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HomeMy WebLinkAboutMiscellaneous - 57 CHRISTIAN WAY 4/30/2018 57 CHRISTIAN WAY 210/104.D-0135-0000.0 Commonweal�h of Massachusetts = City/Town of forth Andover System Pumping Record Form 4 w_ DEP has provided this form for use by local Boards of Health. Other forms may be used, but the same as that provided here. BeforePumping Record form,ng this check be information must be substantially the ubmitted o local Board of Health to determine the form they use.The System p g the local Board of Health or other approving authority within 14 days from the pumpsngdate in , accordance with 310 CMR 15.351. A. facility informati®n 41 lmpotan�When ``` NI 511ing out forms 1. System Location: on the computer, use only the tab -- key to move your Address Ma 01886 cursor-do not North Andover Zip Code use the return State C--dy/i-own key. 2. System Owner: zer Name rman Address(if different from location) State Zip Code City i own Telephone Number B. Pumping Record 15a� 0 2. Quantity Pumped: Gallons 1. Date of Pumping Oate E] Ti9 ht Tank El Grease Trap 3. Type of system: ❑ Cesspool(s) ® Septic Tank ❑ Other (describe): 4. Effluent Tee Filter present. ❑ Yes ❑ No If.yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By }ZC L Vehicle License Number Name Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Hauler Date Signature of Receiving Facility Date System Pumping Record-Pag t5form4.doc-03/06 a �' f Commonwealth�of Massachusetts C.1. W QW n of NORTH ANDOVER, MASSACHUSETTS _ Sy..s e. m Pump ng Record Form 4 DEP has provided this form for use by local Boards of Health. The SystOem Pumping o Record mu: be submitted to the local Board of Health or other approving authority. j A. Facility Information - ImporWnt: When filling out 1. System Location: forms on the computer, usea, 7 only the tab key Address to move your �� /�V�rL _ cursor•do not � use the return Cityfrown key. State — — — -- Zip Code- 2. System Owner: -7— �s .___- --- ._..---- -----_ Name Address(if different from location) - -•---• —•--------- ----- - City own State -- --- Zip Code --- - Telephone B. Pumping Record 1. Date of Pumping Da -- 2. Quantity Pumped: ----- -.. allons 3. Type of system: ❑ Cesspool(s) tic Tank ❑ Tight Tank ❑ other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? Yes r ❑ ❑ NO 5. Condition of System: 6. Sy em Pumped By: ams ------ ------ - Vehicle License Number Company / 7. Location where contents were disposed: $I —$ atura�zu - _..__..._.._..- — - --------- ---- ---- - -' Date http://www.masg�gov/dep/water/ provals/t5forms.htm#inspect 15form4.doc-06/03 System Pumping Record•Page i of AYIlD�VE I SZACH-USETT; ng'Rec'o'rd "<i `( /1;.I`L!/.fC��1�"�'��I.II�r,�il� i•1,,�,' 1,'. SEP 0 8 2008 -DEP hao provlded Sn!# tc)lr!) t,r n r-aclHi y inform, �„ s(Qm !OCaClon /� DIY •,'� "l r i i l CII/I V M (�+, , ;v;,';11'I•r 2.�;Syslem Own ar . (IIdVf�rrnl torn buucr C> ,:Pumping Record - - rn I it, 9X5 Af 3. Tyra GI ox)(Om: �©5S, 0'(91 ..��- r8�, '� •,..�� , EMuan( Tea FII(a( p(owr? ;`•�r ;r1rr •` ,ill i, �—� i ,.gig :9^d:� � tea' . ..lr�•�„�. � .,dig' F Si l�m P�'mpec 8y ^Y,i",'r'� �1° / Y!f' 1�;1 �„ ''•s��J'.1� 'J 1 YOhIG'VJUit -- _ ��•���/ �'/%`�r.,i�I to 11,(Iyi.!��f`dl.!�111`��'Ij I'`11i '�,�1,,,. 7110 • Cn wne(e GOr1lenl3 wale c:s,:sac • • ; , '",1,, :�• ;'�;,'.y1'll:r';i'�• �' T`' �G(Lf fes' /�/'��j , �:.•"n'o'n '^813 d0'I'/Qe;.�yBlef/8r�(QYBf S/(�IOm19 '" � ^�;p^' � _ _ Commonwealth of Massachusetts REEERE� City/Town of No Andover System Pumping Record MT "I tt ? ^M Form 4 Toyy� OF NOh HLIfr p. . DEP has provided this form for use by local Boards of Health. Other forms may a us ;•'ut the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, use only the tab 6-r7 a n4q i n U" key to move your Address cursor-do not No andover Ma use the return - key. Uny/Town State Zip :,ode 1 2. System Owner: �! —ll Z,� ro eW S Name return Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record ?=J�'1. Date of Pumping Date uantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: (? C7�0 6. System Pumped By: �! ,.•---' Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signatur• of Hauler Date ignat f ceivi g-• ility '> �" Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts W City/Town of No ANdover System Pumping Record ` . 2,0'3 Form 4 : M DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, use only the tab 57 Christain Way key to move your Address cursor-do not NO ANdover _ MA key the return City/Town State Zip Code Y 2. System Owner: Zdrojewski Name re¢an Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record �1 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) [Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. stem Pumped By: Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signatu o H Date Signature f Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 1 w OCT 0 7 2005 SOWN U} NCJK1 i( 'lh,) TOI�LgQ� n� �A�JDQVER u., i' ��►� JY3'T'81�•1 P zrr,tir,r e UMPINU RP_C.OKI... )YsrBM OWNER �,nnV17 s--y —_�__�__.._.._..__... _ .......... ._. r•EM r IV6 QOANTITY PUM}'Ee f �'t�sPOUL; NO.. Yt3 14n rVKt CUN 3eRY1Cd: KQvTfH coop c*1goI MIN �1YY p ROOT'3 .�. �Ei,�cFc�t�,p K UN r3.,�•r, 8+XQUIM8 SOLID& -_... PLoom) "OL CD CA IUB YO YAR O TNB R E X P LA IN )7144 f`�r�reJ by i e" 7 �'uMM�NTs. NEW ENGLAND ENGINEERING SERVICES INC BC wAY 2003 t f May 8,2003 North Andover Board of Health Town Hall Annex 27 Charles Street North Andover,MA 01845 RE: TITLE V REPORT: 57 Christian Way,North Andover, MA Dear Sirs: 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, Jr. 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 ENVIRONMENTAL PROTECTION s TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:_!j7 CHR%S i% VA&/ WA N'Q j2Tt-f o�E►Z �nr9 Owner'sName: `% 142fi) vii iAT 1�.1�_ Owner's Address: 5--7 c H 2 t S Tl q N t,v }y U o A)n no 6-rL ^A A Date of Inspection: 6) -71/J 3 Name of Inspector:(please print) Benjamin C. Osgood, Jr. Company Name:New England Engineering Services Inc. Mailing Address:60 Beechwood Drive, North Andover, MA 01 845 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 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: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: C Date: 5 7/0 t, 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. ,6, Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:_ 57(: MSTIAN WAY NORTH ANDOVER,MA Owner: JARED WATKINS Date of Inspection:_ 5/7/03 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. .Syste Passes: 7I 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 H lth;will pass. Answer yes,no or t determined(Y,N,ND)in the for the following statem "not determined"please explain. The septic tank is in . and over 20 years old*or the septic whether metal or not)is structurally unsound,exhibits substantial' on or exfiltration or tank fai a is imminent.System will pass inspection if the existing tank is replaced with a com g septic tank as appr ed by the Board of Health. *A metal septic tank will pass inspecti if it is structura/11y'sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 y ld is available. ND explain: Observation of sewage ba or break out or hi is water level in the distribution box due to broken or obstructed pipe(s)or due to a en,settled or uneven distn tion box.System will pass inspection if(with approval of Board of Hea broken pipe(s)are replaced obstruction is removed distribution box is leveled or repla ND plain: The system required pumping more than 4 times a year due to broken or obstruct ipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_ 57 CkWSTIAN WAY — NORTH ANDOVER,MA Owner: JARED WATKINS Date of Inspection: 5/7/03 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 15.303(l)(b)that the cyst is not functioning in a manner which will protect public health,sa . and the environment: or privy is within 50 feet of a surface water _ Cesspool vy is within 50 feet of a bordering vegetated w d or a salt marsh 2. System will fail unless the Board o ealth(an He Water Supplier,if any)determines that the system is functioning in a manner that pr is a public health,safety and environment: _ The system has a septic tank and so' a tion system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a ce wat supply. _ The system has a septic and SAS and the S is within a Zone 1 of a public water supply. _ The system has a c tank and SAS and the SAS is wi . 50 feet of a private water supply well. The system h a septic tank and SAS and the SAS is less than 0 feet but 50 feet or more from a private water s ly well".Method used to determine distance "Ibis em passes if the well water analysis,performed at a DEP certified tory,for coliform bact . and volatile organic compounds indicates that the well is free from poll ' from that facility and th esence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, rovided that no other ilure 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:_ 57 CHRISTIAN WAY NORTH ANDOVER,MA Owner: JARED WATKINS Date of Inspection: 5/7/03 D. System Failure Criteria applicable to all systems: You must indicate"yes"or`Sno"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or ,clogged SAS or cesspool _✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z 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. 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 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.] (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 gpd to 15,000 You must either`yes"or"no?'to each of the following: (The following triter ly to large systems in addition to the criteria a yes no the system is within 400 feet of a fa uilcing water supply _ the system is within 200 f i a tributary surface drinking water supply the system is I ed in a nitrogen sensitive area(Int ellhead Protection Area—IWPA)or a mapped Zone II public water supply well If y ve answered"yes"to any question in Section E the system is consider ignificant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any lar system considered a significant threat under Section E or failed under Section D shall upgrade the system in a ce with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:_ 57 CHRISTIAN IAN WAY NORTH ANDOVER,MA Owner: JARED WATKINS Date of Inspection:_ 5/7/03 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No _ Pumping information was provided by the owner,occupant,or Board of Health / �/ Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) f_ Was the facility or dwelling inspected for signs of sewage back up? ✓ _ Was the site inspected for signs of break out? �/ Were all system components,excluding the SAS,located on site? V — Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of tthhe baffies or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The sine 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. _ ✓betermined 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)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:_ 57 CHMSTIAN WAY NORTH ANDOVER,MA Owner: JARED WATKINS Date of Inspection: 5/7/03 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): — Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents:-t— Does residence have a garbage grinder(yes or no): 5 Is laundry on a separate sewage system(yes or no):Al2>[if yes separate inspection required] Laundry system inspected(yes or no):= Seasonal use:(yes or no):,6 O Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):-ALc7 Last date of occupancy: civ rr-e^ COMMERCIAIAMUSTRIAL 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: R� L.- Z©O� v n t & a, Was system pumped as part o'the inspection(yes or no):.htD If yes,volume pumped: Qallons—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 _Attach a copy of the DEP approval —Other(describe): Approximate age of all components,date installed(if known)and source of information: /'5- !:j Eta s o 4 D Were sewage odors detected when arriving at the site(yes or no): /�j� Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_ 57 CHRISTIAN WAY NORTH ANDOVER,MA Owner: JARED WATKINS Date of Inspection:• 5/7/03 BUILDING SEWER(locate on site plan) Depth below grade: l$, Materials of construction: iron 40 PVC other(explain): Distance from private water supply well or suction line: /V k Comments(on condition of joints,venting,evidence of leakage,etc.): t� QL Dd KS Fro-Q I /v bA5Cyt AJ I SEPTIC TANK:_(locate on site plan) Depth below grade: t z i Material of construction: ,,concrete metal_fiberglass youlyethylene _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: 15-00 G-A-L L,o Aj 5 Sludge depth: <1° Distance from top of sludge to bottom of outlet tee or baffle: 3y u Scum thickness; Gam"_ Distance from top of scum to top of outlet tee or baffle: 3 w Distance from bottom of scum to bottom of outlet tee or baffle:`` How were dimensions determined: i Ertsu 2E s i cK. Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): -rA.-M, IN &03D C.>/j 0 %T70/v LONG R-e 7e wee-7- IN (,Tull() �o�•n i1oN� ovTLc 11 Pll�r" arcs GREASIETRAP N�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.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_ 57 CHRISTIAN WAY — NORTH ANDOVER,MA Owner: JARED WATKINS Date of Inspection:_ 5/7/03 TIGHT or HOLDING TANK:.Lbtank 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: (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 evidence of solids carryover,any evidence of leakage into or out of box,etc.): IAJ /� NCW ('ON J7 �10�_ �LOw Ie✓ELGP-S ILIO^JS/�D PUMP CHAMBER;]/4 (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.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_ 57 CHMS'1'IAN WAY NORTH ANDOVER,MA Owner: JARED WATKINS Date of Inspection• 5/7/03 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,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.): aizEa r'?�F- ?'T's L K5 "vOZIM 044— CESSPOOLS:,��(cesspool must be pumped as part of inspectionxlocate 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.): PRIVYyL(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 t OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:— 57 CHRISTIAN WAY NORTH ANDOVER,MA Owner: JARED WATKINS Date of Inspection: 517103 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. J� q �3 3 � i b-o c 0-j-)o^�5 CT�P� Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_ 57 CtMSTIAN WAY Owner: NORTH ANDOVER,MA JARED WATKINS Date of Inspection: 5/7/03 SITE EXAM Slope Surface water Check cellar p4j 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 excavators,installers-(attach documentation) ✓Accessed USGS database-explain: You must describe how you established the high ground water elevation: V SSr- s MR PJ I c i4 fY, L'_Wir(Z > ,0` gei-,i, cl N t7 15 +T-� !ZuILT ova 4 s w Pc= 1q1110 rH {NLcS o Sys�c.-►. b�• l4- , „ ����� 1 � r 1 �1 1 T 10 7 p lO r ICS (h4i 4 Ln O FVATIONS TIO IG 5-11 IC,OiS7 D-I-OX OUT IEr It,0.05 PI r 7 15� 53 ► �% i' -� r �� � T r.t C,:,-.-I ,I , -r;ArrHF sFF'c. :s s�Ow�:. •,Hi ;r LJ j A 1 • COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTNtENT OF ENVIRONMENTAL PROTECTION s` TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: C!N i Owner's Name: ,, Owner's Address: Date of Inspection: -f D Name of Inspector: (please print) zZ Lj L ✓�rUCeWZ6 Company Name: iG Mailing Address: mfr �• Telephone Number: 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: Passes Conditionally Passes Nee0s F er Ev luation by the Local Approving Authority / Fai , Inspector's Signature: V i ADate: - d The system inspector shallmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of co pleting 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 Y/eol I Co r � ****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. Title 5 Inspection Form 6/15/2000 page 1 d _ - 11 Page 2 of 1I- OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address ! T v l Cc 1 Owner: e Date of Inspection: — '4 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Syste asses: 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: 2 o Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: L" / —04/ Owner:j I Date of Inspection: p 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: 3 ' Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: t1 ,U owe 2. Owner: 1 Gc1 to (100-R Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes N Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the.surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compoaeds 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.] (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 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. 4 e =' Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: / !j llv�?- .V Owner: f irazu":)irf r' Date of Inspection: Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Ye No _ Pumping information was provided by the owner,occupant,or Board of Health r Were any of the system components pumped out in the previous two weeks? �! Has the system received normal flows in the previous two week period? —/Have large volumes of water been introduced to the system recently or as part of this inspection? 1z Were as built plans of the system obtained and examined?(If they were not available note as N/A) _ Was the facility or dwelling inspected for signs of sewage back up ? _ Was the site inspected for signs of break out? —V Were all system components,excluding the SAS,located on site? _ Were the septic tank manholes uncovered.opened,and the interior of the tank inspected for the condition o the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? AZ— 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 / V 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 15.3 02(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address,, J Owner:Or at C Date of Inspection:Ty/�r?-01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CNQt 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents:�L Does residence have a garbage grinder(yes or no):Ves 12cco/7 C yu al T-c3 IZc/7..Ol.l1a, Is laundry on a separate sewage system(yes or no)-Wf yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no):" Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):9�4' Last date of occupancy: COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,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: A)6 ,A&L. Q,e j((' Was system pumped as part of the inspection(yes of no): If yes, volume pumped: Clpgallons--How was quantity pumped determined? /fid Reason for pumping: ��S o P G T TG 4+,L. TYP'bF 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 _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,d��stal d(if known)and source of information: 14 Were sewage odors detected when arriving at the site(yes or no):1-0- 6 C F $ Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) > Property Address: ? Cft rI ` v Owner:n iaWlz� i G. --6 Date of Inspection: '-O 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:- , f' 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 evidence of solids carryover,any evidence of leakage into or out of b ,etc.): , ra 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,condjtion of pumps and appurtenances,etc.): 8 I Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: �'�, i Date of Inspection: '- -D SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: I Type t �Oleaching pits,number: 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)• _// n We) ✓lx UL �G L �t!aI A j JLl3 joa p 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.): 9 e Page 10 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property AddressSZ !I) &,Z ,� Owner: ► �' Date of Inspection: 'D r 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. 4 ik T I� 0 r !1 i 2- 10 c Page l l of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SXSTEM INFORMATION(continued) Property Address /•/ �V&l '^7 ,v G Gls�l..r Owner: / r1 N W Date of Inspection:41— G 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 excavators,installers-(attach documentation) Accessed USGS database-explain: Ymust desc ibe how you established the hi h g `- �round water elevation: , ioLe ND ev l- .41 /VO Sra1"1 11 TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: � � D� SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) DATE OF PUMPING: '- QUANTITY PUMPED lJa� GALLONS CESSPOOL: NO � YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) SYSTEM PUMPED BY: v G G1�110"�� i i i COMMENTS: I b CONTENTS TRANSFERRED TO: ' .`:ei;{sf{•i:<!�;il,y'�1.•4y';." :'Al6•YI{!?,I:k�'-lt:.•:A::,t•a:.•• .. ,i`,.t�\yi.slS p, 'Kt'' �, +'.e•• .,nM•: ll. •n: '�•f•1• �Yi':;'f: .v�.�r'••;.i. .ds':•N.'.t'v,;ti9" r.l•' '•�'i:. �:��it`"ri\'� 1.r. .�i,'.' '•J +t.l<'• Y:•.•. '1 •1.. �� rr . ' � 1. •.f� .;l.l:�..,�'ri^�il�' ��I:i.•'.• TOWNPF`NO$TH ANDOVER SYSTEM PC-W (3 RECORD 1 •DATE S .. .qp SYSTEM OWNER&ADDRESS ' SYSTEM LOCATION Ddtr� r z 57 G�iris,�eiv G� � • DATE OF PUMPINQ- f UANTITY•PUMPED 22 CESSPOOL NO_�Y'ES;_;__ .. \ / SEPTIC TANK NO YES v NATURE OF SERVICB;;•RQVTNE ' BMERGENCY OBSERVATIONS, GOOD CONDITION°;`+::r:: : FULL'TO COVER _ . . •:.4AVY GREASE '';_;� : BAFFLES IN LACE ROOTS LEACHFIBLD RUNBACK EXCESSIVE SOLIDS_•FLOODED SOLID CARRYOVER OTHER EXPLAIN SYSTEM PU.mfPhD BY yr COMMENTS: TO•` CONTENTS TRANSFERRED TOWN OFNORTHANDOVER SYSTEM PUMPING RECORD 2 203 D'I'EM OWNER & ADDRESS „ SYSTEM LOCATION (example: left from of house) r U \1,C OF PUMPINC: QUANTITY PUMPCDLLc»� 17-7 ;. PO0L: NO YES SEPTIC TANK: NO YESAY--_ a � ATURE OF SERVICE: ROUTINE EMERGENCY (1f1.>FRVATIONS: GOOD CONDITION, FULL TO COVCR HEAVY CREASE V BAFFLES 1N PLAC1'. 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The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out 1. System Location- forms ocation Chr'16ta( n forms on the computer, use only the tab key Address to move your No.Andover Ma 01845 cursor-do not City/Town State Zip Code use the return key. 2. System Owner: -Z (jf ' Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record f\� 1. Date of Pumping Date I ( � 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) [A Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: (A 6. Svstem Pumped By: V)[A-riV, Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment ant, 20 So. Mill Bradford, Ma 01835 Signature of Ha AU Date Signature of Receiving Facility Date I11Y1 ` t5form4.doc•03/06 System Pumping Record•Page 1 of 1