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HomeMy WebLinkAboutMiscellaneous - 585 SHARPNERS POND ROAD 4/30/2018 (2) 585 SHARPNERS POND ROAD Yn d Road 210/090.B-0039-0000.0 r I � ' r a 1 r� i MAR # LOT l_._........................................_._......_.............. PARCEL # _ STREET ._P/7 (J7?��... CONSTRUCT_LON__..APPROVAL. HAS PLAN REVIEW FEE BEEN PAID? YES NO PLAN APPROVAL: DATE APP. BY DESIGNER: ��1 � {� ,0 _ PLAN CONDITIONS T P )cWb WATER SUPPLY: TOWN ._WELL WELL PERMITc�"Ya _ DRILLER ... ... ... ....... WELL TESTS: CHEMICAL DAIE (IPPRUVEIJ-, .1._ BACTERIA I DAIE E f1PPRUVED BACTERIA II DATE APPROVEll COMMENTS: h Le Dr u� FORM U APPROVAL: APPROVAL 1*0 ISSUE YES NO DATE ISSUED 7 BY = _ CONDITIONS: 5e-,4- 19-60 Ile- ............. FINAL APPROVAL: ALL PERMITS PAIDYES NO WELL CONSTRUCTION APPROVAL C}!ES NO SEPTIC SYSTEM CONSTRUCTION APPROVAL S NO OTHER YES NO ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DATE:. ���Z .,,BY IS THE INSTALLER LICENSED? YES NO TYPE. OF CONSTRUCTION: LW REPA I R NEW CONSTRUCTION: CERTIFIED PLOT PLnN REVIEW Yl-s 1\10 CONDITIONS OF APPROVAL YES 110 (FROM FORM U) ISSUANCE OF 'DWC PERMITESQ NO DWC PERMIT N0. gINSTALLER:-Bob BEGIN, .INSPECTION YES NO: EXCAVATION . INSPECTION: NEEDED: PASSED V BY CONSTRUCTION INSPECTION: NEEDED: AS BUILT PLAN SATISFACTORY:' _(::YE APPROVAL TO BACKFILL: DATE: FINAL GRADING APPROVAL: DATE4 _BY- .0 (.Z�.�(.N____--- FINAL CONSTRUCTION APPROVAL: DATE:_ r w Z MAP #. _ ��— LOT #_._...__.....�.................... . ....... _ -. . 41' PARCEL # -- ---------- STREET. s..... /w CQN.STR_UCT_I_QN.- APPROVAL HAS PLAN REVIEW FEE BEEN PAID? PLAN APPROVAL: DATE_-.--__ v\ APP. BY_...,..__:.._ ...'.... DESIGNER: ---------------- PLAN DATE lO. ... .....�`��.................. -,� CONDITIONS--w � � �E---- ---.._ .._.... _ _._ .`T .............. WATER SUPPLY: TOWN WELL WELL PERMITDRILLER..................... ..... ... .. WELL TESTS: CHEMICAL DA I E A1'PRUVEll...... ......___._ ...._._. BACTERIA I'• DAIE 11PPRUVED BACTERIA I I DA-1E APPROVED__._.........._. 1 COMMENTS: '1 FORM U APPROVAL: APPROVAL TO ISSUE NO ' DATE ISSUED BY CONDITIONS: FINAL APPROVAL: ALL PERMITS PAID YES NO WELL CONSTRUCTION APPROVAL YES NO SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO OTHER YES NO ANY VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DATE: DY: ct SEPTI-C_ S TEMzN5..T LLR.�.�.SN. , �i ',,­:­ ISt ; THE INSTALLER LICENSED? YES NO ' • .;,►��' " ' ,t•. TYPE OF CONSTRUCTION: NEW REPAIR `i �+ +`•., �`'.. .NEW CONSTRUCTION: CERTIFIED PLOT PL_n F3EVIEW YES NU ti' "*'' °' CONDITIONS OF APPROVAL YES NO (FROM FORM UY. ) ISSUANCE OF DWC PERMIT YES NO J INSTALLER: DWC PERMIT N0. � -'-'--- --- — .a•. ,...;:. _ BEGIN .INSPECTION YES N0: !. E1XCAVATION . INSPECTION: NEEDED: 3 . PASSED BY -- ----- -- -- r: CO RU ION NST CT INSPECTION: NEEDED AS BUILT PLAN SATISFACTORYC YES:— APPROVAL TO BACKFILL: DATE: __ -•BY�__.,___.__..._. . ._..__._..-___-_- FINAL GRADING APPROVAL: DATE DATE: ,BY___ FINAL CONSTRUCTION APPROVAL: a ' F_ - i * � �' 1 ? Department of Environmental Management o er Resour WATER WELL COMPLE 10 Iµ.u. l WELL LOCATION Address GEOGR PHIC TION 1 Slfl�r'PLV}�S� POI RD _ 60 _ N S R W of (feet) (circle) City/Town N. ANDOVER Sharpners Pond Rei Well owner JAY DION (road/ Address 600 BULLFINCH 10AD 1.1 X S E W of ANDOVER (mi.in tenths) (circle) Board of Health permit: yes ❑ no ❑ intersect. w/ 114 (road/ WELL USE WELL DATA Domestic g Public❑ Industrial ❑ Total well depth 275 ft. Monitoring❑ Other Depth to bedrock 20 ft. Water-bearing rock/unconsolidated material: Method drilled Ro A Y Date drilled Description Brawn Rock CASING Water-bearing zones: Type Steel 1) From 170 To 175 Leng"th 30 ft. Oia(I.D.) 6 in. 2) From 250 To 2603) From—To Length into bedrock 10 ft. Gravel pack well: dia. Protective well seal: Screen: dia. Grout-[] Other Drive Shoe Slott length from—to STATIC WATER LEVEL Static water level below land surface 25 ft. Date 19 WELL TEST Drawdown275 ft. after pumping hr.30 min.at 12 gpm How measured Air Recovery 100 ft. after 1 hr. min. from ri a LOG of FORMATIONS COMMENTS Materials From To a sand av 1 0 20 Driller Gari A Bedfock 20 275 _rmstrona Mass. Regi tra2lo 256 Firm The ROC,k We11Se LTD Address244 Haven Street City/Town Read]ng sillna r of supervising re istered well d /e Please print tirmly BOARD OF HIKALTH COPY 1 LOT I _ , MAY Mo - �� k Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH 'I's. '6, 411 6 0� 19 � _ m *�pAOgAT[DWPPP`y.cy* APPLICATION FOR SITE TESTING/INSPECTION , �SSACHUS�� Applicant �0 v NAME ADDRESS TELEPHONE Site Location Engineer NAME ADDRESS TELEPHONE 41 Test/Inspection Date and Time CHAIRMAN,BOARD OF HEALTH Fee Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. i ":Dr ' v/ e oar s;E�lz o �oo 0. 130 A- 4r16 / A;f I h ga,01140 -V Pot �v /N VCR 1A1 7-0 )'X"r_ �� 1xI To Ado�t 4© '' /pl, Z4- 0 L r. dap "-kch LOW X17- /0/. O a 00 J'84/i PA/CZ S 14 /0 0 C? N OF NQRTIH AN'[X)VF,';.. uAiI YSTENA FUMPINQ r- sh 595 S hQ r'preek P Nd 2cl I � • Q Nbo V e.r� 1'�q . i DAT OF PVIMN hd.4 I`VKIa Ota myte Csta'f"tN CD v 4 Ut C' RECEIVE® F U U ry) LoV�? KRAvY ClUlAsE BAMBS IN FLACI., RCKM ;_. LEACWIELD KUN5A K AUG 12 2005 L:D 4mA+'.Iti o +s�. .. . ()THER EXPLAIN TOW HEALTH DEPARTMENT F NORTH ANDOVER F r (� r G� i Commonwealth of Massachusetts EClV ED City/Town of System Pumping Record SE 5 200 , Form 4 w� • TOWN OF NORI'i AN OVER H-ALTH DEPA'TMTNT DEP has provided this form for use by local Boards of Health. ThehSyst em_Pumpi ecord must be submitted to the local Board of-Health or other approving authority. . A. Facility Information .Important: When filling out 1. System Location: forms on the computer,use only the tab key. ` Address to move your 9J v S7 Elk, !/ !�\✓. cursor-do not . use the.retum Cityfrown State Zi Code .key. 2. System Owner: Name Address(if different from location) City/Town StatZi Code I✓t ``15=� �� Telephone Number B. Pumping Record I. Date.of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) 9-Septic Tank- ❑ Tight.Tank ❑ Other(describe)` 4. Effluent Tee Filter present? ❑ Yes B-10 If yes, was it cleaned? ❑ Yes ❑ No 5. Conditionqf� 6: . System P m Name Vehicle License Number company -- . 7. Location re conte ere())sed: Signat a of a er Date http://www.mass.gov/dep/water/a provals/t5forms.htm#inspect t5form4.doc•06/03 System Pumping Record•Page 1 of 1 COMMONWEALTH OF MASSACHUSETTS Z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION A f ED N A Q M She CT 0 3 2005 TITLE 5 soaR�o -, OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY AS SSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:_585 Sharpners Pond Road _ _North Andover_ Owner's Name:_William Shickolovich_ Owner's Address:_585 Sharpners Pond Road_ _North Andover,MA 01845_ Date of Inspection:9/22/2005_ Name of Inspector: Neil J.Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address:_111 Argilla Road- -Andover, oad__Andover,Ma.01810 Telephone Number:_(978)475-4786_ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ils Inspector's Signature: ` ate: _9/22/2005_ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments: ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:_585 Sharpners Pond Road_ _North Andover_ Owner:_Shickolovich_ Date of Inspection:_9/22/2005_ Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired The system,upon completion of the replacement or repair,as approved by the Board of Health, will pass.Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined' please explain The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_585 Sharpners Pond Road_ _North Andover_ Owner:_Shickolovich_ Date of Inspection: 9/22/2005_ C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**.Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_585 Sharpners Pond Road_ _North Andover_ Owner:_Shickolovich_ Date of Inspection:_9/22/2005_ D. System Failure Criteria applicable to all systems: You must indicate"yes"or`no"to each of the following for all inspections: No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ _No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool No Liquid depth in cesspool is less than 6"below invert or available volume is''/z day flow. No Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ No Any portion of the SAS,cesspool or privy is below high ground water elevation. No Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _No_ Any portion of a cesspool or privy is within a Zone 1 of a public well. An portion of a cesspool or is within 50 feet of a private water supply well. No y p sP >�� feet from a private. t vate water _ _No_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 f This stem asses if the well water analysis, supply well with no acceptable water quality analysis. [ sy p performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:_585 Sharpners Pond Road_ _North Andover_ Owner: Shickolovich_ Date of In_spection:_9/22/2005_ Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes No Yes _ Pumping information was provided by the owner,occupant,or Board of Health No Were any of the system components pumped out in the previous two weeks? Yes_ — Has the system received normal flows in the previous two week period? _No Have large volumes of water been introduced to the system recently or as part of this inspection? Yes _ Were as built plans of the system obtained and examined? Yes_ Was the facility or dwelling inspected for signs of sewage back up? Yes Was the site inspected for signs of break out? _Yes_ _ Were all system components,excluding the SAS,located on site? Yes Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the bales or tees material of construction,dimensions depth of liquid,uid depth of sludgee and depth h of scum? _Yes_ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _Yes_ _ Existing information. —Yes _ if an of the failure criteria related to Part C is at issue approximation of Y Determined in the field i PP es ( Y distance is unacceptable)[3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:_585 Sharpners Pond Road_ _North Andover Owner:_Shickolovich_ Date of Inspection:_9/22/2005_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4_ Number of bedrooms(actual):_4_ DESIGN flow based on 310 CMR 15.203_660_ Number of current residents:_2 Does residence have a garbage grinder(yes or no): No_ Is laundry on a separate sewage system(yes or no):_No_ Laundry system inspected(yes or no): _ Seasonal use:(yes or no):_No_ Water meter reading:_On well water 100'from septic system_ Sump pump(yes or no):_No_ Last date of occupancy:— Current—COMMERCIAL/INDUSTRIAL Type of establishment:__ Design flow(based on 310 CMR 15.203):_gpd Basis of design flow(seats/persons/sgft,ete.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):, Non-sanitary waste discharged to the Title 5 system(yes or no):— Water meter readings,if available: Last date of occupancy/use:_ OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped this year,owner_ Was system pumped as part of the inspection(yes or no):_No If yes,volume pumped:,gallons--How was quantity pumped determined?, Reason for pumping: TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool_Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: No date on as built plan. Design plan dated 5/14/1990_ Were sewage odors detected when arriving at the site(yes or no):_No Page 7 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_585 Sharpners Pond Road_ _North Andover_ Owner:_Shickolovich_ Date of in 9/22/2005_ BUILDING SEWER_X_ (locate on site plan) Depth below grade:_20"_ Materials of construction: _X cast iron _X_40 PVC_other Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.) _4"PVC Thru wall to septic tank.3"PVC in house,no leaks visible_ SEPTIC TANKS:_X Depth below grade:_8"_ Material of construction: X_concrete—metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 10'x 5'x 4'_ Sludge depth 0"_ Distance from top of sludge to bottom of outlet tee or baffle:_27"_ Scum thickness:_0" Distance from top of scum to top of outlet tee or baffle:_8" Distance from bottom of scum to bottom of outlet tee or baffle: 21"_ 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._Inlet tee ok.Outlet tee ok.Depth of liquid at outlet invert. No evidence of leakage. GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_585 Sharpners Pond Road_ North Andover_ Owner:_Shickolovich_ Date of Inspection:_9/22/2005_ TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOXES:—X — Depth of liquid level above outlet invert: _0_ Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.):_D-Boz level&distribution equal.No evidence of carryover.No evidence of leakage _ PUMP CHAMBER:_(locate on site plan) Pump in working order(yes or no):_ Alarm in working order(yes or no):_ Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_585 Sharpners Pond Road_ North Andover_ Owner:_Shickolovich_ Date of Inspection:_9!22/2005_ SOIL ABSORPTION SYSTEM(SAS):_X (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: _X leaching trenches,number,length: 2 trenches 26'long_ — leaching field,number,dimensions:_ overflow cesspool,number: ve/alternative system T e/name of technology: innovate y Type/name Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.):_Soil oL Vegetation oL No sign of ponding to surface._ 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 sludge layer: Depth of scum layer:_ Dimensions of cesspool: -- Materials of construction: _ Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):_ PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of I 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 585 Sharpners Pond Road_ _North Andover_ Owner:_Shickolovich_ Date of Inspection:_9/22/2005_ SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. D-Box A to Inlet Cover=26'8" A to Outlet Cover=3515" ® A to D-Box=41'4" Septic Tank ® B to Inlet Cover=36'4" B to Outlet Cover=3618" B to D-Box=50'6" Dec Driveway B A House To well Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_585 Sharpners Pond Road_ —North Andover Owner:_Shickolovich_ Date of Inspection: 9/22/2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water _4'_ Please indicate(check)all methods used to determine the high ground water elevation: X Obtained from system design plans on record-If checked,date of design plan reviewed:_5/14/1990_ Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain:_ Checked with local excavators,installers-(attach documentation) _ Accessed USGS database-explain:_ You must describe how you established the high ground water elevation: As per design plan_ Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating-Water.& Sewer Lines-Septic Systems&Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 585 Sharpners Pond Road, North Andover Owner: Shickolovich Date of Inspection: 9/22/2005 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. F Neil J. Bateson Bateson Enterprises, Inc. COMMONWEALTH OF MASSACHUSETTS = EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS Y a DEPARTMENT OF ENVIRONMENTAL PROTECTION r i „y 4. Sy• TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 585 Sharpners Pond Road North Andover, MA Owner's Name: Stephen & Lori Clark Owner's Address: 585 Sharpners Pond Road North Andover, MA 01845 Date of Inspection: 9/6/n2 Name of Inspector: (please printf James Wr i �jljt Company Name: R _J_ Tn4pPrtjons , Inc. Mailing Address:_ One nsgood Street mei- MA 01844 Telephone Number: 978--68i -8759 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15 340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Furtherirattion b the hh Local Approving Authority Fails 9� i Inspector's Signature: Date: —'� 6 0 z 0 The system inspectors ubmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. TOWN OF NORTH ANDOV7R/ BOARD OF HEALTH SEP I k0,2002 Title 5 Inspection Form 6/15/2000 page 1 r Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 585 , harm rs PQnd Road North Andover., MA Owner: StPnhen K Lori Clark ark Date of Inspection: 9/6/02 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health, will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: i I 2 I Page 3 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 58harmers Pond Road --North Andyer_mA n j Rqr, Owner: Stephen & Lor, Clark Date of Inspection: q 6 Q 7 C. Further Evaluation is Required by the Board of Health: Conditions exist which require fiu'ther evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. — The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 5 A 5 Sha rjQ�P� pond Road, nTnri-h Andnppr., MA Owner: fitP�hPn & Lori Clark Date of Inspection: 9 A /n D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No� / B"ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or �elogged SAS or cesspool i/ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool 7�� uid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number �6f times pumped y 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. y portion of a cesspool or privy is within a Zone I of a public well. y portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is wi 00 et of a sur -e drinking water supply the system i within 20 f t a tributary to a surface drinking water supply the system is loca d in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or.answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 585 cls-rpner.9pend Road I`Q32th Andav6�r-M.A Owner: StP=hPn Tori Clark Date of Inspection: 9,/6,/Q? Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes,410 Puping information was provided by the owner,occupant,or Board of Health :Were any of the system components pumped out in the previous two weeks? -- Y P P P '__z' 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 ba 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: Ye�tio Existing information.For example,a plan at the Board of Health. _ Determined in the field(if anof the failure criteria related to Part C is at issue approximation of distance y PP is unacceptable) [33 10 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 585 Sharpners Pond Road Nor b Andover, MA Owner: Stephen F, Tnri Clark Date of Inspection: 9,Z.6/n 2 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage g inder(yes or no): eW Is laundry on a separate sewage system(yes or no):7— [if yes separate inspection required] Laundry system inspected(yes or no):_ Seasonal use: (yes or no):,IV(j Water meter readings,if available(last 2 years usage(gpd)): y�y Sump pump(yes or no): Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flown /sgft,etc.): Grease trap prEho es o o): Industrial was� in re nt(yes or no): Non-sanitary e 'sch ed to the Title 5 system(yes or no):— Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): = If yes,volume pumped:_gallons--How was quantrty pumped determined? Reason for pumping: _ TY OF SYSTEM _Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) —Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate nage of all components,date installed(if known)andour of information: Were sewage odors detected when arriving at the site(yes or no): i 6 Page 7 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 585 Sharpners Pond Road North Andover MA 01845 Owner: Stephen & Lori Clark Date of Inspection: 9/6/02 BUILDING SEWER(locate on site plan) Depth below grade: _ Materials of construction:_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK:_(locate on site plan) Depth below grade: Material of construction ✓concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 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: -How were dimensions determined: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of sc o f outlet tee or baffle: Distance from bottom sc bottom of outlet tee or baffle: Date of last pumpin Comments(on p ping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_ 585 Sharpners Po.nd Road North Anrinvar MA Owner: �fiPnhAn lark Date Date of inspection: TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: ons Design Flow: gallons/ y Alarm present(yes or no Alarm level: Alarm in wo7at orde or no): Date of last pumping: Comments(condition of alarm andswitches,etc.): I DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Q 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.): PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no/ Alarms in working orde �Q or o): Comments(note con tion of ip 'a er,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 585 Sharpners Pond Road North An over, MA 01845 Owner: Stephen & Lori C ark Date of Inspection: 9/6/02 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type I leaching pits,number:_ leaching-chambers,number: le ing galleries,number: ,aching trenches,number,length: �� 1 leaching fields,number,dimensions, overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquioosoil, i' Depth of solids laye Depth of scum layer Dimensions of cesspMaterials of constru Indication of groundt or no): Comments(note cogns of hydraulic failure,level of ponding, condition ofvegetation, etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of ign of Hydraulic failure,level of ponding,condition of vegetation, etc.): 9 Page 10 of I 1 I. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 585 Sharpners Pond Road North AndoVer _ MA Owner: Stephen & Lori Clark Date of Inspection: 9,/6,/02 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. I S;)rlZ 1 10 i Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 585 Sharpners Pond Road North Andwpr , MA 01845 Owner: Stephen & T.C)ri Clark Date of Inspection: q 2 SITE EXAM Slope c/ ; Surface water Check cellar y Shallow wells Estimated depth to ground water feet i Please indicate(check)all methods used to determine the high ground water elevation: i Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Che 'ed with local Board of Health-explain: cked with local excavators,installers-(attach documentation) ccessed USGS database-explain: 6 You must describe how ou established the igh groundwater elevation: ' 11 uuPaiutu.W ULCF.usgs.guW can Vm_w1twuntnr v4_vo.i.�t SUMMARY OF GROUND-WATER LEVELS AUGUST 2002 PROVISIONAL (NOTE: Wells with * also available in real-time at top of Ground-Water Data page) WELL L START NET CHANGE DEPARTURE WATER LEVEL T I YEAR IN MONTH IN ONE FROM BELOW LAND- 0 T OF YEAR MONTHLY SURFACE P H RECORD MEDIAN DATUM 0 0 (FEET) (FEET) (FEET) (FEET) DAY MASSACHUSETTS ACTON 158 * TS 1965 - 0.42 - 1.55 - 1.04 20.47 27 ANDOVER 462 VS 1968 - 0.36 - 1.09 - 1.37 16.49 28 ATTLEBORO 83 VS 1964 - 0.38 - 0.76 - 0.70 5.17 27 BARNSTABLE 230 FS 1957 - 0.95 - 1.32 - 1.74 26.27 < 28 BARNSTABLE 247 FS 1962 - 0.42 - 1.20 - 2.38 27.00 28 BECKET 12 TS 1986 - 0.36 - 0.11 + 0.31 3.53 28 BILLERICA 363 HS 1962 - 0.34 - 0.69 - 2.12 12.14 27 BLANDFORD 9 VS 1986 - 0.47 - 0.74 - 0.21 3.14 28 BOURNE 198 FS 1962 - 0.53 - 1.31 - 1.13 34.87 23 BOYLSTON 87 VT 1995 ----- ----- ----- ----- DRY BREWSTER 21 FS 1962 - 0.35 - 1.61 - 3.04 13.27 < 22 BREWSTER 22 * FS 1962 - 0.46 - 1.18 - 2.21 33.33 < 27 CHATHAM 138 FS 1962 - 0.30 - 0.98 - 1.33 25.56 22 CHELMSFORD 384 TS 1987 - 0.53 - 1.18 - 0.89 16.93 27 CHESHIRE 2 HT 1951 - 2.62 - 2.13 - 1.81 10.04 27 CHICOPEE 95 TS 1984 - 0.35 - 2.01 - 2.19 23.78 << 27 COLRAIN 8 VS 1965 - 1.30 + 0.35 + 0.46 20.10 27 CONCORD 165 TS 1965 - 0.21 - 3.40 - 3.49 44.68 27 CONCORD 167 TS 1965 - 0.83 - 1.76 - 2.59 10.92 < 27 CUMMINGTON 13 VS 1986 - 0.50 - 0.30 - 0.48 6.36 27 DEDHAM 231 ST 1965 - 1.88 - 1.17 - 2.29 12.64 26 DEERFIELD 44 VS 1965 - 1.65 + 0.29 - 0.90 4.76 27 DOVER 10 TS 1965 - 0.62 - 0.17 + 0.13 33.74 28 DUXBURY 79 * VS 1965 - 0.82 - 0.94 - 0.54 9.81 27 DUXBURY 80 VR 1965 - 0.78 - 0.62 - 0.23 23.00 27 EAST BRIDGEWATER 30 HT 1958 - 2.33 - 1.62 - 1.07 13.51 26 EDGARTOWN 52 VS 1976 - 0.31 - 2.01 - 2.01 19.64 < 27 FOXBOROUGH 3 TS 1965 - 0.59 - 0.74 - 0.55 20.37 26 FREETOWN 23 TS 1964 - 0.47 - 1.56 - 1.57 15.33 < 27 GEORGETOWN 168 VS 1965 - 0.71 - 0.58 - 0.79 6.43 28 GRANBY 68 VS 1954 - 0.87 - 0.69 - 0.70 9.82 27 GRANVILLE 5 TS 1965 ----- - 2.17 - 2.17 35.09 28 GRANVILLE 6 SS 1965 - 0.83 - 0.87 - 1.50 8.38 28 GREAT BARRINGTON 2 VT 1951 - 0.27 - 0.03 + 0.33 12.26 27 HANSON 76 VS 1964 - 0.42 - 0.90 - 0. 68 5.85 27 HARDWICK 1 TS 1965 - 0.76 - 0.72 - 0.06 15.98 24 HARDWICK 31 TS 1984 - 0.04 + 0.78 + 0.78 10.67 > 27 HAVERHILL 23 TS 1960 - 0.88 + 0.14 + 0.14 13.31 28 HAWLEY 8 ST 1986 - 1.22 - 0.62 - 0.77 5.38 27 HOLDEN 169 FT 1995 - 2.64 - 0.75 - 0.75 5.90 27 LAKEVILLE 14 * TS 1964 - 1.62 - 3.98 - 3.46 20.26 27 LEXINGTON 104 VS 1965 - 0.78 - 0.66 - 0.48 3.78 27 MASHPEE 29 FS 1976 - 0.51 - 1.24 - 0.98 9.80 < 23 MIDDLEBOROUGH 82 VT 1965 - 2.18 - 1.08 - 1.50 16.07 27 MONTGOMERY 19 SS 1986 - 1.40 - 0.89 - 1.20 3. 63 28 NANTUCKET 228 FS 1976 - 0.35 - 0.68 - 0.90 25.25 27 NEW BEDFORD 116 VS 1964 - 0.31 - 0.90 - 0.75 5.13 27 NEWBURY 27 VT 1965 1.96 + 0.01 - 0.10 10.30 28 SUMMARY OF GROUND-WATER LEVELS AUGUST 2002 PROVISIONAL Commonwealth f Massachusetts assachusetts System Pumping Record System Owner System Location GlQx-tic_ 5r- s- ,q�fvl�s Date of Pumping: Quantity Pumped: /`j'?-f:gallons Cesspool: No Yes [] Septic Tank: No [] Yes [-]� System Pumped by: 64&4" License# Contents transferred to: Greater Lawrence Sanitary District Date: Inspector: Tt' 27 I Commonwealth of Massachusetts City/Town of E�EIi/ED a 3° System Pumping Record NOV 13 2008 Form 4 _5 Dye �E NORTH ANDOVER DEP has provided this form for use by local Boards of H althwQ16al18rt8Thi gybe sed, but the information must be substantially the same as that provided ere. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Location: Left fron left r )eft sid6of1houD. Right front, right rear, right side of house. forms on the computer, use ��,, only the tab key Address to move your cursor-do not use the return City/Town State Zip Code key. 2. System Owner: S Name �y Address(if different from location) City/Town StaP a. & ip ode i Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: 0 Cesspool(s) _'Septic Tank Tight Tank Other(describe): . 4. Effluent Tee Filter present? 0 Yes If yes, was it cleaned? 0 Yes No 5. Condition of System: � 6. System Pumped By: Neil Bateson F 5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: .L.S.D Lowell Waste Water 0,4 igna ure of H u r Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 DATE Sheet of BOARD OF HEALTH TOWN OF NORTH ANDOVER / SUBSURFACE DISPOSAL DESIGN REVIEW � �-- �/l ` FEE_ �P PENT # �7/ DATE RECEIVED �O I APPLICANT ASSESSOR'S MAP ADDRESS PARCEL # LOT # I ENGINEER ��/l_/1JII�/k d STREET ADDRESS i PLAN DATE REVISION DATE CONDITIONS OF APPROVAL: APPROVED DISAPPROVED /) - � Cf �- j/iO�- / v Th� ,9 me T 1jGd Se� 3J 5G1/¢d oN �� 191,11A16 i VLR/yy 'g,, _ lScP,��f��vci�s �J , Granite State Analytical 4344337 P. 01 Post-It" brand fax transmittal memo 7171 k df pagas To y U 1\l From V#' /C�f Co. Co, �^y} GRANITE STATE ANALYTICAL, INC. Dept. I�hune# 61 EAST BROADWAY FaxW-2y DERRY, NEW HAMPSHIRE 03038 tj './ - r `} Fax (603)432-3044 LABORATORY RESULTS ------------------ SENT TO: Pheonix Homes TEST NO. : 7782 Box A 6 Apt, B 12 Parmenter Rd TEST Londonderry, NR 03053 LOCATION: Lot 1 Sharpeners Pond Rd, Attn: Joseph Decarolis No. Andover, NA DATE; July 8, 1992 PARAMETER RESULT RECOMMENDED LOWER DETECTION (PPM) MAX.LEVEL(PPM) LIMIT (PPM) ----------- --------------- PH 7.29 UNITS 6._5 - 8.5 2 HARDNESS 164.0, 15 jD0 m9� 0.1 CHLORIDE _80 0.1 NITRATE 0,90 10,0 0.5 NITRITE 0.05 1.0 0.05 SODIUM 12.6 250 1.0 IRON 0.05 0.3 0.01 2 MANGANESE 0.452 0.05 0.001 COLIFORM 0 /100 ML 0 0 OTHER BACTERIA 0 /100 ML 200 0 COPPER 1.0 0.001 ARSENIC 0.05 0.0001 LEAD 0.05 0.0001 CHROMIUM 0.05 0.001 CADMIUM 0.01 0.0001 SULFATE 10.0 250 10.0 COLOR 10.0 CPU 15 1 ODOR TURBIDITY 0.72 NTU 5 0.1 T.D.S. PPM 500 .001 THE TESTED PARAMETERS MEET CURRENT STANDARDS FOR DRINKING WATER. X THE TESTED PARAMETERS MEET"CURRENT PRIMARY STANDARDS FOR DRINKING WATER, BUT SOME SECONDARY PARAMETERS EXCEED STANDARDS. THE TESTED PARAMETlR($) FAIL CURRENT STANDARDS FOR DRINKING WATER, DUE TO PRIMARY STANDAEtris OUTSIDE OF LIMITS. ------------------------- - ' - COMMENTS: ALKALINITY a 140.7 PPM CONDUCTIVITY - 377.0UMOH -^^^ MAGNESIUM . 9.54 PPM CALCIUM - 43.5 PPM -------- ---- ------------------ TNTC DENOTES TOO NUMEROUS TO COUNT. 1 DENOTES PARAMETERS THAT EXCEED PRIMARY STANDARDS; CAUSES TEST FAILURE, 2 DENOTES PARAMETERS THAT EXCEED SECONDARY STANDARDS; DOES NOT FAIL TEST. NOTE: SUBSEQUENT SAMPLES FROM THE SAME WATER SOURCE MAY VARY. L1 f ,►ORTIy , BOARD OF HEALTH ' 120 MAIN STREET TEL. 682-6483 CHUSNORTH ANDOVER, MASS. 01845 Ext. 32 i July 6, 1992 Christiansen & Sergi 160 Summer Street Haverhill, MA 01830 RE: Lot 1 Sharpner's Pond Road Dear Phil: The proposed plans for the gravity-fed septic system at Lot 1 Sharpner's Pond Road have been rejected for the following reasons: 1. Elevations of the house sewer and septic tank relative to the grading elevations are incompatible. 2 . Grading also suggests that there may be problems with ponding and surface runoff at the house. 3 . All piping must be stipulated as SCH40. 4 . Please verify benchmark on site plan; two are present. I Please rectify plans and return for review, along with an addition fee of $25. 00. Thanks. Sincerely, Sandy Starr Health Agent i S � AS-BUILT CHECK LIST and FINAL INSPECTION Proposed Elevations As-Built Elevation House Tank IN Tank OUT 1( /. (,tom 1 0/ D-box IN 161 3,::5-- /.6 / ¢/ D-box OUT /af. / 8 161 . 01-21 Trench Inverts Line 1 Line 2 ��/ ! _ 2 �f /0j Line 3 Line 4 Bottom of Exc. 9 Stone OK? D-box checked? P Pi es cemented? y I . 4 / I M4. 0 7->4til pot 7�-c /r l xI ro 4- �� i emo Lek(At,Nb- loi. 0a /0/• ®o PLAN REVIEW CHECKLIST ADDRESS Q r ENGINEER GENERAL 3 COPIES STAMP b,-' LOCUS SCALE CONTOURS PROFILE (/ SECTIONy BENCHMARK ELEVATIONS SOIL 4 / t & PERC INFO i/ WETS. DISCLAIMER WELLS & WETLANDS i WATERSHED DISTRICT DRIVEWAY WATER LINE DRAINS RESERVE AREA SCH40� SLOPE SEPTIC TANK MIN 1500G. . 17 INVERT DROP GARB. GRINDER (+200% EDF) 25) TO CELLAR MANHOLE TO GRADE ELEV GW D-BOX # OUTLETS FIRST 2' LEVEL STATEMENT INLET OUTLET = (2" OR . 17 FT) LEACHING 100' TO WETLANDS 100' TO WELLS 325' TO SURFACE H2O SUPP 35' TO FND & INTRCPTR DRAINS 4' TO S.H.GW 2% SLOPE 4' PERM. SOIL BELOW FACILITY MIN 12" COVER FILL? (251 if -above natural elevation; 101if below) TRENCHES MIN 660 FT2 SLOPE (min .005 or 6"/100' ) >3 ' COVER? - VENT SIDEWALL DIST. 2X EFF. W OR D (MIN 61 ) IS RESERVE BETWEEN TRENCHES? IN FILL? MUST BE 10' MIN. BOT X LDNG + SIDE X LDNG = TOT (L x W x #) (G/ft`s') (DxLx2x#) WeARM, 1 � _ 64fQ► 1 gwi V-4 i .MRS ► • L.1 �i i ?i,�/ L� • 1bi 1A �` kmI III ME WN ra I Magi a - - W . i slill 12135 MA Irl s Oil - . • • �IAA , . NUKLIFIR FEE THE COMMONWEALTH OF MASSACHUSETTS $95 - 0 fl ... of .......N(j.R.TH...AND.OV.E.R............................... This is to Certify that ---.LaRocque...We11&'....Ud NAME 244A Haven Street, Reading, MA ...................................................................................................................................................................... ADDRESS IS HEREBY GRANTED A LICENSE For .-.....-.-Well Drilling ReT:Mit for Lot #1 Sh��: pers Pond Road .................................I............ . .........-................................ ..........................................I...................................................................................................... ......................... ...................................................................-......................................... .. ......................................... .......................................................................................................................... ................................................ This license is granted in conformity with the Statutes and ordinances relatin,r thereto, and expires.......Dece-mber....31,-.1.992.... C88 sooner suspe rev ked. ........ --•--•- .....-- .............. . ...............•---•-•-•-•19-..9.2 ................. . ........... ..... FORM 433 HOBBS 8 WARREN. INC. . ................. ,'f J Department of'Environmental Management o er lesour t4 # WATER WEL.L.COMPLE 10 l WELL LOCATION: GEOGR PHIC Address 1 SPAAR PERS POW RL7 _ _ N S `t W. (feet) (circle) City/Town N. •P1�IDUVF,R SharpnerS :Pond JAY DICE (road)Well owner i Address 600 51111P7NC 1 ROAD 1.1. Id S E i D t-r _ - yntL,in tenthsl ldrela ER .. Board.of Health permit: yes.[] no [] intersetiC.'w/ 1 (road/ tl WELL USE WELL DATA T Domestic Public Q Industrial Q Total well depth 2.75 i lylonitoring Q Other Depth to bedrock 20 ft. I . Water-bearing rock/unconsolidated that; Method drilled RQtary I Date drilled Description - B1_{34JY1 Rock Water-bearing'zones: CASING at:Gt'1 1) From 1170 To 175 Type Length-_ft.D1a(.I.D.) 6 in. 21 From 250 To 260 C 31 From To Length into bedrock_ 10 ft. Gravel pack weUh ' die. Protective well seal: t Screen: dia. Grout.❑ Other Drive Shtx- Slot"- length from_to— STATIC WATER LEVEL' Static water Level beiow land surface 25 It. Date " I , WELL-TEST. Drawdown275' II.s after pumping hr.30 min:at 12 gpm How measured ALL Recovery 100 1t. 'after 1—hr. mK ' i frcm rj LOG of FORMATIONS. COMMENTS ` Materials Flom To $ l sand/crraiVp 10 20 BtdfoCk- .20 275 Driiii X .Armstrong Mass. F 'rtion1 256 y Firm 'The Rock W011S, LTD Address244 Himmn Street If City/Town Readi64 NUM,'iFR FEE THE COMMONWEALTH OF MASSACHUSETTS Qv ................ /�.. . of ..... This is to Certify that .... C17�i.. G - NAME 4wo....` ...ri m. ,�1/ ------------------------------------------------------------------ AD KESS IS HEREBY GRANTED A LICENSE For ........... / ----------- -- J L1 - .------•-----•-----"•-•.................•------.....................-----..._...... . --••--......---- .. ............................................................... .............•---..._.......---.................... ...... This lie nse is granted in conformity wit the Statutes an inaelatin;, thereto, anal expires....._ � p �" --.. .. -.- -............ :"(Plcss sooeie ende r ...-•------�........ . s .. ............ ••---- ' ------- y. -• ••-- ............._.... .---- --- .. •---..•--- FORM 433 HOBBS 8 WARREN, INC. """"'-"-"-'""" 1 Ile d DATE r0 ( Sheet of fi BOARD OF HEALTH TOWN OF NORTH ANDOVER SUBSURFACE DISPOSAL DESIGN REVIEW FEE PERMIT # DATE RECEIVED td 3 C t— APPLICANT ASSESSOR'S MAP ADDRESS PARCEL # LOT # � r STREET S ENGINEER �lt+'(,1 S i(MJF,--� � 56�t��i�,C . ADDRESS �;,y tt-tE,2, `�i � �(� ►.�a PLAN DATE REVISION DATE CONDITIONS OF APPROVAL: APPROVED DISAPPROVED �i��A^2 �\�� I✓`�Jp�Ot� � �E i►�Dt L�-� t`� /2411 to Dock pls QAAt.,,c IL --s vvj yoQ2, --3 'Tp s`cz "Tl4--n f iuto UEI ou, r" ��.i �J��. his i i2i['��}1 c�r�J �'_�J � i�•C�.Nt`�C-V t:f� K s�DIc> -j?'>6- 1Neok--�-c`-o . 0 -,� : So`�H (�J -(-Z> Coe c � `ir u. y is x, �A '�'so+•r�s 4 rf+r N� -<��.�# t�1, ',�`"y�'Y=3•��,�'*. �yt����4�'t��§i,�r�;'J".'S�'"'tx'��t*,.' af'Le€,-_s� 1, •.i .. .., ,I ; . Town of North Andover, Massachusetts G Form No.s MORIN BOARD OF.HEALTH 19_ • ----��'• DESIGN APPROVAL FOR ' a• S'SA u5E SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM , Applicant 1 Test No - Site Location Reference Plans and Specs. � i,�5T1�tiJ5 ENGINEER. DESIGN DATE Permission is granted for.an individual soil absorption sewage disposal syste o be i `led in accordance with regulations of Board of Health. I. CH N, EA TH • %,`� Site System Permit No.� Fee �'`� � �t i 1 ti it • i' G DATE � f 3 �r Sheet of BOARD OF HEALTH TOWN OF NORTH AN SUBSURFACE DISPOSAL DESIGN REVIEW FEE PERMIT # DATE RECEIVED 7 �f APPLICANT UD(—(l(l D1- ASSESSORS MAP ADDRESS PARCEL # LOT # >` • STREET ENGINEER ADDRESS PLAN DATE lREVISION DATE CONDITIONS OF APPROVAL: APPROVED DISAPPROVED X mkls i toes® 14A, 4,1,ieffl f- -k-Pkv3 V,-- b.-:5 A- "��s`gyp Q- V3GL 'D)si►,jj V o1 o H e ��,Jk O V50 CELS Lo klf?t THCe ,16=,o C `flk -FJ"f CEJ A��-�- f5t�� � L S efl& 1 0o�c._ r "art t Cry K --� t�.V� A� ©.v-ro �-tis-�Zc. c +�(� t 1•-{�+.�vd-(� ��tT��� S. Ltc !� \115,500 4vb4--- r REVIEW CONTINUED SHEET 2- OF L � � 714C WGA wel �i►.� ,�. 1�'t�x-c Tt +�x �r�► til 73 �i l LuiT cv C.��-..�8,....'i�� ��� �F '�"�y►..tD -�, 1��1„t��C-�J S'�NL`T- S ��2i2�� &[art M Lucc> -T`l P6- ov: -Fmcc -56 U-1 Lo Lo -n+e e-,Q-A.o e t-\T 'R ." 5� o"7- kWX4---, Lb 74C 54.1E Ele-7At?oO 05l LC)0 s CA.)I � ���a a ti 4• xf k�rl Y • , r rt �' Wi1rY w r p 2- f `ti rl t iiA��-ill/•(l(/V!1/ "F r1. 1 Ji '� ly1eTa"��r i l Fh ( �f! S I' .,s t��l•T. ���Q�(✓.ix'S FyJ {�.;��� ���y,*,k .h t5.- �y'ly*!���.:iFX�{r`}�, .. ,. i. x ,.- h .y:y�!:,4+a�I �A45.�r�•_A.r�..Ml-k!�t1.i`k �. .._ _ .. M-A::t• :$ x ... �. 2^ �. J,'.:h..e .,. .. ., ,h . 71 IF, t;�ax�F 1N�>i E;r?{ ,+ r. •, tr. t '� �� 3 f ��"'�' {ra Vii. � i u k' 1 T � 1 C, a r i JVI �� cw'��t�' a r r � Y • 3 1 { 9� r ♦ f A� J i t y t 4 t J i Y°r P ^ ` ~ ` , Rice &5ineetiI45 �CtviCC6 ^ . ' 9. 0' BOX 1108 ~ SAUGUS, MA 01906 October 17, 1986 (617) 233'5372 Mr. Mike Graf Board of Health 120 Main Street North Andover, MA 01845 ' Dear Mike, Re: Septic System Design Lot # 1 - Sharpeners Pond Road I am enclosing the following : 1. A print of the original septic system design presented to you for the above referenced property. 2. A copy of the comments that you put on that design. 3. A sketch of a revised proposed design. I believe that the revised design addresses those issues raised by you in your earlier review. The depression to the east of the property does not appear to be a significant contributor to mater over the leaching area. It is separated from the leaching field by a stone mall , and we do not have access to the property to resrade that area. Additionally, there is room for a smale to the south of the leaching area to drain off any mater coming from the east. The same smale will. move any mater coming from the south away to the west. As you correctly pointed out, the reserve area is upgradient of the leaching facility. It was our intent that should the reserve area be required in the future, a chamber and pump mould be required in parallel with the original leaching field to distribute the flow to the reserve area. We mould so note that necessity on the final design. I trust that these modifications will satisfy your concerns. I will be in touch by phone in a meek or so to discuss the design in more detail with you. And, assuming that you. are then satisfied, I will finalize the design for your approval. Very truly yours, Malcolm S. Rice � / ' ii aw T�Cd �r4 Ops- �� .��f .Ru. w o-- "•-� off,•-- : . .. .. + . . .� , . 11, �,1 its 3 r SUBSURFACE--SEWAGE D"ISPO$AL SYSTEMINSPECTION ~F.ORM , 1. Address{ of1. pr1.operty " _h.a2nnc,2s P�,,�/ �e ,v, J ANcYOve/L Evia owner'sy,name ;. , ,?'�Y" �` �-,9rfoFN� Date ofr; Inspection � .�,,qs- . k" PART A. } CHECRLIBT a r , Check tf tthe fol:lowiiiing have b:ee� done.: K P,uxap�ng ,nformation , . ;reques ed of the ,`owner, occupant, .and Board of ea l"th' , ., r ,i ' 1. s None of. the system component have been pumped for.. at least two weeks1. and the system has been :: , . Z.. ng normal_-flow; rates duxing` that period:< Large ,,volumes of water Piave not ;beery introduc"ed into;'the, system recently.,or 'as part of th'as zrispectzon fsr, z 6 6As bulht {`pl11-1:ans have been: obtained` and` examined. ' ,Note �f they are n. 't available with N/A ,- a i xs' z,,_%_,, .. h, �, fac�lxty or dwellzngJwas' 1. inspected for sa.gns of sewage�lback up �.`�i f�„ t t s "tr 4. r`� r i z�.a �`s t cf r`'�1r.x y t:, x A + '� j Thi sato was; inspected for s gns6. ,of reakout. �' A1�; system components, exclud,-ng 'the SAS, have been located or} the 4 n ,{e R n o- C _ 1 . The;°septic tank manholes. werefr uncaverad, opened, .and .the ulterior o.f the septzc tank was �nspectea far=%-condition o ba fles` or tees '` i'Iflaterla,l �Mo`f construc:tlan�,-� dimeisfl,�.ons Jr` depth of 'lzgt.�ld,. dei th of 3 Aa' I @ -d k R. # -f+'*e.,7 7t � w p�rJc,4' 5. Y p .4 .4 sludge, ' depth of scums, x �`� ` � { °x ,;�,� t a :r t % ' + # s The size;lana �oc�ata on of:: they SAS ,bn tie site y2as bee.1111,n determined based on, ,ex�st�ng znformation 'o-4. Ppro4�mated� } " non# ntrus ve�11methods., 'F k °J ' . L ,, Y { t�,5}.. a t �_'� #} :'r y d L .1. 'i M..z°�r r t$°� � } '+ 4�;'ac i'+: �` �qF�l x:,45.y �,{ �;Y T1;1,he fac:ilzty1-:4 o�5.1wner ('and l.,occupants;,�Hi d� ffere it ,From .curer) weI. re provided wzth irifozmation on ;the :proper maintenance of:. SSDS rI. i 'r. . 1. { t +�'r 4,a i �4J r c " i j -,4 7 1. 4 3 ,.1.+ ry 'x f , , i _..r `, r +1f+. f�a I .... J. r 4F .6r nA' ': H Yy : �.' ' a� {fi'. q5 3 V,,, `Pi,., SUBSURFACE: SEWAGE DISPOSAL SYSTEM INSPECTION ;FORM' ,giir PART 8 . e , 1 SYSTEM INFORMATION + t J {. ,� ::' i :, 2 . �,/� ^{ F W CONDITIONS I.fb re's'idential^ 1 ` ' »: .-..__ number1. of °.bedrooms `et num111-111- ber of`: current residents I. BYO garbage grinder, yes or no' ,. `^ laundry connected ;;:to system, . yes or, no �f'oy seasonal ,:use, yes, or no { t If nor ''' 146nt al, calculated `flow; ft Wtate'r �.mete'r re*adings�, if available �-°�-- e �, i all , e 1 5 C. 1Y. YS s A I {- , {'i 1 N 1�11k 4 1 , t ' $ x I L, .. i Y f.S) M' '.t 4 �� �r¢�- ". Last date o occupancI.y • - 5 ' t ' L t %1 F 1 , f l.T s 4 x SY 'i 1` S k t{ ,S "k y ,x y i .� t -.i 4 F .t } s,$:R$, o-r r .. ­14GENERAL INFQRMATION f 4 .r t :.f Y , f' Duping recokdstsand `source af, informataon. >. t,Ak r i. a. '.yw } r } M1 ac 1 t +�„ i .� t Y �' z *. . e%G 4 R , _ i 11, �:;, � ' System"'pumpxed +aas part of` inspectxion, yes oz na if yhes, volume pumped (meq 2, ' Reason fox puping� V' _ /J /�^ /J/ /J 4 ,.� ��� �.' I /Slk � . / :IF,4!��F/L �F�3�x�4���1'', �� j 7 ' s I 11 rA } , '""+'4 ,f Y t { S S ,. tf a .t.t 1 l ..L r a Yr " M t -, r aEir a ! -> ('i :w Y f �4 ry �' t M ! ) " Y t J 4 f Y ut Y '4 }.Y i* .f --3 C'' I'llType of syst�`m t N 'Septic tank./distr�but'ion boars, absorption ¢system Slmgle 'cesspool ' O��rflow:cess;pool r ,� 11. t i,t',#,. -Y �. °>v ».,t .'i t )t< t,t c 4 f w M1 i ' °r . r ,p* y s :il t y (y no "s f es attagk� previous inspecta.on �4 >Y Shared s stem , es-Qz ) Y , �: } "" recgrds 1f -any) . K ff ., ,fi '} e � � < �, t7 r t z i h s t ?a j, f �, N ,'.y e 1 {w4Other� Cexpla n)?� = e } p'a.t.-, t {; eta �, tY r,7. �^-} Y t'!• i ? + \I��Y�'h �y f !4 ,rya Y,4 t f{... I..A .e1 ApproximateI. age of all' components� rDae installed, �f kr;awn Sou�cce of11 r 4 > .i T %> information, i k �� 1. ��a � .1 , 7 77-7777 r �, " t t { - �i eez % r 'i 't` " ` v at" th'e 'site; es or `-no t Sewage. odors detEcte " when; arriV�ng Y a t xF IY l� I e 4 :✓ i ¢ S11; J t t N 'i q I ' 441 ! f ' q .j •. k. R.S, fi.' x } +. :,`.?.Y t 1:1Yt .:iry..r14 .�:� ��4. m Y '.4 .y .: ry }1 -.4 t 7i> i l:,t d wi C 1 11 f ..: .. .. .. +' ., ., , '� .,. t .� .t.'.. .i i i Ax ' T kOK SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .SYSTEM INFORMATION COAt. ued � . SEPTIC TANK (locate: on site ':plan) , depth below grade. material of -construction: ✓^concrete metal FRP other(explain) ." dimens-sons t, L sludge '.depth c c of .outlet '.tee or baffle... , � dzstance from top o ' sludge `to bottom € = ,. '`; distance from. top o;f scum to top. of outle tete. or baffle distance from bottom of scum` to :bottom of outlet tee orbaffle` Comments '(re'commendatiom"for pumping, :.condition t�f. inlea and outlet =`tees oz baffles, depth of liquid `level in .relati.on. to outlet invert; stzuctural:'Iintegrity , evidence of>.leakage; recommendations foz (repairs," etc.). nn01 C 0`N a�� 7fFNK �iy't7 C� pohQ8N-Is DI" STRIBUTIO.N BQX ' (locate on "site;'plan) " r depth o`f liquid_`leve + above :outlet invert C'arrments ' (note if level and distribution xs equal, evidence of solids carryover, ' evidence of.: leakage nto` or out csf boy,, recommendation ror.- repairs w f PIJMP3 CR MBEk (locate: on ysite`;plan) pumps in working order, yes or, no Comments (mote condition, of ,pump chamber, "cohdition of pumps and appurtenances, recommendations for maintenance or r.epai.rs,eto ) r 10 SUHSURFACE' BEWAGE DISPOSAL SYSTEM INSPECTION..FORM _ kPART B.; ; BYSTEM INFORMATION continued SOIL;ABSORPTION SYSTEM (SAS) : a fired but may be o r , • vats on n . t (aacae` on `siteplan; a Possible; exca approx�mated :by non-intrusiV0 methods) >.. r... han; I f not Y determa.ned to, be: present, 1* 1 7777 777-= Type lent I,z pits and number, i leaching chambers and number. leach�n:g galleries and number. r2E,Vct,rs leaching trenches,riumber, lengt"x lech�ng fieldS:' number, dimens� : overflow cesspool, : ( umber Comments : } _ (note"c"ondition' of soil ,' signs. of hydraulic failure, level of ponding, conditanof vegetation._; recommendations for maintenarice .or repairs',etc: ) CESSPOOLS • (`loca e on . site p3 an) ni::Ar,ber ':and' configuration depth •top of l 9V'id :to in invert7777777. depthaof solids layer depth of scum layer dimensions 'af cesspool materials o;f construction ini'cati on 'of groundwater inflow cesspool must be pupped.. as part of :inspection), Comments (nbte ,�condition of :soil, signs of hydraulic fallntenanceeo orepa�rsnetc. ) condition of •vegetation, recommend at ions :.for mai f PRIVY. (Locate onite plan) materials of construction dimension"s' deptof solids Comments ^. oil si ns .. on of .s g of hydraulic failure, level of ponding, .'conditi condition of vegetation, recommendations 'for maintenance or repairs,etc. ) a SUBSURFACE SYSTEM. INSPECTION FORM SEWAGE DISPOSAL. ' PART B BYSTEM INF;ORMATION 'aontinued STEM SKETCH OF SEWAGE.: DISPOSAL SY . in caude 'ties:' to at least<two 'permanent references landmarks or bencriznarks locate all wells.- within .100 ' *7 bw• 3. B� k ' r z i r + : 4 Y Y DEPTH TO GROUNDWATER 'T e r 0 wa t r" , r- depth tq gand - " o- r PP. Me of .determnation or. a r.oximation ��. ,• fY. .12 e SU$SURFACE SEWAGE DISPOSAL, $YS . EM INSPE6CTION 'FORM '. PART .C. FAILURE :CRITERIA Indicate yes, no, or not determi:ned' (Y, N, or ND)':. Describe basis of determination n all . instances.. If. "not, determined" ,''.explain why. +notj. Backup of sewage. into 'facility? .D�scharge. or `:ponding o;f effluent to the surface of the ground .or :surface",waters? ,Staticla quad level in;_; the distribution ,box vabove outlet ,.invert� Liquid depth in cesspool <6" below: invert or available volume,< 1/2 day flow? r Required.pumping .4 times or more in the lase year n'umbe.r of�.times ,pumped� • _ Septi.c tank is metal' ,cracked - structurally. unsound:? substantial. infiltrationsubstantial exfiltration',':tank falure; immnent? hs any portion o the SAS, - cesspool: or privy. below the high groundwater elevation' t within .50` feefi of a surface water' • >z w within 104 feet of a surface water supply or trbutazy to a surface ,,water suppiY..- 1 \ wxthi.n a . Zone :of' a, public well f within 50 feet of <a bordering vegetated wetland or salt marsh ;(cesspools and privies only, not the SAS)`?. _ within 5Q feet of ,a private water supply well' _rless than, 100 feet-but" greater •thari 50 'feet-from a p:r�vate water ' suppl`'y well with rio acceptable;:water quality analysis' If .the well has ,been analyzed to, be acceptable;, attach. copy 'of well water analysis 1 for, colforin bacteria,; volatile organic, compounds, ammonia nitrogen and nitrate nitrogen. , dr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION;.FORM. ,. PART ,D ; " CERTIFICATION Name o'f ,Inpect:or ge.v jA c G o"ci.� 2 Company Name Avo LivCYl ii �=ti'n:t� ca S c rcv� G"s � c�CC Company" Address . k z Certifcati'on Statement ` I . cert fy that, I have p"ersonally;inspeeted the seWage':disposal system at this address andthatthe informat"i,on reported is`;true, accurate and complete as of >the time of :inspection The inspection was" performed and a`ny recommendations ;regarding upgrade, ma ntenance and repair ;`are. ; consis,;tent= with my arainingand experience �n" the ;proper -function and manxteri"ince a _ on=site; sewage disposal systems. Check one _ T ' have. not found any information which andicatesthat. th"e system fails'; to adequately protect'" public health `or" the; .'environment .,as. defined: in 310 CMR """15 303Ot. Any failur..e criteria not evaluated ;are as stated:.,in the FAILURE CRITERIA section of this form P ave determined that `the system "fails ":tq rotect public health and �. the environment "as defined 'in" 3'10 FMR 15 303;; The bass ."for this d'eterimin"ation is provided n'"the FAILURE. CRITERIA, section of ,this ; In`spector,''s Signature (� Date t Original to system'°.owner :. Pies'. to Buyer (i.f. appl�cab`le): Approving authority Town of North Andover, MA Watarshed Septic System Servicing Report Date: APR 2 3 Homeowner: Pumper Street Address: Phone q���- �� Phone Nature of Service: Routine ►� Emergency Observations: Good Condition Full to Cover Baffles in Place Leachfield Runback Excessive Solids Heavy Grease Roots Other (Explain) Description of Work: Comments: opH i F-i nor (_ 5r�(l�f �1�S Pesti1J Kt> r NOI j AtipnVEI,�I MA, 'Ap9lu Cgti l Dpi-Ari (�Jq�G�'{...SpPt�Ly �7 TbWn1 - WEu_ APfouCD Com.._._. ppj�p\jev D,4rt' /PR�0vPN6 /uTlio,?rry cotir�iTIoNS: v(5(oA✓ PAA �ISAPPRUVEp D/�6 Ss-5 �uNoFF- ' Rt�6SoNS ` �-Z-�� G�vc� �rc�i►'�►�a G�. O ,I�- w�(� c,wG i T" �►� 1 j sii0(.1,.Q` IOA J �(NA� l ti5p�rlon� 4PFI�OOEP 0/3TC �4�DIT(D�AL, 1,,j,� �10" 5 (1►=A►jy) �IIJ�4LG� , 3�DM�ST ,vOj �x� 2 DISAPP)�Uvvtio�EV r FkA APPIZVAL O,o-FE L t 1 / TOWN OF NORTH ANDOVERa NORTH Office of COMMUNITY DEVELOPMENT AND SERVICES 3 ?e..:e •_ . e p HEALTH DEPARTMENT 400 OSGOOD STREET � +O��no•�r4h I NORTH ANDOVER, MASSACHUSETTS 01845 'Ss�cHU 978.688.9540—Phone Susan Y.Sawyer,REHS/RS 978.688.9542—FAX Public Health Director E-MAIL:healthdeptt@townofnorthandover.com WEBSITE:hqp://www.townoftiorthandover.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. 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 incere an Y. Sawyer, REHS/RS Public Health Director File Town of North Andover, Massachusetts Form No.3 BOARD OF HEALTH t NORTH l + 19 �/+�/_2 �. •��,,;;:•�`� DISPOSAL WORKS CONSTRUCTION PERMIT ,SgACNUSEt e Applicant ME ADDRESS TELEPHONE Site Location - Permission is hereby granted to Construct�Or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. 4HAIR�MANB�OARDO�FHEAL�TH Fee D.W.C. No. ' NORTN ` 4868 dL • Town of North Andover ` '•�;, ; HEALTH DEPARTMENT ,SSAC MOst� 1� CHECK#: DATE: LOCATION: H/O NAME: / -`',4,/j CONTRACTOR NAME: , y '�?L66J40;;z 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) $ ❑ Title 5 Insp /r'ecto $� t.,T01/Report $- ❑ Other. (Indicate) $ e th Agent Initials White-Applicant Yellow-Health Pink-Treasurer Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessm Is 'gyp ' 585 Shar Hers Pond Road KiWt4 qa N0$'�ANDOVER Property Address Keith Beals Owner Owners Name 1 information is North Andover MA 01810 9/3/2010 " required for every page. Cityfrown 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: only the tab key to move your Neil J. Bateson cursor-do not Name of Inspector use the return p key. Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover Ma 01810 Cityrrown State Zip Code 978-475-4786 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 ❑ Needs Further Evaluation by the Local Approving Authority 9/3/2010 Ins ect rs tignatureDate 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. t5ins-09/08 Title 5 Official Inspection For Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 585 Sharpners Pond Road Property Address Keith Beals Owner Owner's Name information is required for North Andover MA 01810 9/3/2010 _ every page. City/Town 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: 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): t5ins-09/08 Us 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 585 Sharpners Pond Road Property Address Keith Beals Owner Owner's Name information is required for North Andover MA 01810 9/3/2010 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): f ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): li I ❑ 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): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): e. 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: i ❑ 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 ` Commonwealth of Massachusetts v W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 585 Sharpners Pond Road Property Address Keith Beals Owner Owner's Name information is North Andover MA required for 01810 9/3/2010 every page. Cityrrown 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 has aseptic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "*This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria 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 ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•09108 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 585 Sharpners Pond Road Property Address Keith Beals Owner Owners Name information is required for North Andover MA 01810 9/3/2010 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 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 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 ❑ ❑ 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 11 El Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Tftle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 585 Sharpners Pond Road Property Address Keith Beals Owner Owner's Name information is required for North Andover MA 01810 9/3/2010 every page. Cityrrown 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: Y. ® ❑ Existing information. For example, a plan at the Board of Health. ® El approximation 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): 660 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form .; Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M v 585 Sharpners Pond Road Property Address Keith Beals Owner Owner's Name information is required for North Andover MA 01810 9/3/2010 every page. City/rown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] El ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? El Yes Z No Water meter readings, if available last 2 ears usage On well water 9 ( Y 9 (gPd))� Detail Sump pum ? ❑ Yes No p Last date of occupancy: Vacant for two weeks Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 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 i 585 Sharpners Pond Road Property Address Keith Beals Owner Owner's Name information is North Andover MA 09810 / / required for 9 3 2010 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: Pumped 2008 , owner Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Measured tank Reason for pumping: Inspect tank&tees Type of System: ® Septic tank, distribution box, soil absorption system i. i ❑ 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments i 585 Sharpners Pond Road Property Address Keith Beals Owner Owner's Name information is required for North Andover MA 01810 9/3/2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Original, no date on as built plan, design plan date 5/14/1990 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.65 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 thru wall, 3" PVC in house, no leaks visible Septic Tank(locate on site plan): Depth below grade: 0.65 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'x 5'x 4 2" Sludge depth: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts _NEW I Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 585 Sharpners Pond Road Property Address Keith Beals Owner Owner's Name information is required for North Andover MA 01810 9/3/2010 every page. Cityrrown 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 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 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 ok. Depth of liquid at outlet invert. No evidence of leakage. 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: Date t5ns•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 585 Sharpners Pond Road } Property Address Keith Beals Owner Owner's Name information is required for North Andover MA 01810 9/3/2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related 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: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No i. Alarm level: Alarm in working order: ❑ Yes ❑ No Date of lastum in : p p g Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 585 Sharpners Pond Road Property Address Keith Beals Owner Owner's Name information is required for North Andover MA 01810 9/3/2010 every page. CityTrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box level 8i distribution equal. No evidence of leakage. Evidence of light carryover. Pumped d-box to clean 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.): i. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 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 I •''r 585 Sharpners Pond Road Property Address Keith Beals Owner Owner's Name information is required for North Andover MA 01810 9/3/2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching number, trenches 26'eac ng trenches n.amber, length: long ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetation ok. No sign of ponding to surface. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments I 585 Sharpners Pond Road Property Address Keith Beals Owner Owner's Name information is required for North Andover MA 01810 9/3/2010 every page. Cityrrown 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.): I 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.): r: t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 585 Sharpners Pond Road Property Address Keith Beals Owner Owner's Name information is required for North Andover MA 01810 9/3/2010 every page. City/Town State Zip Code Date of Inspection D. 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 Q-� a o 1 S�� c.TaMk 0(; 4vvSe TO ` a"L ro Lq I► _ I L4 t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 i Commonwealth of Massachusetts + _ u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 585 Sharpners Pond Road Property Address Keith Beals Owner Owner's Name information is North Andover MA 0`1810 9/3/2010 required for every page. City/Town 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: 5/14/1990 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: i'. You must describe how you established the high ground water elevation: As per test pit data on design plan. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form m Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 585 Sharpners Pond Road Property Address Keith Beals Owner Owners Name information is required for North Andover MA 01810 9/3/2010 every page. Cityfrown 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 high System Information—Estimated depth to groundwater ® y p g g ou dwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file a, t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts City/Town of System Pumping Record j Form 4 `V I DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be,substantially the same as that provided here. Before using this form,check with your local Board of Health tQ determine the form they use. The System Pumping Record must be submitted to the local.Board of Health mothorjapproving authority. A. Facility Information 1. System ion: Left side of house, Right side of house, Left front of house, Right front of house, eft rear of house, fight rear of house. Left rear of building. Right rear of building. Address ��•� O`{ Pov\cA ROQ_A �JOC f� .A-1,A a.,- P Cityrrown State Zip Code 2. System Owner: Name Address(if different from location) HA O( Fyvi�- Cityrrown State Zip-Code44Y Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): . 4. Effluent Tee Filter present? ❑ Yes ET No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: G.L.S.Dwell aste Water Signature of Hiulei U Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts w City/Town of System Pumping Record ---�-- w Sye�,W Form 4 RECEIVED DEP has provided this form for use by local Boards of Health. Othe formR$by be 6,44 butt ie information must be substantially the same as that provided here. fore using this form, the k with your local Board of Health to determine the form they use.The System UTOP tgMMf'dlrn'MIN bmitted to the local Board of Health or other approving authority. HEALLTH DEPARTMENT A. Facility Information 1. System Location: Left/Right front of house igh�iZU , Left/right side of house, Left/ Right side of building, Left/Right front ofulb`�ding, Left/Right rear of building, Under deck Address City/Town r�\1)�— State Zip Code 2. System Owner. Name Address(if different from location) CitylTown Stnt l Zip Cld , O Y Telephone Number B. Pumping Record � S 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes a No If yes,was it cleaned? E] Yes ❑ No 5. Condition ofSystem:� 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location w e contents were disposed: 01's-P Lowell Waste Water SignAtufe I Haule Date t5form4.doc•06/03 System Pumping Record�Page 1 of 1 i