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Miscellaneous - 626 FOREST STREET 4/30/2018 (2)
626 FOREST STREET t 21.0/105.D-0023-D000A , i A1'1'LIUANT ARVINITIS J i p 550 °;•. o Town of North Andover ,SS,,,,°.•sem HEALTH DEPARTMENT �CHUS 4_ CHECK#: ATE: LOCATION. 6 ab F o�E'j S-t H/O NAME: { CONTRACTOR NAME: 1�( ► n-r S o N 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 $ " Title 5 Report $ / ❑ Other:(Indicate) $ Health Agent Initials,,, White-Applicant Yellow-Health Pink-Treasurer 4 Town of North Andover HEALTH DEPARTMENT S�cut CHECK#: DATE: LOCATION: a6 F a b:t_S %i N . A H/O NAME: CONTRACTOR NAME: 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 Q ❑ k-L� SF ❑ 01- 0 1❑ A ❑ Other:(Indicate) $ HeaA Agent Initials White-Applicant Yellow-Health Pink-Treasurer NORTH - ` 0 4 F 9 Town of North Andover HEALTH DEPARTMENT sSf �cHus CHECK#: DATE: LOCATION: 6.�G a E ST S-t H/O NAME: CONTRACTOR NAME: 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 5Inspector $ Title 5 Report $ ❑ Other:(Indicate) $ HeaA Agent Initials White-Applicant Yellow-Health Pink-Treasurer Commonwealth of Massachusetts Title 5 Official Inspection F r Subsurface Sewage Disposal System Form-Not for Volun sses�ire '' b yy. 626 Forest Street TOWN OR NORTH M V Property Address HEALTH 61PAR°W :, Joseph Kulinetts Owner Owner's Name information is required for North Andover MA 01810 11/17/2010 every page. CityfTown 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: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Neil J. Bateson cursor-dq not Name of Inspector use the retum key. Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover Ma 01810 �O1 Cky/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 ❑ Needpurthe Evaluation by the Local Approving Authority 11/17/2010 lnspbci6rs ignature 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 I� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 626 Forest Street Property Address Joseph Kulinetts Owner Owner's Name information is required for North Andover MA_ 01810 11/17/2010 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17. Commonwealth of Massachusetts r Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 626 Forest Street Property Address Joseph Kulinetts Owner Owner's Name information is required for North Andover MA 01810 11/17/2010 every page. City/Town 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•09/08 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 626 Forest Street Property Address Joseph Kulinetts Owner owner's Name information is required for North Andover MA 01810 11/17/2010 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has 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 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-09/08 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 626 Forest Street Property Address Joseph Kulinetts Owner Owner's Name information is required for North Andover MA 01810 11/17/2010 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection 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 o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 626 Forest Street Property Address Joseph Kulinetts Owner Owner's Name information is required for North Andover MA 01810 11/17/2010 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 600 t5ins-0901 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 626 Forest Street Property Address Joseph Kulinetts Owner Owner's Name information is required for North Andover MA 01810 11/17/2010 every page. C4rrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 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 626 Forest Street Property Address Joseph Kulinetts Owner Owners Name information is required for North Andover MA 01810 11/17/2010 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 2008, owner Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Measured tank. Reason for pumping: Inspect tank&tees Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy vy ❑ 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-09/08 Title 5 official Inspection Forth: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 626 Forest Street Property Address Joseph Kulinetts Owner owners Name information is required for North Andover MA 01810 11/17/2010 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: No as built plan, design plan 1985. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.5 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" PVC in house, no leaks visible Septic Tank(locate on site plan): Depth below grade: 1.5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list ages years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No . Dimensions: 10'x 5'x 4' Sludge depth: 4" t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 626 Forest Street Property Address Joseph Kulinetts Owner Owner's Name information is required for North Andover MA 01810 11/17/2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 26" Scum thickness 5" 8" Distance from top of scum to top of outlet tee or baffle 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 tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-09= Title 5 Official Inspection Forth: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 626 Forest Street Property Address Joseph Kulinetts Owner Owners Name information is required for North Andover MA 01810 11/17/2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No 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 626 Forest Street Property Address Joseph Kulinetts Owner Owner's Name information is required for North Andover MA 01810 11/17/2010 every page. Cityrrown statg 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. No evidence of leakage. Evidence of light carry over.Pumped d- box to clean. D-box cover broken, replaced it. 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 Forth: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 626 Forest Street Property Address Joseph Kulinetts Owner Owner's Name information is required for North Andover MA 01810 11/17/2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1 field 24'x 40' ❑ 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 evidence 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•09108 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 .' 626 Forest Street Property Address Joseph Kulinetts Owner Owner's Name information is required for North Andover MA 01810 11/17/2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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-09108 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 626 Forest Street Property Address Joseph Kulinetts Owner owner's Name information is required for North Andover MA 01810 11/17/2010 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 n i 0 �a93" a� gn 3 t D57 3a`5►� D t5ins-09/08 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 't 626 Forest Street Property Address Joseph Kulinetts Owner Owner's Name information is required for North Andover MA 01810 11/17/2010 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: 10/21/1985 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: Design plan ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: As per design plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09108 Title 5 official Inspection Forth:Subsurface Sewage Disposal System•Page 16 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 626 Forest Street Property Address Joseph Kulinetts Owner Owner's Name information is required for North Andover MA 01810 11/17/2010 every page. Cityrrown 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 Con1mon'wealth of Massachusetts City/Town of System Pumping Record Form 4 V ` 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 front of house, right front of house, left side of house, right side of house, Left rear of house, right rear of house, left side of building, right rear of building, under deck. City/Town State Zip Code 2. System Owner: +S Name Address(if different from location) Cityrrown State Zip Code �� mealy Telephone Number B. Pumping.Record C �- I 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of Sy m: f 6. System Pumped By: Neil J. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc. Company 7. Locat' ere contents were disposed: .L.S. I.Awell WasAe WajK Sign4ret6f Hduler Date t5form4.doc-06/03 System Pumping Record•Page 1 of 1 North Andover Board of Assessors Public Access Page 1 of 1 NORTH Forth Andover Board of Assessors Oe�Tro o,NO "SSACHUse` roperty Record Card Click Seal To Return Parcel ID :210/105.D-0023-0000.0 FY:2011 Community :North Andover SKETCH PHOTO Click on Sketch to Enlarge Click on Photo to Enlar e Search for Parcels rLA Search for Sales �IOIIII�I�I, Summary Residence Detached Structure Condo 626 FOREST STREET Commercial Location: 626 FOREST STREET Owner Name: KULINETS,IRINA JOSEPH KULINETS Owner Address: 626 FOREST STREET City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood:6-6 Land Area: 1.24 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 3752 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 577,300 601,800 Building Value: 368,600 393,100 Land Value: 208,700 208,700 Market Land Value: 208,700 Chapter Land Value: LATESTSALE Sale Price: 506,000 Sale Date: 08/26/2001 Arms Length Sale Code: Y-YES-VALID Grantor: RUSSAVAGE/MARTIN Cert Doc: Book: 06331 Page: 0247 http://csc-ma.us/PROPAPP/display.do?linkld=1707557&town=NandoverPubAcc 1/18/2011 .. Yf. gi COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION r TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: OK -gr°'$7— -57- A /Ud. 4 z ct/ae-& Owner's Name: O'V4 i'f/^j Owner's Address:` Date of Inspection: Name of Inspector: (please print)74- ,1 4 6, ✓;w reA1L o Company Name: '' Mailing Address: 4-1, -) STelephone Number: e9 ?Fj - 3 7,Q - 71// 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: asses Conditionally Passes Needs Further Evaluation by the Local Approving Authority F i 1 s Inspector's Signature: Date: The system inspector sh9 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 owne111 licable,and the approving authority. j0�vBOARD OF HEALTH Notes and Comments I 16 2001FJUL 1 ****This report only describes conditions at the tu" nditions 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. i Title 5 Inspection Form 6/15/2000 page 1 -Page 2 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A / f CERTIFICATION(continued) Property Address:l�d� p Ar-C,57- _ �- Ahl Owner: 177Q'/'l-/AJ Date of Inspection: —D Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: 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. d r Comments: r 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 bo41 -x due to�broken or, II, _.-_ obstructed pipe(s)or due to.a�broke settltd=oriineven'distribution box:S stem'v✓ill ass ins ection if with obstru p ( ) Y P P 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 * 1 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property hAddress: D OctiC Owner:f�'I a f't/ AJ Date of Inspection:4—4 920 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 n-a,.0finer which will prof ci public health, afety and the environment: 1 � 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-volatil�g orgat3ic compounds indicates that thh well is free fromlpollution fr�ci 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: c L 3 r Page 4 of i 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:b 41191-e57— &6 e5 T $'7� r Owner: GQ .V Date ofct o ns a n: I D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No of V' 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 g9u d.orsurface raters due.to an overloaded or clogged"SATS or cesspnol :. C _ /'Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _Lo,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 _eAny portion of the SAS,cesspool or privy is below high ground water elevation. _j,.-,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: _L/'Any portion of a cesspool or privy is within50 feet of a private water supply well. _YAny 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 or 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.] /0 (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...,1 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 Pa( e.5 of 11 v OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST i Property Address:014ox OV-6 aAl :i Owner:lJ9al'f I AJ Date of Inspection: S r:a c4=Cf r Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes o Pumping information was provided by the owner,occupant,or Board of ea i 1 .V. Nr� Were any oixthe systemcom onerts pumped out in the previous two weeks i, Has the system received normal flows in the previous two week period? A/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 backup ? Was the.site inspected for signs of break out? _ Were all system components,excluding the SAS, located on site? S O, Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition i 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 il�A ,of the SobsorP ion System( 1S),on the site h;',beemdetermined based dn: - R- Yes no 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)[3 10 CMR 15.302(3)(b)] t 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: X51. S! G4�2- Owner: Ma/'•t-��c i Date of Inspection: e!!C —/$-DI FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMI�„15.203(for example: 110 gpd x#of bedrooms): Number of current residents:'` Does residence have a garbage grinder(yes or no):90 Is laundry on a separate sewage system(yes or no): [if yes separate inspectio required] " Laundry system inspected(yes no) "or I. ` .' � ` ( �° . , . .' . .., t. '� Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): Last date of occupancy: / Gr"012 COMMERCIALANDUSTRIAL Type of establishment: 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: Was system pumped as part of the inspection(yes or no):_ If yes, volume pumped: gallons--How was uantity pumped determined? { U a q Reason for pumping: J&S'a e-y-._ �. TYPE Q SYSTEM eptic 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 I _Other(describe): Approx ate age of all components,date installed(if known)and source of information: gar Were sewage odors detected when arriving at the site(yes or no)..&d 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: D' Owner: M6?et-/N Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: O Materials of construction:_I Gdl iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): @ SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: oncrete_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: S )c x /0 -6 Sludge depth: ,! " Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 1 11 Distance from top of scum to top of outlet tee or baffle: _ Distance from bottom of scum to bottom of outlet tee or baffle:79 •• �-�- How were dimensions determined:�� w!g Vr" Comments(on pumping recommendation ,inlet and outlet tee or baffle conditio1�structural integty,liquid levels as rel ted to outlet invert,evidence of leakage,etc �U Qd 6 S a. ti ti DO r pe- GREASE TRAP: -(locate_o�site_P an). , -- 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 j as related to outlet invert,evidence of leakage,etc.): t 7 rt P ge8of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address./06 ' .'L Owner: Date of Inspection: ! Q 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): f A t Dimensions: t t Capa ty: , A,loris � f 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:J111111f 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 o �otc.): AM / PA, Ca/!/ Dutd Q PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): "- Comm nts(node condi ion,of pumgjchamberp;condition ofpufnpf"and appurtenances,etc.): 8 Pa 69 of 11 t OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:6 0 G e d� ' Owner: l�/'7 Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: a 4 Type a , � leaching pits,number: leaching chambers,number: leaching galleries,number: 1 ing trenches,number, length: eaching fields,number,dimensions: O overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of pon ing,damp soil,condition of vegetation, etc.): Oo "hj 0 9 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): i Comments(note,condition of soil; ,'gns of hydrulid-failure leveli&pon ing;cpndit n of vegetat p,etc:): t. g j 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.): 1 9 Pae 10 of 11 t OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEMINFORMATION(continued) Property Address: © Owner: �' Date of Inspection: 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. k i � l� CJ A00 U / G 00, A, i 10 Pag 'I1 of 11 i OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:L12 + Owner: oalei,/ti Date of Inspection: SITE EXAM Slope Surface water Check cellar 1/.5 UMP Pu / '%j Shallow wells ' Estimated de}ith to grbund water 4 `,; "� < � • .�,E s t o r 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: served 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 5slablishcd the hi h groundwater elevation: d LA-e r 7Z i 1 u � _ �, F.. ,�. +� i— ,:�'�«..- .. {� e jai�. •, - d � � yi 7 Il ,o�1�,evA W►T;S l� ST KI 0 MERRIMACK ENGINEERING SERVICE 66 Park Street BNEET NO. Of ANDOVER, MASSACHUSETTS 01810 CALCULATED BY DATE J (617)478.3355 CHECKEDBY ^-�y I' DATE_ ji SCALE OT TCC ci�s I : i I � I .... .i l... .-}. ..._...... _. If : EL lop I i I r S5 fi 1 pp J' DLt' OgSF1Zyf�ilo►.1 }kx,E PEGTES k ( x SOIL. TrS l 1-UC ATl 0�,1 S i i ,' Water Pumps b Sewage Pumps Illlll ELL & PUMP CO. Artesian Wells RT.28 WINDHAM,N.H.03087 �V Water Softeners OR St [603]898-4232 a [603]627-9533 a [617]887-5888 Water Tanks Water Testing BILL ARVANITIS Pump Parts 28 YALE STREET LAWRENCE, MASS . 01841 Motor Controls Switches es OWNER' S NAME OR SAMPLE LOCATION: Gua g PARCEL—A LOT—A FOREST STREET, NO. ANDOVER Softener Salt Resin Cleaner WATER TEST RESULTS 12/27/85 TEL NO 686-6742 **** *********** *********** ******* *************** ** Rust Remover HARDNESS 17 .1 (0-50 REC STANDARD) IRON . 5 (0—. 3 REC STANDARD) Potassium Permanganate MANGANESE 0 (0—.05 REC STANDARD) HYDROGEN SULFIDE 0 (0—.01 REC STANDARD) Soda Ash Ph(ACIDITY) 6.5 (6.5-7 . 5 REC STANDARD) Ti,�RBIDITY 8 (0-20 REC STANDARD) Lawn Sprinklers CHLORIDES 12 (0-150 REC STANDARD) Chemical Feeders COLIFORM BACTERIA NEG (0 REQUIRED STANDARD) NITRATES 0 (0-10 REC STANDARD) Tank Alarms NITRITES 0 (0-10 REC STANDARD) SODIUM 7 (0-150 REC STANDARD) Hoist Service Portable Pump Pullers TESTED B Y : *************************** ********************** ***** Air Compressor Trencher ABOVE TESTS MEET REQUIRED STANDARDS AND BASED ON THESE, WATER IS SAFE FOR HOUSEHOLD USE AND HUMAN CONSUMPTION. Pipe Pullers THERE ARE OTHER LESS COMMON MINERALS WHICH CAN AFFECT QUALITY OF WATER. Goulds Aermotor Jacuzzi Aquatron Well-X-Trol Aqua-Air BOARD OF HEALTH Town of North Andover,Mass . Permit Dat APPLICATION FOR WELL &' PUMP PERMIT Application is hereby made for permit to drill a well ( ) . Application is made to install ( a system: _ Location: Address #- - — - - Oian-6r _ Address Tel . Well Contractor 7 6( ic GA)ell 641-A d d,r e s s % o??p;h�. Nle Tel . 86'18 1252 Pump `Contractor ��' c`�qC- �,� Address. dJ (,�1;�;, :,,(,[�1�r Tel . " .WiLL CONTRACTOR (To be` completed 'at time of pumptest') I Type of. We 1.1 6`0 �c^, `e-;..Well used for C_ .Diameter of Well Sizo of ,Cas,ing (42 Depth of Bed Rock Depth , casing into 'Bed 'Rock ' Was Seal Tested? Yes ( , ) `' Date ,of Testing I / 9dd� i Depth of WellZ&O � Well Ended, in What Material �' C Depth to Water � Delive'rs�Gals .Per MLp. for 4 hours Drawdown feet after pumping hours at GPM Date of Completion gna u. Wel Contractor ;°:::�-��-.'.':';;';-.c::-.'.':::'::::'::':-1.':�:':;�k_.'c�.c_.'c �.•'.:::��'.'"k:c:°;c-�':':-.'.':;;::::::';:::::.'::'�:':�':''-':::�'-1.'�';:-.'c-.'c�,`':':::'k�:':;t'�-.'c'lc-!t���*� PUMP INSTALLER (To be filled in before installation) Size & Name Pump Pump Type Used Water Pump DelA.ers GPM Size of Tank Pipe Material Used in Well : Cast Iron (_) Galvanized (_) Plastic (_) Well Pit ( ) or Pitles-s -Adapter ( ) Was sleeve used to protect pipe? Yes (_) NO(_) Type or Name Well Seal Date r s�iti Sh�k s��e s�s4 s4 int Sit int Sit S�slt sit Slt tai Sit Sit iii 44 5fit sit Ski Slt S t Stf S�I51i s �e int sit i�5t 5tirSi i�SSP Sit s is• a v�`-1 _#,;I v Date Water analysis report submitted to Board of Health Date release given tD owner' of record & Bldg. Insp Health Inspector TOWN OF SYSTEM PUMPING RECORD DATE: q-ocZ SYSTEM OWNER& ADDRESS SYSTEM LOCATION (example:left front of house) �llvi-est DATE OF PUMPING: q q-8 QUANTITY PUMPED : �� GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: ` Commonwealth. of Massachusetts RVE® City/Town of I 4 2006 System Pumping Record APR 2 Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 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'. formsto the computer,use only the tab key Address to move your cursor-do not Gi /Town V use the:retum ty Stat Zip Code key. 2. System Owner: ll. Name 1 Address(if different from.location) Cityrrown State i ode 2 Telephone Numb B. Pumping Record - 1: _Date of Pumping Date 2. Quantity Pumped: Gallons I Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight.Tank ❑ Other(describe) 4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No 5. Condi' n of 6. System P mp dB Name Vehicle License Number Company - -- . 7. Location ere contents were ' posed: Sig atur f auler Date http://www.mass.govidepiwater/approvals/t5forms htm#inspect t5form4.doc-003 system Pumping Record•Page 1 of 1 TOWN OF K do vIV En SYSTEM PUMPING CO LF 3 0 2004 DATE: �-�� a DEPARTNIORTH ME TER SYSTEM OWNER& ADDRESS SYSTEM LOCATION Y (example:left front of hoose) DATE OF PUMPING: -0 QUANTITY PUMPED : C� G ONS CESSPOOL: NO YES SEPTIC TANK: NO YES 7 NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS ,T_ LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste •tM I Z� L4 2 '5 fLt Q v- ( < 2 wlN(2tZJV,q TI c 2 -1z •a 3. Z .7 115 7 ' 2 itC ✓J L�C�� i I i I i i l I _ S nv LIt-D Y455ji I ►� �� - cl. i, 4� N I � (;��hsb -h b 1 CfWA/"YJ' -J�sivl Mal 7 b rC9 RkA i . ` (b ) Extensions of the water hal | 10 H be shown in the easement loca Thistie Rnad and Wondberry "a RYH / c ) A sewer \ ine sha1 ] run witI ��hp�-~Y' �� JU� Way right-of-way . A tSewer ~�Yne e, tenIon shall be shown running through \ nts 20 , 2l , and 22 and connect with the euer ( i '/e within the Abhott Street right-of-way through lot 33 . This easement shall be 2� ' *ide . ( d ) Due to the lack of detail and dis�rep�ncie� on the plans and the required modi � icatlnns required by the Planning Board . the Board may upon its own motion require an additional Public Hearing when revised pians have been submitted and reviewed hy the Board . 6. Temporary cul-de-sac E-asement language should he included . Note on the record plan that the Thistl� Road may become a through street in the future under ' the Subdivision Control Law, At this imn a t-mporary . turnaround easement :,hall be placed upon io�s 42 a�d 53 . All pavement will be removed within tempprary turnaround easements with the exception of driveway and services to dwellings on Lot 42 and 53 will be removed and the area loamed aind seeded . upon e::tensiu/` ` ' of Thistle Road into Woodberry Lane, if approved . 7 . Sidewalks shall be shown on one side of the roadway - for both Thistle Road and Nutmeg Lane . 8. The plans will reflect improvements to the t--jr-1 existing culverts which pass under Abbott Street [��t of Easy Street , and a third culvert on Abbott 5trcc+ ' approximate\ y 200 ' West of proposed Thistle jiil be upgraded in size acceptable to DPW for of accetping add itionai stornwater run-off caosed by thi� subdivision. 9 . The prnpnsed catch 13 r3 sins at the interspction ni Aboott Street and proposed Thistle Road should he ' piped in a westerly direction a!onq Abbott Street �o the existing brook . The propo�;ed drainpipe from i]he intersection going the opposite direction or Ahbnt �- Street shall be eliminated ' The `following conditions are to be placed on the rRcorded Definiti�e Pian, (cover sheet ) prior to endnrsement and filinq yith the Reqls�ry o[ Ueeds . 1 . Any changes as a re� a � ult of action undertLen und , M.G .L. Chapter 131 Section 40 or North Andover Wet \ands Bylow �haLl be �ubmitted and revie�ed b� t�`e Planni:g Boar under a Definitive Mndifiration Application . . I(,?- vj-�y ' Mrs.. �OLX- Sep-r(�, $�STeyY� ��i,S he�Y' aFF(,a✓ed Me — n7 G ��✓� wcT�) t-(�e )-rAtik-- axIv\e-C,r(dv7 _ who l ssv� -�o o�t�( �(� tie t�r� � �✓n�� i�-- ' . . (b ) Extenns of the water ndhaIF 410" l | be shown in the easement loca Ti ~~'^' -' � s� �e �nao ano w0000erry ��0��R / c ) A sewer | -Ie CF;hal ] run mit1U� 13hp' 4' 2� Pn% �ay right-o -way �ewer ~ �ne ! r e`: ten��sn shall he shown running through lnts 20 , Pl , and 22 and connect with the -;ewer | ine within the Abhntt Street right-of-way through lot 33. Thts easement shall be 2� ' wide . ( d > Due to the lack of detail and disrrepcie on the plans and the required modificatinns repuired by the Planning Board . the Board may upon its own motion require an additional Public Hearing when revised pLans have been submitted and reviewed by the Board . 6. easement language should he inc1uded . Note on the record plan that the Thistl� Road ma,/ become a through street in the future under ' the Subdivision Control Law, At this � ime a temvorary turnaround easement shall be placed upon lots 42 ar�d 53 . All pavement will be removed within tempnrary turnaround easements with the exception of dri�eway and services to dwellings on Lot 42 and 53 will be removed and the area 1oamed and seeded . upon e:'ten� ion ' of Thistle Road into Woodberry Lane, if appro�ed . ' 7. Sidewalks shall be shown on one side of the ro��way for both Thistle Road and Nutmeg Lane , 8. The plans will improvements to the tyo existing culverts which pass under Abbott Street [��t of Easy Street , and a third culvert on Abbott Strsc� ' approximately 200 ' West of p-roposed Thistle Road miLl ' be upgraded in size acceptable to DPW fnr purpose_-. �_ 'l -Ce to ng *dditionai stornwater run-nff caused subdivision. q. The propnsed catch basins at the inte'section nf Aboott Street and proposed Thistle Road should h� ' piped in a westerly direction alonq Abbott Street ~' o the existing brook . The proposed drainpipp from th(:, intersection going the Opposite direction or Ahbnt \ Street shall be eliminated . The 'following conditions are to be placed on the rRcordpd Defini � i;e Pian, (cover sheet ) prior t,o endnrsement and filing with the Re(-.1itrr o[ Ueeds. 1 . Any changes as a re�.ult of action underta�en undpr M.G ,L, Chapter 131 Section 40 or North Andover �etIands By}aw shal } be submitted and revie�ed by t!`e Plannirg Board under a Definitive Mndjficaticn Application . . ����� A bsurf. Design Check List Page 2 FAIL CR LeachingPits Leaching pits are preferred where the installation is possible Reg 11.2 a) calculations of leaching area-minimum 500 eq ft 11.4 b) spacing 1110 a) surface drainage 2% ? .11 d) cover material e) VaVAO splash pad f) tee at elbow g) no bends in pipe from d-box to pipe Leaching Fields Reg 15.1 a) no gree err an 20 minutes/inch b) are 900 aQ Ft 15.4 c) construction of field 15.8 d) surface' drainage 2 % 3.7 e) 201 from cellar wall or ingrouand, swinning pool Leachiri Tvenches Reg 1.4.1 :0—calculations or iLeaching, area-min 500 sq ft 14.3 b) spacing-4 ft min b ft with reserve between 1.4.1 c) dimensions l 14.6 d) constinction 1.4.7 e) stone 11x.10 f) surface drainage 2% Downhill Slop e' ' a) s OOe y x –Tto be shown) b) y/x X 150 - (to be shown) EMS Reg 9.1 a) approval 9.6 b) stand-by power r BOARD OF HEALTH MM �/ No.Andover, Mass . d_ SUBSURFACE DISPOSAL DESIGN CHECK LIST LOT �.S.. APPROVED - DATE _ _ DISAPPROVED DATE 10-ZS5S r � Provided: l% Reasons: rpl b9 V 01To 5n25- �,� w 1 S � ffMir 1 Ta c tp 5 - 6m PROP s1D~'cia 6 - � rs F� ) Title V FAIL OS . Reg 2.5 The submitted plan must show as a minimum: a) the lot to be served-area,dimensions lot #r`,abutters b location and log deep observation hoes-distance to ties c location and results percolation testa-distance to ties d design calculations & calculations showing required leaching area. (e) location and. dimensions of system-including 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 100' of sewage disposal . system or disclaimer (i) location any drainage easements within L00I of sewage disposal system or disclaimer-Planning Board files (J) known sources of water supply within 200' of sewage disposal system or disclaimer (k) location of any proposed well to serve lot-100 from leaching facilit (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 lax to preparesuch plans Reg 6 Septic Tanks of flog, water table, tees, depth of tees, (a) capacities-1507, access, pumping (b) cleanout (c) 10, from cellar wall or inground swimming pool (d) 251 from subsurface drains Reg 10.2 Distribution Boxes (a) s ,pe greater Ulan 0.08 Reg 10.4 1 b) ,muP u p �So OFSEAL f i� Lo FOF? NoR,1�H /�til?DVEI�, �. ,N2Viivins , 4Pft u eD ❑yE"s C1 No SS v 5tP-rl G SY STFAA �PPr�ov��v D,4r�' AP OVPJ6 Author?) ry J , 1 �7�U/JTro1� 1tiS�.G1-10 Aj V4TC Lj_3-�(, 7#I- JSS FAIL. FINAL IVSP6,�-FIOA) (ticG i t JAJ6 TU v)N)tc 4PFRO\)EP 10 fATC /SPPi�vrn�G ,��T�tOr�i ry F JN5Fbcj jo"5 (lipmay) DtSAPP�dv�D . D,a rC FI -),QL APPROVAL �(�✓��t^a�y1'�1+11.Y�ay Jf'ri 1 ~- ' w ,I:._ + F.' � ,. .. }r'� S I^"}nfiy - f;'� �r ��il}�<�M� -i}2 t {1;r F tf f�iq }J�A1 �_'1'�3 J , � t ', � I Z I ✓ - �.. i 1 p�"7.1 a !;. � r { t tY }t , y �•5 n,, , 1 ;� �k4#i P".;.���•f:'ic.J}'yf}/,M,*:,.{t._f �..t�' i,,�.�-.. ,r::. a r a`:�`.! ., *r t li !rt- I• '?:It°4 5' `TOWN OF NORTH ANDOVER SYSTEM PiTMF►ING RECO RD {� •1M I'1�'.! i �'� RA�i �E. 4. r 'L�:[ ft !.(.w+.�i Oc.,M�4q+'4S'f��1'I♦ {„ . } .-1t.� jAWittpt}r+lal ',h+ , ,, r P "4,;� i ' •a i• � � 4 k � F .�4? ,. } 1 N + r w .1j �,,�. 'y r. 'r f '+ F!•yl ,. 'r. OWNER&ADDRESS SYSTEM IpCATION rt, r+ 40, b u (CU4PPW W •front 4f hou") .i �t qtr f t rp .. �ti ..y ;.` �• {;` r^� #i�' :•It.•i.aul�:o.s.wr_ se+.w—. .�4 i,.• i r 1 1 , kI�N ,i.' ,r,� }ia r� r r I r�µy•.tyr,:.� �� > r � r _ 77 77 ; � AyTE DF P�TMP • F 'QUANTITY PUMPED - GALLONS .+� �� c)t f� ��iy1{¢t?t7�Y�ft'a,,t'��+�i�i�{ J I'�.��^ r�� .✓ � I i 'C 11+t�'' }- - . J }tai ' YEla t}�' r' 1 ft i • .NO •+EP 1l4 TANA• NO YES - +.9�' 1�tfi, Air •r ..,' i 1::e ,�i� f ^'T *'�.M.�R•�+Va/� ROVT�E s''Lli'. ' . ,It ' �,,,,, CMERGENCY �• 't�,!1 ,;y..,Zei+y4 f]frr 'wrns�(}� t)iw. n � � 1, t* �•' } � .. ..... O {�r'aI r I ?�, GOOD U'�NDITION � - ; { .... :` FULL TO COVER .� GREASE r �al�'► '', � t� ;'r t� �V'GREASE. B 4� ROOTS BAFFLES IN PLACE _ �j Y S r LEACSFIELD RUNBACK EXCESSIVE SOLIDS : ^�• CIC FLOODED } SOTdDS CARRYO "O -- . TIER vER t o /EVA •��� ,n�ri.e� ate* ..3.?� + htki 'if� -'l� Tc {/ t 9.2001. - 4�j • / � �, L'/ yT 1 {'�'f y �t 17 I�I b✓-��'�����j:� ?:}� - �{ t�jtai� 1 1��1r1.11�t f r_j,i�f't 4. /w/ �`.♦' I 5. r' . r rh....If �'.»,17,ra �tFe���1 t F ,) :�� 1��// �L/• t'`� .. - Commonwealth of Massachusetts RECEIVE City/Town of System Pumping Record MAY 2 12008 a' Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 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 Important: When filling out 1. System L cation: forms on the computer,use 1 only the tab key Address to move your cursor-do np dot Cityfrown" State ZiCode use the return key. 2 System Owner: Name 11 Address(if different from location) Citylrown Stat & Zip Code(e Telephone Number B. Pumping Record 1. Date of Pumping 7bate 2. Quantity Pumped: talions 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ElYes D-No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of Stem: 6. Systerp Pu pe�Fly: C ' Name ��'���✓v \ _ Vehicle License Number R, Company 7. Locati wha con is disposed: r r Sign re auler Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 ,{ COMMONWEA ,TH OF MASSACHUSETTS EXECUTIVE OeFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON. MA 02108 617-292-5500 V WILLIAM+F.WELD TRUDY CORE Governor Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A De so �O s, 1A�5 .CERTIFICATION Property Address: �j,�-a SS S� Address of Owner: Date of Inspection: /1- ! "" (If different) Name of Inspector: A t4,4E in�—=-S i I am a DEP approved system spector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: _. Mailing Address: it pig f-oiA, Telephone Number: CERT FI(CATION STATEMENT w I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: 6 SYSTEM CONDITIONALLY PASSES: I /! 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. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (reviaad 04/25/97) Page 1 of 10 DEP on the World Wide Web: http:/twww.magnet.state.ma.us/dep 0 Punted on Recycied Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address Owner: Date of Inspection: B] SYSTEM CONDITIONALLY PASSES (continued) �J Sewage backup or breakout or high/static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board.of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four 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 x f Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER •� WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT THE SYSTEM 15 FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria-and volatile organic compounds indicates that =• _ =the:well-is-free from-polIution zfrom that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximationnot valid). 3) OTHER (raviaad 04/2S/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: d PS 0 V4,6/P V Date of Inspection: !� �7 D) SYSTEM FAILS: You must indicate eithter"'Y s" or"No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an 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 sbove 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. - LARGE SYSTEM FAILS: , You must indicate either "Yes" or "No" as fo each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility.with.a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health andsafety and,the ,-env ironment;because one or more of the following conditions exist: 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'll of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and•6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 4, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: &.:L6 fi Ke 5 fi Owner: P ps d fi(a S /£' Date of Inspection: Check if the following have been done: You must indicate either "Yes" or"No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. f 1 if As built plans have been obtained and examined. `Note if they are not.availabig.with'N/A. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of / Sub-Surface Disposal System. _ Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)) c (revised 04/25/97) Page 4 of 10 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: C1�� fo S Date of Inspection: � �4 FLOW CONDITIONS RESIDENTIAL: Design flow: e.p.d. -room for S.A.S. Number of bedrooms •-�� Number of current resi ents:_ Garbage grif-Aer (yes or no):- a Laundry connected to system (yes or no):--\Z- #5 Seasonal use (yes or no): )k/4 Water meter readings, if avail le (last two (2) year usage(gpd): Sump Pump (yes or no): /�, Last date of occupancy:--4—eCV ( P ;� �6 '" �M 4`� 4`1 j"'e COMMERCI.AUINDUSTRIAL• Type of establishment: Design flow:_gallons/day 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: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: j l� System pumped as part of inspection: (yes or no) If yes, volume pumped: 0 O gallons Reason for pumping l'A C fi r TYPE OF SYSTEM Septictank/dtstrabuzson,box/fpil-abso�ptioh,system Single cesspool. Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contracts' Other APPROXIMATE AGE of all components, date installed (if known) and source of information: / `j e Sewage odors detected when arriving at the site: (yes or no)' {1 (revised 04/15/97) Page 5 of 10 T: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) zG IrIge5"r- .rr Property Address: Owner: ps o r'l Date of Inspection: f(j_• �i' BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: _cast iron _40 PVC_other(explain) Distance from private water supply well or suction hrf- D iameter Comments: (condition of joints, venting, evidence of leakage, etc.) O.0 P !d rig/>tr''�/u� • _ SEPTIC TANK:�p� (locate on site plan) Depth below grade: Material of construction: _ oncrete _metal _Fiberglass _Polyethylene —Other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: f Sludge depth: s Distance from top of sludge to bottom of outlet tee or baffler Scum thickness:_* .� Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) 4,o u 2 P P.AV Di rAv i 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: (recommendation. for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 .r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C �j SYSTEM INFORMATION (continued) Property Address: Owner: E's.d✓4 ' 1 r 0- Date of Inspection: TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: NIJ- Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Alarm in working order_Yes` _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOXJ_ ) (locate onsite plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) 57 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.) (revised 04/25/97) Paye 7 of 10 4j SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: / ry SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) V,- to l� r(u w n n 32 r n (revised 01/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: UV G Date of Inspection: 1 Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) V Determine it from local conditions Check with local Board of health V Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) � 4tf m"'or``" ell- (revised 04/2S/97) Paye 10 of 10 Address �' , Title of File Pae f 9 0 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