HomeMy WebLinkAboutMiscellaneous - 555 FOREST STREET 4/30/2018 555 FOREST STREET v -I
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PUBLIC HEALTH DEPARTMENT
Town of North Andover
Community Development Division
CERTIFICATE OF
COMPLIANCE
As of: 1/4/2013
This is to certify that the individual subsurface disposal system received a
SATISFACTORY INSPECTION of the:
Tank and D-Box Repair
'By: Todd Bateson
At:
555 Forest Street
Map 106B Lot- 46
orth Andover, MA 01845
'-'I he'Issuance of th' ejahall not be construed as a guarantee that the system will function satisfactorily.
c
M1 is ele Grant
Public Health Agent
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
Commonwealth of Massachusetts rFEB
ECEIVED
City/Town of 2a 2013
System Pumping Record
Form 4 TQwN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for us&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.
A. Facility Information
1. System Location: Left/Right front of house Rig rear of hous Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/ Ig rear of building, Under deck
Address
City/Town State v Zip Code
2. System Owner.
Name
Address(if different from location)
Citylrown State
Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [go If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
c
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
is S• Lowell Waste Water
Signitule 4 HauleV Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Of MO'D7N
j 6303
1
Town of North Andover
HEALTH DEPARTMENT
,SSrICHU
CHECK#: DATE:
LOCATION:
H/O NAME: Y
CONTRACTOR NAME:
d
Type of Permit or License: (Check box)
❑ Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service-Type: $
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal(Septic)Hauler $
❑ Recreational Camp $
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ Trash/Solid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
Title 5 Report $
❑ Other:(Indicate) $
I06
Health Agent Initials
White-Applicant Yellow-Health Pink-Treasurer
-
Commonwealth of Massachusetts
r, - Title. 5 Offidial Inspection Form RECEIVED
Subsurface Sewage Disposal System Form Not for Voluntary Assessment
FEB 21 2013
555 Forest Street
MN OVINORTH ANDOVt
ProertY Address HEALTH DEPARTMENT
.F .,y.::..gti .
Judith Giarrusso
Owner Owner's Name
information is
required for North Andover MA 01845 2/4/2013
every page. Cityrrown 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: A. General Information
When filling out
forms on the
computer,use 1. Inspector:
only the tab key.
to move your Neil James Bateson
cursor-do not Name of Inspector
use the return
key. Bateson Enterprises Inc.
Company Name ..
fi>r
= ffi 111 Argilla Road
Company Address
Andover MA 01810
" t`O_City/Town '— State, Zip Code
-978-475-4786 S115
Telephone Number License Number
B...Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
infopnation 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 thele proper function andmaintenance of on site
sewage disposal systems. l am a DEP approved system,inspector pursuant to Section 15.340 of
Title( X310 CMRsystem:
Z Passes i,. 0 Conditionally Passes Fails
0 Needs Further Evaluation by the Local Approving Authority
::2/4/2013
ct s'Sig.,at re Date
.. -
""' "Thesystem inspector hall�submit a copy� Pao
this inspection report to the Approving Authority Board
P P .APP 9 tY
of Health or DEP within'30 days of completing. t
Is inspection. If the s stem is a shared system or
has a design flow of 10,000 d or reater, the inspector and the system owner shall submit h
9P 9 P Y the
reportto 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
t e game or different conditions of use
,,;•_ .''fi\..C:Y.".' ... to
t5ins•11/10 Tdle 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts,. „: .;..*,.;.:•.
Title 5. Official insp ection Form
Subsurface.Sewage.Disposal System:Form-Not for Voluntary Assessments
yt 555 Forest Street
Property Address
Judith Giarrusso
Owner Owners Name
information is
required for North Andover MA 01845 2/4/2013
every page. Cityfrown :. 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:
After permit from B.O.°., install`new 1'5 gallon septic p
00 allon se tic tank&new d-box, inspection from B.O.H.,
;v',.septic system oow-passes Title 5.,In4pp0on:'
B)- System Conditionally passes: .
El
:w Qne 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
i-q.,,:determined please explain.
The septic tank Ji ,.Xpejql,Apo.oypr 20 years,old*or the septictank(whether metal or not) is
structurally unsound,;gxhibits substant/al infiltration or exfltration or tank failure is imminent. System
will pass inspection if tie 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.
D .YQ N ❑ ND(Explain below)
• �;: t ctl:. ...y_ct:'tg; .,K,�!'J3.t":a.;,��,FiM;".t?`'i' i-•
t5ins'-11/10
'� This 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
555 Forest Street
Property Address
Judith Giarrusso
Owner Owner's Name
information is
required for every North Andover MA 01845 10/18/2012
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
I
C) Further+Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
16'303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
555 Forest Street
Property Address
Judith Giarrusso
Owner Owner's Name
information is
required for every North Andover MA 01845 10/18/2012
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for 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
El ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
555 Forest Street
Property Address
Judith Giarrusso
Owner Owner's Name
information is
required for every North Andover MA 01845 10/18/2012
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
[:1 ® 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.
❑ ® An portion of a cesspool or privy is less than 100 feet but greater than 50 feet
YP P P Y
from a private water supply well with no acceptable water quality analysis. [This
system passes N the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
The system fails. I have determined that one or more of the above failure
E] ® criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes"in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304.The system owner should contact the appropriate
regional office of the Department.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
555 Forest Street
Property Address
Judith Giarrusso
Owner Owner's Name
information is
required for every North Andover MA 01845 10/18/2012
page. Cityrrown State. Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no" as to each of the following:
Yes No.
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
❑ ® Were as built plans of the system obtained and examined?(if they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 600
t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
P. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
w 555 Forest Street
Property Address
Judith Giarrusso
Owner Owner's Name
information is
required for every North Andover MA 01845 10/18/2012
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
On well water
Detail:
I
i
Sump pump? ® Yes ❑ No
Last date of occupancy: Current
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.
Inddstrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-09/08 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
555 Forest Street
Property Address
Judith Giarrusso
Owner Owner's Name
information is
required for every North Andover MA 01845 10/18/2012
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Pumped May2012, owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
❑ Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ b 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
555 Forest Street
Property Address
Judith Giarrusso
Owner Owner's Name
information is
required for every North Andover MA 01845 10/18/2012
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:
No as built plan, design plan 1979
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: ee
Material of construction:
® cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
4"cast iron thru wall. 3" PVC in house, no leaks visible
I
i
Septic Tank(locate on site plan):
Depth below grade: .6t
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain).
If tank is metal lista a:•
�_ g years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Tx5'x4'
Dimensions:
Sludge depth: 0
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
l
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
W
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
555 Forest Street
Property Address
Judith Giarrusso
Owner Owner's Name
information is
required for every North Andover MA 01845 10/18/2012
page. CitylTown 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
N/A
Scum thickness 0
Distance from top of scum to top of outlet tee or baffle N/A=Tank leaking l'of liquid in
tank
Distance from bottom of scum to bottom of outlet tee or baffle N/A
How were dimensions determined? Tape measure
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Inlet tee ok. Outlet tee ok. Liquid level in tank 3' below invert, evidence of leakage.
Grease Trap(locate on site plan):
Depth below grade:de:
feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.-Page 10 of 17
1
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
555 Forest Street
Property Address
Judith Giarrusso
Owner Owner's Name
information is
required for every North Andover MA 01845 10/18/2012
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
v Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
555 Forest Street
Property Address
Judith Giarrusso
Owner Owner's Name
information is
required for every North Andover MA 01845 10/18/2012
page. City/Town . State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box level &distribution equal. No evidence of carryover. No evidence of leakage.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M ,•''r 555 Forest Street
Property Address
Judith Giarrusso
Owner Owner's Name
information is North Andover MA 01845 10/18/2012
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:
® leaching fields number, dimensions: 1 field 20'x 40'
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Soil ok. Vegetation ok. No sign of ponding to surface.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
a a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'r 555 Forest Street
Property Address
Judith Giarrusso
Owner Owner's Name
information is
required for every North Andover MA 01845 10/18/2012
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
m
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 555 Forest Street
Property Address
Judith Giarrusso
Owner Owner's Name
information is
required for every North Andover MA 01845 10/18/2012
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
w-
e_
�, cm
r
t
L40 le
Lf Lf
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
°
Commonwealth of Massachusetts f
F0rm
I Inspection
Title 5 Officia
Subsurface Sewage Disposal System Form-Not for.Voluntary Assessments
555 Forest Street
Property Address
Judith Giarrusso
Owner Owner's Name
information is
required for every North Andover MA 01845 .10/18/2012
page. City/Town State Zap Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 4
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 4/19/1979
Date
❑ Observed site (abutting property/observation hole within 150 feet of:SAS)
® Checked with local Board of Health -explain:
Design plan
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
i
You must describe how you established the high ground water elevation:
As per test pit data on design plan
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
555 Forest Street
Property Address
Judith Giarrusso
Owner Owner's Name
information is
required for every North Andover MA 01845 10/18/2012
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
I
m
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
• '
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n , MCOPY
�jDoR Awl
PUBLIC HEALTH DEPARTMENT
Town of North Andover
Community Development Division
CERTIFICATE OF
COMPLIANCE
As of: 1/4/2013
This is to certify that the individual subsurface disposal system received a
SATISFACTORY INSPECTION of the:
Tank and D-Box Repair
By: Todd Bateson
At:
555 Forest Street
Map 106B Lot 46
North Andover, MA 01845
The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily.
Michele Grant
Public Health Agent
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 918.688.9540 Fax 918.688.8416 Web www.townofnorthandover.com
v J, ,a
�.s ED-tea
North Andover Health Department
Community Development Division
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: 555 Forest Street MAP: 106. B LOT: 46
INSTALLER: Todd Bateson TI ANK AND D-BOX
DESIGNER:
PLAN DATE:
BOH APPROVAL DATE ON PLAN:
INSPECTIONS
TANK INSPECTION: 2/4/2013 (TANK AND D-BOX
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
X Bottom of tank hole has 6" stone base
X Weep hole plugged
X 1500 gallon tank has been installed
H-10 loading
X Monolithic tank construction
X Water tightness of tank has been achieved by
visual testing
❑ Inlet tee installed, centered under access port
X Outlet tee installed, centered under access port
(gas baffle/effluent filter)
❑ inch cover to within 6" of finish grade
installed over one access port
X 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
X Installed on stable stone base
X H-20 D-Box
❑ Inlet tee (if pumped or >0.08'/foot)
X Hydraulic cement around inlet & outlets
X Observed even distribution
X Speed levelers provided (not required)
Comments:
• ���t °res .• Commonwealth of Massachusetts Map-Block-Lot
Lot
Booas
BOARD OF HEALTH
--- ------------------
North Andover
CERTIFICATE OF COMPLIANCE
THIS IS TO CERTIFY,That the Individual Sewage Disposal System (Repair)
by Todd Bateson
Installer
at No 555 FOREST STREET
has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the
application for Disposal Works Construction Permit No. BHP-2012-078 Dated December 04 2012
-----------------------------------------------------------------
Printed On:Dec-04-2012 BOARD OF HEALTH
• 5�� rEnr • Map-Block-Lot
Commonwealth of Massachusetts
.., ` • 106.60046
BOARD OF HEALTH -----------------------
Permit No
.r North Andover -BHP-2012-0785
-,
------------ -----
----
�-•- ��� FEE
F�RATgp A��
$125.00
-----------------------
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted Todd Bateson
----------------------------------------------------------------------------------------------------------------
to(Repair)an Individual Sewage Disposal System.
at No 555 FOREST STREET
-----------------------------------------------------------------------------------------------------------------------------------------------------
as shown on the application for Disposal Works Construction Permit No. BHP-2012-078 Dated December 04,2012
-----------------------------------------------------------------
Issued On: Dec-04-2012
----------------------- — BOARD OF HEALTH
NORiM 6319
Town of North Andover
`�.;5 o:•��' HEALTH DEPARTMENT
gACNUSt
CHECK#: g DATE
LOCATION:
1-1/0 NAM
CONTRACT R NAME-Eajt.�,
Type of Permit or License: (Check box)
❑ Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service-Type: $
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal(Septic)Hauler $
❑ Recreational Camp $
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ Trash/Solid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
❑ Septic-Soil Testing $
❑ Septic-Design Approval $�
❑ Septic Disposal Works Construction(DWC) $�_
❑ Septic Disposal Works Installers(DWI) $
❑ Title 5 Inspector $
❑ itle 5 ort $
❑ Other:(Indicate)i—?5 !i $
Health Agent Initials
White-Applicant Yellow-Health Pink-Treasurer
Application for Septic Disposal.System
°c TODAY'S DATE
pConstruction Permit — TOWN OF
° : +r,• $250.00-Full Repair
ACHUS ORTH ANDOVER, MA 01845 $ 25,00-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 ❑6-F a air or replace an existing system component—What? 7�3N/`
cursor-do not
use the return
key. A. Facility Information
_S5.s �--o r_.P_5f S
rab Address or Lot#
ream City/Town -2 . Vzr-- N-4 • DEC 04 2112
2.- *TYPE OF SEPTIC SYSTEM*: TOWN OF NORTH ANDOVER
❑ Pump ravity(choose one) HEALTH DEPARTMENT
***If pump system,attach copy of electrical permit to application***
onventional System (pipe and stone system)
❑ 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)(Attach Draft Maintenance Agreement)
❑ Pressure Dosed (D-Box Present)S.A.S.
2. Owner Information
Name
Address(if different fro above)
1'14-
City/T wn State Zip Code.
Telephone Number
3. Installer Information
-_ P>+1 30A..'
Name ,^ Name of Comp
MSON ENTERPRISES,INC.
111 ARG ILLA ROAD
Address L ANDOVER,MA 01810
�j,•p «9(�G®
City/Town State Zip Code
Telephone Number(Cell Phone#if possible please)
a. 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
:r°RTN, Applicati•on..for Septic Disposal :System
. •• TO AY'S DATE
} �C.onstruction -Permit =TOWN -OF
$.250.00-Full Repair
* �---� • 40 . �ORTH ANDOVER MA 01.845
4r"40 `' $725.00.-Component
CRUS
PAGE 2OF2
A, Facility.Informatio.n continued....
5. Type-of BuildinA edientiai 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,and not to place the system in operation until a Certificate of Compliance has
been Issued byjh1s Board of Health.
Name We
Application rove By: (Board of Health Representative) 1�
Nam7ication
Date Z� /
App Disapproved.for the following reasons:
For Office Use Only:
1 Fee Attached. : Yes No
2.• Project Manager Obligation Form Attaebed? Yes No
3,: PumpSvstem? Ifsoi Attach co,py ofElectrlcal Pe.-mit,. Yes No
4. FoundadoaAs Built?(new construction-ronly); Yes' No
(Same scale as approved plan)
S. FloorPlans?(hew construction only); 'es_ No
Appifcition'ior mpoal System Construction Permit Page 2 of 2
•
SEP'CIC SYSTEM.�INSTALL�+ER-PRGJE AGEMENT OBLIGATIONS
for'tl e.constrtxetioti for�the septic system-fo�r.the'prop"at
As the North Andover licensed installer
10 12-
For plans by
(Address of septic system) gineer)
Relative to the.application of� And dated
(in'staller's name) rl a ate .
Dated 48s-Ma
With revisions dated e 'ast revised date)
I understand the following obligations for management of-this project:
1. As the installer,I am.obligated to obtain.alI permits and Board of Health approved plans'pAo_r to
<perfonning any.work on a site. I must have the ant�roved flans and the permit on site when anv work is
Ecing d ne.
2. As the installer,•Imust-call-for any and allinspections. 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•b e.applicable.
1 As the installer,I atm•required to.have.the necessary work cotnpieted prior;to the.applicable inspections as
indicated below.,I iitrdefttand that requ-6tine an inspection,without comliletion•of the items in.accordance
with Title 5�ncl the Board of leaith Reilatons may resu7tiri a$50 OO fine briii •levied-a me.
aBo'tfotri of B.ed Generally,this-is the.-fitst:(.1"j inspection pnless.there is.'retaining wall,which
shotdd-be-dtine:&st. The installO:Mui st#quest the inspection but sloes.not have to be present. .
b. Final-Cons .. :b ti Inspection–E.ngineei r snus't`fitsi:do them umspoction for elevations;'t es, etc.
As-�iult of verbal OK(or a-mail•tio:hCalthdetitOtownofnorthandover.com):from the engineer must
be stibniitfed to.t ie.Board'of Health,afto.,.w rich mstaller.calls�for:an inspection time. Installer must
be present for this.inspection, with a pump&ystem,'all electrical wo k.xnust be ready and able to
cause pump.to arork aad;alartn.to funotion..
c. -FindVG�a lhstaller must request inspection when�—grading-is complete.- Installer does not
have to be-on-site.
4. As-the installer;I understand that only I-Ynay perform the work(other than:ri�le excavation)and I am required
to complete the installation of the system identified in tlie:attached.application for installation:'.I farG_h
undergand::that work done h$others unlicensed.*to-iristalf sepitic-systems•in North Andover can constitute
reasor:s for denial-of the.system andlor'rmlevocatiotz•or senston of.my Heense•to operate in.the Tnavn.of
North Andover,significant fines.to all persons involved ire also possible.
' 5.. As the.instiller l uiaderstand t6t'.I wus"b' on-site during th0.p4r &mance-of the following construction,
steps:
a: Detemiinatioj i dwt the proper elevation of the e�car2 on has been reached
b. Inspeetion of tbe'sand and stgne-to be used.
c. Finalinspectiofr byBoartf ofHealth staffor consultant.
d. Installation..oftank,D Box Apes,stone, vent,p=ump chamber,tet.rti wall and other
compo=nents.
6. as the installer;f uridersind that Earn sblely responsible for the installation.of the system as per the
approved 1Aans. No instructions by thehomeQmger,general.contractor_,or•any.othtr persons shall-absolve
me 2f this obli tion.
Undersigned Uceased Septic.Installex: (Z'pdal►'s
74me:–Prim)
,8."•r, OW
� ixF l i.
F .. °•. •.
Add ress S � Title of File Page of
Date File Open: Date file closed:
Doc Document/Action Title Date of Refer to other Purpose of Document/Action and notes
action Document/ document/
Num. Action Department
i
Board of Appeals - Board of Health — Plannung Board Conservation Commission — Boilding Departrnent
� G