HomeMy WebLinkAboutMiscellaneous - 61 FOREST STREET 4/30/2018 61 FOREST STREET _
210/106-4-10168-0000.0
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
DEP has provided this form for us&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(Ceft// ig r of . , Left/right side of house, Left/
Right side of building, Left/Right front of bulldtfig, Left/Right rear of building, Under deck
Address
r-
City/rown State Zip Code
2. System Owner.
Name
Address(if different from location)
Cityrrown
Telephone Number ;
x
B. Pumping Record
1. Date of Pumping Date �epfic
nti Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yeas No If yes, was it cleaned? ❑ Yes ❑ No;
5. Conditip , . /►
' O C lav)
6. System Pumped By.
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca' e ntents were disposed: DEC 0 9 2013
GLLS-Q Lowell Waste Water
SignAtufe 9t HaulejuDate
t5form4.doc-06103 System Pumping Record•Page 1 of 1
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
,
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:/4!a/r' QST.
i. z /' F !
Owner's Name: �/
Owner's Address
Date of Inspection:
Name of Inspector: (please print),)Flmw el,
Company Name:SkI.,wz A
Mailing Address , m
Telephone Number: 271--,5 1'7V7/
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:
P- PoSasses
Conditionally Passes
Nees Further Evaluation by the Local Approving Authority
7' Faiys
r '
Inspector's Signature:
I .Rate: �
The system inspector shall submit a co of this inspection report to � rovin Authority Board of Health or
Y P PY P P �f, PP g tY(
DEP)within 30 days of co4ipleting this inspection.If the system is a s ed 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.
Title 5 Inspection Form 6/15/2000 page 1
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` Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: F'S 74 .5
Owner: / 1
Date of Inspectio
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. 03 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired:The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
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Page 3 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner: lg-�,;IIIV17
Date of Inspection.' ,l
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
- Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well".Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: ' S
Owner:
Date of Inspection•
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No/
_ 1/ ckup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
�scharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
ogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
-5e�sspool
L quid depth in cesspool is less than 6"below invert or available volume is less than''/2 day flow
equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
e Afy 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.
-40eAny 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 compomads
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303.therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to.each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
_ the system is within 400 feet of a surface drinking water supply
_ the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone.II of a public water supply well71
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.
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Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: & ii f' ;,4 �S
Owner:
Date of Inspectio
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Y-0
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?
V Were as built plans of the system obtained and examined?(If they were not available note as N/A)
P--' 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:
Yeo
Existing information.For example,a plan at the Board of Health.
V"o Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[3 10 CMR 15.302(3)(b)]
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Page 6 of l l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
- r
Owner: r. _
Date of Inspection:
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): Y(')
Number of current residents:
Does residence have a garbagegrinder(yes or no):
Is laundry on a separate sewage system(yes or no):,QQ [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use:(yes or no)./A2D
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no):/li 0
Last date of occupancy: 1
COMMERCIAL/INDUST��RIAL�TT
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: r FG T
Was system pumped as part of t1fe inspection(yes or no):�LPS
If yes,volume pumped: JdO gallons--How was quantify pumped determined?
Reason for pumping: S �2Fc T ii/U 1C
TYPE OF SYSTEM
Septic tank,distribution box,soil absorptian 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:
�+ a r
Were sewage odors detected when arriving at the site(yes or no)f tJO
6
• Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:f<'/� .
Date of Inspecti U3
BUILDING SEWER(locate on site plan)
Depth below grade: 3 6
Materials of construction:_cast iron V40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: I/ (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: �> X -6 X /D 6
Sludge depth: 41
Distance from top of sludge to bottom of outlet tee or baffle:?O
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: cl
Distance from bottom of scum to bottom of outlet tee or baffle:y
How were dimensions determined: /iN P_ P l f'Gl f u/ e
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as rel o outlet invert,evt�ience of Jeakage,etc.): /
c,vim ,v C/ Pf + �nG9 /17..
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.):
7
Page 8 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner•,
Date of Inspect'
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 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
le a into or out obox,etc.):
// /
UCL i� — 1/6 r,( rAi"v!�, nUl!'
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
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• Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: �� PS S4
Owner:
Date of Inspectio .
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:_
leaching chambers,number:
r1 Ching galleries,number:
eaching trenches,number,length: 0X,r 1 rs ? o c
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 liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
• Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM'INFORMATION(continued)
Property Address:
Owner: /";/-
Date
Date of Inspectio �,'
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.
ro ��ST Al--
J
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10
Page l l of l l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: #f/ ' r% �--
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
_ZObtained from system design plans on record-If checked,date of design plan reviewed:/2—
Observed
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 ust de cribe how you established the high ground water elevation:/l
r, J �2,
11
Address Qgg:a: Title of File Page of
Date File Open: Date file closed:
Doc Document/Action Title Date of Refer to other Purpose of Document/Action and notes:
action Document/ document/
Num. Action Department
Board of Appeals — Board of Health — Planning Board — conservation commission — Building Department
G
Board of Health 5EPTIC STSTEH F7
North AndnverZHnre. IN3TAMATICK CHECK LIST LOT
DAT e, DI SAPP"ii CNID
IlAT zjAVA��CN Ob FAIL
6if
ea�nst
wL -
FAIL og
1. Distance To:
12�����
a. Wetlands
b. Drains
c.. Well
2. Water Line Location
3. No PVC Pipe
4. Septic Tank
a. _Tees -_Length & To Clean oat Covers
b. Cement Pipe to Tank On Both Sides of Tank
5. Distribution Box
a. Covers & Box - No Cracks "
b. All Lines Flowing Equal Amounts
c. No Back Flow
6. Leach Field or Trench
a. Dimensions
b. Stone Depth
c: Capped Ends
d. Clean Double Washed Stone
7. Leach Pits
a. Dimensions
b. Stone Depth
c. Splash Pads
d. Tees
e. Cwt Pipe to Pit - Both Sides
f. Clean Double Washed Stone
8. No Garbage Disposal
9. .Final Grading Inspection
10. Barricading Covered System
11. As Built Submitted
a. Lot Location
' b. Dimensions of System
c. Location with Regard-to Pere Test
d. Elevations
e; Water Table
Y
TOWN OF NORTH ANDOVER. MASSACHUSETTS r
OFFICE OF
CONSERVATION COMMISSION
f Aor,TH 1
�a�•'' � °oma TELEPHONE 683-7105
4�
�,SSACMUSES
Pursuant to the authority of the Wetlaads protection Act,
v;]Ssachusetts General Laws Chapter 131 , Section 40, as amended,
clid the Toi,m of North Andover' s Wetland Protection .By Law, the
No-rt-_i-i "Mclovor. Conservation Conunission will hold a Public Hearing
c;T, January 23, 1985 at 8 :00 P.M. at the Town Building
120 Main Street, North Andover, Mi'� on the Notice
of Intent of General Store Realty Trust to alter land at
lots 32 , 33, 35 & 39 Carlton Lane l ,r purposes of
constructing single familytdwellings
Plans are available at the Conservation C, mmission Office,
Town Building,, 120 Main Street North Andover, ), A, on Tuesday
from, 12 :00 noon to 2 :00 p.m. and by appointmen. ,
By: A. Galvagna
Chair-Zan
_._ run once in the N.A. .Citizen on Jan. 17, 1985
Copies sent to:
Planning Board
Board of Health —""'
Public "orks
Highway Dept.
--- Applicant
Engineer
DE1E
BOARD OF HEALTH
No.Andover, Mass .
SUBSURFACE DISPOSAL DESIGN CHECV, IST
�E-
LOT
APPROVED - DATE DISAPPROVED DATE
Providedt Reasons q -t,�
Title V FAIL IK
i'
Reg 2.5 The submitted plan must show as a minimumt
a) the lot to be served-area dimensions lot #,abutters
bat
ion and log deep observation hoes-distance to ties
c location and results percolation tests-distance to ties
d design calculations & calculations st- Wring required leaching area
(e) location and dimensions of system-in.c.ud3ng reserve area
f) existing and proposed contours
(g) location any wet areas within 100' of sewage disposal system or
disclaimer-check wetlands mapping
(h) surface and subsurface drains within 00, of sewage disposal
system or disclaimer
(i) location any drainage easements vithi:, L00I of sewage disposal
system or disclaimer-Planning Boar ' files
(3) known sources of water supply within 'C n' of sewage disposal b
system or disclaimer
(k) location of any proposed well to serve lot-1001 from leaching facility
(1) location of water lines on property-101 from leaching facility
(m) location of benchmark
- -- (n) driveways
(o) garbage disposals
(p) no PVC to be used is construction
(q) profile of system-elevations of basement, plumb, pipe, septic tank,
distribution box inlets and outlets, distribution field piping and
Other elevations
(r) maximum ground water elevation in area sewage disposal system
(s) plan must be prepared by a Professional Engineer or other
professional authorized by law to prepare such plans
Reg 6 Septic Tanks
(a) capacities-15U of flow, water table, tees, depth of tees,
access, pumping
(b) cleanout
(c) 101 from cellar wall or inground suim ing pool
(d) 251 from subsurface drains
Reg 10.2 Distribution Boxes
(a) s pe greater than 0.08
Reg 10.1 b) sunp
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. 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:
forma the C 1
computer,use t
ION-
only the tab key Address
to move your
cursor return not
ret
use the Clty/Town Sfate Zip Code
key. _ 2. System Owner:
Name
ICS Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record -� °\
1. Date of Pumping Date 2." '"`� 2. Quantity Pumped: Gallons�
3. Type of system: ❑ Cesspool(s) .,Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumpe By:
onow
ame Vehicle License Number
7. Locatio where contents were dispo ed;
Signature of Hauler Date
http:/twww.mass.gov/deptwater/approvalslt5forms.htmffinspect
t5fonn4.doa 06/03 System Pumping Record•Page 1 of 1
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