HomeMy WebLinkAboutMiscellaneous - 582 SHARPNERS POND ROAD 4/30/2018 (2) I_, 582 SHARPNERS POND ROgD Id Road _
210/090.__0000.0 j
6458
Ot MO eT.1ti
Town of North Andover
HEALTH DEPARTMENT
CHUSt�
j CHECK#: `,�, l DATE:
-,
LOCATION. ? ,
H/O NAME:
CONTRACTOR NAME: �v
Type of Permit or License:(Check box)
❑ Animal $
❑ Body Art Establishment $
❑ Body Art Practitioner $
❑ Dumpster $
❑ Food Service-Type. $
❑ Funeral Directors $
❑ Massage Establishment $
❑ Massage Practice $
❑ Offal(Septic)Hauler $
❑ Recreational Camp $
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ Trash/Solid Waste Hauler $
❑ Well Construction $
SEPTIC Systems:
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
x❑ Title 5 InspectorTitle 5 Report $�
❑ Other:(Indicate) $
Health Agent Initials
White-Applicant Yellow-Health Pink-Treasurer
FILE# A ad3aa 13
-�" RECEIVED
N
26, 2013
'TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
V INSPECrT®NS
Dean G. Luscomb H&Sons
. P.O.Box 135
Middleton,MA 01949
_ 978-774-4065
_ 1
Licensed Plumber#20285
fSUBSURFACE SEWAGE DISPOSAL SYSTEM INPSECTION FORM
i
f
� PROPERTY OWNERS NAME' e.('e_ _
PROPERTY ADDRESS ,53a S h Q r o h e rS P� d P-d
IN. h d o ver
ADDRESS OF OWNER(if different)
DATE OF INSPECTION a C-
NAME OF INSPECTOR I�e Q n G LU,5 c o ren h TL
f .
. _ QUALITY IS NUMBER ONE TO US_
Commonwealth of Massachusetts
Title 5 Official Inspection Form '
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
582 Shar vers Pond Rd
Property Address
Tecce
Owner Owner's Name
information is
required for N. Andover MA March 22, 2013
every page. City/Town 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. RECEIVED
Important:
illi
When filling out A. General Information
forms on the MAR 2 6 2013
computer,use 1. Inspector:
only the tab key TOWN OF NORTH ANDOVER
to move your Dean G. Luscomb II HEALTH DEPARTMENT
cursor-do not Name of Inspector
use the return
key. Dean G. Luscomb II & Sons
Company Name
P.O. Box 135
Company Address
Middleton MA 01949
City/Town State Zip Code
978-774-4065 S1848
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
❑ Needs Further Evaluation by the Local Approving Authority
�Ny March 22, 2013
InspOtors Signature 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.
15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
i
Y
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
;M 582 Sharpners Pond Rd
Property Address
Tecce
Owner Owner's Name
information is
required for N. Andover MA March 22, 2013
every page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Checl(3b,C,D or E/always complete all of Section D
A) System Passes:
® 1 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.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
t{�! 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):
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
582 Sharpners Pond Rd
Property Address
Tecce
Owner Owner's Name
information is
required for N. Andover MA March 22, 2013
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
d ❑ 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 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
t5ins-11/10 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 3 of 17
. 1
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
582 Sharpners Pond Rd
Property Address
Tecce
Owner Owner's Name
information is
required for N. Andover MA March 22, 2013
every page. City/Town 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,
a �- 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 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:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
El ® Backup of sewage into facility or system component due to overloaded or
1t�� clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 4 of 17
t ' I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
582 Sharpners Pond Rd
Property Address
Tecce
Owner Owner's Name
information is
required for N. Andover MA March 22, 2013
every page. City/Town 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
l O 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 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 syst you must indicate either"yes"or"no"to each of the following, in addi " to the
questions in Sectio
Yes No
❑ ❑ the system is wi t�" 400 feet of a surface dri g water supply
❑ ❑ the system is within 200 fe f a tri ary to a surface drinking water supply
❑ ❑ the system is located in a " gen sitive area (Interim Wellhead Protection
Area—IWPA) or a m ed Zone II of a liic�w,ater supply well
If you have answered "yes"to an stion in Section E the system is` Ggg idered a significant threat,
or answered"yes" in Section ove the large system has failed. The owner or operator of any large
system considered a si " (cant threat under Section E or failed under Section D shaU ggrade the
system in accord a with 310 CMR 15.304. The system owner should contact the appropriate
regional offi the Department.
t5ins-11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
582 Sharpners Pond Rd
Property Address
Tecce
Owner Owner's Name
information is
required for N. Andover MA March 22 2013
every page. Citylrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms (actual): 4 -
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 gpd
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
a
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 582 Sharpners Pond Rd
Property Address
Tecce
Owner Owner's Name
information is
required for N. Andover MA March 22, 2013
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Owner
Number of current residents: 4
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d private well
9 ( Y 9 (gP ))�
Detail: ��4Qn�.- s�� b�C✓�
Sump pump? ❑ Yes ® No
Last date of occupancy: Current
Date
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 3 F R 15.203): Gallons per d pd)
Basis of design flow(seats/persons/sq.ft.,
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank pre ❑ Yes ❑ No
Non-sanitary waste c arged to the Title 5 system? Yes ❑ No
Water meter readings, if available:
t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
582 Sharpners Pond Rd
Property Address
Tecce
Owner Owner's Name
information is
required for N. Andover MA March 22, 2013
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: date
Other(describe below): '
General Information
Pumping Records:
Source of information: unknown
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: D
gallons
How was quantity pumped determined?
Reason for pumping: No need at this time
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-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
J
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
° 582 Sharpners Pond Rd
Property Address
Tecce
Owner Owner's Name
information is
required for N. Andover MA March 22, 2013
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
System was installed in 1982-31 years old -owner, town and previous title v
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
24"
Depth below grade: feet
Material of construction:
❑40 PVC 4"cast iron
® cast iron El (explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Main line and joints are in very good condition with no signs of any problems.
Septic Tank(locate on site plan):
712"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
Precast rectangular concrete 1500 gallons
If tank is metal, list age:
ears
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes
Dimensions: 5' D x 5'W x 10' L /500
Sludge depth: 1
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
. a
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w 582 Sharpners Pond Rd
Property Address
Tecce
Owner Owner's Name
information is
required for N. Andover MA March 22, 2013
every page. City/Town 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
34"
Scum thickness
1"
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
15"
How were dimensions determined? sticks and 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.):
The septic tank and baffles are in very good condition. The solids in the tank are very light. The liquid
in the tank is running at it's correct working heigth. The tank does not require pumping at this time.
i
Grease Trap(locate on site plan):
ID Depth below grade: feet
Material of constr n:
El concrete El meta El fiberglass Ellpolyeth�e [FD_lther(explain):
Dimensions:
Scum thickness
Distance from top of scum to to outlet tee or baffle
Distance from bottom o um to bottom of outlet tee or baffle
Date of last p_ ing: Date
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
582 Sharpners Pond Rd
Property Address
Tecce
Owner Owner's Name
information is
required for N. Andover MA March 22, 2013
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Commer4(on pumping recommendations, inlet and outlet tee or baffle condition, structur rity,
liquid levels astTz ed to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
! Material of construction:
❑ conce,tp ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions: ,
Capacity:
" gallons
Design Flow-
gallo.ag per day
Alarm present: `�., ❑ Yes ❑ No
Alarm level: 4— Alarm in working order: ❑ Yes ❑ No
N.
Date of last pumping: '
Dat6"-'."
`-,
Comments (condition of alarm arfloat switches, etc.): `
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
4
Commonwealth of Massachusetts
H Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
582 Sharpners Pond Rd
Property Address
Tecce
Owner Owner's Name
information is
required for N. Andover MA March 22, 2013
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
r Distribution Box(if present must be opened) (locate on site plan):
/ Depth of liquid level above outlet invert Zero"
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.):
The d-box is 26" below grade. It is 20"x 20"square. The d-box is in very good condition both
structurally and working. The liquid in the d-box is running at it's correctr working heigth. The soil in
this area is clean and dry.
Pump Chamtber(locate on site plan):
Pumps in working order: ❑ Yes ❑
Nu/ Alarms in working order: � ❑ Y ❑ No
1 A`condiComments note condition of pump chambeof pump appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
�j If SAS not located, explain why:
S.A.S. was located by asbuilt drawings and previous title v.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
582 Sharpners Pond Rd _
Property Address
Tecce
Owner Owner's Name
information is
required for N. Andover MA March 22, 2013
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
I
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions:
1 -20'x 60'
❑ 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.):
The S.A.S. is in very good condition with no signs of any problems. The soil in this area is clean with
no signs
signs of ponding or breakout �3
1+�,e S �-rse.G�. i s C�u�a�� e�o�8'"�tl��e�� S`�i� rs✓�hr� �'�e��� 1 ��
5'
- (00
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and config 'on
Depth—top of liquid to inlet inv
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of constructio -
Indication of ndwater inflow ❑ Yes ❑ No
t5ins-11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 17
t i
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M ,. 582 Sharpners Pond Rd
Property Address
Tecce
Owner Owner's Name
information is
required for N. Andover MA March 22, 2013
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, conditio egetation,
etc.): �''•-
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of s gns of hydra c'failure, level of ponding, condition of vegetation,
etc.): `-
t5ins-11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 17
fie,*-roers Adam
Commonw alth of Massahusetts
W Tine Official nspection Form
Subsurface ewage Disposal S stem Form -Not for Voluntary Assessments
582 Shar ers.Pond Rd
—
Property dress
T
Owner, Own s Name
information is MA March 22, 2013
required for . Andover
"every page. City/Town State — Zip Code Date of Inspection
D: System fo ation (co )
Sketc f Sewage posal System: ovide a view of the sewage disposal system, including ties to
j at ast two permane reference landm ks or benchmarks. Locate all wells within 100 feet. Locate
ere public water sup enters the build) Check one of the boxes below:
® hand-sketch in the area ow
❑ drawing attached separatel14
�ZSaher5 o
5pw
A
a c�k a
Aix jq/ H 7 �k o� Ise
6.)Y,
x
�+v
D-,
Z.j
� r
20
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
582 Sharpners Pond Rd
Property Address
Tecce
Owner Owner's Name
information is N. Andover MA March 22, 2013
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water POn-C
® Check cellar _'Dr
® Shallow wells W&AAL-
depth to high round water: feet below grade
Estimated de
p 9 9 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. 12-12-80
Date
® Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
Proposed asbuilt, permit and previous title v on file.
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
Topsfield 1
You must describe how you established the high ground water elevation:
The bottom of the system as assumed 90'with the water noted at 84'. This would show a 6' ground
water separation William S MacLeod, Andover Consultants. _
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 582 Sharpners Pond Rd
Property Address
Tecce
Owner Owner's Name
information is
required for N. Andover _MA March 22, 2013
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-11/10 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
-
44"owl l-
E "N,07
_
" 'TITLE V INSPECTIONS FILE
Dean G. Luscomb II&Sons
wo: P.O.B. 135
1 Middleton,MA 01949 -
^ 1-508-774-4065
ICENSED PLUMBER #20285
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
X .
PROPERT`! OWNERS NAME: v c d /V f c h o I S o h
PROPERTY ADDRESS: SSS ro n C"s PD n Cl Ij• ,Anclouer
t ADDRESS OF OWNER: m P
' (if different)
DATE OF INSPECTION: �J/J /�� /D, / 99
ria NAME OF INSPECTOR: L u S CO iy
s
i Na
ry -
4Q U A L I T Y I S N U M B E R 0 N E T 0 U S
' r
Dean G. Luscomb II & Sons
P.O. Box 135
Middleton, MA 01949
1-978-774-4065
- COMMONWEALTH OF MASSACHUSETTS
-- '� EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
1=:
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON M-A 02108 (617) 292.5500
TRUDY CORE
Secretary
ARGEO PAUL CELLUCCI DAVID B STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
/ ERTIFl TIO
Owner � ✓�o�/V�C�d�lo�
Property Address: Name of Owner
--�� 9 Address of Owner: P0.
Date of Inspection: du/A! /O/i999
Nerve of Inspector: (Ptease Print) )CQn z L_Uf-cok Z_]
I am a DEP approved system inspector pursuant to Section 15.340 of T-rde 5(310 CMR 15.000)
Cornparry N erne: Dean G Luscomb IT & S n n s
.Mafng Address: P 0 BOX 1 3 5
Teiept-neNumber: Middleton MA 01949
CERTIFlCATION 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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-sitesewagedisposal systems. The system:
Passes
_ Conditionally Passes
_ Needs Further Ev luation By the Local Approving Authority
_ Fails
Inspector's Signature: Date: -
The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30) days of
completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of'fnvironmental Protection. The original should be sent to Ztm
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
I
'`e-.-LSed 9 2!98 Page Iof11
n
�� Pnnred on RecKled Paper
Dean G. Luscomb II & Sons
Middleton , MA 01949
1-978-774-4065
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
arpn ars �n� Rol, /J
Property Address:
Owner: &XCh0(,50n
Dere of Inspection:G/I Q/91?
INSPECTION SUMMARY: Chech A,/B, C, or D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. SYSTEM 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.
Indicateyes,no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined",explain why not.
/A1-/1 The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of
Health).
broken pipe(s) are replaced
obstruction is removed
App /1 distribution box is levelled or replaced
/_V The system recluhed pumpingmore than fourtfines a yeardue to broken or vtrsrructed pipe(s). The zy"em wiR-pass^
inspection if (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
I
Dean G. Luscomb II & Sons
Middleton, MA 01949
1-978-774-4065
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (c hued)
opertY`A'dd►ess:
0
Date
Date of Inspecbon:C//0/9n
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 the
public health, safety and 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 FUNCT10NING IN A MANNER WHICH.AILL PRQTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
�-( Cesspool or privy is within 50 feet of surface water
L 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 AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system end the SAS is within a Zone I of a public water supply well.
" The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well:
OV The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
N
rev—, sed 9., 2/98 P2ge3of11
Dean G. Luscomb II & Sons
Middleton , MA 01949
1-978-774-4065
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (corttirwed)
Property Address:67Z•SGa�/7e��OrJC! �aJ /moi/7C/!/e�
Owner:VI'Ch olso,7
Date of Inspection: 6110199
D. SYSTEM FAILS:
You must indicate either "Yes' or "No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
LJ Backup of"wage i"to 4ecilit"r-sntem"mponertf d111e10 an overloaded orckagged 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.
I v Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped _.
i
_) Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
_ ,v Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
_ N 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.
NAny portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
—coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You indicate either "Yes" or "No" to each of the following:
The wing criteria apply to large systems in addition to the criteria above:
The system serves cility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public
health and safety and the ronment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface dri er supply
the system is within 2 ;Pfaaurfaoslhinlcir►g supply
the s is located in a nitrogen sensitive area(Interim Wellhead Protection Area • A) or a mapped Zone.11 of a pt•blic
ter supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult th I regional
office of the Department for further information.
9 /2/198 PaRe4orII
Dean G. Luscomb II & Sons
Middleton , MA 01949
1-978-774-4065
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
/ CHECKLISTS
opetty Address:.SSZ
Owner: /Wr-40 r-40 /Sar7
Date of Inspection: (9/10/w
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
v _ None of the system compoAanu hau �--n puaspediiiiatJeast two weeks an&the system has 6woascsiaog4016s+sa!.flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
As built plans have been obtained and examined. Note if they are not available with NIA.
✓ The facility or dwelling was inspected for signs of sewage back-up.
I
The system does not receive non-sanitary or industrial waste flow.
✓ The site was inspected for signs of breakout.
tJ All system components, excluding the Soil Absorption System, have been located on the site.
LI _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System orrthe site has been determined based on:
Existing information. For example, Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
/
11 5.302(3)(b)]
_✓ _ The facility owner (and occupants_if differanf from.owner).wara-prouWed.wiih infounation.on ttha_.rLapw nyaint&n&nc- of
Subsurface Disposal Systems.
revised 9;2/98 P2ge5of11
Dean G. Luscomb II & Sons
Middleton, MA 01949
1-978-774-4065
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Propety AddressWZ S/eLrj"6rs Ron e;e4 tV, 4nclover-
0—ne :
er-Dwne : Ins1�t1vI Son
Date of pection:6//6/99
FLOW CONDITIONS
RESIDENTIAL:
Design flow: //() g p d.lbedro m.
Number of bedrooms (design):V Number of bedrooms(actual):
Total DESIGN flow 40
Number of current residents: 0
Garbage grinder (yes oca.'1:tio
Laundry (separate system) lyes o(no) N_ If yes, aeparateinspaction required
Laundry system inspected (yes or&P,
Seasonal use (yes or no):-"—UL Wait
Water meter readings, if available (last two year's usage(gpd): �( I V0.`e e�
Sump Pump (yes o<0
N l
Last date of occupancy:
COMMERCIAUINDUSTRIAL:
Typ establishment:
Design flow: d ( Based on 15.203) �s ..
Basis of design flow ,, y
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: r not_
Non-sanitary waste dischar a Title 5 system: (yes or no)_
Water meter readin available:
Lest date of panty:
OTHER: (Describe)
Lest date of occupancy:
GENERAL INFORMATION ,/
PUMPING RECORDS and source pf infor ation S/011 h/JphLS
GS t/0. • NoAie cLs a ��I�SG _ ��L Cada
System pumped as part of inspection: (yes o o�O (�W 1 ier1 (J
If yes, volume pumped: gallons
gallons
Reason for pumping: Pr t�J¢staC 2�' AiS �1V►.Q.
TYPE QF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or nol (if yes, attach previous inspection records, if any)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
AP OXIM�+TE AGE of all components, date installed{if known) nd ource o4,Wermstion: �✓// �-�'��" ~�'
j �, `7O��
Sewage odors detected when arriving at the site: (yes o6-0-)) U
rev1sed 9/2/98 Page 6of11
Dean G. Luscomb II & Sons
Middleton , MA 01949
1-978-774-4065
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:�a[. Jr9GrpnerS
Owner: /VtcAd$017
Date of Inspection:6 1101q'?
BUILDING SEWER:yt7S
(Locate on site plan)
Depth below grade:!
Material of construction: ✓cast iron 40 PVC_ other (explain)
Distance from piivate water supply well or suction line IV f,
Diameter
n
Comments: (condition of joints, venting, evidence of faakage,-etc.)
Plli'he- anj
111
r r ►�.S F
SEPTIC TANK:y-4?-,,
(locate on site plan) 1� / �t Ale.lW� C�nl��" �c>b^e/ 17t.E�fT'uP, (-/G- S{�GI I)�ca:r fY�l�.
Depth below grade: �
Material of construction: t�oncrete _m t _Fiberglass Polyethylene_other(explain)
if tank is metal, list agets4 IA Is.age.c firmed by Certificate of Compliance &Yes/No)
Dimensions. � ( X /W:66, X I01 Lc,nS
Sludge depth: Z "
r�
Distance from top of sludge to bottom of outlet tee or tsaffle: �?�
Scum thickness: nFI_
p
Distance from top of scum to top of outlet tee or baffle: ���
Distance from bottom of scum to bottom of outlet tee or ba e::
How dimensions were determined: 5�iC 11 7Pe.gal ll�e
Comments:
(recommendation for pumping, c ndition of inlet and outlet toes or-baffles, depth of liquid II vel in relation to outlet ' vert, structN e�+ntegrity,
avid nce of lea etc.) ") .St—
I Q/I
n - es- u an,' e-
GREASE TRAP:
(1-c-a-, on site plan)
Depth below grade:
Material of construction: _ rete _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.
(recommendation for pumpin ition of inlet and outlet tees or baffles, depth of liquid level in relation t flet invert, structural integrity,
evidence of leakage —
I
i
I
rev1sed 9/2/98 Page 7of11
Dean G . Luscomb II & Sons
Middleton , MA 01949
1-978-774-4065
40
Sl1RSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFO ((continued)
P.cxk>(ty Address: C3, �
A)r INFORMATION�/7AO(/��
Ow neY:AJ,-C-ho I
Date of lnspec-bon C,1101'gc
TIGW HOLDING TANK (Tank must be.pumped prior to, or at time of, inspection)
(locate on site !
Depth bele- grade
Material o' construction _comet metol _Fiberglass _Polyethylene —other(explain)
Dimensions:
Capacity: gallons "°'�• �..
Design flow gallons%day
Alarm present
Alarm level: Alarm in working order. Yes _ No_
Date of previous pumping
Comments
(condition of inlet tee, condition of alarm and itches, etc.)
„l
DISTRIBUTION BOX:(eS a6 fl �QW q�" "
(locnte on site plan)
Depth of Mould level above outlet invert ,Zero n
� m
r, s� -3aX ti"S l-;h�e�- �N/A re
Comments 17-3p k �r S oZ� uetr—� 1 ,r.
(note f level and d str but)o i; equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) 'tC 0-���_ /s
cy( n r m r h
n t"7. -JR -r vCl o i r`1A^ - / i r'S
PUMP CHAMBER:1�/d
Roca site plan)
Pumps in working or Yes or No)
Alarms in working Order (Yes O fV•9.J,_
Comments "^�,•,•'�
nose condition of pump chamber, condition of� umpsurtenances, etc.l
_ c _ PARe 8 Of I1
wean v. Luscomb li & Sons
' Middleton, MA 01949
1-978-774-4065
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
//
SYSTEM INF�rO�RMATIO�N/(continued)
Property Address:
Owner: NiC40/56-''7
Date of Inspection: 4/101,7q
SOIL ABSORPTION SYSTEM(SAS):-es
(locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods)
If not located, explain: / / / / [�
�C O ca i400 1-74/ �S4?1e i/ �rG'G.� rl ITS -
Type:
leaching pits, number:_
leaching chambers, number:_
leaching galleries, number:_ )
leeching trenches, number, length: / / / _n �jf O1AIL
leaching fields, number, dimensions:
overflow cesspool, number:_ /r –77 V C / Ile
Alternative system: / I
I19.
9
Name of Technology: jo�r„� a!F S/�,5,
Comments:
(note c�Qnditio of soil, signs ofdr a lit failure, level of ponding, damp oil, conditio?o vegetation, etc.i
C li.f ° C�l/�t7Pi A'I"�°�� �.V /rr7 Ve"e-1 4�7� C.001 .,n /G►f �A/� /�4 �6s7 s ��Gi✓16
� ai S O-! n' ins P Ir.' a,- !�/
SPOOLS:�O
(locate site plan)
Number and co�uration:
Depth-top of liqert:
Depth of solids
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool mus pumped as part of inspectio
Comment
(note ndition of soil, signs of hydraulic failure, level of pending,condition of-vegetation, etc.)
i
PRIVY:L v
(Iota site plan)
Materials of construe_' Dimensions:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure, love o co vegetation, etc.)
.-e-.,--. sed 9/2/98 Page 9ofII
y Dean G. Luscomb II & Sons
QO-rrY S' d Middleton , MA 01949
a
Fomes}- s{-. 1-978-774-4065
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
S STEM INFORMATION (continued)
Property Address/ `
: �•" " ,..
Owner:,/,,.C74, `,510,9 /
Date of Inspection: �� ✓ \\
SKETCH OF SEWA DISPOSAL SYS �\
includ ies to at least two ermane reference landmarks or benchmarks
to to all wells within 10 " (4ocate w re public water pply comes into house)
/ � U
U 5-
LJ D - i15 '
i
En
11
f ,j 8,2, Sha�pn,er-s Pono)
-Rd. to D over h2�-�
B
L_Teck
Sert;C to T- /6
0 Ta„k T3 66T = 0 '
pb, D 36'
S D- Co7-
1 eQc%,1hq Flelq' Fr
revised 9//2/98 P2ge10OfII
I
Dean G. Luscomb II & Sons
Middleton , MA 01949
1-978-774-4065
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYS/TEM INFORMATION (continued) '
PTOpe"y Address: /�... r�[I�U
Owner: /VjG401SOO
Date of Inspection:
NRCS Report name w))II S(41'VL'► �?� ES-St-_X 6204
Soil Type_ }f •heXXAdW 1Qa(N,,
Typical depth to groundwater
USGS Date website visited 61folqq
Observation Wells checked 7—apsr'e ( �� //
Groundwater depth: Shallow �}e-s�2,,57' Moderate � Ze (� Deep J 66
SITE EXAM Slope 15- r� 2-5 <6
Surface water QIH
Check Cellar A)d 'LA1 P
Shallow wells kylq
Estimated Depth to Groundwater I/Feet
Please indicate all the methods used to determine High Groundwater Elevation:
/Obtained from Design Plans on record
Observed Site (Abutting property, observation hole, basement sump etc.)
I
Determined from local conditions
oil
Checked with local Board of health
VChecked FEMA Maps
N4Checked pumping records
Checked local excavators, installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
04
�LI'S� CI�OL//G�S/�IOG✓ b / G raU,i WC/?1
Ad/ove�
rev.- sed 9/2/98 Page 11 or 11
P
A146(4h ANLYwer 2.6. 4.-
)�� MC�,n St STSMT S SEPTIC TANK SERVICE
47 RAILROAD STREP
A/d/lh A►lncver BRADFORD, MA 01835
L1q,u Lac f S/-Cap j4
978-372-7471
lns' GII L4 r-
MONTH REPORT FOR TMN OF
DATE ADDRESS GALLpNiS OONlS
163 UJ
f �
is clhMoo
rr �
1
1l1 N2 Ctlih4er S¢
:e Cherk5t' 0-t - lw
"U e T enn
, r�
PQc
ro In
n cr.r
andover
consultants 213 BROADWAY
Once METHUEN, MASSACHUSETTS 01844
(617) 687-3828
C DATE SEC. /2
TO : NORTH ANDOVER HEALTH DEPARTMENT
TOWN HALL NO. ANDOVER , MASS
RE : SUBSURFACE SEV AGE DISPOSAL SYaTEP4
NO. ANDOVER , MASS .
I hereby certify that I halre inspected the construction of the
disposal system at Low ����-pr,��-s d�., ,P North Andover, Mass .
and that the location and elevations are as shown on the As-Built
Drawing dated AF-C, 12, lf6O
ANDOVER CONSULTANTa INC.
G -2
William S . MacLeod
Registered Sanitarian
This certification is notto be construed as a guarantee of the system.
Z53-99
r.
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40 LOT I
r,
1 2,43 Ae
28 9. ±
o -471` Q�„_W
39
N
N kA
26'
CD�t/C N
z � -
T.9.V K
27 47N E 266. 9/
O /it/vE,e r E G E d<)T/O.c/S
fid T f1041SE ,t/DT �/,1.lST4L G 62>
® �1 TANK /NLEr 9¢. ec.e
TAitl� OUTGET q¢-57
Box /NGET 9/. 99
C}; Agog Oe-ITL E T
N E.vv of �3Ev 9i s¢
® _ Ul
4S BL//G T ,04 4A/
�SL8.SU2<AG E 1>/SPOS9L Sy.STEM
LOT!, SHARPAJERS f--OAdb Kb- u n d o ve r �`JH of y
r •�
It/OETI-/ ,41VD0VE,e , M4,33 consultants
” 12 I_2 /�G EVAQEL) Fox-_ inc1 �V/ D
WESL/E REA LTY 7RL/ST �+o 2
Z SC4LEGJ .
o
213 Broadway , r�tt t h u e n , M o s s FfpN�TE
SAN�lP�
1-)-4 7-6-, 1DE`C. /Z, /9Bo Te, 687 - 3828
SOIL PROFILE & PERCOLATION TEST DATA y,
f
North Andover,Mass i' No.&Street S_ l S PO.�D � Lot No. 6
Loc./Subdiv. Plan �- .Owneraml
Investigator .. ( ; Observer
SOIL PROFILES-DATE
1' Elev. 2. Elev. 3' Elev. 4'Elev.
0 0 0 - 0
1 1 1 1
Ties to Test Pits
2 2 2 2 Q
36`
3 � 3 3 3
4 '' >�4 4 4 -
S 5 _ 5 " S `•-��� -�
f
7 ; 7 7 7
8 8 8 8
9 9 9 9 '
10 10 10 10
Benchmark Location
Elevation Datum
Percolation Tests-Date
Pit Number 1 2 3 4 S
Start Saturation
Soak-Mins.
Start Test-Time
Dro of 311-Time --
Drop -of
"-Time --Dro _of 611-Time
Mins. lst 3"Dro ' }
Mins. 2nd 3"Dro
Notes & Sketches on Back /�
IXVEo- �
- - - - �
RO.V � ��--� rl I��i. i`?L ED 11' 'r, �_? 5 tT r:J�J�!� OK
ATLO
1 . Distance To:
Wetlands
/ Drains
Well
2. Water Line Location
,2;. TTo PVC Pipe
4. Septic Tank
Tees - Length & To Clean Out Covers
Cemen, Pipe to Tank - On Both Sides of Tank
5. Distribution Box
/ Cower & Box - No Crac'-s
All Lines Florin- Equal Amounts
No Back Flow
(7-.. Leach Field or Trench
S t o;ri e Depth
CaUped h'.-l('iS
Clean Double +Washed Shone
7.
Leac.h Pit.
Di,,_en �bns
Ston Depth
Spl sh Pads
Te s
C gent Pipe to Pit - Both S_I.des
pan Double ,7a.s',)ed S'ccne
8. To Se Disposal
;final -ad_ng- Inspect-.ion
10. Ba.r_ scr :.d -nrr Ce,.re.-ed S s'.em j
As - Built Si,bmi teed
Lot Loca-i,ion
D mensions of Sys gem
r 1 evations
Table
C pt; co y zbllc ":0!'KS
SUBSURFACE DISPOSAL SYSTEM CHECK LIST
NORTH ANDOVER BOARD OF HEALTH ""V't4&a
�� ...
APPROVED DATE PROVIDED DISAPPROVED DATE TIMe REASON
God
Title 5
Reg. 2. 5 Fail OK The submitted plan must show as a minumum:
to be served (area,dimensions ,lot #,abutters)
(Planning Board files)
location and log of deep observation holes-distance
to ties
location and results of percolation tests-distance
to ties
d design calculations & calculations showing required
eaching area
e location and dimensions of system (including reserve
area) -
xisting and proposed contours
location of any wet areas within 100' of the sewage
disposal system o t- disclaimer (check wetlands mapping) I
surface and subsurface drains within 100' of sewage
disposal system or- disclaimer
location of any drainage easements within 100' of
sewage disposal system or disclaimer (planning board
files)
known sources of water supply within 200' of sewage
disposal system or disclaimer
location of any proposed well to serve the lot (100'
from leaching facility)
location of water lines on property (10' from leaching
facilities)
location of benchmark
riveways -
rbage disposers
no PVC is to be used in construction
a profile of the system (elevations of basement , plumbers
pipe septic tank, distribution box. inlets and outlets ,
distribution field piping and any other elevations)
maximum ground water elevation in area of sewage disposal
System
-s-)r'plan must be prepared by a Professional Engineer or
other professional authorized by law to prepare such
plans
Septic anks
Reg. 6 (a. Capacities - 1506 of flow, water table , tees , depth
of tees , access, pumping.,
(b) Cleanout
ZI (c) 10' from cellar wall or inground swimming pool
(d) 25' from subsurface drains
North Andover Subsurface disposal system check list - Page 2
Fail OK Distribution Boxes
Reg.10.2 a Slope greater than 0.08
Reg.10.4 (b� S
Leachin Pit
eacTing pits are preferred where the installation is
possible
Reg.11 .2 (a) Calculations of leaching area (minimum 500 S.F. )
Reg.11 .4 (b) Spacing
Reg.11 .1 (c Surface drainage 2%
Reg.11 .11 (d) Cover material
Leaching., fields '
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i
Reg.15.1 (a)AAGreater than 20 minutes/inch
Reg 15.1 (�b°) Area (minimum 900 S.F. )
Reg.15.4 (c) Construction of field
Reg.15.8 (d) Surface drainage 2%
Reg. 3.7 (e) 20' from- cellar wall or inground swimming pool
Leaching Trenches
Reg.14.1 (a) Calculations of leaching area (min. 500 S.F. )
Reg.14. 3 (b Spacing (4 ft. min. 6 ft. with reserve between)
Reg.14.4 (c� Dimensions
14.5
Reg.14.6 (d) Construction
Reg.14.7 (e) /Stone
Reg.14.1 (f / Surface drainage 2%ownhill Slope
(a) Slope y/x = (to be shown)
V(b) y/x X 150 = (to be shown)
Pumps
Reg. 9.1 (a) Approval
Reg. 9.6 (b) Stand-by power
TOWN OF NORTH ANDOVER N°RTa
Office of COMMUNITY DEVELOPMENT AND SERVICES o:°���� �
HEALTH DEPARTMENT #_
400 OSGOOD STREET
NORTH ANDOVER, MASSACHUSETTS 01845 �'Ss;CM sty
978.688.9540—Phone
Susan Y.Sawyer,REHS/RS 978.688.9542—FAX
Public Health Director E-MAIL:healthdept@townofnorthandover.com
WEBSITE:http://www.townofnorthandover.com
April 11, 2005
To all Sharpeners Pond Road Residents:
Please.note that it has come to the attention of the Health Department that many residents are
leaving their trash barrels and trash bags out at the curbside for days, or weeks at a time.
Empty trash barrels blowing about in the road are a safety hazard, and trash and debris along the
roadway is a health hazard. Please be mindful of this, as the Health Department will conduct
periodic inspections of the area to determine who is in violation, and fines will be issued if
protocol is not followed.
The Board of Health follows the State Sanitary Code regarding Human Habitation,
105.CMR.410, Section 1:
410.600
(A): Garbage or mixed garbage and rubbish shall be stored in watertight receptacles with tight-
fitting covers. Said receptacles and covers shall be of metal or other durable,rodent-proof
material. Rubbish shall be stored in receptacles of metal or other durable, rodent-proof material.
Garbage and rubbish shall be put out for collection no earlier than the day of collection.
(B): Plastic bags shall be used to store garbage or mixed rubbish and garbage only if used as a
liner in watertight receptacles with tight-fitting covers as required in 105 CMR 410.600(A),
provided that the plastic bags may be put out for collection except in those places where such
practice is prohibited by local rule or ordinance or except in those cases where the Department of
Public Health determines that such practice constitutes a health problem. For purposes of the
preceding sentence in making its determination the Department shall consider, among other
things, evidence of strewn garbage,torn garbage bags, or evidence of rodents.
410.602
(A) Land. The owner of any parcel of land, vacant or otherwise, shall be responsible for
maintaining such parcel of land in a clean and sanitary condition and free from garbage, rubbish
or other refuse. The owner of such parcel of land shall correct any condition caused by or on
such parcel or its appurtenance which affects the health or safety, and well-being of the
occupants of any dwelling or of the general public.
(D) Common Areas. The owner of any dwelling abutting a private passageway or right-of-way
owned or used in common with other dwellings or which the owner or occupants under his
control have the right to use or are in fact using shall be responsible for maintaining in a clean
and sanitary condition free of garbage, rubbish, other filth or causes of sickness that part of the
passageway or right-of-way which abuts his property and which he or the occupants under his
control have the right to use, or are in fact using, or which he owns.
w
Residents should know the following:
The Town has a mandatory paper and cardboard recycling ordinance that requires
residents to separate these items from their household trash. Paper and cardboard are
collected every other week on the same day as the household's normal trash. Residents
can call the DPW at 978.685.0950 to get their recycling schedule.
Residents
are responsible for picking up loose trash left at the curb after collection.
Banned Items and Recycling Requirements:
Please refer to the DPW website for a complete list of all the recycling requirements:
http://www.northandoverrecycles.com.
Please contact the Health Department if you have any additional questions. Thank you.
Sincere
an Y. Sawyer, REHS/RS
Public Health Director
File
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Commonwealth of Massachusetts
North Andover, Massachusetts
System Pumping Record RECOVER
System Owner& address: JUN 1 3 2008
Laura Tecce TOWN OF NORTH Ai�1DOI
582 Sharpners Pond Road AMD
North Andover, MA
Location of system: Rear, Right Side
Date of Pumping: June 4, 2008
Type of system: Septic Tank
Gallons Pumped: 1500 Gallons
System pumped by:
Service Pumping& Drain Co.,Inc.
5 Hallberg Park
North Reading, MA
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License#: BHP 2007 0728, 0725, 0727,0722, 0724, 0726
Contents transferred to: Greater Lawrence Sanitary District
Dater r.�une�4�2®®8 F� Pumypir f lirh 5 MWS
s, a ...
This is PROPRIETARY and CONFIDENTIAL information that may be used only
by the Board of Health for regulatory purposes