HomeMy WebLinkAboutMiscellaneous - 547 SALEM STREET 4/30/2018 (2) 547 SALEM STREET
210/038.0-0006-0000.0 _
S�gTlED ��'
PUBLIC HEALTH DEPARTMENT
Town of North Andover
Community Development Division
CERTIFICATE OF.
COMPLIANCE
As of: 6/29/16
This is to certify that the individual subsurface disposal system received a
SATISFACTORY INSPECTION of the:
Repair of D-Box
By: Daniel Giard
At:
547 Salem Street
Map 038.0 Lot 0006
North Andover, MA 01845
jThes�,suance of this certificate all not e-eons�r`ued as a guarantee that the system will function satisfactorily.
C t .
Michele Grant
Public Health Agent
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 918.688.9540 Fax 918.688.8416 Web www.townofnorthandover.com
;Commonwealth.of Massachusetts
;Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,. 547 Salem St
!Property Address
jFrank Ghinassi
Owner ;Owner's Name
information is
required for every .Worth Andover MA 01845 6-20-2016
page. !CitylTown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
Tway. Please see completeness checklist at the end of the form.
Important:When
filling out forms A. General Information
on the computer, ii
use only the tab Inspector: JUL 18 2016
key to move your
cursor-do not John DiVincenzo TOWN OF NORTH ANDOVER
use the return EALTun EPARTMENT
key. i Name of Inspector H
d LI
J and S Development Corp. dba Stewart's Septic Service, Andover Septic '��
Company Name J
58 South Kimball st
Company Address --- i
Bradford _ Ma 01835
Cityrrown State Zip Code
978-372-7471 s113386
Telephone Number License Number
i
6. Certification
I!certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(314 CARR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
yoesher E ation b the Local Approving Authority
7/12/2016
ature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving.authority.
This report only describes conditions at the time of inspection and under the conditions-of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official. Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
547 Salem St
Property Address
Frank Ghinassi
Owner Owner's Name
information is
required for every North Andover MA 01845 6-20-2016
page. /Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A�) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Replaced d-box, and inspected by town. Installed by anther company verified by town.
i
i
I
�) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
ugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments547 Salem St
Property Address
Frank Ghinassi
Owner Owner's Name
information is
required for every North Andover MA 01845 6-20-2016
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When
filling out forms General Information RECEIVE
on the computer,
use only the tab 1. Inspector: JUL 18 2016
key to move your
cursor-do not John DiVincenzo
use the return OF NORTW ANDOVER
key. Name of Inspector wE�LTW pEp
J and S Development Corp. dba Stewart's Septic Service, Andover Septic
�y Company Name
58 South Kimball st
Company Address
ram Bradford Ma 01835
Cityrrown State Zip Code
978-372-7471 s113386
Telephone Number License Number
. Certification
I;certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my trainingand experience in the proper function and maintenance of n
P P Pe o site
sewage disposal
systems. I am
a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
❑ Passes ® Conditionally Passes ❑ Fails
❑ Neecjd F her Eva "on b he Local Approving Authority
6-20-2016
In ector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
u W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
547 Salem St
Property Address
Frank Ghinassi _
Owner Owner's Name
information is
required for every North Andover MA 01845 6-20-2016
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
u Wo Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M
547 Salem St _
Property Address
Frank Ghinassi _
Owner Owner's Name
information is
required for every North Andover MA 01845 6-20-2016
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
® distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
needs new dbox
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
GSM 547 Salem St _
Property Address
Frank Ghinassi
Owner Owner's Name
information is North Andover MA 01845 6-20-2016
required for every _ _
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or
El ® clogged SAS or cesspool
El ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
547 Salem St
�M
Property Address
Frank Ghinassi
Owner Owner's Name
information is
required for every North Andover MA_ 01845 6-20-2016
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 m
9 q ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
j E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
u W Title 5 Official Inspection f=orm
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
GSM
547 Salem St
SyO
Property Address
Frank Ghinassi _
Owner Owner's Name
information is
requireded.for every North Andover _ _ MA 01845 6-20-2016
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 -- Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Farm - Not for Voluntary Assessments
547 Salem St
Property Address
Frank Ghinassi
Owner Owner's Name
information is
required for every North Andover MA 01845 6-20-2016
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
mnths
Last date of occupancy: 6 Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.): —
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
547 Salem St
Property Address
Frank Ghinassi
Owner Owner's Name
information is North Andover MA 01845 6-20-2016
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Stewarts Septic
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: gallons
How was quantity pumped determined? site gee on truck
Reason for pumping: _inspect tank
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
El Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
547 Salem St
G7M SV9Bv ',
Property Address
Frank Ghinassi _
Owner Owner's Name
information is
required for every North Andover _ MA_ 01845 6-20-2016
page. City/Town _ State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
60 + yrs
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
_
Depth below grade: 24"feet
Material of construction:
® cast iron ❑ 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 8"Leet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
547 Salem St _
Property Address
Frank Ghinassi _
Owner Owner's Name
information is
required for every North Andover MA 01845 6-20-2016
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
28"
Scum thickness — —
6"
Distance from top of scum to top of outlet tee or baffle —
Distance from bottom of scum to bottom of outlet tee or baffle
16"
How were dimensions determined? Tape measure , sluge judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Both Baffles good , no leaks ec,�, li uid level good _
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions: --
Scum thickness
es
Distance from top of scum to top of outlet tee or baffle —
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
I Date
t5ins•3/13 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 547 Salem St
Property Address
Frank Ghinassi
Owner Owner's Name
information is North Andover MA 01845 6-20-2016
required for every _
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: —
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° 547 Salem St
GSM
Property Address
Frank Ghinassi _ _
Owner Owner's Name
information is North Andover MA 01845 6-20-2016
required for every _
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present mu=st be opened) (locate on site plan):
Depth of liquid level above outlet invert .0__1_.__________
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box; etc.):
Box needs replacing . leakage around outlet invert .
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
547 Salem St
Property Address
Frank Ghinassi
Owner Owner's Name
information is North Andover MA 01845 6-20-2016
required for every —
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 3-40'
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
No hydraulic failure , no ponding ,, no damp soils
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth -top of liquid to inlet invert
Depth of solids layer
layer
Depth of scum la
P Y
Dimensions of cesspool — -
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
547 Salem St
Property Address
Frank Ghinassi
Owner Owner's Name
information is
required for every North Andover MA 01845 _ 6-20-2016
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction: -
Dimensions — -
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
547 Salem St
Property Address
Frank Ghinassi
Owner Owner's Name
information is North Andover MA 01845 6-20-2016
required for every _
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 547 Salem St
Property Address
Frank Ghinassi
Owner Owner's Name
information is North Andover MA 01845 6-20-2016
required for every _
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
❑ Surface water
® Check cellar
❑ Shallow wells
6'
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: may 9 1955
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
ulp led files — - - - - --
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database- explain:
You must describe how you established the high ground water elevation:
No water in cellar open hole for pump. Hole is dry a rp ox 6' below bottom of trenches
i
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
547 Salem St
Property Address
Frank Ghinassi
Owner Owner's Name
information is North Andover MA 01845 6-20-2016
required for every _
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
I
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file _
i
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
I
tiTj �.iNi l.l .i:� dS 1.{ �J::'? S 7
h1: A .1. I dl..,i'[S•I,.al+j l+'.j�l....00li' Ia ::1ii.LA tz�;'. t s
.1 hereby make application for permit for a e1'.." ;Q disposal
at. Salem St. I will instal, taus system in accord-
at
ance a a. utas o e COmirtonweulth of l assechusetts and regulations
of the Board of Health of the To= of Aorth ndove�«
Further, 1 will construct the house sewor of dell and spigot pipe, frac
minimum diameter being 4 inches, and will maintain: a minlraum gr&d.e of 1"'. uult
10 feet precedfn�; the cesspool or septics tank, wliei e the grads shall not
exceed .. Z will i.nstall a or septic teak of_____500 al. in
size. k manhole ( s} permitting easy cleaning raid. , be Provid d ,,bait :-enao abl
cover (A) of iron or concrete within 12 inches of the ground surgw,ces I
will provide subsurface disposal, field with open jointed bell and spigot
pipe or perforated pipe at leest 4 inches in diaimeter. and laid in seplea
Of trenches, the. bottom of which will provide a wi4imum. of
Lineal (ice) feet of eff ae tive absorption are�aa' The i es wi _ � �
� i p p
on a 6 inch layer of clean gravel or crushed stone r ai%ing in size f_.-om 6/1).
to i£ Inches (dia. ) and the pipes will be surrounded y similar mate,-Ial to
a height of 2 inches above the crown of the pipe, The' Joints of tl-;.esG pi.pGs
will. 'be ;protected from clogging s.nd before filling this trench, 2 inches of
gravel or stone 1/8" to 1/4" (dia. ) will be placedover the course gravel or
stone. !The disposal field will be installed at G grrde. of 4 to. 6 Inches/:1oc.
feet. Nd single tile line will exceed 100 feet In length and in any case,
two lines of the wi.l`3 be installed. A ri.aijwanm ofl 6 feet will b® arazntsa-an.0
between jthe center lines of the disposal field tre�,she's and the average
depth of, trench, shall not exceed 36 inches. In the case of the extension
of a tspool into a subsurface..disposal field or Onother cesspool both
inlet ,d outlet connectionsto the cesspool shall be provided with.
°isanitmry tees't. xll measurements of cesspool shall be taken at: the bottoia
of the inlet pipe. Pio part of the installation will be less than 1,00 feet
from any private water supply, 25 feet from any s dean, 20 feet from any
dwelling or 10 feet from aray property line. I fuxther agree not to cover
any portion. of ,this installation ut . , io1z arr
as provided., an o incorporate a toina requirements �cct
may be Attached to the permit'
I hereby issue the above permit for t Boas d Og' Health of the Toruf'
North Andover, Massachusetts. � - -
Da to
gnial Q —or 7Ma EF 118371
S have inspected the uncovered system. indicated above and find ev'erythi.ng
done a s
described,
Date
8
ign.g`t nap�nZ F" c;=3
Percolation Teat
i I
May 7,1.955
Miss Mary Sheridan
Health Agent
Board of Health
NoAh Andover,Massachusetts
Bear Diss Sheridan:
An examination has been made relative to 'the suitability
of the soil for sub-surface disposal of sewage on the Salem Street
building site of Mr. Winning.
The soil in the area consisted of -a mixture of clay and
gravel. The percolation time was three minutes.
It is recomended that 120 lineal feet of drainage Pipe be
installed..
yours.,
,
Y y
Ernest F. Romano
Pasterof Science in Public Health
v
RATED Al
North Andover Health Department
(ommunity and Economic Development Division
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: 547 Salem St. MAP: 038.0 LOT: 0006
INSTALLER: Daniel Giard
DESIGNER:
PLAN DATE:
BOH APPROVAL DATE ON PLAN:
INSPECTIONS
D-box INSPECTION: (p C
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
❑ Contractor reports any changes to design plan
❑ Existing septic tank properly abandoned
❑ Internal plumbing all to one building sewer
❑ Topography not appreciably altered
Comments:
SEPTIC TANK
❑ Building sewer in continuous grade, on
compacted firm base
❑ Cleanouts per plan
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ 1500 gallon tank has been installed
H-10 loading
❑ Monolithic tank construction
❑ Water tightness of tank has been achieved by
visual testing
❑ Inlet tee installed, centered under access port
❑ Outlet tee installed, centered under access port
(gas baffle/effluent filter)
❑ inch cover to within 6" of finish grade
installed over one access port
❑ Hydraulic cement around inlet & outlet
Comments:
PUMP CHAMBER
❑ Bottom of tank hole has 6" stone base
❑ Weep hole plugged
❑ 1500 gallon Pump Chamber installed
❑ H-10 loading
❑ Monolithic tank construction
❑ Inlet tee installed, centered under access port
❑ Pump(s) installed on stable base
❑ Alarm float working
❑ Pump On/Off floats working
❑ Separate on/off floats
❑ Drain hole in pressure line
❑ cover at final grade installed over pump
access port
❑ Water tightness of tank has been achieved by
testing
❑ Hydraulic cement around inlet & outlet
Comments:
CONTROL PANEL
❑ Alarm & Pump are on separate circuits
❑ Alarm sounds when float is tripped
❑ Location of control panel: basement
❑ Alarm signal located inside: basement
Comments:
DISTRIBUTION-BOX
M�
Installed on stable stone base
H-20 D-Box
❑
/ Inlet tee (if pumped or >0.08'/foot)
[� Hydraulic cement around inlet & outlets
[� Observed even distribution
Speed levelers provided (not required)
Schedule 40 PVC Pipe
Comments:
•:,t LED Commonwealth of Massachusetts Map-Block-Lot
.— . 038.00006
• �3 ---- ---------------
BOARD OF HEALTH Permit No
North Andover -----------------------BNP-2016-0219
$.
FEE
a7o �v $175.00
-----------------------
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Daniel A. Giard
--------------------------------------------------------------------------------------
to(Repair)an Individual Sewage Disposal System.
at No 547 SALEM STREET
- I--------------------------------------------------------------------------------------------------------------------------------
as shown on the application for Disposal Works Construction Permit No. BHP-2016-021 Dated June 28,2016
( ' DYµ
--------------- i_L_ -
---- --------------
-_ --- _
Issued On: Jun-28-2016 BOARD OF HEALTH
L.
• Application for Septic Disposal System
�•
TODAY8 DATE
Construction Permit - TOWN OF
'"' Full Repair
NORTH ANDOVER, MA 01845 MORO Component
Important: Application is hereby made for a permit to:
When filling out ❑ Construct a new on-site sewage disposal system*
forms on the
computer,use ❑ Repair or replace an existing on-site sewage disposal system*
only the tab key
to move your ❑ Repair or replace an existing system component—What?�I J — / o
cursor-do not
use the return A. Facility[ � ti
Information
key. C T / ,O 1 k 977
Address or Lot#
un
U a dJ nda v e/L
City/Town
�'
2.-*TYPE OF SEPTIC SYSTEM*:
➢ ❑ Pump ®Gravity(choose one)
***If pump system, attach copy of electrical permit to application***
➢ XConventional System (pipe and stone system)
➢ LJ Infiltrator or Biodiffuser(Gravel-Less)(Attach a copy of your certification to install this type of system.)
➢ ❑ Pressure Distribution S.A.S.(No D-Box)
➢ ❑ Pressure Dosed (D-Box Present)S.A.S.
➢ ❑ Does the system require an effluent filter? Yes No
If yes, does plan specify make and model of filter? YES =(no further info. needed)
NO=(installer must specify brand of filter before DWC issuance)
What is the Make? What is the Model.
2. Owner Information
Name 1'"
(/ I VA//A,11
Address differenj from above)
City/Town State Zip Code
Email address Telephone Number
3. Installer Information
Name Name of Company
/30 A-
�dbm/eT ou
Address
g Qte2
City/Town State Zip Code
q ?s'?;p
Telephone Number(Cell Phone#ifpossible please)
4. Designer Information
Name Name of Company
Address
City/Town State Zip Code
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit-Page 1 of 2
13
•sem, , Application for Septic Disposal System
{ "'�' �•
Construction Permit - TOWN OF TODAY'S DATE
$350.00-Full Repair
NORTH ANDOVER, MA 01845 $175.00-Component
PAGE 2OF2
A. Facility Information continued....
5. Type of Buildina: &esidential Dwelling or❑Commercial
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the afore-described
on-site sewage disposal system in accordance with the provisions of Title 5 of the
Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of
North Andover. I understand that until a final Certificate of Compliance has been issued by
this Board of Health, the installed system is not approved.
Name Date
,/i ,licat'on Appro y: (Board f Health Representative)
LP Io2S_oZO 00
ame Date
Application Disapproved for the following reasons:
For Office Use Only:
1. Fee Attached? Yes No
2. Project Manager Obliga . n Form Attached? Yes No
3. Pump S sy tem? If so,Attach co o ectrical Permit Yes No
Applicant received copy of
"Electrical Inspection Notes for Septic Sys s" Yes No
Handout?
4. Reviewed approvalletter, all paperwork received? Yes No
Missing.•
5. Foundation As-Built?(new construction only): Yes No
(Same scale as approved plan)
G. Floor Plans?(new construction only): Yes No
i
Application for Disposal System Construction Permit•Page 2 of 2
SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
SVp? &42rh S �� q¢ ',jo ,,ez- M 4.
(Address of septic system) For plans by
(Engineer)
(Installer's name)
Relative to the application of."— q r yt, �j.9 A-d/
And dated
(Originaldate)
Dated 1/'
o ay s ate With revisions dated
(Last revised date)
I understand the following obligations for management of this project:
1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to
performing any work on a site. I must have the approved plans and the permit on site when any work is
being done.
2. As the.installer, I must call for any and all inspections. If homeowner, contractor,project manager, or any
other person not associated with my company schedules an inspection and the system is not ready, then
item three shall be applicable.
3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as
indicated below. I understand that requesting an inspection,without completion of the items in accordance
with Tide 5 and the Board of Health Regulations may result in a $50.00 fine being levied against me and/or
my company.
a. Bottom of Bed—Generally, this is the first (ls� inspection unless there is a retaining wall,which
should be done first. The installer must request the inspection but does not have to be present.
b. Final Construction Inspection—Engineer must first do their inspection for elevations, ties, etc.
As-built of verbal OK (or e-mail to: healthdept&townofnorthandover.com) from the engineer must
be submitted to the Board of Health, after which installer calls for an inspection time. Installer must
be present for this inspection. With a pump system, all electrical work must be ready and able to
cause pump to work and alarm to function.
c. Final Grade—Installer must request inspection when all grading is complete. Installer does not
have to be on-site.
4. As the installer, I understand that only I may perform the work (other than simple excavation)and I am required
to complete the installation of the system identified in the attached application for installation. I further
understand that work done by others unlicensed to install septic systems in North Andover can constitute
reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of
North Andover, significant fines to all persons involved are also possible.
5. As the installer, I understand that I must be on-site during the performance of the following construction
steps:
a. Determination that the proper elevation of the excavation has been reached.
b. Inspection of the sand and stone to be used.
c. Final inspection by Board ofHealth staff or consultant.
d. Installation of tank, D-Box,pipes, stone, vent,pump chamber, retaining wall and other
components. .
6. As the installer, I understand that I am solely responsible for the installation of the system as per the
approved plans. No instructions by the homeowner,general contractor, or any other persons shall absolve
me of this obligation.
Undersigned Licensed Septic Installer: /lo (Today's Date)
"' Nr C I lam-! J_ 4
(Name—Print) me—Signef
-7
Gl�,, D L'I (MM' JA>'.)I`j .'tL IT I G;,O
I hereby make applicritiori. for v. fifer fora -,Posal lnst�S-Ilatiar
S e P 8a� di,
at Salem St.
- I ,All irlstfill this Et Fhi K e is 0 1 Mas"Iy stem in accord-
anc
t
la ---- e�Coinraonyjettlth of itassaci-jusetts and raL,,ulatiozas
w i av
of. the Board Of HeRlth Of the TO= of 44orth !;ndover,
Further, 1, will construct the house sewer of bell and spigot pipe,, the
mirliratun diameter being 4 inchesp and. will wAijjj,.j a tajainjurabm grz�de of
10 feet preceding the cesspool orseptle tank., wher-e the grade 91hali not
axceed 2%,., 1 will install & Cmagpol or septics tarLk of 00_gal*
Size. A manhole ( o) permit ting easy oleanij-%, will be j;-X,-F7=c6d—,2MET -emovablo
cover (s) of iron Or concrete Within 12 Inches o`' the grouria a-arface' I
will provide subsurface disposal field with open Jointed bell any ;i,pjgot
Pipe or perforeted pipe at leest 4 inches in diAmeter and leid :L,.
sej�j.es
Of trenches n a,
., the, bottom of which will provide a, minirmm, of 120
Linoal (EMIA&P) feet of effective obsorption araza. The pip7e�
on. a 6 inch layer of clean . t? =
gravel. or crushed starts rauging j.11 sj.z.,) f2am X614-
to I!-- Inches (dia. ) and the Pipes will be surrounded by similar to
a height of 2 inches above the crown of the pipe, 111.9 joints of th.ese p1pos
will be protected from cloggiiig
g &n.d before fillias the tranch., 2 inchos of
gravel Or stony 1/8" to l/P (dia. ) will be placed over trio course g.raV ej, oI r
stone. The disposal field -will be installed at a grrde, of 4 to 6 lnches/a,00
feet. No single tile line will exceed 100 feet in length and in anorlsep
two lines of tile will be installed. A minlaram of 6 i','eet vrill be
between, the center lines of the disposal fielaA tronclaes and the average
depth of trenab shall not excaed36 inches. In the case of the- exten8lon
of a cesspool into a subsixr4ece disposal'. field ox� ano!;.1her cesspool botb.
inlet and outlet connections to the cesspool shall be provided witli
sarAtary tees" , All 'rileasurements of cesspool. I)e t6�.kexj ,,,t -,; e, bottoia
bb
Of thG in'-Ot Pipe. No part of the instLIlation will be loss than 100 feet
from any private viater sikpply, 25 feet frora an".y ,,,tream, 20 feet ft-oal ar
dwelling or 10 feet from any propel-ty line. T fttrtlaer jky
.�E—eo not to oolrar
any port on of this installation until ap '0 P'e Ot 10 It C. Vi 0 p
V r 0 V-7.Z. = Ins 6--
lam — Z
Ine
as pro;Vj 'B701 ,-a- I
Acorpora' an,
ii-quy be attached to the permit.
r5r,
I hereby issue the above permit for t'« .hoard of Healtil of the ,'ojv
North Andover, MassFahusetts. -7 7 0 -2
Da t
ii 4a
I have inspected the uneovered system, Indicated above and fizad av'orything
done as described,
Date - ,2
=5 &T;'=Kt1UVR) OR
Percolation Test
-,
--
_ �
r Y`r- � �
�- _•�, �
_ _ �
r
l
3
May 7,1955
Mass Mary Sheridan
Health Agent
Board of Health
North Andover,Massachusetts
Dear Miss Sheridan:
An examination has been made relative to the suitability
of the soil for sub-surface disposal of sewage on the Salem Street
building site of Mr. Winning.
The soil in the area consisted of a mixture of clay and
gravel. The percolation time was three minutes.
It is recommended that 120 lineal feet of drainage Pipe be
installed.
Sincerely yours,
Ernest F. Romano
!easter of Science in Public Health