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Miscellaneous - 614 SHARPNERS POND ROAD 4/30/2018 (2)
` ✓ 614 SHARPNERS POND ROAD 210/090.6-0019-0000.0 d Road — �r 1 t t E 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Q Subsurface Sewage Disposal System Form - Not for Voluntary Assessme ' b M e s � Propy Address Owner Owner's W J� Na information is / required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, RECEIVED 1 tlED use only the tab 1. Inspector:key f JAN �11 f1 y s� cursor omdo not ove your C i► l�< ii1Y 0 JU 1�1 use the return key. NWe of Inspe TOWN OFNQRTMANUWV HSALTH DEPARTMENT Co any Name 14 C impaqAddress City/Town State Zip Code I '2S- (f 2.3 C1 S LZ.1 41 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 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts "�; j• 4 -- 17Ji"tle.5 Official Inspection Form 4 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments (( i ' S Property Addres Owner Owner' Na e r information is . required for every , ' page. CitylTown State Zip Code Date of Inspection R' 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: J 113 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. Chthe box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not deteermi " please explain. The septic tank is tal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits subs I infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank i laced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is cturally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 y s old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 s +t Commonwealth of Massachusetts � _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments n' - Property Address Owner Owner's);7��a information is required for every /v page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. System Conditionally Passes (cont.): ❑ Obse 'on of sewage backup or break out or high static water level in the distribution box due to broken o structed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection i h approval of Board of Health): ❑ broken pipe(s) are rep ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ ❑ N F-1ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed i P e(s). The P 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 Requi the Board of Health: ❑ Conditions exist which require further evalu ion by the Board of Health in order to determine if the system is failing to protect public health, safety orthe environment. 1. System will pass unless Board of Health determinin-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 vegetatedw P P Y etland or a salt marsh t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 n Commonwealth of Massachusetts -- Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address NISOwner O Na information is required for every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) tem will fail unless the Board of Health (and Public Water Supplier, if any) termines that the system is functioning in a manner that protects the public health, sailety and environment: ❑ Th system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet a surface water supply or tributary to a surface water supply. ❑ The sys has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system ha septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic to and SAS and the SAS is less than 100 feet but 50 feet or more from a private water sup well". Method used to determine distance. **This system passes if the well water analysis, pe ed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of am nia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are . ered. 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 ❑ R( Liquid depth in cesspool is less than 6" below invert or available volume is less (� than '/z day flow t5ins•3/13 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 �t Aj-e L,,—S C-n1L Property Address . Owner 0 ner s Na information is required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ` ❑ A 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. ❑ f 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 �( p p y 50 feet of a private water supply well. ❑ � Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303 therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a desi flow of 10,000 gpd to 15,000 gpd. For large s ems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Se 'on D. Yes No ❑ ❑ the syste i within 400 feet of a surface drinking water supply ❑ ❑ the system is within feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a ni en sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone f a public water supply well If you have answered "yes" to any question in Section E the sy is considered a significant threat, or answered "yes" in Section D above the large system has failed. owner or operator of any large system considered a significant threat under Section E or failed under S ion D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should con t the app appropriate riate regional officeof the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts -_-W Title 5 Official Inspection Form s Subsurface 3Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owrier Owner's Narht information is required for 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 k ❑ 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) �R....yy[ ❑ Was the facility or dwelling inspected for signs of sewage back up? Id\J u VV the SILO inSpeCted ror 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): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins-3/13 Title 5 Official Inspection Forth: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 G^.4 Property Address OwnerK..�t • Ow s Nam information is required for every a'1 .✓� ' _ a/ Z —/J! page. CitylTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: � Does residence have a garbage grinder? El Yes No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes No Laundry system inspected? ❑ Yes ( ' No Seasonal use? ❑ Yes No Water meter readings, if available (last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes No Last date of occupancy: b�l'L ti w!' Date Commercial/industrial Flow Conditions: Type of Establishment: Design (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flo ats/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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 7 of 17 Commonwealth of Massachusetts -- W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address C Owner Owner's Na information is required for eve /'�I�a-' bL�1� 1 ---I —� page. CitylTown 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: `o `J!/as system pumped as pari of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: rVSeptic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy Shared system (yes or of (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 s ° Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V W Property Address Owner Or wne's N information is required for 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: ,tom leaching fields ? fid Ute. 9 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 ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 M Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address lip Owner A00n er's NaTIV information is ✓ required for every �l 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, \elofonding, condition of vegetation, etc.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 e • `. Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w � 1 M � L Property Address Owner Owner's Na e , information is / required for every � ' page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid lev s a elated to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pu ed at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ po hylene ❑ other(explain): Dimensions: Capacity: gallons De ' n Flow: gallons per day Alarm prese ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, e *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No l5ins•3/13 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 M 0 6-VL w Ck.S fV Property Address Owner O ner's Na e information is required for every cj page. CitylTown 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 - �_ 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.): 4 J-tcl Pump Chamber(locate on site plan): Pumps working order: ❑ Yes ❑ No* Alarms in work order: ❑ Yes ❑ No* Comments (note conditi f pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a con "tional pass. Soil Absorption System (SAS) (locate on site plan, excavation n required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M / g -� �e Property Address Owner Owner's Nam / information is required for every c+L + ��/'►- ���`C� ? Z- l J page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: / ka 's Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: �1 cast iron ❑ 40 PVC ❑ other(explain): /Distance from private water supply well or suction line: feet Comments tts (on condition of joints,venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: feet Material of construction: Zconcrete ❑ meta! ❑ 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: Sludge depth: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owners N / ,ation isrequire � �ry �Jk— 0 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness A- 7 'l Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): t -camh76L3 -4 Grease Trap (locate on site plan): Depth below grade: feet Ma erial of construction: ❑ con ete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts . E-MOM W Title 5 Official Inspection Form Subsurface Sewage Disposal>System Form- Not for Voluntary Assessments Property Address Owner Owners Na G information is required for every A4%• a�t'`-- ©� Z—!�—f S page. Ciity/Town State Zip Code Date of Inspection E. Report Completeness Checklist [� Inspection Summary: A, B, C, D, or E checked Inspection Summary D(System Failure Criteria Applicable to All Systems) completed System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M / 0&u Property Address Owner owner s ry k � information is required for 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 i t5ins-3/13 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 Property Address Owner' Owner's Na information is 1 required for every /'v page. CitylTown State Zip Coe Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 5 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 I 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: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 lop t , , Of 5. .,hO V ( 6 1 i Town of North Andover `,�'•�,,,,o.: ,' HEALTH DEPARTMENT ,SSACNUs�t CHECK#:,3 7 23 DATE: LOCATION: A/c///// � H/O NAME: _ 1YC.Y) CONTRACTOR NAME: /7/G Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning'. $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ �1 Title 5 Report '❑` Other:(Indicate) $ He 41-Agent Initials White-Applicant Yellow-Health Pink-Treasurer COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS r DEPARTMENT OF ENVIRONMENTAL PROTECTION Y Yt V TITLE 5 OFFICI4L INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM RT EA CERTIF ICATION CATION -fPv`&T A o �� �� ,/ 1 BOP,.Q 0�HES Property Address: �f! APR Owner's Name P r Owner's Address: $ Date of Inspection: lglo L4 Name of Inspector: (please print) .�(Jt7? �1151a Company Name: ("A i1prfyice— Mailing Address: c9D 1�01 [01/l .S7: T-3 ren- Na. Telephone Number: C-)3'7,9 y71 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5'(310 CMR 15.000). The system: Passes '•• Conditionally Passes Needs Further Evaluation by the Local Approving Authority", ; Fails + Inspector's Signature: rA/-J"e- dk:�-- Date: 1/--7- oV 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 ka shared system or has a design flow 017.10,000 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. t � J 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 f Fage 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: A 17'r ", "") x0d N ma Owner: O N i Date of Inspection:�-�f�Q 11( l � _ _ Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: 1/6 5 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: r. B. System Conditionally Passes:H 4 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. f 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 f +� Page 3 of l l .4t OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM tip. PART A C. CERTIFICATION(continued) Property Address: 61 Q r5 lQty!LEd . Q$ C 7Q Owner: -hf -�� Date of Inspection: /C. Further Evaluation is Required by the Board of Health:N 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 wilt 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 s • Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 6/4 0 Owner: �'(11J�-'f'� ,(ir1N1)GVc'�kF / ,1(1 ' Date of Inspection: i? A 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 mi 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''/z day flow 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. t 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 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.] o (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: A To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B / / f CHE PropertyAddress: LD�`� ShOr )�l S N D Pd Owner: (1 N -6 r Date of Inspection: Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health `Were any of the system components pumped out inI 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? J11 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: Yes no _ Existing information.For example,a plan at the Board of Health... _V_ 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)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INtFORMATION Property Address•, S l-) S N0. OA1 l),Y 'e, rl)(`i Owner: )YUAn_f,? Date of Inspection: q/171h',`/ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual):-3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: 112- Does residence have a garbage grinder(yes or no):L1_0 Is laundry on a separate sewage system(yes or no):— [if yes separate inspection required] Laundry system inspected(yes or no)://u , Seasonal use:(yes or no): Ay o Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): //6 Last date of occupancy: 0 cc up f COMMERCIAL/INDUSTRIAL J Type of establishment: Y Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,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: y•S I Was system pumped as part of the inspection(yes or no): Y S If yes,volume pumped��j/�gallons--How was quantity pumped determined? Reason for pumping: r r 7's4.,i S 2 u c rwe e TYPE.OF SYSTEM Lt-'Septic tank,'distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) -Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information l` D ' Were sewage odors detected when arriving at the site(yes or no):Aid 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: ILI Owner: 7 J Date of Inspection: 14 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_(locate on site plan) Depth below grade: 4/j T u Gen pu ,, 4 1.26 4.,U Material of construction:_,_�crete_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: 5 5 Sludge depth: a " Distance from top of sludge to bottom of outlet tee or baffle: 3 V Scum thickness: f t, Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: 4 How were dimensions determined: 61-1 S / Tr Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): _.. KFPOI.af .,,,o�, ,L_�f(-�Zr. /��� s.�e,h4 Cob n Cup-t0 1-1 - U air 1 GREASE TRAP:_(locate on site plan) ; I Depth below grade: Material of construction:_concrete a metal fiberglassl_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 x Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C // SYSTEM INFORMATION(continued) Property Address: & I q Si )' ,r,5 Po /w Nya. ONIJQIL CY1l Owner• Date of Inspection: TIGHT or HOLDING TANK:(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: y 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:Le- (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:�v1 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.): A-44x 4Od0 iiO / S l cvP/1 PUMP CHAMBER:J-_/Alocate 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 'Page 9 of 11 A a OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:(�I ..�hfr 12 �ONl� No Owner: ! e k. Date of nspection: , 14 SOIL ABSORPTION SYSTEM(SAS)19-5— SAS)1- S (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches,number,length: V leaching fields,number,dimensions: L/ 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.): 0 pey 9 i,'-/i 0 '1 CESSPOOLSQ (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.): , PRI . -t_(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: lj Sh,,7rPn,,rANn Rd- -4 d- Na. on[v) VPt'� a �)� • Owner:()A:P P Date of Inspection: q1211N 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. J,t 9 8 � 0 ,9- 0- r3 0 90- r30 1=J,rc 0 f r y Llt-l�S 10 Page 11 of 11• OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6 _ riC1)ner,-,l ON D kP . J V/� 0N1.1D�/fk Owner: 1j um-r"r' Date of Inspection: T17 1-04 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground watef(', feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: u- Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked.with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Q U Gi A-7' 0-/3 d L/ r Trrt R� 11 '_ 1l1JIfL"LA.MI1tAI VIIIYJA w♦ fi IP OVED DATE III FctCTVED „ . AVATIC�t 0K FAIL �zeaspnst BAIL OK I. Distance Tot A. Wetlands b. Drains c. Well 2. Water Line Location 3. No PPC Pipe 1 �. Septic Tank - a. . -Teas -_Length Ec To Clean-Out Cowers. - -,. b. Cement Pipe to Tank -- on Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracke fi ,/' b. All Lines Flowing Equal Amounts c. No Back Flow i Leach Field or Trench ' a.. Dimensions r bStone Depth c: Capped Ends - ' d. Clean Double Washed Stone 7. Leach Pit'. r - a. ons ' b. Sto a Depth { c. ash Pads d. eas e. eraent Pipe to Pit - Both Sides. f. Clean Double Washed Stone 3 8. No Garbage Disposal. •Final G rarlin 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 • 'i • i %andover C c 'F EIGHTJLTON STREET C METHUEN. MASSACHUSETTS 01644 inc. (617) 657-3828 911jesslcma/ (0-ngirw(Irs D A T'E 7, me 0 'Vand C-411"'ll.?Yors rn TO : NORI'h jil'�'DGVE"R HEALTH '1'04iEALL , 1"1G. A_1NLjO,,T_L'R , lv,j-i6s RE : SUBSURFACE -SEaAGE DIIS)PWAL SYST_,;,'_-'K 40r 3 0 6&14ePU6'2S 0VAJ1--) A-44 , NO,. ANDOVER , MASS . I hereby certify that I have inspected the construction of the disposal system at e-07— North Andover, 1\�iass . and that the location and elevations are as shown on the As-Built Drawing dated &C7% 7 /17,00 ANDOVER, ON-ULTANTS INC. illimT� cL William 17, Leo d Registered Sanitarian This cerci ,Lcat-ion is not to be construed as a of the system. f iy cer zz o�Fxoe 71yA g gOX Ol/T�E"r. _ . 96.99 rd 6 a 4,s — 01—I/C. T DR4W /NCS �? �a ` cSUB�SUi2FAC'E CSEbt/AGE D/SPOSAL cSYSTE/1/1 2),47,E: DC'r. 7 /98D lilt SL/E .PEAL/TY T1eU.sT .�.��� �-�:�� 3,• �`�� 202 L.4�'f� ,ST. • if/o. �iUCJo�/E,t� , �IA.SS. EX�sr. LOCA T/OAA LOT 3 5'�11�.f',dr{/E".�5' IWIVa 4!910/)WINOD,*Tj N,,4' ,4ssEssa�e"5 /lil.4,o Alo. — , L o T / lo. — andover �'; W1L 39� consultants - �,-o N0. 74MOM .` s AOOD inc. 213 Broadway ,Methuen , Mass. y���WYiI try`, Tel. 687- 3828 K//7-/-/ .47-7-AC/-/E4 CE•2T/F/CAT/ON TO BE COit/S T,2 L/EL> A,5 A <:�7G/,4,e,4/V TEE THAT T,-/EE SYSTEM W/LL FUNCT/ON SUBSURFACE DISPOSAL SYSTEM CHECK LIST NORTH ANDOVER BOARD OF HEALTH ` Y APPR,QVED DATE PROVIDED DISAPPROVED DATE TIME REASON 3 44 Title 5 Reg. 2. 5 Fail OK The su ' tted plan must show as a minumum: the lot to be served (area,dimensionsilot //,abutters)Board files) location and log of deep observation holes-distance �o ties c location and results of percolation tests-distance to ties design calculations & calculations showing required leaching area (e)---location and dimensions of system (including reserve area) )---existing and proposed contours ocation of any wet areas within 100' of the sewage disposal system or- disclaimer (check wetlands mapping) surface and subsurface drains within 100' of sewage disposal system or disclaimer i location of any drainage easements within 100' of sewage disposal system or disclaimer (planning board files) known sources of water supply within 200' of sewage disposal system or disclaimer ��ocation of any proposed well to serve the lot (100' _, from leaching facility) 1) location of water lines on property (10' from leaching facilities) location of benchmark driveways - garbage disposers PVC is to be used in construction ' (q a profile of the system (elevations of basement , plumbers pipe septic tank, distribution box inlets and outlets , ; distribution field piping and any other elevations).00 { maximum ground water elevation in area of sewage disposal; stem plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such j plans i Sept,; � Tanks Reg. 6a) Capacities - 150% of flow, water table, tees , depth of tees , access, pumping, 4/(b) Cleanout € i } (c) 10' from cellar wall or inground swimming pool (d) 25 from subsurface drains 1 ' North Andover Subsurface disposal system check list - Page 2 t t ail OK Dist button Boxes ` Reg.10.2 a) Slope greater than 9.08 Reg.10.4 (b Sump Leaching Pits f Leaching pits are preferred where the installation is possible Reg.11 .2 (a) Calculations of leaching area (minimum 500 S.F. ) Reg.11 .4 (b) Spacing Reg.11 .1 (c) Surface drainage 2% Reg.11 .11 (d) Cover material Leaching Fields Reg.15.1 kb,) reater than 20 minutes/inch Reg.15.1 Area (minimum 900 S.F. ) Reg.15.4 ) Construction of field Reg.15.8 ) Surface drainage 2% Reg. 3.7 ) 20' from- cellar wall or inground swimming pool Leaching Trenches Reg.14.1 (a) Calculations of leaching area (min. 500 S.F.) Reg.14. 3 (b) Spacing (4 ft. min. 6 ft. with reserve between) Reg.14.4 (c Dimensions 14.5 Reg.14.6 (d) Construction Reg.14.7 (e) Stone Reg.14.1 (f) Surface drainage 2% Downhill Slope Slope y/x = (to be shown) (b) y/x X 150 = (to be shown) Pump e Reg. 9.1 (a) Approval Reg. 9.6 (b) Stand-by power SOIL PROFILE & PERCOLATION TEST DATA North Andover�Mass. No•&Street _)_PWA'W_4 496j�b Lot No. Loc./Subdiv. Plan OwnerG*I pB *-&yqP Investigator J,,�.D Observer L ,,PIhCtw .�, SOIL PROFILES-DATE - Elev. Elev.� 3' Elev. 4'Elev. 0 0 0 0 1 \ 1 1 1 Ties to Test Pits 2 2 2 2 a0(' of 3 3 3 3 4 4 4 4 5 5 5 5 6 6 6 6 7 7 7 7 8 8 8 8 /Va, ` 9 9 9 9 10 10 10 10 Benchmark Location Elevation Datum Percolation Tests-Date Pit Number 1 2 3 4 5 Start Saturation Soak-Mins. Start Test-Time Drop of 3"-Time - Drop of 6"-Time 3:3 Mins. lst 3"Dro Mins. 2nd 3"Dro Notes &. Sketches on Back cwt I T r �..,^epK'.^:"�'1 _�,�r ,}-�-�^r rr .• �---�-w_.. -• - - ...wsr... ..tii::�-1-�s�?-^�'�k�..:�... - '_ �"4" . /v I 1 ` ( 4x Ir WELL DATABASE I ADDRESS. AGE OF WELL: WELL DRILLER: WELL PERNET T: ? WELL LOCATION: ALV, WELL PERMIT DATE: DEPTH OF SELL: �' � � TYPE OF WELL: C- DRILLED b. DLT Gam, c. UNKNOWN TYPE OF WATER BEARING ROCK: - j°s2 — �' �Z J WATER ANALYSIS DATE: 3-1 HIGH MANGANESE: Y ON: Y N. OTHER CONTANENAiNTS: Y HIGH IR LI� !' ;W, �YII.^ aw k ' M kN`�i�v T �� ���°{ . �{� �4.F• �'AC �'(ry� d t[ tr 'u Lrk i;r,1 '' . ti- ;'.r"Y�Art y,"rS l-+0'fi �4 S.� r.1 / - . 4 k r arpner s Po y ; , IAC rr, „nd Road, No . Andover Test Pits conducted f� Z1d Witn.e d b trJ, 1.+ 6 r{ i taw rp;.l y .f lessed n s r� ' "Co= "es Y Michael Rosatti . conducted /13/84 and ,.witness ed by MichaelGraf. tq rs�i' t�✓ ��x n .(/ ��tl�, .fi�.ti+rr�� .�.���w L.i���Q,��,.r��,'Fy �4i111� ' _ ;• To P & Subsoil 9 Boney Compact Silt ' �° '' 4t '� �' '�+ " Vo"�t y Till � ��r, �xound�rater encountered �� r t untered ms,�,<s Y0�3Ir Top and. .Subsoil Sb 1 Boney Compact Silty Till encountered 6. y� M ab �ro�nYF �yT, IT Top & Subsoil rSdi F k'�<" 31 1081' ✓��:.: r ,xBoey Compact Silty Till t '. 1* !�3 } 1a�aFr," c' rbltdS�a' e2' e n countered +Test Percolation rate' 22 wtz� ,'a' ` ` �t ` 4G IrBr� Percolation rate = 25 minmin/in �[ FIN - a N (w I4 qrt t,,1F d �-ey����.�.4a 21. IC4�ftTf J ,4 I. r F,py jlgSrd�,l1 { 1 c r rr„ - rx` t4tin IL vi �..r ` .. �tly,�tf r. �„�x��i.T•ai� m Affbr t C,�t1,71�� i -• r a '.. iS`t v� f,t r�yt�`"tr -.cYPtiN R; £17•} ra�yh{�'�,i�+kLr ,�a,^ fir'` •;f �hu �.,�R�4i�,a �°�s�'���,.c°j��.;'iii•f x';� _ `. �y ENGINEERING SERVICES Iw .. i6 .t. 1S sad � Nor h`� ndover, Mass. Street No ,•- l S� Lot No ?oc/Sub"v. _ ---- Pland _N-ner Z5���C> investigator_ Observer Ark— SOIL `"/y kSOIL PROFILE DATES I_F.7.ev 2.Elev 3.Elev 4.Elev 0 0 0 0 Ties to Tesi Pits ? 2 2 2 - f - 4 N&1 4 . 10 4 � 4 �� -'` - 5 --- - 5 ---Ir - 5 6 6 6 ------I-5l----- 6 ------ j --- -- 7 -- 7 _ 7 - ------- 8 8 --_ 8 -------- 8 -- 9 --------- - 9V 9 - -- 9 ------ 10! -- - --- 1.0 --- -- = -O -- ----- - - 10 - ---- - cnc: nark loci -don Elevation - - -- ------ Dat,f --- - -- -- ----------- PxRCOAJ'-0. TZ-5TS 14 Pit N-LL ib e r 0�� Fe 2 3 ---,+-- - - --- - I - Start Saturation ------ ------- ------- ------------- -- --------- --- �tart les �,-•!1;�,e--------- - ------of .) - - ------- — ---- �(� - -------i--- - - --------- Dr� of 6"--Time -��- 0 -----�a ILAP -- ----- --- ------- Dro Ali- � � � � �'° � � ' � _ ,� S `�� o� V � � ��� � CA-ZZo Bd Cp y,� { �S N� S CC.� .S y T T�' IJ'1 /i - — --- I - _y.._-___. � C�_y .:�� t `%'\�`'✓ - .22 3r 7611 1000, 4 A t{[5 /Soo GA /• SEG-f/C f�.Y/ 1� � i i i BOARD OF HEALTH Town of Narth Andover ,Mass . Permit # Date 19� APPLICATION FOR WELL & PUMP PERMIT/ -made for permit to drill a well (cam'. Application is Application is hereb�Y p _ made to install (_� a pump system*. / Location: Address /� S a �2�1 Lot # Owner l,� , ,�Z,. 2Address /7 �u� v e Tel . -Z?-.�V22 Well Contractor�j�l���gy��, si/�,�, Address !S �vvc�:� �vTel .�tj ��dS� Pump Contractor Address Tel . . , WELL CONTRACTOR (To be completed at time of pump test ) / Type of Well /e/X�_.�rdG, Well used for Diameter of Well 4 Size of. Casing Depth of Bed Rock d Depth casing into Bed Rock �D Was Seal Tested? Yes ( rte" No (_) Date of Testing Depth of Wil l – - Well Ended in Wha-t- Material Zee,-�e–1 Depth to Water f —Gals . Per Min . for 4 hours �� Delivers /'8 Drawdown �j feet after pumping _hour2aure Date of Completion %� ,F6 el Contractor PUMP INSTALLER (To be-- filled in before installation) p_� ---Pump Type UsedSo,lmc-,k J, /- Size & Name Pum ��✓ Water Pump Delivers /0 GPM Size of ,Tank cad Z--- Pipe Material Used in Well : Cast Iron ( ) Gal.vnni.zed (_) Plastic ( Well Pit ( ' ) or Pitless ,Adapter (J-� sleeve used to protect pipe? Yes (Zr' NO( ) T e or Name Well Seal Was slee p P P _ Date �4�r►M*���M►M�M�r�M v'e�r�a�a►a�4�a���4��th ti4 tk�t ti4 ti4 ti4�a t�tia sit ti4 Sk�r;4;�;'t;N;4 ti'r�� ti r;'c i°:i. ,:„ . .. . ..:. .. . .. . .:.. .. rrs:::, Date Water analysis repor--t submitted to Board of Health Date release given tD owner of record & Bldg. Insp Health Inspector MERRIMACK ENGINEERING SERVICE JOB 66 Park Street SHEET NO. OF ANDOVER, MASSACHUSETTS 01810 CALCULATED BY DATE (617) 475-3555 CHECKED BY DATE 1-7 -qbi 10 SCALE Ui—A o v ...... ....... ,.............�(... .... .................. .......... ............. .......... ......................... ............ ......................... .......... 6" - ............ ............ ............................ ................................- ........... ...... ......................- .......................... ...............:.............. ......................................... .......... .................................... ........... U L 1-0 tP?OY I t-A A ............ ..... ........................................... .......... .............. ........................... . . ...... ...G ...... .......................... .......... .. ......... ...................................... ......... 4 El- . ......................... ................................................. ..........................4............ ............. .................................................................... ....................................... ........... ....................................... .. ........................................................................ . .................................................. ................................................................................ ................ ................................ ............I .............. ...........4...................... ........................... ........ ..........i............. ..................... ............................................... .......... ...................... ....... ........s.... .......... ............. ............ ........... ......................... ........... ........... .......................................I .............. .........? ........................ .........................I... ............. ...... ............ . .................................................................... ........... ...................................... ....... ....................... ..... .......... .. . .......... ............. .............. ......................... . ............. .......... ...................................... .............. ............ ......................... ........... ....................... .... . ........ ........................i ............ .......... ............•.......................... .......... .............................. .......... .......... ............ ...... .............................................. ....................................... 0 .................. ...A ..............- .............................................................. .......... ...............: ....................... ......... ............................. ...... ..................... .......... ............ ..................... ..............!.............. ................... ............. ...... ....................................... ......... . ..............i .............. A ............ .......................... .............. .... ...........i ........... ............. ............. ............... ...........................4 ........................... ................................... ......... .......... ..... ........... ........................... ........... ..............-...................................... ............. .......................... .....................................V. .......................... ............. -If ............. ......................... ....... •.......................... .......................... ............. .......... ............................ .... ............. .......... 1.................... .......... .......................... .............. . ................... .... 4 .1........... ............. .... ............................ ................... i . ........... ................... ........... ............. ........... ...................................... ................................................... ............ ........... ........... ..... ........................................ ........................ ....... ......................................... ...........? .......... .......................... . .... . ......... .. .. ........... _......................».._ . ........... ........................................i ......... ....... .................. .......... ......................... ........... ............ ............. ................. ........... ............. ............. ........... .......... ......................... .. .......................... ....................................... ........... ..... ..... ..... .......... ............... 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V) IRS Or Nii-� nor 3 s R � � �D R r-r�►�sT ° •;'VdI�TM /�ti►�oU�l�, MA, PLS ��ti j � SS I L-10 �ovDlT�otiS= �ISAPPRUVED 1A�E R�4SoNS CY,CAV4T(c►,AJ )A-)'s.t�-C—ponj U/JrG Q PASS p ��►c._ ,dPPI�i��E1> 04TC /SPP(���NG AvT�tDl�liy �4�1�IT(01JA(., J�l5t�j lONS �1�=-A►�y) � "�'`� � T N r (ti ta � DJS/�Pj7) UO jF DArC FwA,L 16PPF�jVA L 4PPi3WVJ6 �+ �;, wr►�E /�tel�l�►��tQ�K SCJ- Nora S v5E• OARD Ok' 14 „ ALTH o':Andover, Mass . OSAL DESIGN CHncK LIST oF`FcK&5T5T 55 LOT ,pRoM _ DATE 11-.4 s DISAPPROPED DATES �ovided: Reasons: _. P40J Sit wiN; l- 11 O1,�'095 5HOWN 10' (Iv wJZC)/JG Ly_ 4 - Ltle V FAIL OK 3g 2.5 The submitted plan must show as a minimum: a) the lot to be served-area dimensions lot i ,abutters b location and loca ion and 1resultsdeep percolation tests-distance eto ties to s c d design calculations & calculations showing required leaching area (e) location and dimensions of system-including veserve area f) existing and proposed contours g) location any vet areas within 100' of sewage disposal system or disclaimer-check wetlands mapping (h) surface and subsurface drains within 100' of sewage disposal system or disclaimer (i) location any drainage easements within 100' of sevvge disposal system or disclaimer-Planning Board files (J) knows sources of water supply within 2001 of sewage disposal n system or disclaimer (k) location of any proposed well to serve lot-1001 Brom 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 in 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-15D% of flow, water table, tees, depth of tees, access, pumping (b) cleanout (c) 10t from cellar wall or inground swimming pool (d) 25+ from subsurface drains ,eg 10.2 Distribution Boxes (a) slope greater th 0.08 eg 10.4 (b) sump •d Biornarine Research Corporation 16 E. MAIN ST., P. 0. BOX 1153,GLOUCESTER, MASS.01930•TELEPHONE: (617)283.7705 To: Quinn Realty Development Report No.: 13427 179 Newbury St. Date: 3/11/86 Danvers, MA 01923 Attn: ' Mr. Neal Quinn Re: Well Water Analysis Sample No.: 14684 Sample Description: Sample of water taken from a new artesian well, 400 feet deep, and located on the property at the corner of Sharpner's Pond and Forrest Street, North Andover, MA. This well was drilled by the American Artesian Well Co. Sampled By: Delivered by customer. Date: March 5, 1986 Findings: pHValue.. .... .. ... .. . .. . . ........... .. ... ..... 6.55 Hardness (as CaCO,, mg/0........ 25 Iron Contort (a�'L,).. .. . .... ..... .. .... ..... ... U.tv LManganese Content ( )......... . . ... . ....... . <0.02 Sodium Content (mg/�. ..... 4.08 Nitrate Nitrogen Content (mg/L .. .. .. .......... <0..02 Specific Conductance (pmhos/cm).. ............ .. 105 Total Coliform Bacterial Count Der 100ml (MF).. Not Requested Remarks: Inspection of pH, hardness and specific conductance indicates that this water may be corrosive. However, with continued usage and flushing of the well, this characteristic may change. By: � ' Q.l ynthia A: Foster �- Chemist Biomarine Research Corp. CAF/bmc I ' TOWN OF NORTH ANDOVER MoRTH Office of COMMUNITY DEVELOPMENT AND SERVICES o:°�> HEALTH DEPARTMENT 400 OSGOOD STREET NORTH ANDOVER, MASSACHUSETTS 01845 �'SSAC14 978.688.9540—Phone Susan Y.Sawyer,REHS/RS 978.688.9542—FAX Public Health Director E-MAIL:healthdept@townofnorthandover.com WEBSITE:http://www.townofnorthandover.com April 11, 2005 To all Sharpeners Pond Road Residents: Please note that it has come to the attention of the Health Department that many residents are leaving their trash barrels and trash bags out at the curbside for days, or weeks at a time. r Empty trash barrels blowing about in the road are a safety hazard, and trash and debris along the roadway is a health hazard. Please be mindful of this, as the Health Department will conduct periodic inspections of the area to determine who is in violation, and fines will be issued if protocol is not followed. The Board of Health follows the State Sanitary Code regarding Human Habitation, 105.CMR.410, Section 1: 410.600 (A): Garbage or mixed garbage and rubbish shall be stored in watertight receptacles with tight- fitting covers. Said receptacles and covers shall be of metal or other durable,rodent-proof material. Rubbish shall be stored in receptacles of metal or other durable,rodent-proof material. Garbage and rubbish shall be put out for collection no earlier than the day of collection. (B): Plastic bags shall be used to store garbage or mixed rubbish and garbage only if used as a liner in watertight receptacles with tight-fitting covers as required in 105 CMR 410.600(A), provided that the plastic bags may be put out for collection except in those places where such practice is prohibited by local rule or ordinance or except in those cases where the Department of Public Health determines that such practice constitutes a health problem. For purposes of the preceding sentence in making its determination the Department shall consider, among other things, evidence of strewn garbage, torn garbage bags, or evidence of rodents. 410.602 (A)Land. The owner of any parcel of land,vacant or otherwise, shall be responsible for maintaining such parcel of land in a clean and sanitary condition and free from garbage, rubbish or other refuse. The owner of such parcel of land shall correct any condition caused by or on such parcel or its appurtenance which affects the health or safety, and well-being of the occupants of any dwelling or of the general public. (D) Common Areas. The owner of any dwelling abutting a private passageway or right-of-way owned or used in common with other dwellings or which the owner or occupants under his control have the right to use or are in fact using shall be responsible for maintaining in a clean and sanitary condition free of garbage, rubbish, other filth or causes of sickness that part of the passageway or right-of-way which abuts his property and which he or the occupants under his control have the right to use, or are in fact using, or which he owns. Residents should know the following: • The Town has a mandatory paper and cardboard recycling ordinance that requires residents to separate these items from their household trash. Paper and cardboard are collected every other week on the same day as the household's normal trash. Residents can call the DPW at 978.685.0950 to get their recycling schedule. • Residents are responsible for picking up loose trash left at the curb after collection. Banned Items and Recycling Requirements: Please refer to the DPW website for a complete list of all the recycling requirements: http://www.northandoverrec_ycles.com. Please contact the Health Department if you have any additional questions. Thank you. S incere awyer, REHS/RS Public Health Director File