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HomeMy WebLinkAboutMiscellaneous - 57 BOXFORD STREET 4/30/2018 (3) XFORD / 57 BOA-006 STREET J 2101106.A-0065-0000.0 \\ 1 i I of IF COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ROTE C ON TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION RECEIVED Property Address: 57 Boxford Street North Andover,MA SEP 15 2005 Owner's Name: Terri Sullivan Owner's Address: 57 Boxford Street North Andover,MA TOWN OF NORTH ANDOVER Date of Inspection: July 16,2005 HEALTH DEPARTMENT Name of Inspector: (please print) Benjamin C.Osgood,Jr.Certified Title 5 Inspector Company Name: New England Engineering Services Inc. Mailing Address: 60 Beechwood Drive North Andover,MA 01845 Telephone Number: 978-686-1768 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 the on site sewage disposal stems. I am a DEP approved stem inspector pursuant n systems. to Sectio PP sy P 15340 of Title 5(3 10 CMR 15.000).The system: _Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date:— / oS The system inspection shall submit a copy of this mspection 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 _:tvt- —1, ,1 d� I�orte PP/Zfb(Zvrl,t� %11 vP_2[i� i _ t L C �C_ 21 c%1� c V (zt��r�S AS 3 fln/ �9 i Z GTS c)i2 (rlN � a2 03 ,� G C� ****This report only describes conditions at the time of inspection and under the conditions of use at that e. This ftwection does not address how the system will perform in the future under the same or different conditions of use. -2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 57 Boxford Street North Andover,MA Owner's Name: Tem Sullivan Date of Inspection: July 16,2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: `5E, 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: /V 0�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_ -3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 57 Boxford Street North Andover,MA Owner's Name: Terri Sullivan Date of Inspection: July 16,2005 C. Further Evaluation is Required by the Board of Health: A)J 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 (SAS)Soil Absorption System and the(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 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 organize 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 5ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 4of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 57 Boxford Street North Andover,MA Owner's Name: Terri Sullivan Date of Inspection: July 16,2005 D. System Criteria applicable to all systems: You must indicate`eyes or No"to each of the following for all inspections: Yes No z 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 overload or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overload or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than V2 day flow 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 r/ 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrogen is equal to or less than 5ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) N (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 be considered a large system the system must serve a facility with a design flow of 10,000 d to 15,000 gpd. You must cate either"yes"or"no"to each of the following: (The followin tena apply to large systems in addition to the criteria above) Yes No The system is within eet of a surfs g water supply The system is within 200 f a ' utary to a surface drinking water supply The system is ed in a nitrogen sensitive (Interim Wellhead Protection Area—IWPA)or a mapped Zone H of a p water supply well If you answered"y s"to any question in Section E the system is considered a cant threat,or answered"yes"in Section D above the large system has failed. The owner or operator of any large system considered . cant 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. • •5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 57 Boxford Street North Andover,MA Owner's Name: Tern Sullivan Date of Inspection: July 16,2005 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 an 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 sign of break out? Were all system components,excluding the SAS,located on site? Were all 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 difference from owner)provided with information on the proper maintenance of the subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes i No 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) [3 10 CMR 15.302(3)(b)] •6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 57 Boxford Street North Andover,MA Owner's Name: Terri Sullivan Date of Inspection: July 16,2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design)_=_Number of bedrooms(actual): k—pv-u is DESIGN flow based in 310 CMR 15.203(for example: 110 gpd x #of bedrooms): Number of current residents: { Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): --- Seasonal use: (yes or no): NO . Water meter readings,if available(last 2 years usage(gpd): wFt-L Sump Pump (yes or no): NO Last date of occupancy_,,,, r e.tiT COMMERCIAL/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: Inst date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:_ /V D U e YO e E-P- moo y Pct O—jNE r2- Was system pumped as part of the inspection(yes or no): /Vc7 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 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 Attached a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 0)0 K N o 1, Were sewage odors detected wen arriving at the site(yes or no): •7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 57 Boxford Street North Andover,MA Owner's Name: Terri Sullivan Date of Inspection: July 16,2005 BUILDING SEWER(locate on site plan) Depth below grade: /Sr Materials of construction: ✓cast iron 40 PVC other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): PLS' t-ego)/.S n IL, l AJ g ASCA4 Etirr SEPTIC TANK: (locate on site plan) Depth below grade: I a Material of construction:xconcrete 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: toot C---ALLC NS Sludge depth: 1-12- Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: <I Distance from top of scum to top of outlet tee or baffle: 6 Distance from bottom of scum to bottom of outlet tee or baffle I�t How were dimensions determined: 14 eusu o e7 ,s'rt.c. Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structuraliurtegrity,liquid levels as related to outlet invert,evidence of leakage,etc.): TAti1K i,.! n►.l c'n��>"��it- Fc t{ a� PUc_ -mac% Ins �� GREASE TRAP: j (locate on site plan) Depth below grade: Materials 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 sludge 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. ,8of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 57 Boxford Street North Andover,MA Owner's Name: Terri Sullivan Date of Inspection: July 16,2005 TIGHT OR HOLDING TANK: &//j4 (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Materials 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: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidnence of solids carryover,any evidence of leakage into or out of box,etc.): �Jn ►nJ dX ,,I tip C-110^, i rZkF ON Q—)AC , i✓J ��7)DCNC� O� t/v PUMP CHAMBER: (locate on sire plan) Pumps in working order(yes or no) Alarms in working order(yes or no) Commends(note condition of pump chamber,condition of pumps and appurtenances,etc.): ,9of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 57 Boxford Street North Andover,MA Owner's Name: Terri Sullivan Date of Inspection: July 16,2005 SOIL ABSORPTION SYSTEM(SAS): (locate on site Plan,excavation not required If SAS not located ex.-plain why TYPE leaching pits number leaching chambers, number leaching galleries number leaching trenches,number in length _ leaching fields,number,dimensions: overflow cesspool,number innovative/alternative system Typetname of technology: Comments(note condition of soil,signs of hydraulic failure.Level of ponding,damp soil,condition of vegetation,etc) i"d.v9"N �—, DAMS <01c, 02- 0^j0SLJ14L v% -j -7-70,4/, 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) Material of construction: Dimensions: Depth of solids Comments(note condition of soil signs of hydraulic failure,level of ponding,condition of vegetation,etc. r s ,10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 57 Boxford Street North Andover,MA Owner's Name: Terri Sullivan Date of Inspection: July 16,2005 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. �t.ocATE b t � 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 57 Boxford Street North Andover,MA Owner's Name: Terri Sullivan Date of Inspection: July 16,2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavator,installers-(attach documentation) Accessed USGS database-cxplain: You must describe how you established the high ground water elevation: p5GtSC m!n i O i.» sO.vt- uM -}� �3 ora(? p-eO12wE-- L-2 w ET W rT t--FR N r_> S�s�r , I of 11 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 57 Boxford Street North Andover,MA Owner's Name: Terri Sullivan Owner's Address: 57 Boxford Street North Andover,MA Date of Inspection: July 16,2005 Name of Inspector:(please print) Benjamin C.Osgood,Jr.Certified Title 5 Inspector Company Name: New England Engineering Services Inc. Mailing Address: 60 Beechwood Drive North Andover,MA 01845 Telephone Number: 978-686-1768 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 the on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15340 of Title 5(3 10 CMR 15.000).The system: _Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: 1 - Date• /6 oS The system inspection 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. 2of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 57 Boxford Street North Andover,MA Owner's Name: Terri Sullivan Date of Inspection: July 16,2005 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: B. System Conditionally Passes: 0 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_ 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 57 Boxford Street North Andover,MA Owner's Name: Terri Sullivan Date of Inspection: July 16,2005 C. Further Evaluation is Required by the Board of Health: A)V 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 i 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 (SAS)Soil Absorption System and the(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 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 organize 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 5ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 4of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 57 Boxford Street North Andover,MA Owner's Name: Terri Sullivan Date of Inspection: July 16,2005 D. System Criteria applicable to all systems: You must indicate`eyes or No"to each of the following for all inspections: Yes No .1/ 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 overload or clogged SAS or cesspool. ✓ Static liquid level in the distribution box above outlet invert due to an overload or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than'h day flow 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 4z Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. 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 nitrogen is equal to or less than 5ppm,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 be considered a large system the system must serve a facility with a design flow of 10,000 d to 15,000 gpd You must hocate either`yes"or"no"to each of the following: (The followin feria apply to large systems in addition to the criteria above) Yes No The system is within eet of a surfs g water supply The system is within 200 f a utary to a surface drinking water supply The system is in a nitrogen sensitive (h►terim Wellhead Protection Area—IWPA)or a mapped Zone II of a pu water supply well If you answered"y s"to any question in Section E the system is considered a cant threat,or answered"yes"in Section D above the large system has failed The owner or operator of any large system considered cant 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 5o f11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 57 Boxford Street North Andover,MA Owner's Name: Terri Sullivan Date of Inspection: July 16,2005 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 an 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 sign of break out? Were all system components,excluding the SAS,located on site? Were all 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 difference from owner)provided with information on the proper maintenance of the subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes , No 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) [3 10 CMR 15.302(3)(b)] 6of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 57 Boxford Street North Andover,MA Owner's Name: Terri Sullivan Date of Inspection: July 16,2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design)__=_Number of bedrooms(actual):-Z- DESIGN DESIGN flow based in 310 CMR 15.203(for example: 110 gpd x #of bedrooms): Number of current residents:_ Does residence have a garbage grinder(yes or no): /V O Is laundry on a separate sewage system(yes or no): IVO [if yes separate inspection required] Laundry system inspected(yes or no): --- Seasonal use: (yes or no): N 0 . Water meter readings,if available(last 2 years usage(gpd): uV t-U Sump Pump (yes or no): NO Last date of occupancy_,, _i- COMMERCIAIANDUSTRIAL Type of establishment:_ Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgt 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: /V 0 U e YO E-2 Dov Pct O—J DoE:2 Was system pumped as part of the inspection(yes or no): IUcD 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 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 Attached a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 0N11.No�,�N til Were sewage odors detected wen arriving at the site(yes or no): 7of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 57 Boxford Street North Andover,MA Owner's Name: Terri Sullivan Date of Inspection: July 16,2005 BUILDING SEWER(locate on site plan) Depth below grade: /Or Materials of construction: cast iron 40 PVC other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): PL/l1% J-00)4,1- n 1- 1 X, R R-C."EKY SEPTIC TANK: (locate on site plan) Depth below grade: I a Material of construction:_ - 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: loo CAL-Le Sludge depth: 1-12- Distance 12-Distance from top of sludge to bottom of outlet tee or baffle: 3 3 Scum thickness: Z) Distance from top of scum to top of outlet tee or baffle: 66 Distance from bottom of scum to bottom of outlet tee or baffle 14 u How were dimensions determined: v eas,,o.e Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): �Rn1K �ti! nl), map)iZa/t Fct{ Q� GREASE TRAP: d (locate on sitelan P ) Depth below grade: Materials 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 sludge to bottom of outlet tee or bale: 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. 8of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 57 Boxford Street North Andover,MA Owner's Name: Terri Sullivan Date of Inspection: July 16,2005 TIGHT OR HOLDING TANK: L1114 (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Materials of construction: concrete metal fiberglasspolyethylene 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 umpingComments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: D Comments(note if box is level and distribution to outlets equal,any evidnence of solids carryover,any evidence of leakage into or out of box,etc.): �JX ins dK tOMfj iTlJ✓�, (J1JT2�gv"TON E���4C! i✓J E�7)D�NCE O� PUMP CHAMBER:—(locate on sire 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.): 9of11 I, OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 57 Boxford Street North Andover,MA Owner's Name: Tem Sullivan Date of Inspection: July 16,2005 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required If SAS not located explain why TYPE leaching pits number leaching chambers, number leaching galleries number leaching trenches,number in length ,x 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) "&?� UT 1--l6LD t-00Ks /V02 _rJN9,AJ.(,rF DAMF j.'011. 0/a 0NvS0AC- 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: j 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) Material of construction: Dimensions: Depth of solids Comments(note condition of soil signs of hydraulic failure,level of ponding,condition of vegetation,etc. 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 57 Boxford Street North Andover,MA Owner's Name: Terri Sullivan Date of Inspection: July 16,2005 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. O Lot" C OG Wfub W 1TH METAL D�TCCYO(L /06 J� � 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 57 Boxford Street North Andover,MA Owner's Name: Terri Sullivan Date of Inspection: July 16,2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record—If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health—explain: Checked with local excavator,installers—(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: w GCT 1-a^/D, (,y r7 k-44 N r) s 6 ` P, c_v �, v942-Ew 6:F- -5- Commonwealth of Massachusetts :Or'NORTH ��D Ajk� ���IMassachusetts 292 TOANDOVERHARTMENT system Pum pine Record System Uumer System Location Z u 6ric%A-R,q Date of Pumping: f�� ��( Quantity Pumped: gallons Cesspool: No � Yes . ❑ Septic Tank: No ❑ Yes E RAGGS SEPTIC SERVICE, INC. System Pumped by: d.b.a. E. A. COMEAU SEPTIC License r: Contents transferred to: WATER SOLUTIONS GROUP, TAUNTON Date Inspector RAGGS SEPTIC SERVICE, INC. F 74 COMMORWw"of N ANDOVER . Massachusetts REC6V N. A 0 ER JUN 0 9 2008 TOWN OF NORTH ANDOVER I. • HEALTH DEPARTMENT SvSftM. System ane • stem Location ROBIN & RAn ZUBICARAY 57 BOXFORD STREET tit Pumped: gallons. uan 1000 Date of Pumping: 5/0.7/()8 Q Cesspool. No Yes ❑ S ePt ic ? l: No ❑ Yes 0 • • RAGGS SEPTIC SERVICE, INC. system Pumped by d.b.a. -E. A• COMEAU SEPTIC License R; FITGHBORG Contents transferred to: • Date 5/07/08 Inspector RAGGS SEPTIC SERVICE, INC r Commonwealth of Massachusetts - -- -- City/Town of NORTH ANDOVER, MASSACHUSETTS System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information KEGEIVED Important: When filling out 1. System Location: NOV 2 p 2006 forms on the computer,use 57 BOXFORD STREET only the tab key Address HEALTH DEPART�E0T .ANDOVER ER MA to move your N cursor-do not 01841; use the return City/Town State Zip Code key. 2. System Owner: RAUL ZUBICARAY Name Address(if different from location) City/Town State Zip Code Telephone Number i B. Pumping Record 1. Date of Pumping Date 10/13/06 2. Quantity Pumped: 1000 Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ® Yes ❑ No If yes, was it cleaned? 2 Yes ❑ No 5. Condition of System: MOD 6. System Pumped By: RAGGS INC. Name Vehicle License Number Company 7. LlClcilti,2111 1111111 ere contents were sposed.:._ TER SOLUTIONS _ 11 /15/06 Signature of Hauler Date http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect t5for n4.doc•06/03 System Pumping Record•Page 1 of 1 i NEW ENGLAND ENGINEERING SERVICE INC j R RE r September 13, 2005 SEP 15 200.5 TOWN o` :VER HEAL*: vT North Andover Board of Health 400 Osgood Street North Andover,MA 01845 RE: REVISED TITLE V REPORT: RE: 57 Boxford Street North Andover, MA Dear Sir or Madam: Enclosed is a copy of the revised Title V report for the above referenced property. The system PASSED our inspection. If there are any questions please call me at my office, 686-1768. Sincerely, Benjamin C. Osgood, r. Certified Title 5 Inspector 60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(9 78)685-1099 NEW ENGLAND ENGINEERING SERVICES ,' INC [�HEA:L'rh `1VFD July 27, 2005 North Andover Board of Health w�R 400 Osgood Street � -jN: ��� North Andover, MA 01845 RE: TITLE V REPORT: RE: 57 Boxford Street,North Andover, MA Dear Sir or Madam: Enclosed is a copy of the Title V report for the above referenced property. The system PASSED our inspection. If there are any questions please call me at my office, 686-1768. Sincerely, Benjamin C. Osgood, J Certified Title 5 Inspector 60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 I Vx NEW ENGLAND ENGINEERING SERVICES INC a .LL31 2z'D November 4, 2005 NOV - 7 2005 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Ms. Susan Sawyer North Andover Board of Health 400 Osgood Street North Andover, MA 01845 RE: TITLE V REPORT: RE: 725 Boxford Street North Andover, MA Dear Ms. Sawyer: Enclosed is a Revised Title 5 Report for the above referenced property. The system Passes the Title 5 inspection. If there are any questions please call me at my office, 686-1768. Sincerely, Benja C. Osgood, J . Certified Title 5 Inspector 60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of LV Environmental Protection i W1111am F. Weld , Gw+,na Trudy Coxe 3. EOEA David 9. Struhs i.OTTRypner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR PART A CERTIFICATION Property Address: -5'7 kaon A=O R Address of Owner: Date of Inspection: /O - y—574 (If different) Name of Inspectocu"0–5 A=—P// 0/798146-4LLO Company Name, Address and Telephone Number: CERTIFICATION STATEMENT I cert(N that I have personally inspected the sewage di sposal system at this address and that the information reported below is true, accurate ar.1 complete as of the time of inspection. The inspection was performed based on my training and experience in the proper (unction and maintenance of on-site sewage disposal systems. The system: _ Passes ditionally Passes Needs Further Evaluatian By the Local Approving Authority Fads Inspector's Signature�o�/,i/. 9 /� ,s- _ Oeste: The 5%,siern Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this nsoecT or : the ss stem is a shared s,,-stern or has a design flow of 10.000 gpd or greater, the (nspecu• and the system owner shall submit the rd,^rn to :he appropriate regional office of the Department of Environmental Protection. T he or:E:nal should be sent to :ne ).stem owner anu topica sent to the buyer, .f applILWo and the al,,roe Ing au;h0raj. INSPECTION SUMMARY: Check A. 8, C, or 0 A) SYSTEM PASSES: have not found any infounation which indicates that the system viola(es.any of the failure criteria as defined in 310 CMR 15.303. An allure criteria not evaluated indicated Y art aced below. 8 SYSTEM CONDITIONALLY P 1 ASSES: _ One or more system components need to be replaced or repaired. The system, upon completion of the replamment or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or NO). Describe basis of determination in all instances. If'not determined', explain why not) The septic tank is meta! cracked structural) unsound, infiltration r _ p y sou , hsows substantial Inf ttrat ono exfiltration, or tank (allure is imminent. The system will pass Inspection If the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8:15/9s) 1 One Winter Street . e Boston, Massachusetts 02104 a FAX(417)334.1049 is Telephone(417)292.3.300 *�)vauR a itecld�(Apr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) .roperty Address:S 7 Box)C`9 D S f' )wner: _D0yV•41'D P l kii I'll ate of Inspection: /O 1'96 S�S T E.M CONOITIONAIIY PASSES (continued) _ Sewage backup or-breakout or high static en distribution observed x. The yin the stembution box is due to will pass inspection broken(w�th approval of he p oe(si or due to a broken, settled or uneve Boaro of Healtn;: IS CR/�CKf=- broken pipe(s) are replaced L)- B0_X obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass nspece:on if twith aoproval of the Board of Health): broken pipes) are replaced obstruction is removed U F RTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: _ t the ton b the Board of Health in order .o determine if the system is fading to protea Conditions exist w"'ch require furher evaluation Y ;,bl c health, safety and the environment. ARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER t) SYSTEM WILL PASS UNLESS 80 WHICH WILL. PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or prjk•� is within 50 feet of a surface water _ Cesspool or pri%% s ��ichtn 50 feet of bordenng vegetated wetland o. ! salt marsh. Hlll F. UNLESS THE BOARD OF HEALTH (AND PU THE SYSTEM FUBLtC WATER ?UPPIIER, IF APERMINES THAT THE SYSTEM I$ fU`CTIOHING IN A MANNER THAT PROTECT THE PUBLIC FEALTH AND SAFETY AND THE E�vIRONmENT• . The ciPm nd• a scout tank ana sari wsorption system and is within J tet, to • surface %water supply The wee- ha• a septic tank and soil absorption system and is within Zone I of a public water supplywell- feet supply well The sister++ has a septic tank and soil absorption systes anted is is it tF x')hin 100 feet but 50 feetror more from a private water The SY>1e^% h. a sep:�c tan{. and soil absorption System well water analysis for coliform bacteria and vo_t to organic compounds fmd ''equal totor�less well than 5 a to I .ell, unless -.7.-Sen and nitro nitrogen supply free from pollution from that facility and the presence of ammonia r :�_g ppm• OI SYSTEM FAILS: - The basis rs I have determined that the system violates one or moof the following failure Criteria as defined in 310 CMR 15.303. for this determination is identified below. The Board of Health should be cor:.:ced to determine what will be necessary to correct the failure. _ Backup of sewage into facility or system component due to an overt,,�c:ed or dogg ed SAS or Cesspool- Backup ndin of effluent to the surface of the ground'or sur-ace due to an overloaded or clogged SAS or _ Discharge or po g cesspool. 2 irevised r;:s/95 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: S 7 B6X,"`62 D S>t Owner: Do/V#ZD R! tc'i. !E Date of Inspection: 01 SYSTEM FAILS (continued): Stant liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. !;quid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day now. 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Anv porton of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any porton of a cesspool or privy is within SO 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. Ei LARGE SYSTEM FAILS: The follo%%.ng criteria apply to large systems in addition to the criteria above- Tie desltr% f,ow of system is 10.000 gpd or greater (large System) and the system is a significant threat to public health and safety and :he en..ronment because one or more of the following conditions exist: the s%,ster+ .s within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply ;he system is located in a netrogen sensitive area (Interim Wellhead Protection Area ,IWPA) or a mapped Zone II of a public hater supply well) Tile owner or operator of any such syuem shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 acrd 6.00. Please consult the local regional office of the Department for further information. revised $/!S/9S) 3 i SUBSURFACE SEWACE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: .S 7 80A /-oK D 5 t Owner: DolVaLD Rf ) tLC(OF Da-e of Inspection: /0 -y - yk J the following have been done: umping information was requested of the owner, occupant, and Board of Health. � "One of the system components have been pumped ' r at least two weeks and the system has been receiving normal flow rates (/during that period. large volumes of water have not been introduced into the system recently or as part of this inspection. IVA'As built plans have been ob;ained and examined. Note if they are not available with N/A. 6_- - facility or dwelling was inspected for signs of sewage back-up. 1 ,zfhe system does not receive non-sanitary or industrial waste flow ne site was irspected for signs of breakuui. All system components, excluding the Soil Absorption System, have been located on the s1:e. 4-�. he 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. ,Z<he size and location of the Soil Absorption System on the site has been determined based on existing information or approximated b% non-intrus-%a methods he iac.Lt, o,.nc- .;-- oc::.-Jr':s, 1f d fe'"- ff.-'r 0%%ne•' wve provided wish information on the proper maintenance of Sub. Surface Disoosai Svstem 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: �'7 I30A ILOR b 57,-- 0-,e,-. DU/vRL d R Date of Inspection: FLOW CONDITIONS RESIOE"sTIAL: Des:gn flow- 330 gal!o..s Number of bedrooms Number of current res den:_. Garoage gander !yes or no _6LO laundr; connected to system (ves or no; NO Seasoral use (yes or noi._ Water meter readings. f aN::Jable: �RO PL/?f Y / ON. ✓� L Last date of occupants />l f pRESGiV l` COMMERCIAUINDUSTRIA'.. Type of estaolishment: Design flow itailons. '3y Crease trap present. (yes or .,ot_ Industrial Waste Holding T.•k present. ty_-. ',r not_ Non-sanuary waste discharg_d to the T,tl�e ; system: (yes or no)_ Water mver readings, if avz :aUle: Last date,of occupancy. OTHER: (Describe! Last date of occupancy GENERAL INFORMATION PUMPING RECORDS and --ince of -nior-r3: an- System pumped as pan of (yes or no)-.VC=S If yes, volume p..T c<i 1Go0 gallons Reason for pumper; f0 %/VSPC—e t— COND/t0iy GF SEPI—/C f41vk TYPE OF SYSTEM Septic tank/distnbt.:.on_hox/soil ac:.rption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes. .itzch previous inspection records, if any) Other (explain) APPROXIMATE AGE of all :mponents, irstalled (if known) and source of information: uN k N 0 w A/ Sewage odors detected whe- 3rrivin6 at the s,,„ (yes or no) UO (zevi aC 1/:S/95c S L SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: S 7 5 oX /.p le p S t Owner: Date of Inspection: 0- 9 --q.G SEPTIC TANK:,� l :aca(c on sGe plan) Ceoth below grade: 12 -•.ater al of construct on• 4-etrcre!e _rne.:il _FRP —other(explain) 0­er5-ons: ,—�/ b S;.,dge depth: 4 '1 O+stance from top of sludge to bosom of ol:de! tee or baffle: Sum thickness: 2-11 O,stance from top of scum to too of outlet -_e or-baffle. 0 stance from bottom of scum to bosom of outlet tee c: baffle: L:�rnment5 •,ecommer,datlon ;or pumping. condition :: nle! and t:-:Ie! tees or baffles, depth of liquid level in relation to outlet invert, structural 'n:egrlry. evidence or tea�age. etc.! C' WAWA- i C,--,o Q L�u/I! i GREASE TRAP:_ locate on site plant Ziepth beto%v grade. `taterlal of construction. _concrete _m•. ,:I _FRP _ other(explain) D,s:ance from top or sc::•,n to too of outlet •:e or baffle: !.0^' yOt1c)— r 'Urlw r@-C• hahle. liquid IIS recommendation tar pumping, cond,t-on ;.• Inlet and c'raet tea or baffles, depth of level to relation to outlet Invert, structural evidence or leakage etc.l (revised I/!Si9Si 6 ii I c SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: .5 7 BOX jtlOp, $ 7— Owner: ofolvgLD R/ fCGt/E Date of Inspection: TIGHT OR HOLDING TANK:_ iou:e on s,te pian) v?om oelow grade `a:V':al of construct on _concrete _metal _FRP —other(explain) D,mens ons: _30ac:N ---__3allons :es.gn flow: aailons/day A�la!r level. Comments cone-oon of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION SOX:) doc_rr on site plan► ^ep(r of liquid level ano•,e outlet invert: Comments e' cf!-3(d! ca-vever evidence of leakage into or out of heti. etc.) I PUMP CHAMBER:_ fioca(e on site plan) Pumps in working order-(yes or not­__, Comments: (note condition of pump chamber, condidan at pumps and appurtenances, etc.) (revised 11/1S/SS: 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) P•operty Addres!:S"7 6cl-X joR,b 5ic. C'wner: L>01V' Z,0 Rr te/t !E Date of Inspecticn: 511-1•L ABSORPTIC,. SYSTEM (SAS):./--- '�;cate on site PIZ f possible; excavation not required, but may be approximated by non-intrusive methods) 1` .not determined •o oe present, explain: :ie leaching numter:_ leaching - nbers, number__ ;eaching ones. number: f f l?aching :nes, numoer,length. 3 30 ;eacning number, dimensions. -:iverrlow •ooi, number• -:nments 'no(e c: in of soil, signs of hydraulic failum level of ponding„ condition of vegetation,e:c.) "ESSPOOLS: on s•te Alar- ',;,.^,ber and config . _ __:'1•(ou o+ llould :_ -riven, h of solids lave- of -um.. la%e- _ c; cess:..! a'ar:ak 0' constr� - ca::on o: grounc - inflow ice,:: •nust be pumped as part of inspection) renis mote cc • . if soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) q I VY: _ :tate on site plani aterials of construe-;;i• Dimensions: -pth of solids: :mments: (note col-':.' :,l a: soil, signs of hydraulic failure, letrei of ponding, condition of vegetation, etc.) _ :sed $/:5/9s1 e i r { SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) rroperty Address: ti j /3o,(Fp/e p S t Owner: 'Dplry Lp R� tCl1l� Date of Inspection: �L)- SKETCH OF SEWAGE DISPOSAL SYSTEM: nc!ude ties to at feast two permanent references landmarks or benchmarks ovate all wells w th n 100' E.A/,E L L fd P /Vo f V i 5 I SL C DEiF- kmt1vED 8X oL,,1/VER l Jr 0 ,4— DEPTH TO GROUNDWATER Depth to groundwater feet method of determination or approximation: revi.ed 1/!S/SS; 9 1 Address o p. ST Title of File Page of Date File Open: Date file closed: Doc Document/Action Title Date of Refer to other Purpose of Documeant/Action and notes. action Document/ documient/ Num. Action De artment Board of Appeals — Board of Health — Planning Board — Conservation Commission — Building Department TOWN OF NORTH ANDOVIEP,, U/1 l'F. SYSTEM PUMPINQ RECO►ZL JAN 0 6 20G5 �pL . . SYSTEM 0 ^ WNER& ADDRESS:: SYSTEM LOCATION - `s 0 6 d u DATE OF PUMPiNQ; Q JANTITY PUMPED: k'tSSPOOL: NO__.........YES.. SOPUC 1'ank: NU ons NA 1'UKrr ON SERVICE: KUU'C1NE.. �MERUlrNC'Y UdSERVA'CIUNS: , GOOD CONDITION FULL 'M(-,OVER �y HEAVY ORWB BAFFLES IN PLACE. ROOT3 _i LEA,.0 PI LD RUNBACK T BXCESSiVE SOLIDS .._.. FLOODED SOLrD CARRYOYER,,,�,.•_.OTHER EXPLAIN symom Pumpcd by _F CPO VUMMENTS. t.'UN PEN'I'S fKANSF6RR5D 11) TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD I � 1 FEM OWNER & ADDRESS SYSTEM LOCATION (example; left front of house) U \'I C OF PUMPINC: QUANTITY PUMPCD_ ,� LL�� � � C. 1:SSI'OOL: NO YES SEPTIC TANK: NO YES w MATURE OF SERVICE: ROUTINE _L�EMERCENCY GOOD CONDITION- L✓ FULL TO COVEk HEAVY CREAST BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK . CXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER 0�HFR (EXPLAIN) S .STLM PUM PCD BY: L�l U N I I:^ rs TIzANSFCIZIiLD TO: 107 Forest St. FORM 4-SYSTEM PUMPING RECORD . Middleton,MA 01948 (508)7742772 Commonwealth of Massachusetts Massachusetts .�w, �`Z s„,i • Al vg Record ;. ystem. ocatton ' r 6 � Date of Pumping: Quantity Pumped: Cesspool: No YesC .'•- :' .S tic Tank: No eP Ye�/�] `r SN,stem Pumped by: License #: ` Contents transferred to: Date61 Inspector ctor 19 THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY 0 Commonwealth of MassachusettsRECEI ED Massachusetts TOWN OF NORTH ANDOVER HEALTH DEPARTMENT &Aem Pum Z Record System %%mer bystem Location Date of Pumping: ��3�/D Quantity Pumped: p d gallons Cesspool: No Yes . ❑ Septic Tank: No ❑ Yes RAGGS SEPTIC SERVICE, INC. System Pumped by: d.b.a. E. A. COMEAU SEPTIC License Contents transferred to: WATER SOLUTIONS GROUP, TAUNTON Date Inspector RAGGS SEPTIC SERVICE, INC .