HomeMy WebLinkAboutMiscellaneous - 61 ESSEX STREET 4/30/2018 (2) 61 ESSEX STREET
210/103.0-0005-0000.0
North Andover Board of Assessors Public Access Page 1 of 1
0
NORTH North Andover Board of Assessors
Of 4•�an �1ti0
♦i rf7�9i� 4#
4'•41.0��1'
roperty Record Card
Click Seal To Return Parcel ID:210/103.0-0005-0000.0 FY:2009 Community:North Andover
SKETCH PHOTO
Click on Sketch to Enlarge Click on Photo to Enlarge
,
Search for Parcels F-7
Search for Sales u'`#
Summary
Residence
Detached Structure
Condo 61 ESSEXSTREET—.E— °
Commercial
Location: 61 ESSEX STREET
Owner Name: SCULLY,STEPHEN J
Owner Address: 808 GREAT POND ROAD
City: NORTH ANDOVER State: MA Zip: 01845
Neighborhood: 6-6 Land Area: 7.16 acres
Use Code: 101-SNGL-FAM-RES Total Finished Area: 2300 sqft
ASSESSMENTS CURRENT YEAR PREVIOUS YEAR
Total Value: 553,600 605,600
Building Value: 277,300 329,300
Land Value: 276,300 276,300
Market Land Value: 276,300
Chapter Land Value:
LATESTSALE
Sale Price: 1 Sale 01/30/2000
Date:
Arms Length Sale F-NO-CONVNIENT Grantor: STEPHEN SCULLY
Code:
Cert Doc: Book: 05667 Page: 0057
http://csc-ma.us/PROPAPP/display.do?linkId=1463894&town=NandoverPubAcc 7/28/2009
• Commonwealth of Massachusetts
Title 5 Official Inspection For
" Subsurface Sewage Disposal System Foran-Not for Voluntary A rat /
�e 61 Essex Street b 3
Property Address L
Chris Scull
Owner Owner's Name
information is
required for North Andover MA 01845 3/5/2013
every page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms r9avilaLkLa.1tered in any
way. Please see completeness checklist at the end of the form.
ECEIVE®
Important: A. General Information
When filling out LTOWNOF
12013
forms on the
computer,use 1. Inspector: TH ANDOVER
only the tab key PARTMENT
to move your Neil James Bateson
cursor-do not Name of Inspector
use the return
key. Bateson Enterprises Inc.
Company Name
111 Argilla Road
Company Address
Andover MA 01810
AQP" City,rrown 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
r
3/5/2013
Inspector's ignatur Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•11110 Title 5 Official Inspection Foran: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
61 Essex Street
Property Address
Chris Scully
Owner Owners Name
information is
required for North Andover MA 01845 3/5/2013
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
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•11A0 Title 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
61 Essex Street
Property Address
Chris Scully
Owner Owner's Name
information is
required for North Andover MA 01845 3/5/2013
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
0
61 Essex Street
Property Address
Chris Scully
Owner Owner's Name
information is
required for North Andover MA 01845 3/5/2013
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 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: Tape Measure
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® 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•11/10 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
61 Essex Street
Property Address
Chris Scully
Owner Owner's Name
information is
required for North Andover MA 01845 3/5/2013
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
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 facilitywith 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
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.
151ns•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 117
Commonwealth of Massachusetts
Title '5 Official Inspection Form
a Subsurface Sewage Disposal System Form Not for Voluntary Assessments
61 Essex Street
Property Address
Chris Scully
Owner Owner's Name
information is
required for North Andover MA 01845 3/5/2013
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:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
.Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•11/10
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
61 Essex Street
Property Address
Chris Scully
Owner Owner's Name
information is
required for North Andover MA 01845 3/5/2013
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 3
Does residence have a garbage grinder? ® Yes ❑ No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage (gpd)): On well water
Detail:
Sump pump?. ❑ Yes ® No
Last date of occupancy: Current
Date
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•11/10 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
61 Essex Street
Property Address
Chris Scully
Owner Owners Name
information is
required for North Andover MA 01845 3/5/2013
every page. City/Town 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 4 years ago, owner
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1000
gallons
How was quantity pumped determined? Measured tank
Reason for pumping: Inspect tank& baffle&tee
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest.
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•11/10 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
61 Essex Street
Property Address
Chris Scully
Owner Owner's Name
information is
required for North Andover MA 01845 3/5/2013
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:
48 years old, 7/3/1965, D-box&outlet tee in septic tank was replaced July 2009, as built plan &info
at B.O.H.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.5
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" Cast iron wa113"cast iron in house, no leaks visible
Septic Tank(locate on site plan):
Depth below grade: .5
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:
6'x 4'
Sludge depth:
3"
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
4 v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
61 Essex Street
Property Address
Chris Scully
Owner Owner's Name
information is
required for North Andover MA 01845 3/5/2013
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"
3"
Scum thickness
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
18..
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 baffle 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
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y 61 Essex Street
Property Address
Chris Scully
Owner Owner's Name
information is
required for North Andover MA 01845 3/5/2013
every page. Citylrown 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
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
61 Essex Street
Property Address
Chris Scully
Owner Owners Name
information is North Andover MA 01845 3/5/2013
required for
every page. Cityrrown 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&distribution equal. Evidence of light carryover, pumped d-box to clean, no
evidence of leakage
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.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
+ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
61 Essex Street
Property Address
Chris Scully
Owner Owners Name
information is
required for North Andover MA 01845 3/5/2013
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching'trenches number, length: 5 trenches 30'
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.):
Snow covering lawn. 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•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'< 61 Essex Street
Property Address
Chris Scully
Owner Owner's Name
information is
required for North Andover MA 01845 3/5/2013
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•11/10 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
61 Essex Street
Property Address
Chris Scully
Owner Owner's Name
information is
required for North Andover MA 01845 3/5/2013
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
(_o
sem:r. ,
Ik
Q
i
l
L lnrdi
f
33t5
a- = L4 o
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
• Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y 61 Essex Street
Property Address
Chris Scully
Owner Owner's Name
information is
required for North Andover MA 01845 3/5/2013
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: Date
❑ 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:
Essex County Soil Map
You must describe how you established the high ground water elevation:
Essex County Soil Map, Sheet#30, Charlton Soil, Water>6' Deep
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
• Commonwealth of Massachusetts
a Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
61 Essex Street
Property Address
Chris Scully
Owner Owner's Name
information is
required for North Andover MA 01845 3/5/2013
every page. Citylrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
•
Commonwealth of Massachusetts j
k1j' City/Town of
System Pumping Record
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house, Left kRLqht rear of hous Left/nigh a of house, Left/
Right side of building, Left/Right front of building, Left/Rig rear of building(-Under d
Address
Cityrrown State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town State , Zi de
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s)B--Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
S. Condition of System:a
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7.jgt
re contents were disposed:
Lowell Waste Water
THaule Date
t5form4,doc•06103 System Pumping Record•Page 1 of 1
OLICY
TM
aPR 0.9 .2013
WELL & PUMP
TOWN OF NORTH ANDOVER'
HEALTH DEPARTMENT
W
ATER
. .. ' . SYST'faMS ' : • .
cgwxant Pressure
Subrh6rsibir PW-i s
cls�ro scUL
LY . : iYu>�aaex �tsa3::
Booster��mps ,
61 E+5 °ST.' :rTriganon Piiml►s
NO.ANDQVER MA 01845 Scvragc JetFa.gc*s um
•
Fips
. : . .. . .. , .. • . •.• SumQ Pumps.. ' . : , .
SAMPLE FROM: 61 ESSEX ST. .N6,ANIDOVE1t;MA 01845 lviotbr controls .
- :. . . Pipe,Parts&&Access.
Receiv=ed,:(03127/201310:38 AM).. . Water Taxxks
'fest Roults. Over.MCL Maximum Coutaniinaat Le7e1
_ �__��� -------- ------ - —__ ' --------- ------------ W.--- WATER
pg..I ------=---=-�---- 7.7. (6.5�.8.5 : EPA Sec Std) . TESTING.
H 4ess(as•CAC03)-- X5.0' . .(75 PPM EPA;Scc Std) f�xs�z c
Chlorides: ------ <S.0 i : (250 PFM ERA See Std) 'Bacteria
:Sodium._.-- --e=-= 30.4.' ': (254 : PFM EPA Sec Std) Basic-
Nitrates—�-----------------� X0.5 (10 1'PM E1'A Pri St{1)- Coiripxehensive: :
Nitrifies-- - X0:5 (1. PPM EPA Pri Std) FkA&VA
Iran:T--- _, ^--------- <0:1 PPM EM Sec Std) Radon
. ,Manganese..------- {0.fi5 (0.05 PM.EPA See Sid) •. .Vacs. ;
'Copper�_ _.____�--.. - tQ,5 (1,3 PPM EPA Pri Std)'.
'E.Coll]Bacteria - A:.. (0` :' FPNt EPA Pri Std)
ColifOrin•Bacteria----� A ,(0 : . . PPM EPA Pri
Turbidity-�-- — -c1.0+. (5,-.. PPM EFA Sec Std) TREATMENT.
:Arsenic---_------------ . 4;012..: ** (Q:01 FPM EPA Pri Std). Carbon filtexs. -
Color'-=- -- 0 (15 Color�J�ait9..ETA Sec Std} Caxtzidge'Filters
X5.0 (104: PPM EPA.S0 Std)' Multi=Media hittrs
Fluoride - - {0.5 (4 PPM EFA Sec"Std} Ncutralizcrs
Leac1-=-----=- -=-=-= . .. X0:005: • (0:415' PPM EPA Pini Std) Oxidation Filters
Resin Softezxers
TpWd by dew Jim `re Certafcd,Lab#1020944 �ver9e Oszzaasis
Ri sults entered by:. " Sanitizers
Ultra-Violet .
This sa.mpae 3fa,11s EP.A*SOfe.drrAklog standaNs based-on he.primary items with WeI1.Chlorinstiou
11 you Dave any:questions please dill 1'ulicy:Well&Pump at X03398-4232
TREATMENT..
St1PP�IES
Page 1 of : Chax�coal:Cartrzclgta .
Sediment.Cartridges
Soda Ash
Ncutralizcr.Mcdia
Softtntr Salt'
Route 28` P Ot wax•900-.Yt�xidha ,N.03087 VVeA Sazaitaier.
(� )898=4232 .�.(800).9927867 # Fax.(�03}898-95�L.. .
Gain
VxSit'US..,t www.p Co*
b
Commonwealth of Massachusetts REC IV
Title 5 Official Inspection For
a 2 9 2009
Subsurface Sewage Disposal System Form Not for Voluntary Ass smera��
61 Essex Street TOWN OF NORT ANDOVER
Property Address
Stephan Scull
Owner Owner's Name
information is North Andover MA 01845 7/22/2009
required for
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may n t tered 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
key. Bateson Enterprises Inc.
Company Name
r� 111 Argilla Road
Company Address
Andover Ma 01810
City/Town 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
® N eds Further Evaluation by the Local Approving Authority
7/22/2009
Inspector's Sign atur Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
b
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
wM 61 Essex Street
Property Address
Stephan Scully
Owner Owner's Name
information is
required for North Andover MA 01845 7/22/2009
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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M s•'' 61 Essex Street
Property Address
Stephan Scully
Owner Owner's Name
information is
required for North Andover MA 01845 7/22/2009
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
® Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•09108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 61 Essex Street
Property Address
Ste han Scull
Owner Owner's Name
information is North Andover MA 01845 7/22/2009
required for State Zip Code Date of Inspection
every page. City/Town
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 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: Tape Measure
**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.
ther:
Outlet tee , outlet pipe&d-box needs to be re laced
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 '/2 day flow
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
wM 61 Essex Street
Property Address
Stephan Scully
Owner Owners Name
information is
required for North Andover MA 01845 7/22/2009
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-
1 0,000g pd.
❑ ® 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
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 Title 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
61 Essex Street
Property Address
Stephan Scully
Owner Owner's Name
information is
required for North Andover MA 01845 7/22/2009
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
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 s 61 Essex Street
Property Address
Stephan Scully
Owner Owner's Name
information is
required for North Andover MA 01845 7/22/2009
every page. City[Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ® Yes r.'; No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d On well water
9 ( y 9 (gP ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Current
Date
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
61 Essex Street
Property Address
Stephan Scully
Owner
information is Owner's Name
required for North Andover MA 01845
7/22/2009
every page. City/Town 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 2004, owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the UA system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-09/08
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
M 61 Essex Street
Property Address
Stephan Scully
Owner Owner's Name
information is
required for North Andover MA 01845 7/22/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
34 years old, 7/3/1965, as built plan
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.5
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"cast iron thru wall, 3"Cast iron in house, no leaks visible
Septic Tank(locate on site plan):
Depth below grade: .5
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: 6'x 4'
Sludge depth:
1"
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 61 Essex Street
Property Address
Stephan Scully
Owner Owners Name
information is
required for North Andover MA 01845 7/22/2009
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle N/A
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle N/A
Distance from bottom of scum to bottom of outlet tee or baffle N/A
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 baffle ok. Outlet baffle corroded off, was replaced with elbow by others. Depth of liquid at 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
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
61 Essex Street
Property Address
Stephan Scully
Owner Owner's Name
information is
required for North Andover MA 01845 7/22/2009
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
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
w 61 Essex Street
Property Address
Stephan Scully
Owner Owner's Name
information is
required for North Andover MA 01845 7/22/2009
every page. CityrTown 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 &distibution not equal. Evidence of carryover. Evidence of leakage. D-box badly
corroded needs to be replaced.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
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
M 61 Essex Street
Property Address
Stephan Scully
Owner Owner's Name
information is
required for North Andover MA 01845 7/22/2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 5 trenches 30'
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 Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
61 Essex Street
Property Address
Stephan Scully
Owner Owner's Name
information is North Andover MA 01845 7/22/2009
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-09/08 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
wM 61 Essex Street
Property Address
Stephan Scully
Owner Owner's Name
information is
required for North Andover MA 01845 7/22/2009
every page. Cityrrown 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
�a o
3 A ceu,�
IA�se_
0
W(2�11
l-fk2
i
3
7:-3
1.401
ra t 5 `
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
61 Essex Street
Property Address
Stephan Scully
Owner Owners Name
information is
required for North Andover MA 01845
7/22/2009
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: 6
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:
Date
❑ 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:
Essex County Soil Map
You must describe how you established the high ground water elevation:
Essex County Soil Map Sheet#30, Chariton soil, water>6'deep
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09108
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
. 5
11 �
Commonwealth of Massachusetts
N Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M y 61 Essex Street
Property Address
Stephan Scully
Owner Owner's Name
information is
required for North Andover MA 01845 7/22/2009
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
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Jul 2b 09 05: 34p Bateson Enterprises 94847t►5451 p. 1
Report#: 72709553
Date: 7127!2009
�. a •� r,o.�"�— --- 7-27-09 Visa
— --
Home Inspection Assoc.. Inc. Matrix: Drinkintl Water
105 Haverhill St. = Shj±en J. Scilly
Methuen,MA 01844-4205 Sample 61 Essex St
Location Nath Andover MA 01845
Phone (97e)ass-saga
This sample taken by SJS at 4:30:00 PM on 712312009.
Point at aottection,Kitchen
Public Drinking Water
Results EPA Limits
General BacteMa
Total Coliform Absent Animal or Vegetational Laclede 0
Fecal/E.Coli Absent Animal Bacteria o
General Cftm
Sodium 22.1 moll. 20.0 mylL is Mass.DEP Guideline 250.0 mg&
Potassium 1.7 moll A Cornportent of Salt. No Limit
Copper 0.01 mglL indicates Plumbing Corrosion 1.30 mg/L
Iron 0.35 nagll grown Stains,Bitter Taste 0.30 mg&
Manganese 0.00 mglL May Cause Laundry Staining 0.05 mtglL
Magnesium 5A mg1L A Component of Hardness Noumit
Calcium 18A mgtL A Component of Hardness No Limit
Arsenic 0.008 m91L Mama occurring Bement 0.029 mglL
Lead Not Detected AToxic Metal 0.01smgll.
PN 7.77 SU Ackil8asic Oetereninadon 6.5-LS SU
Turbidity 1.6 N.T.U. Presence of Particles No Limit
Color Not Detected Clarity(0).Discoloration(15) 15.0 C.U.
Odor Not Detected Odor due to Confatwitation 3.0 T.O.N.
Conductivity 215.0 unities Electrical Resistance(umhosfan) No Limit
T.D.S. 129.0 MOIL Total Oissohred Minerals Present $00.0 MOIL
Sediment Absent Undissolved Solids Present
Alkalinity 110.0 mglL Ability to Neutralize acid No Limit
Chlorine Not Detected A Disinfaetant 4.0 mglL
Chloride 24 mgil. A component of$OR 230.0 mglL
Hardness 68.2 mg/L 0-75 Is considered soft No Limit
Nitrate Not Detected InttFeator of Biological Waste 10.0 mg/L
Nitrite Not Detected Indicatorol Waste 1.0 MOIL
Ammonia Not Detected Indicator of Waste No Limit
Sulfate 8.4 mgfL A Mineral.Can Cause Odor 250.0 mg/L
t The integrity of the sample and results are dcpandent on the qu aliry of sanWling.The results apply only to the actual sample lested.
Environmental Testing and Resesrcb Laboratories shall be held harmless from any liability arising out of the use of such results.
29 Fuller Street Leominster MA 01453d22S (978)640-2941 (800)3442977 Page 1 of 1
info@obiabs.com www.etrWm.com
TOTAL P.01
TOWN OF NORTH ANDOVER µoRTk
' Office of COMMUNITY DEVELOPMENT AND SERVICES 3:°•t�"° a"�o�
HEALTH DEPARTMENT A
1600 OSGOOD STREET; Building 2-36
NORTH ANDOVER,MASSACHUSETTS 01845 "SSRCHUStit`h
Susan Y. Sawyer,REHS/RS 978.688.9540—Phone
Public Health Director d /Dy/' 978.688.8476—FAX
D-BOX
❑ Installed on stable stone base
❑ Inlet tee (if pumped or >0.08'/foot)
Hydraulic cement around inlet & outlets
Observed even distribution
Speed levelers provided (not required)
Comments:
SOIL ABSORPTION SYSTEM
❑ Bottom of SAS excavated down to soil layer, as
provided on plan
❑ Size of SAS excavated as per plan
❑ Title 5 sand installed, if specified on plan
❑ 3/4-1 Y2" double washed stone installed
❑ 1/8-1/2" (peastone) double washed stone installed
❑ Laterals installed and ends connected to header
❑ Laterals vented if impervious material above
❑ Orifices @ 5 & 7 o'clock positions
❑ Gravel-less disposal systems: type, number and
location as per plan
❑ Elevations of laterals installed as on approved plan
❑ 40 Mil HDPE barrier installed
❑ Retaining wall (boulder/ concrete /timber/ block)
❑ Final cover as per plan
Comments:
Wastewater System Documentation—Feb 2006
Page 3 of 6
NORTH
t _
0 0
O �n
o .C..
�9SSACHUS����
PUBLIC HEALTH DEPARTMENT
Community Development Division
CFR2IFICAr1_(F O F C09Y('CI OgVM
As of:
August 11, 2009
This is to cert that the individuafsu6surface Su posafsystem received a
SA`IISFAC7ORTINSTEM0Nof the:
qW&cement of(D-Boas and'Outret Tee Onfy
By.
ToddBateson
At:
61 Esser.
Map — 103; (Parcel-5
NorthAndover, WA 01845
The Issuance of this certificate shaff not 6e construed as a guarantee that the system wilt
function satisfactorily.
r
LL 4Wzch
. Grant
Pu6lzc Ifeafth Inspector
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 918.688.9540 Fax 918.688.8416 Web www.townofnorthandover.com
Map-Block-Lot
Commonwealth of Massachusetts 1os.00005
-------------------
3j Board of Health Permit No
s BHP-2009-0647
• North Andover ----------------------
• FEE
P.I. $125.00
�a••
� i F.I. -----------------------
DISPOSAL WORKS CONSTRUCTION PERMIT
mission is hereby granted Todd Bateson
----------------------------------------------------------------------------------------------------
LLatNo
D-Box&Outlet Tee)an Individual Sewage Disposal System.
ESSEXSTREET -------------------------------------------------------------------------------------------------- - -
n the application for Disposal Works Construction Permit No. BHP-2009-064 Dated __August 06,2009------------ V ----------
ug- _6-2009
bad fIYealtli---�------
F
Application for Septic Disposal Svstem
TODAY'S DATE
AConstruction Permit - TOWN OF
`�°' " ��• •`` ORTH ANDOVER AU 01845 $250.00-Full Repair
s.,c --$77y�1��25.00-Compon nt
Important: Application is hereby made for a permit to: /
When fining out ❑ Construct a new on-site sewage disposal system*
forms on the
computer,use ❑ Repair or replace an existing on-site sewage disposal system*
only the tab key /
to move your [ tepair or replace an existing system component-What? b"'6-0 X P-•1�z /-ems_
cursor-do not
use the return
key. A. Facility Information _
l0 ls -
I�V Address or Lot# —
City/Town
2.-*TYPE OF TIC SYSTEM*:
❑ Pump ETGravity(choose one)
***If�p system, attach copy of electrical permit to application***
L` l7 ononventional System(pipe and stone system)
❑ Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of syste
❑ Pressure Distribution S.A.S.(No D-Box)(Attach Draft Maintenance Agreement) ,
❑ Pressure Dosed (D-Box Present) S.A.S.
2. Owner Information
Name z
Address(if different from above)
Cityrrown State Zip Code
Telephone Number
3. Installer Information / _
Name Name of Company
Address
City/Town State Zip Code
7 a7s_ _
Telephone Number(Cell Phone#if possible please)
4. Designer Infor atio
Name Name of Company
Address
City/Town State Zip Code
Telephone Number(Best#to Reach)
i
Application for Disposal System Construction Permit•Page 1 of 2 I
Application for Septic Disposal System -`�
dt °°� TODAY'S DATE
Construction Permit — TOWN OF
*��o $ 250.00—Full Repair
�,ss,,,,.•°�h ORTH ANDOVER, MA 01845 $125.00-Component
�C5�
PAGE 2OF2
A. Facility Information continued....
5. Type of Building: esidential Dwelling or❑Commercial
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the afore-described
on-site sewage disposal system in accordance with the provisions of Title 5 of the
Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of
North Andover, and not to place the system in operation until a Certificate of Compliance has
been issued hiss Board of Health.
Name Date
7
Application pproved By:, oard of Health Representative)
N/ami � / Date
,Application Disapproved for the following reasons:
For Office Use Only:
L Fee Attached. Yes No
2. Project Manager Obligation Form Attached. Yes No
3. Pump Svstem? If so,Attach copy ofElectrical Permit Yes No
4. Foundation As-Built. (new construction ronly). Yes No
(Same scale as approved plan)
5. Floor Plans?(new construction only): Y s No
Application for Disposal System Construction Permit•Page 2 of 2
i
• ' : S SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
(Address of septic system) For plans by
eer)
Relative to the application of �� --�-So,N
(Installer's name) And dated 7
ateDated �—W —p 7
o ay s ate With revisions da4drt revised date)
I understand the following obligations for management of this project:
1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to
performing any work on a site. I must have the approved plans and the permit on site when any work is
being done.
2. As the installer, I must call for any and all inspections. If homeowner, contractor,project manager,or any
other person not associated with my company schedules an inspection and the system is not ready,then
item three shall be applicable.
3.' As the installer, I am required to have the necessary work completed prior to the applicable inspections as
indicated below. I understand that requesting an inspection,without completion of the items in accordance
with Title 5 and the Board of Health Regulations may result in a$50.00 fine being levied against me and/or
my company.
a. Bottom of Bed—Generally,this is the first (15)inspection unless there is a retaining wall,which
should be done first. The installer must request the inspection but does not have to be present.
b. Final Construction Inspection—Engineer must first do their inspection for elevations, ties, etc.
As-built of verbal OK(or e-mail to: healthdeptntownofnorthandover.com) from the engineer must
be submitted to the Board of Health,after which installer calls for an inspection time. Installer must
be present for this inspection. With a pump system,all electrical work must be ready and able to
cause pump to work and alarm to function.
c. Final Grade—Installer must request inspection when all grading is complete. Installer does not
have to be on-site.
4. As the installer, I understand that only I may perform the work (other than simple excavation)and I am required
to complete the installation of the system identified in the attached application for installation. I further
understand that work done by others unlicensed to install septic systems in North Andover can constitute
reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of
North Andover,significant fines to all persons involved are also possible.
5. As the installer,I understand that I must be on-site during the performance of the following construction
steps:
a. Determination that the proper elevation of the excavation has been reached.
b. Inspection of the sand and stone to be used.
c. Final inspection by Board ofHealth staff or consultant.
d. Installation of tank D-Box,pipes, stone, vent,pump chamber,retaining wall and other
components.
6. As the installer,I understand that I am solely responsible for the installation of the system as per the
approved plans. No instructions by the homeowner,,general contractor,or any other persons shall absolve
me of this obligation.
Undersigned Licensed Septic Installer: (Today's Date)
�-L�_
ame—Print) ame—
Sawyer, Susan
From: Sawyer, Susan
Sent: Monday,July 08, 2013 3:24 PM
To: 'cjscully76@aol.com'
Subject: 61 Essex Street
Dear Mr.Scully,
The Health Department received a Title V Inspection report for 61 Essex Street, North Andover, MA,on April 1, 2013. As
stated on Page 4 of the report**This system passes if the well water analysis, performed at a DEP certified laboratory,
for specific criteria as long as the water test report is attached. The Health Department acknowledges the receipt of the
well water report as required and that,as it applies to page 4 of the report, it fulfills the requirement set forth in the MA
DEP regulation.
This inspection report will be kept on file at the Health Department.
Thank you,
Susan
Susan Sawyer
Public Health Director
Town of North Andover
1600 Osgood Street
Suite 2035
North Andover,MA 01845
Phone 978.688.9540
Fax 978.688.8476
Email mailto:ssawver@townofnorthandover.com
Web www.TownofNorthAndover.com
•iii dq.yy.
1
Grant, Michele
To: mlombard@mlombard.com
Cc: Sawyer, Susan; Blackburn, Lisa
Subject: 61 Essex Stree"
Attachments: 201307111043_0001.pdf
Hi Michael,
As per your request, attached, please find a copy of the e-mail sent to Mr. Scully on July
8th, 2013.
If you have any further questions please don't hesitate to call me.
Michele E. Grant
Public Health Agent
Town of North Andover
1600 Osgood St I Suite 2035
North Andover, MA 01845
Phone 978.688.9540
Fax 978.688.8476
Email mgrant(@townofnorthandover.com Web www.TownofNorthAndover.com
-----Original Message-----
From: noreply(@townofnorthandover.com [mailto:noreply(a@townofnorthandover.com]
Sent: Thursday, July 11, 2013 10:43 AM
To: Grant, Michele
Subject: Message from "ComDev-Health-Ricoh"
This E-mail was sent from "ComDev-Health-Ricoh" (Aficio MP C3002).
Scan Date: 07.11.2013 10:43:17 (-0400)
Queries to: noreply(@townofnorthandover.com
Please note the Massachusetts Secretary of State's office has determined that most emails to
and from municipal offices and officials are public records. For more information please
refer to: http://www.sec.state.ma.us/pre/preidx.htm.
Please consider the environment before printing this email.
1
r
GRANITE STATE ANALYTICAL,LLC
22 MANCHESTER ST,UNIT 2,DERRY,NH I
PHONE3038
(8001699-9920 (6031432-3044 FAX 16031434-4831
i
DATE PRINTED: 07/08/2013 Legend
Passes
CLIENT NAME: Policy Well&Pump Fails EPA Primary
CLIENT ADDRESS: PO Box 900
Windham, NH 03087 Fails EPA Secondary
Fails EPA Proposed Limit X
CERTIFICATE OF ANALYSIS FOR DRINKING WATER
SAMPLE ID#: 1307-00136-001 DATE AND TIME COLLECTED: 07/02/2013 10:00 AM
SAMPLED BY: Policy Well &Pump DATE AND TIME RECEIVED: 07/02/2013 1:12 PM
ANALYSIS PACKAGE: Arsenic-MS
SAMPLE LOCATION:, 61 Essex St.,No'Andover,MA RECEIPT TEMPERATURE: 24.7 CELSIUS
Test Description Results Test Units Pass EPA Limit Method Analyst Date&Time Analyzed
/Fail
Arsenic* <0.001 mg/L 0.010 mg/L EPA 200.8 WL 07/05/13 7:05 PM
J
The results presented in this report relate to the samples listed above in the condition in which they were received.
*MA Accredited Analysis Donald A.D'Anjou,Ph.D.
A list of our certifications is available on request. laboratory Director
This analysis meets Massachusetts requirements except as noted.
This certificate shall not be reproduced,except in full,without the written approval of Granite State Analytical,LLC
i
Page 1 of 1
APR-8-2013 03:29 FROM:BATESON ENTERPRISES 9784755451 TO:9786888476 P.1/1
POLICY
WELL lea -
not ,
*. ,
- WATER
+ C.lwa=PY+fJsure
51317ImR�l11C PS..,
CEW$T0 SC Y .. Samliie 1�1ut�pib�r 9�.3 c n
Wpuqil
•. pw
brim
Sivaplumpb..
SAMPLE PROMs 61$ss I� C sT. .No:A,PiD R;M-4 Ol m
:Motor ConmIs
. Pipe,Pua&Ac •
watti'iWO
Tai RPWt ' hater-8vrt MCL Nlu r�4�qp rti laigat L wl
g,.._:.Y.;...:....:.... ..,..... ; 7.7 :(6S 8.a -E?A►,S Std) m-nNQ. ;
ard�je�s(asp CaC,U3)•- <5.9�'. . (�$ •PPI i Spec Std . '
Cil �idcd -•�:–:--- .d: : (ZSp PPM EPA.Soc Std) ictatiu
Sod'i�n1a. �.- 1._.::.: (230 Pl'M 1FA Sec Std=
ppm.EPA?dstd)
l�itrit�ea- •�0; (l. PPN�EPA Fri'Std) 1! U► VA
(Q:3. QPM XPA S Std) R?iclvn
' n r- <Q.iiS (0.06 �pm.EPA Sm gid) Y-M&
C;opm --- - .�.� �a. (1.3 - : PPM A;Pri S4
E;halt$eeterui'•:.- A!., f 0 1'Pm EPA Pri Sid) ,
Col#for ri Bacteria w- A .(0 PPM ZPA Pri S. NATER
Tur iidtty X1.0". (5 'PP11r11F:PA rr Std) TPIFJ4TMEHT
:Ars¢uic at01�..: :•'�* :.( ;s)I PPA+�'EPA r15td) Carbm Vis-
Color 0*. (1S - C•oinr Uaits,�A Sec$tda akmdge7*m
Calcium;:�-- ---- !<s 0 (baa: 'Y'1Vi 11;P,�.S'ec$td) littt�st�a FiZtcra
Flootide s.r.:..•�:•••••:••.� c0.� .('4. 1 "Af,1EF'A Sec Std) Ncutralixbr+. ; '
Lead 1—r-7 77-1 o:o0s' (a:oai5 M EPA Pri sta}
T by Na:�Harapr ¢Cc'rW�'f iAb#102099-A � lta�ac0e bW
Agalt�amend bJ:- 5aaitiztir
Tills sample•�s Es 4-aofadr.Wking staa�lar4s based•on he�prlmary 1tcm�a . j ""*K* c+v u ctaoi
xtyou b vs^ ti ►q est<iotis Ike+► 1`AIi'P lic ; elt Perri at 03498-A *tl*TfAEljT1
.. - - sediaun�e Cai�idges , .
Route 28, 04$axnah.900• .'w� 08d$7 wdl�aniize�.
)'096402 *.(800):997.7867 fAx(603)098.96
visifm ax ww%Gpw o:coirt� -
pORTi4
O
0 �
Ab
° LOCMIL lWKK y1.
�SSACHUS��
PUBLIC HEALTH DEPARTMENT
(ommunity Development Division
August 4,2009
Stephen J. Scully
61 Essex Street
North Andover,MA 01845
Re:Title V Inspection
Dear Mr. Scully
This letter is in response to your written request received at the Health Department on July 28,2009.The North
Andover Sewer-tie in regulations requires all properties to tie-into sewer when available.Your request at this time
is to allow the repair of the distribution box and a tank tee only. This letter is to document that due to the extreme
distance to the sewer connection,and the fact that the system passed a Title V inspection for all other criteria except
these items,that at this time a disposal works permit to perform this work will be approved.
This approval in no way is a waiver to or absolves this property from the North Andover Board of Health
Regulations regarding sewer tie-in.
;S/inceryer, HS/RS
Puc ealth Director
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 918.688.9540 Fax 918.688.8416 Web www.townofnorthandover.com
STEPHEN J. SCULLY
61 ESSEX STREET
NORTH ANDOVER MA 01845
RECEIVED
Ms. Susan Sawyer JUL 2 S 2009
Board of Health
1600 Osgood Street, Building 20, Suite 2-36 TOWN OF NORTH ANDOVER
North Andover, MA 01845 HEALTH DEPARTMENT
Dear Ms. Sawyer:
This is in regards to the septic system at 61 Essex Street, North Andover, MA.
As you may know, Neil Bateson did an inspection on the property, as I am about to sell
this home to my son. The inspection revealed no abnormalities, and the leaching field
was fine; however, he felt that a pipe to and the distribution box should be replaced.
As far as a sewer hook-up, this would present a tremendous financial hardship, as it is
about '/ mile or about 1300 feet up a steep hill.
I am requesting your approval to allow continued use of the present existing system for
the two occupants in this home. This would avoid the tremendous financial outlay that
would be required.
Sincerely, � �
Stephen J. SculI y5�
411�4 r6_ _9
�dc.�
J. J, Segedglli
Lot 41 zssex St.
APPLICATION FOR SEWAGE DISPOSAL INSTALLATION
HEALTH DEPARTMENT - NORTH ANDOVER, MASS.
I hereby make application for a permit for a sewage disposal installation at
Lot 4, zssex St. . I will install this system in ac-
cordance with all the laws of the Commonwealth of Massachusetts and regulations of
the Board of Health of the Town of North Andover.
Further, I will construct the house sewer of bell and spigot pipe, the minimum
diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre-
ceding the septic tank, where the grade shall not exceed 2%. I will install a con-
crete septic tank of 1000 gal* in size. A manhole (s) permitting easy cleaning
will be provided with removable cover (s) of iron or concrete within 12 inches of
the ground surface. I will provide subsurface disposal field with 4 inch perforated
or open jointed pipe and laid in a series of trenches, the bottom of which will pro-
vide a minimum of 200 lineal ( U) feet of effective absorption area.
The pipes will be laid on a 9-In-ch layer of washed gravel or crushed stone ranging
in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar
material to a height of 2 inches above the crown of the pipe. The joints of these
pipes will be protected from clogging and before filling the trench, 2 inches of
gravel or stone 1/8" to 1/4" (dia.) will be placed over the course gravel or stone.
The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single
tile line will exceed 100 feet in length and in any case, two lines of tile will be
installed. A minimum of 6 feet will be maintained between the center lines of the
disposal field trenches and the average depth of trench shall not exceed 36 inches.
No part of the installation will be less than 100 feet from any private water supply,
25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line.
I further agree not to cover any portion of this installation until approved by the
inspection officer, as provided below, and to incorporate any additional requirements
that may be attached to the permit. Plot Plans must be submitted with application.
DATE / I `-/ -- (v L(
Signat e--of Ap icant
I hereby issue the above permit for the Board of Health of the Town of North
Andover, Massachusetts.
DATE y
Signat a of Health Agent
I have inspected the uncovered system indicated above and find everything done
as described. �g
DATE 12
Signature of pecting Officer
Percolation Test 5 min. Soil: clay
Garbage Grinder No
BOARD OF HEALTH OF NORTH ANDOVER, MASSACHUSETTS
SEWAGE DISPOSAL
DATE Noyemher 14, 1964
NAME OF APPLICANT J. J. Segad.elli, Inc.
LOCATION Lot #4, Essex Street
Address of lot no.
BUILDING: Dwelling X Other
SYSTEM: New X Repair
GENERAL DESCRIPTION OF LAND High
SUBSOIL: Clay X Gravel Sand
PERCOLATION TEST 5 minutes per inch.
- - - - - - - - - - - - - - - - -
MINIMUM INSTALLATION RECOMMENDATIONS
CONCRETE SEPTIC TANK 1,000 gallon capacity.
LEACH FIELD 200 lineal feet of drain pipe.
William J. D oll , Engine r
Board of Healt
,4
BOARD OF HEALTH
1 TOWN OF NORTH ANDOVER, MASS.
�it77/ /�+- �ALT/""-•..
I P610 GAL. C:..lC.-rJg0tG �
{
I
1. NAME @ �'PI�� .� DATE t ( I'LL _
2. ADDRESS W I k '� T v�u V, LOT NO. TEL.
3. NO. OF BEDROOMS DEN YES &.00 NO
4. GARBAGE GRINDER YES NO
5. SHOW DIMENSIONS OF HOUSE
6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES
7. SHOW DIMENSIONS OF LOT
8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL
g. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM
10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC.
11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE
NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY.
� '� � 4 1--'
!; .5ey so
SEPTIC SYSTEM INSPECTION FORM
ADDRESS CD L
DATE INSPECTED
PROPERLY FUNCTIONING? N
WEATHER CONDITIONS
COMMENTS :
a
WA I ER QUALITY TES T E'b ? JZES0,7S?
DYE TEST PERFORMED? Y N
DATE?
SKETCH: