HomeMy WebLinkAboutMiscellaneous - 56 BRIDGES LANE 4/30/2018 (4) � ' � three,
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COMMONWEALTH OF MASSACHUSETTS `
E EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
F
Y
'� yV
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 56 Bridges Lane
_North Andover_
Owner's Name:_Thomas Kennally_
Owner's Address:_56 Bridges Lane_
North Andover_
Date of Inspection:_7/7/2001_
AUL 3 e 2001
Name of Inspector: Neil J.Bateson_
Company Name: Bateson Enterprises Inc._
Mailing Address:_111 Argilla Road_
_Andover,Ma.01810_
Telephone Number:_(978)475-4786_
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
M_AF *
Inspector's Signature: Date: _7/7/2001_
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.
Notes and Comments
****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.
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:_56 Bridges Lane_
North Andover—
Owner: Kennally
Date of Inspection: 7/7/2001
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_X I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the 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.
ND explain:
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
obstruction is removed
distribution box is leveled or replaced
ND explain:
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
obstruction is removed
ND explain:
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Page 3 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 56 Bridges Lane_
_North Andover—
Owner: Kennally
Date of Inspection: 7/7/2001_
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
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 and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 56 Bridges Lane_
_North Andover—
Owner: Kennally
Date of Inspection:_7/7/2001_
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or'nW'to each of the following for all inspections:
Yes No
_No_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
—No— Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
_No_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_No_ Liquid depth in cesspool is less than 6"below invert or available volume is less than'/2 day flow
_No_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
_No_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
_No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_No_ Any portion of a cesspool or privy is within a Zone I of a public well.
_No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_No_ 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To he considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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.
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Page 5 of l l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 56 Bridges Lane_
North Andover_
Owner: Kennally
Date of Inspection:_7/7/2001
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
Yes_ _ Pumping information was provided by the owner,occupant,or Board of Health
No Were any of the system components pumped out in the previous two weeks?
Yes _ Has the system received normal flows in the previous two week period?
No Have large volumes of water been introduced to the system recently or as part of this inspection?
Yes _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Yes_ — Was the facility or dwelling inspected for signs of sewage back up?
Yes _ Was the site inspected for signs of break out?
Yes_ _ Were all system components,excluding the SAS,located on site?
_Yes_ _ 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 ?
_Yes_ _ 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:
Yes no
Yes _ Existing information.for example,a plan at the Board of Health.
No Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable)[3 10 CMR 15.302(3)(b)]
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Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:_56 Bridges Lane
_North Andover-
Owner: Kennally
Date of Inspection:_7/7/2001_
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4_ Number of bedrooms(actual):_4—
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x 9 of bedrooms):_600_
Number of current residents:_4
Does residence have a garbage grinder(yes or no):-Yes-
Is
es_Is laundry on a separate sewage system(yes or no):_ [if yes separate inspection required]
Laundry system inspected(yes or no):-No-
Seasonal
o_Seasonal use:(yes or no):_No_
Water meter readings:_Jan.00 To Jan.01=9700 Fe x 7.5=72,750 Gals.J 365 Days=199 GalsJ Day _
Sump pump(yes or no):_No_
Last date of occupancy:_Current
COMIVIERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:_Pumped this year,owner_
Was system pumped as part of the inspection(yes or no)::_No_
If
yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
—ivy
_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)
_Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:_17 Years old. 6/26/1984.
As built plan._
Were sewage odors detected when arriving at the site(yes or no): No_
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_56 Bridges Lane_
North Andover—
Owner: Kennally
Date of Inspection:_7/7/2001
BUILDING SEWER(locate on site plan)X
Depth below grade: 32"
Materials of construction:—X—cast iron _X 40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):_4"Cast iron thru wall.3"PVC in house.
No leaks._
SEPTIC TANK: X locate on site plan)
Depth below grade: 20"
Material of construction:—X—concrete_metal_fiberglass polyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: 10'x 5'x 4'
Sludge depth 0
Distance from top of sludge to bottom of outlet tee or baffle: 27"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle:_20"
How were dimensions determined:_Subtract scum&sludge depth to tee length._
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.Depth of liquid at outlet invert.
No evidence of leakage._
GREASE TRAP:_(locate on site plan)
Depth below grade:_
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:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
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Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_56 Bridges Lane_
_North Andover
-
Owner: Kennally
Date of Inspection: 7/7/2001
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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: X (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-boa level&distribution equal,has flow levelers.No evidence of leakage.No
evidence of carryover._
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
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Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_56 Bridges Lane_
North Andover—
Owner: Kennally
Date of Inspection: 7/7/2001
SOIL ABSORPTION SYSTEM(SAS):_X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
X leaching pits,number:_3_
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
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.):_Soil ok.Vegetation ok.No sign of ponding to surface.Pit#1 holding 13"of water.Pit#2 holding 6"of
water. Pit#3 holding 8"of water.Camera inside of pits thru outlets pipes in d-box._
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 or no):
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.):
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_56 Bridges Lane_
_North Andover—
Owner: Kennally
Date of Inspection:_7/7/2001_
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch 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.
Septic Tank House
Driveway
2 1
B Water
Meter
D-Box
Pit#1
Pit#3
Pit#2
Ato1=14'4"
A to 2=24'2"
Bto1=21'2"
B to 2=2212"
B to D-Box=12'3"
C to D-Box=3517"
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Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_56 Bridges Lane_
North Andover—
Owner: KennaHy
Date of Inspection:_7/7/2001_
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water >4_feet
Please indicate(check)all methods used to determine the high ground water elevation:
_X_Obtained from system design plans on record-If checked,date of design plan reviewed:
_X_Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:_Test pit data show no water 11'deep.
Transfer elevation of wetlands in rear yard to pit bottoms.
Tel: (978) 475-4786
Fax: (978) 475-5451
BATESON ENTERPRISES, INC.
Excavating-Water.&Sewer Lines-Septic Systems&Pumping Service
111 Argilla Road Andover, Mass. 01810
Title 5 Inspection Report
Property Address: 56 Bridges Lane, North Andover
Owner: Kennally
Date of Inspection: 7/7/2001
My report contained herein does not constitute a guarantee of future usage and the functionality of the existing
septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further
operation of your current septic system.
Neil J. Bateson
Bateson Enterprises, Inc.
Address P-crJGss A, Nl Title of File Page of
Date File Open: Date file closed:
Doc Document/Action Title Date of Refer to other Purpose of®ocumeEnt/Action and notes
action Document/ document/
Num. Action Department
Board of Appeals - Board of Health - Planning Board - Conservation Commission- Building Department
r e '
COMMONWEALTH OF MASSACHUSETTS
ExECtmrn OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTEMON
ONE WINTER STREET,BOSTON MA 02108 (617)292-6500
TRUDY COXE
$eceetes9
ARGEO PAUL CELLUCCI DAVID B.STRUMS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address:
(� 7V�� Now of Owtneir Y1 Will n
���� �
Address o1 Ownier:. t
Name of inspector:(PI a se P�rintl✓Date of Inspectim: �H4) . y
I am a DEP approved system Pursuant to Section 15.240 of Title 5(310 C"15.000)
Company Name:
Mat7ing Address: 4 .4LY'l
Telephone Number: _
CERTIFICATION STATEMENT ,
I certify that 1 have personally inspected the sewage dispotal system at this address and that the Information reported below Is true,accurate
and complete as of the time of inspection. The Inspection was performed based on my training and experience In the proper function and
maintenance of on-site sewage disposal systems. The system:
_ asses
Conditionally Passes ;
Mes Fj"hr Evaluation By the Local Approving Authority
ei
lttapector•s Signature: v Daft: ��
if L
The System Inspector shall submit a copy of this Inspection report to the Approving Authority(Board of Health or DEP)within thirty(110)days of
completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the Inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection.. The original:should be sent,to,the ..
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS ,/) (�( �� V� �, ��� u
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revised 9/2/98 Pao iof11
%3%Printed do Recyded Paper
Town of North Andover, Massachusetts
Form No.3
f
N0RT1j BOARD OF HEALTH
OL17
19_
4'
DISPOSAL WORKS CONSTRUCTION PERMIT
Applicant
NAME
ADDRESS TELEPHONE
Site Location / •,,;c��
Permission is hereby granted to Construct ( ) or Repair
Sewage Disposal System as shown on the Design Approval ( ) an Individual Soil Absorption
val S.S. No. ./✓�
J} CHAIRMAN, BOARD OF HEALTH
Fee
D.W.C. No. lL-r
I
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE:_ !' CURRENT INSTALLER'S LICENSE#
LOCATION:
LICENSED INSTALLER: . ,-- d c
SIGNATURE: TELEPHONE#
CHECK ONE:
REPAIR: NEW CONSTRUCTION:
IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUILT.
Administrative Use Only
$75.00 Fee Attached? Yes_' No
Foundation As-Built? Yes No
Floor Plans? Yes No
Approval Date:
/ �, . .. .
TOWNOAR OF HEALTH VER/
C'x_ _ E �.
COMMONWEALTH OF MASSACHUSETTS
.EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
EI'A�RTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET,BOSTON MA 02108 (617)292-5500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
CommissionerCom +��ioner
Governor
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
PropaRy wda►gss: S6 { � `' Ulama of Owner
Oct
Vg'r Address of owner- —Raba of Inspe M—' �qc`�\ tel , 1l G . f�Name of 4spector. Pnnt)
1 am a system- to Section 15.340 of Title 5(31 O CMR 15.000)
Company Name: 0. S � �
Mooing pddres ,'.._ L�'1 `VU 4 , �'1G_ I'Pt"l v
Telephone IWarrber - "'
CERTIRCATION STATEMEIIfT
1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal.systems. The system:
Oonditionally Passes
Nee s Further Evaluation By the Local Approving Authority
Inapeaws Signaburac Date:
The system.Inspector shall submit a copy of this inspection 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 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the
system.owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
'��+vYur LC- ✓
G�- u'y&_
revised 9/2/98 Pagel or 11
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Or Printed on Recycled Paper
6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ..
PART A
CERTIFICATION(condmod�)
Property Address; J`� F3 LUQ
Owner:
Date of Inspection:
OSPEC71ON SUMMARY:. ,ChocA11, C, or A
A.. SYSTEM PASSES:
1 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 COyp4p8NALLY PASSES:
One or more system components as described In the"Conditional Pass" section need to be replaced or repaired. The system,upon
mpl on of the milacernerlt or repair,as approve by the Board f eat wiltass. ,
Indicate yes,no,or not determined( N,or NO). Describe basis of determination in all instances. If"not determined",explain why not.
L4 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.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pips(s)
or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
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):
broken pipe(s)are replaced
obstruction is removed
revised 9/2/98 page 2orn
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A '
CERTIFICATION(continued)
Property Address' a�{ �Y1 .
owner. V
Date of btspsction:�j�Q`�'41
C. FURTHER EVALUATION IS REduikm 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 the
public health,safety and the environment.
I SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.30311)(b)THAT THE SYSTEM
IS NOT FUNCTIONING W A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
0
2) SYSTEM WILL FAQ UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUN TINING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system hasa septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well Is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5.ppm. Method used to determine distance (approximation not valid).
3) OTHER
n
revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(eorttirwad)
b
Property Address: �`�� 1_VV
Owner:
Date of knpection:
D. SYSTEM FAILS:
You must indicate either"Yes" or "No" to each of the following:
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 contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
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 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipets).
Number of times pumped_.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. .
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply:
Any portion of a cesspool or privy is within a Zone 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. 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 indicate either"Yes" or"No" to each of the following:
The following criteria apply to large systems in addition to the criteria above:
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
T 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 11 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 inforInation.
,
revised 9;2/98 Page4of11 -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST e
Property Address: . c^ es, G V\- po— `A-ki,
Date of kapectiont �
Check if the following have been done:You must indicate either"Yes"or"No" as to each of the following:
Yes o '
Pumping information was provided by the owner,occupant, or Board of Health.
_ None of the system components have been pumped for at least two weeks and the system has been•receiving rronnal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
Inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
e
The site was inspected for signs of breakout.
All system components,excluding the Soil Absorption System,have been located on the site.
The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles
or tees,material of construction,dimensions,depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
- Existing information.for example, Plan at B.O.H.
V _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
The facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of
SubSurface Disposal Systems.
n
revised 9/2/98 Page 5of11
I r .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �•
PART C
> SYSTEM MFORMA71ON
y
Address:
Owner: . ,
Dow of inspection:
FLOW CONDfTIONS
RESIDENTIAL:
tt
Design flow: / g.p.d./bodroom. '
Number of bedrooms(design).-L4- Number of bedrooms(actual):
Total DESIGN flow
Number of current tesidants:
Garbage grinder(yes or no):
Laundry(separate system) ( es or no►:L�s If yes,separate Inspection required
Laundry system Inspected as or no) HA rC \Ct
Seas6nal use lyes or no): 1�'; �� J �)�3 ��5=
Water meter readings,if 421 pble(last two year's usage(gpd):
Lump Pump lyes or no):
Last date of occupancy: CYC
COMMERCIALMdDUSTRIAL•
Type of establishment:
Design flow: gad (.Based on 15.203)
Basis of.design flow
Grease trap present:(yes or no)_
industrial Waste Holding Tank present:(yes or no)_
Non-sanitary waste discharged to the Title 5 system:lyes or not_
Water meter readings,if available:
Last data of occupancy:;
OTHER:(Describe)
Last date-of occupancy:
GENERAL INFORMATION
PUMP06 RECORDS and source of information:
)
� o u Gt
System pumped as part of inspection:(yes or no) PS
If yes,volume pumped: 1-V90 gallong
Reason for pumping: i y`,Q ': a- �z.�2S.6
TYPE OF S LSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system lyes or no) (if yes,attach previous inspection records,if any)
1/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
PPROXIMATE AGE of all components,date installed(if known)and source of information: �� 7
\ �A- %CtA.^—
Sewage odors detected when arriving at the site:(yes or no) lyes
n
revised 9/2/98 Page 6of11
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Addres3: S ('. QC`j UA.
owner:
Date of Inspection:,jC.��7� V-)
BUILDING SEWER(Locate
V
(Locate on site pla
Depth below grade:"
Material of con truc�icast l"` t iron w 40 PVC_other(� ain)
�a t
C c�4� c. 1.1 A� y G V\
Distance fro T prlVate water supply well or suction line
Diameter L
Comments (condition ioints,venting, evidence of leakage,etc.)
SEPTIC TANK•
(locate on site plan)
li
Depth below grade:<-A-)
Material of construction:_co"" ncrete_metal_Fiberglass _Polyethylene_other(expiain)
If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(Yes/No)
Dimensions: 0rx S X 1.� I
Sludge depth: ''
:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: or
Distance from top of scum to top of outlet tee or baffle: /1
Distance from bottom of scum to bo�tom o� f outlet tag or baffle:_
How dimensions were determined: . Y )�
Comments: V
(recommendation for pumpin ndition of in and utlet tees or bqMes,depth of liquid lav I in rplation to ouget invert, ctural�rtteg
dente of leakage,etc.) �'
T
GREASE
(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(expiain)
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:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.)
I
k
revised 92/98 Page 1of11
R
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued!
4'
P"gWtY Address: Qt��car ,2� uvv.
Owner:
Date of-ape-&-C t��►
TIGHT OR HOLDING TANK4W (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 alarm and float switches,etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: O
Comments:
(note if 1e an dist ibtm Is el,evidence of solids arryover evide-nr.9 of�leakage into o ut of�ox, tc.)
_ lc-1 en , .
PUMP CHAMBER__
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order IYes or No)
Comments:
Inote condition of pump chamber,condition of pumps and appurtenances,etc.)
revised 9/2/98 Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC710M FORM r.
a PART C
r
SYSTEM INFORMATION(continued)
Property Address•
Owner:
Daft of Inspection; '
SOIL ABSORPTION SYSTEM(SAS):
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
Type:
leeching pits,number-_j
leaching chambers,number:_
leaching galleries,number;�
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:_
Alternative system:
Name of Technology:
Comments; _
(n co dition f soil,signs of hydireplic faPure,level of po ding, da p soil,condition of vegeta n,7j k AA c) et
1v�[
CESSPOOLS:
(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:
Materiels 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•_
(locate on site plan)
i
Materials of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
h
revised 9/2/98 Page 9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM +.
PART C
r SYSTEM INFORMATION(eontirvued)
Property Address: r�
. owner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at feast two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
i v(2..-
145
3 �
CD Ll
=QIt
n
revised 9/2/98 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
11 SYSTEM�I NFORMATION(erred)
Property Address) J� �
Owner:
Date of Inspection:
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater , Feet
Please in all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
�� PAM<-
V O'bs�emed Site(Abutting property,observation hole,basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators,installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
AD U-V'�
•
revised 9/2/98 page ii of 11
f
Tel: (978) 475-4786
Fax: (978)475-5451
BATESON ENTERPRISES, INC.
Excavating-Water.& sewer Lines-Septic Systems & Pumping Service
111 A.rgilla Road Andover, Mass. 01810
Title 5 Inspection Report
Property Address: 156 �t`, �`� LY)-
Owner:
Date of Inspection:
My report contained herein does not constitute a guarantee of future usage and
the functionality of the existing septic system. Such report issued herewith is merely
based upon my observations,and I hereby disclaim any further operation of your
current septic system.
Neil J.°Bateson
Bateson Enterprises, Inc.
SOIL PROFILE & PERCOLATION TEST DATA
r
North Andover, Mess. Street No s r�� PZ _Lot -Na ¢.
Loc/Subdiv. Pland Owner
Investigator Gy/O Observer
SOIL PROFILE DATES
1.tlev L 2.Elev 3.Elev 4.Elev
0�
0 0 0 0
�v
Ties p �
e s est
2 2 2 2 l
l
3 �i t S 3 3 3
4 4 4 4
5 5 5 5
6 . 6 6 6
7 S 7 7 7 v °.L
V `
8 8 8
9b 9 9 9 "W4
10 10 10At-
Ij
Ocie:.
Location
Elevation Datum
PERCOLATION TESTS
DATES �� °'Q�'j \ (b 3
Pit Number 1 2 ; - 3 4
Start Saturation ( Z,\3
Soak-Minutes
Start e
Drop of 3"-Time I
Drop of 6"-Time f v
Mmms-lst 3" drop
1,ins.2nd " Drop To � '
Percolation
SOIL PROFILE & PERCOLATION TEST DATA
North A�iidover, Mass,. Street No y, Lot No �
Loc/Subdiv. Pland Winer -=kA.., L.O
Investigator a- �'8C> _ Observer 1-�1'J�2•-
SOIL PROFILE DATES
`l.)Elev 2.Elev 3.Elev 4.Elev
0 0 0 0
1 1 1 1
Tres Pits est
2 2 2 2
3 3 3 3
4 4 4
5 5 5 5
6 6 6 6
7 7 7 7
8 8 8 8
9 9 9 9
10 10 10 10
Benchmark Location
Elevation Datum
PERCOJ kTION TESTS
DATES i3 8 7 13 0> 7114 ef-j,
Pit Number 16J 2 �, '# Z 4
Start Saturation Z• -Z Z:i3 Z*00
Soak-Minutes
'2.' ZS Z-••30 'L�t�O
Start a
Drop of 3"-Time
Drop of 6"-Time Z: 44,
Moms.lst 3" drop wrip _
Mins.2nd " Drop4$'
Percolation \
Board of Health
North An SEPTIC sisTE n'
ver Hasa. INSULLATICK CHECK LIST LOT''
' ,. AVATI OK FAIL
CNID DATg DI UPPROM
4 4Y -
easons:
_ T
{j �. Z WT
1. Distance Tos
a. Wetlands
b. Drains
c.. Well
2, Water Line Location
3. No PPC Pipe
}�. Septic Tank -
a. -Tees -_Length do To Clean Oat Covers.
b. Cement Pipe .to Tank - Sides of Tank.
5. Distribution Box
a. Covers & Box - No Cracks
b. All Lines Flowing Equal- Amounts
c. No Back Flow
6. Leach Field or Trench
a. Dimensions
b. Stone Depth
c: Capped Inds
d. Clean Double-Washed Stone'
7. Leach Pits
' a. Dimensions
b. Stone Depth
., c. Splash Pads
d. Tess
e. Gement Pipe to Pit - Both Sides
f. Clean Double Washed Stone
8, No Garbage Disposal
9. -Final Grading Inspection
10. Barricading Covered System
As Built Submitted
a. Lot Location
b. Dimensions of System
c. Location with Regard-to Pere Test
d. Elevations
` e: Water Table
r�
.1
Board cf t -;..
r
LOT
lS.CrRl.v. -.r-
=
_ Title V yk`
.R 2.� e- submitted
eg sion:,r7; t• `,abutters
a} the lot to b._ ties
b location anci on h��mac: ,-distance to
' -�n te, i,,-cli stance to ties
- - � c Location and < �> � .
d --&sign `cal.cn� L� 4-.'•ons atxo:i r�g required leacr'ng
e) location and
ding reserve area
--_ I and ;c.,'
- _ - f} 'e�dsting �.
- - Ig� lrication any ,.' �' 'JJO' of se.�age disposal sps`=Jn c•
_-di --laimer-Ci, . .. ?tom,r.r; ,a ng
(h} surface and -with{.rt 1C\ of seuag-e disposa3
_ =
System or di `
(i};location -�� oo I =of•serge di s o 33-1
_ system o {: V? _; Do are, fiI es
(3) kno�,a s;, �; ue: -d.t?1III 20�), of serge disnoi al
system Or
-- f fsa se. �_ot
(k) _100I foam leach,_n, i.
-location of ,
I (1) location of c ,�µ"'t 'C from leaching fac'
(m) location of t
(n) drivevys
A (o) gage d3.s:L-. .
--(p) no PVC to be Ion ,
F (q) profile of sr Er _ `� _•F bas, }t, plusab, pipe, septic
- distribution ' -l�, � t ; .sets, di F t_*3bution field pi.pin
0ther eleca_
(r) mard=m E:1~c�:, 4-.r e,1 e-, in a:C_� ac,:,-age disposal sr sten
- (s) plan mist be _ _ = F;.' t36• _,Festc,r�=? Ikigineer or other
- ' professicr.�' : i 7.,--' t :' to p,-E-__ e such plans
Reg 6She Ta_rks
(a) eapacitjc:s-�' r; tabs•.; t�:es, depth of tees,
access,
(b) cleanout
(c) 101 from cc Pool
(d) �5f from su: r
Reg 10 2 Distribz of
(a) sop gr,?{ 0
Reg 10 t; i 3, b) sur
I
APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE: 3—Jrj— l 9 CURRENT INSTALLER'S LICENSE#
LOCATION: �(p Q r�'�q1� S �� ,
LICENSED INSTALLE :
SIGNATURE: TELEPHONE#
CHECK ONEZ
REPAIR: NEW CONSTRUCTION:
b—�)OK bpi 4( k
IF NEW CONSTUCTION, F/LEASE ATTACH FOUNDATION AS-BUILT.
Administrative Use Only
$75.00 Fee Attached? Yes No
Foundation As-Built? Yes No
Floor Plans? Yes No
Approval Date: