OF SOIL,SIGNS OF HYDRAULIC FAILURE,LEVEL OF PONDING,CONDITION OF VEGETATION,ETC.) PRIVY:N_ (LOCATE ON SITE PLAN) MATERIALS OF CONSTRUCTION: DIMENSIONS: DEPTH SOLIDS: COMMENTS: (NOTE CONDITION OF SOIL,SIGNS OF HYDRAULIC FAILURE,LEVEL OF PONDING,CONDITION OF VEGETATION,ETC.) REVISED 9/2/98 PAGE 9 OF 11 ru `d SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , PART C w y SYSTEM INFORMATION(CONTINUED) f ;PROPERTY ADDRESS:546 FOSTER ST. OWNER:MOORE `DATE OF INSPECTION:9 SEPT 1999 $SKETCH OF SEWAGE DISPOSAL SYSTEM: INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCE LANDMARKS OR BENCHMARKS LOCATE ALL WELLS WITHIN 100' (LOCATE WHERE PUBLIC WATER SUPPLY COMES INTO HOUSE). �--S TCC S t . sit yore. 2 I sepix Ak l 1 .. �0 11 25 . e 1/ 1L i" T I 14 TIIT— r j Al + REVISED 9/2/98 PAGE 10 OF 11 }i. \.SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(CONTINUED) PRb�'ERTY=ADDRESS 546 FOSTER ST O,WIVER MOOR A .: r `�- ��i~�; < �>r: " -._ r•, ` R `M �. _. DATE OF INSPECTION 9 SEPT 1999'i SKETCH OFSEWAGEDISPOSAL SYSTEM 'S } INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCE LANDMARKS OR BENCHMARKS LOCATE ALL WELLS WITHIN 100' (LOCATE WHERE PUBLIC WATER SUPPLY COMES INTO HOUSE) �6 S T • �f(r fix, e �• + 1..' L { r t Ycl r s . y � ��.lir Sr+' , ~tib 1. � ',}•. ��, n . E <' f,rr-2 r k r 4 TanK(To 1, ul a / ep r$(p `REVISED'9/2/98,,,. i r NAGE 10 OF 11 ` r '� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(CONTINUED) PROPERTY ADDRESS:546 FOSTER ST. OWNER:MOORE DATE OF INSPECTION:9 SEPT 1999 NRCS REPORT NAMEN/A SOIL TYPE N/A TYPICAL DEPTH TO GROUNDWATER N/A USGS DATE WEBSITE VISITED OBSERVATION WELLS CHECKED GROUNDWATER DEPTH: SHALLOW N MODERATE DEEP SITE EXAM SLOPE SURFACE WATER CHECK CELLAR SHALLOW WELLS ESTIMATED DEPTH TO GROUNDWATER 8'FEET PLEASE INDICATE ALL THE METHODS USED TO DETERMINE HIGH GROUNDWATER ELEVATION: N OBTAINED FROM DESIGN PLANS ON RECORD Y OBSERVED SITE(ABUTTING PROPERTY, OBSERVATION HOLE,BASEMENT SUMP,ETC.) Y DETERMINED FROM LOCAL CONDITIONS N CHECKED WITH LOCAL BOARD OF HEALTH N CHECKED FEMA MAPS Y CHECKED PUMPING RECORDS N CHECKED LOCAL EXCAVATORS,INSTALLERS Y USED USGS DATA DESCIBE HOW YOU ESTABLISHED THE HIGH GROUNDWATER ELEVATION. (MUST BE COMPLETED) THE HOUSE HAS A SUMP PUMP IN BASEMENT AND IT'S DAMP.THE HOUSE HAS 6'FOUNDATION.NO SIGNS OF PONDINGS IN YARD NEAR SYSTEM.NO ABUTTING PROPERTY'S WELLS WITHIN 100'FROM SYSTEM.WHILE DIGGING IN YARD,DUG A DEPTH OF 3'AND FOUND WATER,FINDING THAT THE SAS IS IN WATER TABLE. REVISED 9/2/98 PAGE 11 OF 11 APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: .%`//7 f CURRENT INSTALLER'S LICENSEn LOCATION: FoSfi2_(L_ ST , LICENSED INSTALLER: Co SIGNAT r _ TELEPHONEr. CHECK ONE: REPAIR: NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS- BUILT. T � Administrative Use Only $75.00 Fee Attached? Yeses----- No Foundation As-Built? s No i Floor Plans? es� No Approval Date: ////,7/7q ���� l S � . s B Iway Saturday Totals 0 0 0 Compensatory Hours Accrued Sunday Monday Tuesday Wednesday Thursday 2 Friday Saturday Total Used Previous Total 23 Total to Date 25 1 Town of North-Andover of „OaTly , OFFICE OF 32 g�. ° COMMUNITY DEVELOPMENT AND SERVICES A 27 Charles Street `� North Andover,Massachusetts 01845 9 WILLIAM J.SCOTT SSHCHUSO- Director (978)688-9531 Fax(978)688-9542 September 28, 1999 Ms.Deborah Moore 546 Foster Street North Andover,MA 01845 Re: Title 5 inspection at 546 Foster Street Dear Ms.Moore: The North Andover Health Department has received and reviewed the inspection report that was generated from the inspection of your septic system on 9/9/99. The system inspection has been determined that your system was no deemed to be"...failing to protect of threatening public health and safety or the environment..."as stated in Title 5 of the State Sanitary Code. However,from the report,this office has determined that you must: Retain the-services of a North Andover licensed septic installer to obtain a disposal works construction permit and: Install a new v r inlet ✓ outlet tee in your septic tank Repair or replace your leaking septic tank i� Repair or replace your damaged/unlevel distribution box Repair or replace damaged piping Retain the services of a licensed plumber to obtain a plumbing permit and: Remove your garbage disposal Re-route your laundry drainpipe to your septic system Other: Please have all work performed within 60 days of receipt of this notice. If you have any questions,feel free to call the Health Department at 978-688-9540. Sincerely, .�J Sandra Starr,R.S. Health Administrator BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 107 FOREST STREET FILE# 9999A MIDDLETON,MA 01949 (978)774-2772 SEPTIC & DRAIN CURRIEIL SERVICE SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ;PROPERTY OWNER'S NAME: MOORE PROPERTY ADDRESS: 546 FOSTER ST. N. ANDOVERMA ADDRESS OF OWNER: SAME (IF DIFFERENT) DATE OF INSPECTION: 9 SEPT 1999 :nR�HA<<h� -.-� NAME OF INSPECTOR: THOMAS CHIGAS 271m * THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY 107 FOREST STREET FILE#9999A MIDDLETON,MA 01949 (978)774-2772 SEPTIC&DRAIN r SERVICE SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION PROPERTY ADDRESS:546 FOSTER ST. NAME OF OWNER: MOORE N.ANDOVER,MA ADDRESS OF OWNER: SAME DATE OF INSPECTION: 9 SEPT 1999 NAME OF INSPECTOR: (PLEASE PRINT)THOMAS CHIGAS I AM A DEP APPROVED INSPECTOR PURSUANT TO SECTION 15.340 OF TITLE 5 (3 10 CMR 15.000) COMPANY NAME: CURRIER SEPTIC &DRAIN MAILING ADDRESS: 107 FOREST STREET, MIDDLETON, MA 01949 TELEPHONE NUMBER: 978 774-2772 CERTIFICATION STATEMENT I CERTIFY THAT I HAVE 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 PREFORMED BASED ON MY TRAINING AND EXPERIENCE IN THE PROPER FUNCTION AND MAINTENANCE OF ON-SITE SEWAGE DISPOSAL SYSTEM. THE SYSTEM: PASSES YES CONDITIONALLY PASSES NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY FAILS INSPECTOR'S SIGNATURE: gi % DATE: 9 SEPT 1999 THE SYSTEM INSPECTOR SHALL SUBMIT A COPY OF THIS SPECTION REPORT TO THE APPROVING AUTHORITY(BOARD OF HEALTH OR DEP) WITHIN THIRTY(30)DAYS OF COMPLETING THIS INSPECTION. IF THE SYSTEM IS A SHARED SYSTEM OR HAS A DESIGN FLOW OF 10,000 GALLON 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. NOTES AND COMMENTS: THE D-BOX IS LEAKING,AND SHOWS POOR CONDITION.THERE'S NO OUTLET TEE BAFFLE,OR INLET TEE BAFFLE. REVISED 9/2/98 PAGE I OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) PROPERTY ADDRESS:546 FOSTER ST. OWNER:MOORE DATE OF INSPECTION:9 SEPT 1999 INSPECTION SUMMARY: CHECKRA, 0 C, OR D: A. SYSTEM PASSES: N I HAVE NOT FOUND ANY INFORMATION,WHICH INDICATES THAT ANY OF THE FAILURE CONDITIONS DESCRIBED IN 310 CMR 15.303 EXIST. ANY FAILURE CRITERIA NOT EVALUATED ARE INDICATED BELOW. COMMENTS: B. SYSTEM CONIDTIONALLY PASSES: YESONE 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. INDICATE YES,NO,OR NOT DETERMINED(Y,N,OR ND). DESCRIBE BASIS OF DETERMINATION IN ALL INSTANCES. IF"NOT DETERMINED",EXPLAIN WHY NOT. N THE SEPTIC TANK IS METAL,UNLESS THE OWNER OR OPERATOR HAS PROVIDED THE SYSTEM INSPECTOR WITH A COPY OF A CERTIFICATE OF COMPLIANCE(ATTACHED)INDICATING THAT THE TANK WAS INSTALLED WITHIN TWENTY(20)YEARS PRIOR TO THE DATE OF THE INSPECTION;OR THE SEPTIC TANK,WHETHER OR NOT METAL,IS CRACKED,STRUCTURALLY 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 COMPLYING SEPTIC TANK AS APPROVED BY THE BOARD OF HEALTH. N 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). N BROKEN PIPE(S)ARE REPLACED N OBSTRUCTION IS REMOVED YES DISTRIBUTION BOX IS LEVELLED OR REPLACED N 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): N BROKEN PIPE(S)ARE REPLACED N OBSDTRUCTION IS REMOVED REVISED 9/2/98 PAGE 2 OF I 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) PROPERTY ADDRESS:546 FOSTER ST. OWNER:MOORE DATE OF INSPECTION:9 SEPT 1999 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N CONDITIONS EXIST WHICH REQUIRE FURTHER EVALUATION BY THE BOARD OF HEALTH IN ORDER TO DETERMINE IF THE SYSTEM IS FAILING TO PROTECT THE PUBLIC HEALTH, SAFETY AND 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRNONMENT: N/A CESSPOOL OR PRIVY IS WITHIN 50 FEET OF SURFACE WATER N/A 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 AND SAFETY AND THE ENVIRONMENT: N THE SYTEM 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. N THE SYTEM HAS A SEPTIC TANK AND SOIL ABSORPTION SYSTEM AND THE SAS IS WITHIN A ZONE I OF PUBLIC WATER SUPPLY WELL. N THE SYSTEM HAS A SEPTIC TANK AND SOIL ABSORPTION SYSYTEM AND THE SAS IS WITHIN 50 FEET OF A PRIVATE WATER SUPPLY WELL. N THE SYSTEM HAS A SEPTIC TANK AND SOIL ABSORPTION SYSYTEM AND THE SAS IS LESS THAN 100 FEET BUT 50 FEET MORE FROM A PRIVATE WATER SUPPLY WELL, UNLESS A WELL WATER ANALYSIS FOR COLIFORM BACTERIA AND VOLATILE ORGANIC COMPOUNDS NDICATES 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. METHOD USED TO DETERMINED DISTANCE (APPROXIMATION NOT VALID). 3) OTHER: N/A REVISED 9/2/98 PAGE 3 OF I 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) PROPERTY ADDRESS:546 FOSTER ST. OWNER:MOORE DATE OF INSEPCTION:9 SEPT 1999 D. SYSTEM FAILS: YOU MUST INDICATE EITHER"YES"OR"NO"TO EACH OF THE FOLLOWING: N I HAVE DETERMINED THAT ONE OR MORE OF THE FOLLOWING FAILURE CONDITIONS EXIST AS DESCRIBED IN 310 CMR 15.303. THE BASIS FOR THIS DETERMINATION IS IDENTIFIED BELOW. THE BOARD OF HEALTH SHOULD BE CONTRACTED TO DERTERMINE WHAT WILL BE NECESSARY TO CORRECT THE FAILURE. YES NO N BACKUP OF SEWAGE INTO FACILITY OR SYSTEM COMPONENT DUE TO AN OVERLOADED OR CLOGGED SAS OR CESSPOOL. N DISCHARGE OR PONDING OF EFFLUENT TO THE SURFACE OF THE GROUND OR SURFACE WATERS DUE TO AN OVERLOADED OR CLOGGED SAS OR CESSPOOL. N STATIC LIQUID LEVEL IN THE DISTRIBUTION BOX ABOVE OUTLET INVERT DUE TO AN OVERLOADED OR CLOGGED SAS OR CESSPOOL. N/A LIQUID DEPTH IN CESSPOOL IS LESS THAN 6' BELOW INVERT OR AVAILABLE VOLUME IS LESS THAN 1/2 DAY FLOW. N 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 SOIL ABSORPTION SYSTEM,CESSPOOL OR PRIVY IS BELOW THE HIGH GROUNDWATER ELEVATION. N/A ANY PORTION OF A CESSPOOL OR PRIVY IS WITHIN 100 FEET OF A SURFACE WATER SUPPLY OR TRIBUTARY TO A SURFACE WATER SUPPLY. N/A ANY PORTION OF A CESSPOOL OR PRIVY IS WITHIN A ZONE I OF A PUBLIC WELL. N/A ANY PORTION OF A CESSPOOL OR PRIVY IS WITHIN 50 FEET OF A PRIVATE WATER SUPPLY WELL. N/A ANY PORTION OF A CESSPOOL OR PRIVY IS LESS THAN 100 FEET BUT GREATER THAN 50 FEET FROM A PRIVATE WATER SUPPLLY 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. E. LARGE SYSTEM FAILS: YOU MUST INDICATES EITHER"YES"OR"NO"TO EACH OF THE FOLLOWING: THE FOLLOWING CRITRTIA APPLY TO LARGE SYSTEMS IN ADDITION TO THE CRTERIA ABOVE: N THE SYSTEM SERVES A FACILITY WITH A DESIGN FLOW OF 10,000 GPD OR GREATER(LARGE SYSTEM) AND THE SYSTEM IS A SIGNIFICANT THREAT TO PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT BECAUSE ONE OR MORE OF THE FOLLOWING CONDITIONS EXIST: 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 SYSEM IS LOCATED IN A NITROGEN SENSITIVE AREA(INTERIM WELLHEAD PROTECTION AREA-IWPA)OR A MAPPED ZONE II OF A PUBLIC WATER SUPPLY WELL THE OWNER OR OPERATOR OF ANY SUCH SYSTEM SHALL UPGRADE THE SYSTEM IN ACCORDANCE WITH 310 CMR 15.304(2).PLEASE CONSULT THE LOCAL REGIONAL OFFICE OF THE DEPARTMENT FOR FURTHER INFORMATION. REVISED 9/2/98 PAGE 4 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INPSECTION FORM PART B CHECKLIST PROPERTY ADDRESS:546 FOSTER ST. OWNER:MOORE DATE OF INSPECTION:9 SEPT 1999 CHECK IF THE FOLLOWING HAVE BEEN DONE: YOU MUST INDICATE EITHER"YES"OR"NO"AS TO EACH OF THE FOLLOWING: YES NO Y PUMPING INFORMATION WAS PROVIDED BY THE OWNER, OCCUPANT, OR BOARD OF HEALTH. Y NONE ON 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 SYTEM RECENTLY OR AS PART OF THIS INSPECTION. N/A AS BUILT PLANS HAVE BEEN OBTAINED AND EXAMINED.NOTE IF THEY ARE NOT AVAILABLE WITH N/A. Y THE FACILITY OR DWELLING WAS INSPECTED FOR SIGNS OF SEWAGE BACK-UP. Y THE SYSTEM DOES NOT RECEIVE NON-SANITARY OR INDUSTRIAL WASTE FLOW. Y THE SITE WAS INSPECTED FOR SIGNS OF BREAKOUT. Y ALL SYSTEM COMPONENTS,EXCLUDING THE SOIL ABSORPTION SYSTEM HAVE BEEN LOCATED ON THE SITE. Y 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: Y EXISTING INFORMATION.FOR EXAMPLE,PLAN AT B.O.H. Y DETERMINED IN THE FIELD(IF ANY OF THE FAILURE CRITERIA RELATED TO PART C IS AT ISSUE,APPROXIMATION OF DISTANCE IS UNACCEPTABLE) [15.302(3)(b)] Y THE FACILITY OWNER(AND OCCUPANTS, IF DIFFERENT FROM OWNER)WERE PROVIDED WITH INFORMATION ON THE PROPER MAINTENANCE OF SUBSURFACE DISPOSAL SYSTEMS. REVISED 9/2/98 PAGE 5 OF 11 SUBURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION PROPERTY ADDRESS:546 FOSTER ST. OWNER:MOORE DATE OF INSPECTION:9 SEPT 1999 FLOW CONDITIONS RESIDENTIAL: DESIGN FLOW: 330G.P.D.BEDROOM. NUMBER OF BEDROOMS(DESIGN): 3 NUMBER OF BEDROOMS(ACTUAL): 3 TOTAL DESIGN FLOW: 330 NUMBER OF CURRENT RESIDENTS: 1 GARBAGE GRINDER(YES OR NO):NO LAUNDRY(SEPARATE SYSTEM)(YES OR NO):NO;IF YES, SEPARATE INSPECTION REQUIRED LAUNDRY SYSTEM INPECTED(YES OR NO):NO SEASONAL USE(YES OR NO):NO WATER METER READINGS,IF AVAILABLE(LAST TWO YEAR'S USAGE(GPD): SUMP PUMP(YES OR NO):YES LAST DATE OF OCCUPANCY: CURRENT COMMERCIAL/INDUSTRIAL: TYPE OF ESTABLISHMENT: DESIGN FLOW: GPD(BAESED ON 15.203) BASIS OF DESIGN FLOW: GREASE TRAP PRESENT(YES OR NO): INDUSTRAIL WASTE HOLDING TANK PRESENT(YES OR NO): NON-SANITARY WASTE DISCHARGED TO THE TITLE 5 SYSTEM(YES OR NO): WATER METER REDAINGS,IF AVAILABLE: LAST DATE OF OCCUPANCY: OTHER(DESCRIBE): LAST DATE OF OCCUPANCY: GENERAL INFORMATION PUMPING RECORDS AND SOURCE OF INFORMATION: SYSTEM PUMPED AS PART OF INSPECTION(YES OR NO):NO IF YES,VOLUME PUMPED:N/A GALLONS REASON FOR PUMPING:WILL NEED PUMP DURING TIME OF REPAIRS. TYPE OF SYSTEM YES SEPTIC TANK/DISTRIBUTION BOX/SOIL ABSORPTION SYSTEM N SINGLE CESSPOOL N OVERFLOW CESSPOOL N_ PRIVY N SHARED SYSTEM(YES OR NO)(IF YES,ATTACH PREVIOUS INSPECTION RECORDS,IF ANY) N I/A TECHNOLOGY ETC. ATTACH COPY OF UP TO DATE OPERATION AND MAINTENANVE CONTRACT TIGHT TANK COPY OF DEP APPROVAL OTHER:N/A APPROXIMATE AGE OF ALL COMPONENTS,DATE INSTALLED(IF KNOWN)AND SOURCE OF INFORMATION: INSTALLED 8/82;OWNER SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE(YES OR NO):N REVISED 9/2/98 PAGE 6 OF 11 SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C SYSTEM INFORMATION(CONTINUED) PROPERTY ADDRESS:546 FOSTER ST. OWNER:MOORE DATE OF INSPECTION:9 SEPT 1999 BUILDING SEWER: (LOCATE ON THE SITE PLAN) DEPTH BELOW GRADE:9" MATERIAL OF CONSTRUCTION: CAST IRON YES 40 PVC OTHER(EXPLAIN) DISTANCE FROM PRIVATE WATER SUPPLY WELL OR SUCTION LINE:N/A DIAMETER: 3" COMMENTS: (CONDITION OF JOINTS,VENTING,EVIDENCE OF LEAKAGE,ETC.) NO SIGNS OF LEAKAGE IN OR AROUND PIPE,SOILS ARE CLEAN AND DRY. SEPTIC TANK: YES (LOCATE ON SITE PLAN) DEPTH BELOW GARDE: 2"+ABOVE GRADE MATERIAL OF CONSTRUCTION:YESCONCRETE METEL FIBERGLASS POLYETHYLENE OTHER (EXPLAIN): IF TANK IS METAL,LIST AGE N/A IS AGE CONFIRMED BY CERTIFICATE OF COMPLIANCE(YES/NO) DIMENSIONS: 81 X 5'W X 5'H OUTLET INVERT 6D,4'2"= 1000 GAL SLUDGE DEPH: 8" DISTANCE FROM TOP OF SLUDGE TO BOTTOM OF OUTLET TEE OR BAFFLE:N/A SCUM THICKNESS: <2" DISTANCE FROM TOP OF SCUM TO TOP OF OUTLET TEE OR BAFFLE:N/A DISTANCE FROM BOTTOM OF SCUM TO BOTTON OF OUTLET TEE OR BAFFLE:N/A HOW DIMENSIONS WERE DETERMINED: SLUDGE JUDGE,ROD,RULER COMMENTS: (RECOMMENDATION FOR PUMPING,CONDITION OF INLET AND OUTLET TEES OR BAFFLES,DEPTH OF LIQUID LEVEL IN REALTION TO OUTLET INVERT, STRUCTURAL INTEGRITY,EVIDENCE OF LEAKAGE,ETC.)THERE'S NO INLET OR OUTLET TEE BAFFLES.THE INLET PIPE IS 3"PIPE.THE OUTLET PIPE IS SCH2O 4"PIPE.SHOWS SIGNS OF PONDING IN LINE.THE TANK IS NOT LEVEL AND SHOW NO SIGNS OF LEAKAGE IN OR OUT,SOILS ARE CLEAN AND DRY. GREASE TRAP: N_ (LOCATE ON SITE PLAN) DEPTH BELOW GRADE: MATERIAL OF CONSTRUCTION: CONCRETE METAL FIBERGLASS POLYETHLENE OTHER (EXPLAIN) DIMENSIONS: SCUM THICKNESS: DISTANCE FROM TOP OF SCUM TO TOP OF OUTLET TEE OR BAFFLE: DISTANCE FROM BOTTOM OF SCUM TO BOTTON OF OUTLET TEE OR BAFFLE: DATE OF LAST PUMPING: COMMENTS: (RECOMMENDATION FOR PUMPING,CONDITION OF INLET AND OUTLET TEES OR BAFFLES,DEPTH OF LIQUID LEVEL IN REALTION TO OUTLET INVERT,STRUCTURAL INTEGRITY,EVIDENCE OF LEAKAGE,ETC.) REVISED 9/2/98 PAGE 7 OF I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(CONTINUED) PROPERTY ADDRESS:546 FOSTER ST. OWNER:MOORE DATE OF INSPECTION:9 SEPT 1999 TIGHT OR HOLDING TANK:N(TANK MUST BE PUMPED PRIOR TO,OR 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/DAY ALARM PRESENT: ALARM LEVEL: ALARM IN WORKING ORDER: YES NO DATE OF PREVIOUS PUMPING: COMMENTS: (CONDITION OF INLET TEE, CONDITION OF ALRM AND FLOAT SWITCHES,ETC.) DISTRIBUTION BOX: YES (LOCATE ON SITE PLAN) DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT: 0" DEPTH BELOW GRADE,14" COMMENTS: (NOTE IF LEVEL AND DISTRIBUTION IS EQUAL,EVIDENCE OF SOLIDS CARRYOVER,EVIDENCE OF LEAKAGE INTO OR OUT OF BOX,ETC.) THE D-BOX IS IN POOR CONDITION SHOWS SIGNS OF LEAKAGE AND DECAY.THERE'S ONE INLET AND THREE OUTLETS PUMP CHAMBER:N_ (LOCATE ON SITE PLAN) PUMPS IN WORKING ORDER(YES OR NO): ALARMS IN WORKING ORDER(YES OR NO): COMMENTS: II' (NOTE CONDITIONS OF PUMP CHAMBER,CONDITION OF PUMPS AND APPURTENANCES,ETC.) REVISED 9/2/98 PAGE 8 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(CONTINUED) PROPERTY ADDRESS:546 FOSTER ST. OWNER:MOORE DATE OF INSPECTION:9 SEPT 1999 SOIL ABSORPTION SYSYEM(SAS): YES (LOCATE ON SITE PLAN,IF POSSIBLE;EXCAVATION NOT REQUIRED,LOCATION MAY BE APPROXIMATED BY NON-INTRUSIVE METHODS) IF NOT LOCATED,EXPLAIN: TYPE: LEACHING PITS,NUMBER: LEACHING CHAMBERS,NUMBER: LEACHING GALLERIES,NUMBER: LEACHING TRENCHES,NUMBER,LENGTH: LEACHING FIELDS,NUMBER,DIMENSIONS: ONE LEACHBED APPROX 20'X 40' OVERFLOW CESSPOOL,NUMBER: ALTERNATIVE SYSTEM: NAME OF TECHNOLOGY: COMMENTS: (NOTE CONDITION OF SOIL,SIGNS OF HYDRAULIC FAILURE,LEVEL OF PONDING,DAMP SOIL,CONDITION OF VEGETATION,ETC.) NO SIGNS OF HYDRAULIC FAILURE OR SIGNS OF WETLAND VEGETATION IN OR AROUND S.A.S.THE STONE AND SOILS ARE CLEAN AND DRY. CESSPOOL: N (LOCATE ON SITE PLAN) NUMBER AND CONFIGURATION: DEPTH-TOP OF LIQUID TO INLET INVERT: DEPTH OF SOILD LAYER: DEPTH OF SCUM LAYER: DIMENSIONS OF CESSPOOL: MATERIALS OF CONSTRUCTION: INDICATION OF GROUNDWATER: INFLOW(CESSPOOL MUST BE PUMPED AS PART OF INSPECTION) COMMENTS: (NOTE CONDITION OF SOIL,SIGNS OF HYDRAULIC FAILURE,LEVEL OF PONDING,CONDITION OF VEGETATION,ETC.) PRIVY:N_ (LOCATE ON SITE PLAN) MATERIALS OF CONSTRUCTION: DIMENSIONS: DEPTH SOLIDS: COMMENTS: (NOTE CONDITION OF SOIL,SIGNS OF HYDRAULIC FAILURE,LEVEL OF PONDING,CONDITION OF VEGETATION,ETC.) REVISED 9/2/98 PAGE 9 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(CONTINUED) PROPERTY ADDRESS:546 FOSTER ST. OWNER:MOORE DATE OF INSPECTION:9 SEPT 1999 SKETCH OF SEWAGE DISPOSAL SYSTEM: INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCE LANDMARKS OR BENCHMARKS LOCATE ALL WELLS WITHIN 100' (LOCATE WHERE PUBLIC WATER SUPPLY COMES INTO HOUSE) r5 r�-r s . T-Y-al yo(1-1 qu �-�OUS� O TanK(To 7i ��x . i LLlb i � TZ, 1 35 3 REVISED 9/2/98 PAGE 10 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(CONTINUED) PROPERTY ADDRESS:546 FOSTER ST. OWNER:MOORE DATE OF INSPECTION:9 SEPT 1999 NRCS REPORT NAMEN/A SOIL TYPE N/A TYPICAL DEPTH TO GROUNDWATER N/A USGS DATE WEBSITE VISITED OBSERVATION WELLS CHECKED GROUNDWATER DEPTH: SHALLOW N MODERATE DEEP SITE EXAM SLOPE SURFACE WATER CHECK CELLAR SHALLOW WELLS ESTIMATED DEPTH TO GROUNDWATER 8'FEET PLEASE INDICATE ALL THE METHODS USED TO DETERMINE HIGH GROUNDWATER ELEVATION: N OBTAINED FROM DESIGN PLANS ON RECORD Y OBSERVED SITE(ABUTTING PROPERTY,OBSERVATION HOLE,BASEMENT SUMP,ETC.) Y DETERMINED FROM LOCAL CONDITIONS N CHECKED WITH LOCAL BOARD OF HEALTH N CHECKED FEMA MAPS Y CHECKED PUMPING RECORDS N CHECKED LOCAL EXCAVATORS,INSTALLERS Y USED USGS DATA DESCIBE HOW YOU ESTABLISHED THE HIGH GROUNDWATER ELEVATION. (MUST BE COMPLETED) THE HOUSE HAS A SUMP PUMP IN BASEMENT AND IT'S DAMP.THE HOUSE HAS 6'FOUNDATION.NO SIGNS OF PONDINGS IN YARD NEAR SYSTEM.NO ABUTTING PROPERTY'S WELLS WITHIN 100'FROM SYSTEM.WHILE DIGGING IN YARD THERE WAS NO SIGNS OF WATER.SOILS WERE CLEAN AND DRY. REVISED 9/2/98 PAGE 11 OF 11 FORM 4-SYSTEM PUMPINGW-COAD CUR ER SEPTIC & DRAIN SERVICE 107 FOREST STREET;MIDDLETON,MA 01949 (978)774-2772 COMMONWEALTH OF MASSACHUSETTS 1 V O - A n WQ V e - ,MASSACHUSETTS SYSTEM PUMPING RECORD SYSTEM OWNER: m d,O,� e SYSTEM LOCATION: 6-rzo&� DATE OF PUMPING: 99 QUANTITY PUMPED: GALLONS CESSPOOL: NO YES 0 SEPTIC TANK: NO YES SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE CONTENTS TRANSFERRED TO: LS U DATE: / 7� INSPECTOR:fm- r"CSA N OF NO APd 009 BOARD0_ ®HEALTH -9 19N I or` M A oi'sys o�P�N FORI114 SYS TE>\I PLT,I1PNG RE COIzD 5 gE Commonwealth of Massachusetts Massachusetts Svstem Pumnin�ecard Wner y�'00(-e I ' ystem ocation No - A Jalc r- 7a S-- ' Pumping- -: Pumping• 9- 3 -V Quantity Pumped: IWO ,allons Yes ❑ Septic Tank: No ❑ Yes Pumped by: CU ►�«�� ', I Transferred to: r. License #: . Inspector THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY 0 Commonwealthof assac usetts RECElVEB City/Town of h. 4 ,, System Pumping Recor DEC 0 S 2008 Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms may be used, but e 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 1. System Location: forms on the LkToSd- computer,use only the tab key Address to move your �lc1� ��(�QJC/ /� �� (A g y cursor-do not < use the return City/Town State Zip Code key. 2. System Owner: D Abd« /'A6 6k- Name 5 Address(if different from location) City/Town State Zi Code Telephone Number B. Pumping Record 1. Date of PumpingDate C� O 2. Quantity Pumped: Gall noccls 3. Type of system: ❑ Cesspool(s) U/Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? E] Yes ❑ No If yes, was It cleaned? ❑ Yes ❑ No 5. Condition of System: g -� qck 6. System Pumped By: _ Z�e��' /'AcA C Name Vehicle Licenseumber W-,a� ('fie/ Ipswich water Company Treatment Plant 7. Location where contents were disposed: -wlch, MA 01938 Signature of auler Date Signature of Receiving Facility Date t5form4.doc•03/06' System Pumping Record•Page 1 of 1 1 Commonwealth of assac usetts City/Town of System Pumping Recor M Form 4 I ZOO DEP has provided this form for use by local Boards of Health. Other for s may be used, but the information must be substantially the same as that provided here. Befor vatilwo,WvORM WTM!Mtl your local Board of Health to determine the form they use. The System Pum n Hod ed 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 1. System Location: forms the computer,use only the tab key Address to move your ��,(d�E� cursor-do not G — use the return City/Town State Zip Code key.. - 2. System Owner: A 0�P Name ILS Address(if different from location) City/Town State Zip Code '928 -mac-2263 Telephone Number B. Pumping Record 1. Date of PumpingDl/ y 2 Quantity Pumped:ate pan ns�v 3. Type of system: ❑ Cesspool(s) �Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ YesNo If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 660 6. Syste umped By: L Name Vehicle License Number Company swich ater 7. Location where content lis ose s raaitf1enf Plant 1pswich, Signature of Hauler Date Signature of Receiving Facility Date t5form4.doc•03/06' System Pumping Record•Page 1 of 1 Commonwealth of 'Massachusetts CitylTown of System Pumping Record ,NORTH ANDOVER Form 4 DEP has provided this form for use by local Boards of Hesltl . Other forms may be used,but the information must be substantially the same as-thatprovided here.86tbre uting 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 2 pproving authority vvAthin 14 days from the.'pumping date to accordance with 31D CMR 15.351_ A. Facility information lmportant. Wien,arg out 1. System Location; C forms on the �¢�/ _ lr � c:7 •�nj1 _ computer:use arty thetab key Adtlress to.mbve Your WN OF NORTH ANDOVER ' cursor-do,ngl A ffiMm � — �a EAL�N OEPAR�MENT ip Code — - uEe the return. Ker. 2, rysterrt Owner, Name Address'(if different,tom location) CifylTOWrrs — — - — State — Ip.Code Telephone Number B. Pumping Record . Pumped- bate 1. Date of Pumping 2. aijantity Pumped- Gallant 3. Type of system, [] Cesspooks) gp<septic Teak Aigh.1 Tank Grease Trap Q Qther(describe): --— 4. Effluent Tee Filter present? '[] Yes, `_ No if yes,was it.cleened? [] Yes o 3. Condition of System;. 6: System Pumped By: 'NBrrie. Vehcle'License Number Company 7. t_ocation where contents were disposed- . - -.ofDate &igaat ime 'Hauler Signalure.of Receiving Facility Date i5famA.0v 03106 SysW.n Pumplrg tt pvd-Page i bf t