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Home My WebLink AboutMiscellaneous - 571 FOREST STREET 4/30/2018 (2) 571 FOREST STREET i` i J I, Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 571 Forest Street Property Address Paul Swartz Owner Owner's Name information is required for North Andover MA 01845 8/24/2015 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: When filling out A. General Information forms on the computer,use 1. Inspector: RECEIVED only the tab key to move your Neil J. Bateson cursor-do not Name of Inspector L 1 use the return key. Bateson Enterprises Inc. �pN -R Q„� Company Name TOWN r �'' 111 Argilla Road HEALTH DEPARTMENT Company Address Andover MA 01810 Citylrown State Zip Code 978475-4786 S115 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the 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 ❑ Fails ❑ Nees urther Evaluation by the Local Approving Authority 8/24/2015 Inspe r ig ture Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. i t5ins•3r13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 I i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 571 Forest Street ,p Property Address Paul Swartz Owner Owner's Name information is required for North Andover MA 01845 8/24/2015 every page. cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: After permit from B.O.H., install new inlet cover, new outlet tee with gas baffle, new outlet pipe to d- box, new d-box, & replaced crushed pipe, inspection from B.O.N., septic system now passes Title 5 Inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 ears old*or the septic tank(whether p y p ( ether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 �.S�,�TtiED'�ag6 • • PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF. COMPLIANCE As of: 8/25/15 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Repair of Outlet Tee and D-Box, crushed pipes By: Todd Bateson At: 571 Forest Street Map 105.D Lot 0080 North ndover, MA 01845 The Idsu"ance of this certcate/sl ail not b construed as a guarantee that the system will function satisfactorily. AS Ichele Grant Public Health Agent 1600 Osgood Street,North Andover,Massa(husetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com • North Andover Health Department (ommunity and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 571 Forest St MAP: LOT: j INSTALLER: Todd Bateson V INSPECTIONS DATE OF FINAL CONSTRUCTION INSPECTION: 8/24/15 ® Outlet tee installed, centered under access port (gas baffle) ® 24" inch cover to finish grade installed over one access port DISTRIBUTION-BOX ® Installed on stable stone base ® H-20 D-Box ® Inlet tee (if pumped or >0.08'/foot) ® Hydraulic cement around inlet & outlets ® Observed even distribution ® Speed levelers provided (not required) ® Schedule 40 PVC Pipe Comments: SOIL ABSORPTION SYSTEM (General) ® Portion of lateral on street side replaced Comments: Approximately 8' section replaced. BM = Top of bottom step (assumed) BM = 100.00 HR = 4.34 HI = 104.34 SYSTEM ELEVATIONS ROD AS-BLT INVERT DESIGN INVERT ELEVATION ELEV ELEV Benchmark Septic Tank OUT 6.74 97.27 18'+/- Slope = 0.015' Distribution Box IN 7.00 96.99 Distribution Box OUT 7.17 96.82 Lateral 1 TOP 722/726 Lateral 1 INVERT 96.77 / 96.73 Application for Septic.Disposal System Construction Permit - TOWN OF TODAY'S DATE NORTH ANDOVER, MA 01845 $425 00 comRepair Important: Application is hereby made for a permit to: When filling out ❑Construct a new on-site sewage disposal system* forms on the computer,use ❑Repair_or replace an existing.on-site sewage disposal'system* only the tab key to move your epair or replace an existing system component—What? cursor-do not G r'wS Q { ,f.e 5 LeotA use the return A. Facility Information key. —67/ r�,z 5 4 s4 * _ Address or Lot# Cityfrown AUG 7 f - 2: TY * PE OF SEP"M SYSTEM*: ➢ ❑Pump UMravity(choose one) # �� "T pump system,attach copy of electrical permit to application'" ➢ ❑Conventional System(pipe and stone system) ➢ ❑Infiltrator or Biodiffuser(Gravel-Less)(Attach a copy of your certification to install_this type of system.) ➢ ❑Pressure Distribution S.A.S.(No D-Box) ❑Pressure Dosed(D-Box Present)S.A.S. ➢ ❑ Does the system require an effluent filter? Yes No If yes, does plan specify make and model of filter? YES=(no further info. needed) NO=(installer must specify brand of filter before DWC issuance) what is the Mabe? ghat is the Modc 1. 2. Owner Information Name 5 7/ r�5 � ° Address(if different from above) Cityrrown Stat Zip Code 78'i Q Y i - / 7d-3 Telephone Number 3. Installer Information Name Name of Company BATEEMN ENTr-Aon,.z... r�G -- Address 111 ARC►LLA RO,0 141� ANDOVER, NSA 0181p City/Town /' State Zip Code 777 90-5--A-7- Telephone Number(Cell Phone#if possible please) 4. Designer Information Name Name of Company Address Cityf town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 a Ap-plication,.for Septic Disposal :S�s#em -/,_,S 3?�`I� ��.apt- . .i i�.��.��, �� - �Construction -Permit ' TOW OF TODAY'S DATE � W s � If ORTH AND OVIER' 112A 01:845 $.25D.66 T Full Repair C s $125.00.-Component S� Nu ' PAGE 2 OF 2 A. Facllity.Information continued.... S. Type of Building: esidential Dwelling or❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-des'cr/bed on-site sewage disposal system in accordance with the provisions of Title s of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover,and not to place the system fn operation until a Certificate of compliance has been Issued y this Board of Health. Name Date Applic Ap IIvenndnnB , a of He / RepresentativeJQ e Date Application Disapproved.for the fo lowing reasons: For C)ffiise Use Onw• 1 Fee Attached? Yes No 2.• ProjectMidaget Obligation Form Attached. Yes No 1: Pin&M—M? Ifso)Attach�cony ofElec ical Permit` �'es No� 4. FoaadationAs Built.?(hew construction-ronly). Yes__ (Same scale ss aPP Y P ro ed laa No ) . 5. FloorPlaas?'(he.w construction only). NO ApplrCatton foroisposal ysterit: onstrndTori Permft' Rage 2 of 2 ��OBLiGA�Iom As Qie.N Aadwec hcnasetlitis�fos etdi•st:t q 10.16 epdc��qp�fo thep�ppettya� 5 71 (A&*of sq*systeac} .-gam pim a9 Re]ativa to th pp8eadou of 4,f�5, { . Abd dated Dated �-� ►-t Wit iWWM dated • . . rtvFaed dte} I nadentoutd the following bougsdons for r ragement ofos project: 1. As the iasad:4 I am.ob%aW is obu&mgpe,�andlloand ofl eakh�1 �� anp voA oa a altm 2. As 6i hwft.j.pbjtwa in my and erparsoiz aotzasoedated th T£h� 'pj*jeet=mvt, harray . IIe. pia mapaa and the sy►ettsa s`a notreeady,then sign tied��wt•• • (I" p me* , al:ba�d b a se tot •notbane tobcprmm, OW, for �- .etc. a wee bxt�Ifi-(Or ami to from the must It ttibmitfcd•tn c-Strad ofHa ,ail; a eco.pm,. iri;st �ov�o�TC�• s F �"k&P.tie 4dy aftd able to cow • � • �� oxo .. , • ' • . : . - •.. . _ . t rot�ioeptni!$:ags esp ; Ilei doss not . . hang#o beoa�te.• - . •- , 4 Aste as m WI= I ted dist lDdy'l tmy p ow io�t'�t i't ►to a�)pact Aa I atei rEg fired tapiene tltg na of tke sy itt#iiti . ¢ pplt t t. addta n.j. Ail A Old Como T. 5.. 1Sbtb`ciaadllle�•Ier etat,�ail I pucef� c� ' SVC tmc on a Detkrarlaa�tamt tfral.s3 paekvn aft&e s+eyredt ' . b� Iasp�cta�arfthe"enact�rads�exb he maeat . � - . c Feldoape�otrbp8o�olart�TtAft�rarattavas�. d IastAQlfnefara�dit�a&,D�-. aagp ,r,ms's tit:p=p .WIlsf other - a-mod Inijigko h, '� amdu Underd Ud Sapdc.bw p . wr Commonwealth of Massachusetts Map-Block-Lot 105.D0080 - -- ___---- _ BOARD OF HEALTH Permit No North Andover BHP-2015-0343 PA. FEE F.I. $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd-Bate-son ----- ---------------------------------------------------------------------------------------------- to(Construct)an Individual Sewage Disposal System. at No 571 FOREST STREET -------------- -------------------------------------------------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. BHP-201 ted August-12,2015 ______________ __COPY Issued On:Aug-12-2015 ARD OF HEALTH • 4r � p;�,a" , Commonwealth of Massa hu etts Map-Block-Lot • 105.D0080 .� BOARD OF HEAL H ----------------------- North Andover ERTI ATE OF C MPLI NCE THIS S TO CERTIFY That e Individual Sewa e Disposal Syste (Construct) by Todd-Bateson- ------------- -------- ---- ---------------------------------------- --------------- -------------------------------- ------------- - Installer at No 571 FOREST STREET has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. BHP-2015-034 Dated August 12,2015 ----------------------- ------- ---------------------------------------------------------------- Printed On:Aug-12-2015 BOARD OF HEALTH Commonwealth of Massachusetts `� Title 5 Official Inspection Igor Subsurface Sewage Disposal System F�-Not for Volunt m Voluntary Assessments G,r^� ✓ 571 Forest Street Property Address Paul Swartz Owner 's information is OwnerName required for every North Andover MA 01845 page. C' /Town 7/16/2015 State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Imout When A. General Information fillingmo out forms - on the computer, O') use only the tab key to move your 1. Inspector: JUL z 8 2015 Jv�b� cursor-do not Neil J. Bateson TOWN OF NORTH ANDOVER use the return key. Name of InHEALTH DEPARTMENT spector Bateson Enterprises Inc. Company Name 111 Ar ilia Road Company Address Andover City/Town MA 01810 978-475-4786 State Zip Code Telephone Number S115 License Number B. Certification I certify that I have personally inspected the sewage disposal system at this a information reported address and that the p d below is true accurate and complete as of the time of was performed based on my training and experience in the proper funcon the inspection. The inspection and S sewage disposal systems. I am a DEP approved system inspector pursuant o ee ce Title 5(310 CMR 15.000). The system: ct on 15.340 of ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority N ___... Inspe or' signat 7/16/2015 Date The system inspector shall submit a copy of this inspection report to the Approving Authority Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions at that time.This inspection does not address how t of use hes stem w' the same Y will perform or different conditions of use. p to the future under t5ins•3/13 Me 5 official Inspection Form:Subsurface Sewage Disposal System•page 1 of 17 t f Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form -Not for Vm Assessments lug 571 Forest Street Property Address Paul Swartz Owner 's information is ownerName required for every North Andover MA 01845 page. Cityfrown State 7/16/2015 Zip Code Date of Inspection B. Certification (cont.) Inspection p on Summa : Check ck A,B,C,D or E/always y 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 allure criteri a note Indicated below, valuated are Comments: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y N ND)for the following statements. If"not determined,"please explain. ' The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ® N ❑ ND (Explain below): t51ns•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection For Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 571 Forest Street Property Address Paul Swartz Owner Owner's Name information is required for every North Andover MA page. C*Town 01845 7/16/2015 Date of B. Certification (cont.) State Zip Code Inspection ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if Pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ® N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND(Explain below): ❑ distribution box is leveled or replaced p ed ❑ Y ® N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pies . T system will pass inspection if(with approval of the Board of Health): p ( ) he ❑ broken pipe(s)are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to deter the system is failing to protect public health, safety or the environment. mine if 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: h, ❑ Cesspool or privy is within 50 feet of a surface water ❑ Sins 3113 Cesspool or privy is within 50 feet of a bordering vegetated wetland or a • salt marsh Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 571 Forest Street Property Address Paul Swartz Owner information is Owner's Name required for every North Andover MA 01845 page. City/Town 7/16/2015 State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system y em has a septic c tank and SAS and the SAS is within n 50 feet of a private supply well. p vate water ❑ The system has a septic tank nk and SAS and the SAS Is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other. Outlet tee in septic tank,outlet pipe to d-box, d-box, crushed leach pipe needs to be replaced&roots in leach pipe removed D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facilit s Y orsystem component due to overloaded or clogged SAS or cesspool Y ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than'/day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 571 Forest Street Property Address Paul Swartz Owner 's information is OwnerName required for every North Andover MA 01845 page. City/Town 7/16/2015 State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water Supply or tributary to a surface water supply. p y ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence Of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface,drinking water supply pP Y ❑ ❑ 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 si or answered"yes"in Section D above the large grnficant threat system system considered a significant threat under Section E or failed under Section D shall upgrade. The owner or operator of any system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Sins•3/13 Title 5 official Inspection Form:subsurface Sewage Disposal system•page 5 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Foran-Not for Voluntary Assessments 571 Forest Street Property Address Paul Swartz Owner Owner's Name information is required for every North Andover MA 01845 page. cityrrown 7/16/2015 C. Checklist State Zip Code Date of inspection Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 -- Number of bedrooms (actual): 4--- DESIGN DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 6060 t5ins•3/13 Tide 5 Official Inspection Foran:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 571 Forest Street Property Address Owner Paul Swartz information is Ovmer s Name required for every North Andover S page. City/Town MA 1p _ 7/16/2015 tate 21p Code D. System Information Date of Inspection Description: Number of current residents: 0 Does residence have a garbage grinder? Is laundry on a separate sewage system?(Include laundry system inspection Yes ® No information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Seasonal use? El Yes No ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): On well water Detail: Sump pump? - ❑ Last date of occupancy: Yes ® No Vacant one year Commercial/Industrial Flow Conditions: Date Type of Establishment: Design flow(based on 310 CMR 15.203): per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Gallons Grease trap present? ❑ ❑ Industrial waste holding tank present? Yes No ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Sins•3113 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 571 Forest Street Property Address Paul Swartz Owner information is Owner's Name required for every North Andover MA 01845 page. Cityrrown .7/16/2015 state Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date i Other(describe below): General Information Pumping Records: Source of information: Unknown Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection F p orm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 571 Forest Street Property Address Paul Swartz Owner information is Owner's Name required for every North Andover MA 01845 7/1.6/2015 page. cityrrown State Zi Code Zip Date of Inspection D. System Information (cont.) Approximate age of all components,9 p nents, date Installed(if known)and source of information: 25 ears old, 8/6/1990, Certificate of occupancy y Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.8 feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): 4"PVC through wall, 3" PVC in house, no leaks visible Septic Tank(locate on site plan): Depth below grade: 0.8 feet Material of construction: ®concrete El metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, lista e: g years Is age confirmed by a Certificate of Compliance?P (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'x 5'x4' Sludge depth: 311 t5ins•3113 Tide 5 Official inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 571 Forest Street Property Address Paul Swartz Owner 's information is OwnerName required for every North Andover cityrrown MA 01845 page. 7/16/2015 State ZIP Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle N/A Scum thickness 311 Distance from top of scum to top of outlet tee or baffle N/A=outlet tee has corrosion holes Distance from bottom of scum to bottomN/A of outlet tee or baffle How were dimensions determined? Tape measure Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumped septic tank. Inlet tee ok. Outlet tee has corrosion holes, needs to be replaced. Depth of liquid at outlet invert. No evidence of leakage. Outlet pipe to d-box has dips&roots, needs to be replaced. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: (Sins•3113 Date Title 5 Official Inspection Form:Subsurface Sewage Disposal System,page 10 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection For Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 571 Forest Street Property Address Owner Paul Swartz owner's Name information is required for every North Andover MA 01845 page. cityrrown 7/16/2015 State Zip dCoe Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural inte rit liquid levels as related to outlet invert, evidence of leakage, etc.): g y' Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site ) Ian : p Depth below grade: Material of construction: ❑concrete El metal F-1 fiberglass ❑ polyethylene El other(explain): Dimensions: Capacity: gallons Design Flow: Alarm present: gallons per day ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Sins-3113 Title 5 official inspection Form:Subsurface sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection a Subsurface Sewage Disposal System Form Y Form-Not for Voluntary Assessments 571 Forest Street Property Address Owner Paul Swartz 's information is OwnerName required for every North Andover page. City/Town Sta 01845___________pCode Date of Inspection 7/16/2015 Zi D. System Information (cont.) Distribution Box(if present must be opened (locate to on siteIan P ) Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids ca evidence of leakage into or out of box, etc.): n'Yover, any D-box level&distribution equal. Evidence of carryover. Evidence of leakage. D-box has corrosion holes 8�hea root invasion, needs to be replaced. . Pump Chamber(locate on site plan). Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Sins 3113 Title 5 official Inspestlon Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection a Subsurface Sewage Disposal System Form y Form-Not for Voluntary Assessments 571 Forest.Street Property Address Paul Swartz Owner information is Owner's Name required for every North Andover MA 01845 page. City/town 7/16/2015 State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1 field 20'x 45' ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetation ok. No sign of ponding to surface. Heavy root invasion in one pipe& crushed pipe in one, both pipes needs to be replaced. 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 t5ins•3113 ❑ Yes ❑ No Title 5 Oficial Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 571 Forest Street Property Address Paul Swartz Owner information is owners Name required for every North Andover MA 01845 page. Cityrrown 7/16/2015 State Zip Code Date of Inspection - D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts wN 131 Title 5 Official Inspection F Subsurface Sewage Disposal System Form-Not for Form Voluntary Assessments 571 Forest Street Property Address Paul Swartz Owner information is owner's Name required for every North Andover MA 01845 page. CRO I own 7/16/2015 State Zip Code Date of Inspection Q. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately ()C�`' a a- I5'b D 33 4 k t5lns•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Tithe 5 Official Inspection p Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 571 Forest Street Property Address Paul Swartz Owner information is Owner's Name required for every North Andover MA page. City/Town 018_ 45 7/16/2015 State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 4 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 5/16/1981 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Design plan ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Test pit data on design plan Before filing this Inspection Report, please see Report Completeness Checklist on ,sins•3113 next page. Title 5 Official Inspecdon Form;Subsurface Sewage Disposal System•page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 571 Forest Street Property Address Owner Paul Swartz Ovmer's Name information is required for every North Andover MA page. City/Town 01845 7/16/2015 State Zip Code Date of inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file l I I51ns•3113 Title 5 Oficial Inspection Form;Subsurface Sewage Disposal System•Page 17 of 17 CERTIFICATE OF US E & OC of ��Te CVPANCY Building Permit Number_ 139 -(198 7) Date AUGUST 6 1990THIS THE BUILDING LOCATED ON LCERTIFIES THAT MAY BE OC # 5 Y FOREST STREET OCCUPIED SINGLE FAMILY DWELLING W (571) WITg THE PROVISIONS OF 2-CAR GAR R . INACCORDANCE THE MASSACHUSE UNDER OTHER REGULATIONS AS TTS STATE BIDING CODE AND SUCH MA►Y APPLY. ♦10 R i k t CERTIFICATE ISSUED TO t ;,t• James Harti 'Sg ADDRESS 15 A S PPa100 s a S t . Building Inspector Town of North Andover, Massachusetts Form No. , NORTH BOARD OF HEALTH ° ,. LED ib gtiO 3� h� °L 3 i gS 7- 0 F- A * 7y APPLICATION FOR SITE TESTING/INSPECTION �.9 QDg1TED h?P��S SSACHUSE Applicant ME ADDRESS TELEPHONE Site Location Engineer cz�2 ME ADDRESS TELEPHONE Test/Inspection Date and Time CHAT MAR-WF VEALTH Fee "-�D Test No- S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts Form No.z ppRTM BOARD OF HEALTH /l p L � w s or` • •-=•-�••-- DESIGN APPROVAL FOR ,SSACHUSE`� SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant J' �—JI A-) Test No. Site Location Lyf i/UG4tc5 S T Reference Plans and Specs. 13oRWA&V ENGINEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. CH RMAN, BUMCD OF HEALTH Fee Site System Permit No. �Z(� y pORTq �,SSACHUSft THE COMMONWEALTH OF MASSACHUSETTS TOWN OF NORTH ANDOVER BOARD OF HEALTH Permit # 021 Fee: $50.00 Date: 6/29/01 This is to certify that: C.M. Rollins Co., Inc. IS HEREBY GRANTED A LICENSE FOR THE PURPOSE OF DRILLING A WELL AT: 571 Forest Street This license is granted in conformity with the statutes and ordinances relating thereto, and expires DECEMBER 31, 2001 unless sooner suspended or revoked. ^� Gayton Osgood, Chairman i 1 \ Francis P. MacMillan, M.D., Member John S. Rizza., D.M.D., Member NORTq ��11� D'617r� F h p Y ♦ Too i "k HU 2t� THE COMMONWEALTH OF MASSACHUSETTS TOWN OF NORTH ANDOVER BOARD OF HEALTH Permit # 021 Fee: $50.00 Date: 6/29/01 This is to certify that: C.M. Rollins Co., Inc. IS HEREBY GRANTED A LICENSE FOR THE PURPOSE OF DRILLING A WELL AT: 571 Forest Street This license is granted in conformity with the statutes and ordinances relating thereto, and expires DECEMBER 31, 2001 unless sooner suspended or revoked. Gayton Osgood, Chairman Francis P. MacMillan, M.D., Member John S. Rizza, D.M.D., Member CtyORTi+ p so., 1b0 f Y 1 wrar...• ��'•.,,o ••�h BOARD OF HEALTH i SS�cwusE NORTH ANDOVER, MASS. APPLICATION FOR WELL AND PUMP PERMIT Permit # Date A permit is requested to: drill a well install a pump LOCATION:- J ? t.e s S i . Lot .� f Owner �1 A#'W 5 4AAr% Cr4 rj Address VA t4"JeZ'�: NA , Tel 17?-- 7.7 '_ c�• �x Fa2�, Well Contrctr C' dy1. �,��'NS z+�� Add. \meq 4c'r Tel R 78- ('d'7 - z 32-0 Pump Contrctr Ly0Wj_j2_ Add. Tel �kkk*********4eYtk�ekiie4e9r4ekkkie9e* Ir�e�e�c1eF�e ►eie•kIe* ie�riskF9e�e�r* k* Ir�elrir9ek51e�e*�ctrkktic�e* te�e WELLS (To be completed at time of pump test. ) , Type of well Use Diameter of well Size of casing Depth of bed rock Depth casing into bedrock Seal been tested? Yes (_) No (_) Date of test Depth of well Water-bearing rock Depth to water Delivers GPM for (how long?) Drawdown feet after pumping hours at GPM Date of completion �- { Signature o ` well contractor PUMPS (To be filled in before installati.on. )f. Name & size of pump �pe `'' d;\ Size of tank Pump delivers , P09, Pipe used in well: Cast iron (_) Galvanized ( Plastic (_) Sleeve used to protect pipe? Yves (_) No (_) Type weh1 seal t, Date Signature of pump installer Date water analysis report submitted to Board of Health Plumbing inspector Wiring inspector Board of Health `j�`i�� 7 rJ J `f LIN n/2 K�D ILSL/Y it�/ G f! yL /Y(1 _aJ�,D �"-�-"-.1_•"r ��C.�!,.3C ._��J •f�` /1/o GAR 6!� G,�' G RteL_�.,.�._._... --- --.---- fc� s t � ' V \ j o o t REs Fa R ES t 5 t7R 6-e Cx1Sd7 49;/Z /ZoLE lZ/N/SA Ic1�3 /1 FiQg�Sl� of LQ ? P,eoPOSEv SasSaRX-4" SEwA4 bispo44_ Sy,srE,f . ANO SCALE = / �= �o � 44rE OWA. M S � 71 /V o l/o ,S/q _ _L ivE - - LOCAT/o N: ------- 20 f S',9 ,Co R E S 7` S r- LEES/G�tlER ora COMM04, cTasEA�l cT �AQBAbALL O , �s• �'�'',�� F9� / u/ESTL�JA�Qd ClRCcs � N ,06S/GA.1 DATA = TYPE of 6u1441AIcr 1/ 6,,, 44Ari6 CEUAt AUIVSIA14 CA- -/TIES N'P ' SEWA4-E FLOW E3'TlMATE 90 G-P D' SEPrlC r AIX : /;So a C-/;; 4,6saePT/ON .4REA : c/o Q C •F• CPEO PFiQccz.4T/OM TESTS D4 7ZP E4.E✓Ar/OrN ,9O77aM &".4 rA-p W //,S AvAl. Mi v. W/n/ Mi,v rs G' ORa� g1A.1- MI A41. Af M/ L O 7rsr PITS DArF rOP 64EVAT/ / jolt. TYPES S+•t 6,s L I'd o / � -� AAJO 6'GRI9 VEL 7•s) a WA Me 7-A84E � GotA r/d N Na o BorrOM ELEV/AT 4 /a IS TESTS Ccrv&jcTED BY s .TOSEFN r 64,QBA6AC40 , R S M S f o NE TEST'S W/rNES.SED. BY : M u IC G R R F PzAAi cDes of 2 PAeT/AL BED E�/D SECT/D Aj CFOe 510ECIFICAT-10AIS — SEE 5EC71,01,1 A7' LOWER ,e/GNT) 4„CAST.Z,PN-1, S �SOQO 94L. CONC,eETE 56P7-le- TANK r09C/.,ZEALED TOin/TS 4wT Rye. _ SO/NT ,� - SOS/O • I i r �.'1 •s - ��.s amu/� ' u W ell r tn S• N• �^/• 1l7•S xAGE 14/0'2. l��-�� klfR77 ��' ?RDF/LE Qr I • �„¢ <S'EALED Jl�vr, �S'ocio P. .1/.C. P/PE EQa WACEV7-) CAPOED EitlOS Coe EQa1P'ALE'NT) AecA > ,,elsarlolJ 5nr Ll n S � I Q nn ABsoR PTioly LED rL A AJ /UDT TD cSC.4LE YS! • cSEL EG 7- &4c&4C K F!C L i •' ��.,rb f/8” WAS NE'D • � ;1. • . � � C,2USNE0 sroNE •�' -- tit, - • •.•: SFl e �"4 PE�FoeArED • R Y.C. P/PE D� • e • EQ[.//YAI ENT `�/�'•TQ !l�k- 1' ASNEG O N CD cRaSNE'D STONE Q O \ CAoc/BI.E WASNED TD MEET �.A•SN.O. Q65ORPT/oA/ BEZ) SEc rio,v L o f SA o,e 7'- o BED PGAA1 Av4 SECrloNS SfAEE7- off' Z CERTIFIED FOUNDATION PL AN LOCATED IN NOL , SCALE.-I"= 4- v DATE S.L.GILES R.L.S. u,) L AWRENCE 8 NORTH ANDOVER ' I po J�Y_ Y O,1 i Ol 1 l 'ERT/FY THAT THE OFFSETS SHOWN ARE FOR THE USE OF OFFSETS SHOWN THE BUILDING INSPECTOR ONL Y, 8 SUCH CONFORM TO THE USE IS FOR DETERMINATION OFZOIVING /ONI.-V G B Y L A W OF CONFORMITY OR NON C ONFORMI T Y •�: i /�vj WHEN CONSTRUCTED !o(3