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Miscellaneous - 64 NORTH CROSS ROAD 4/30/2018
44 NORTH CROSS ROAD 210/0380000.0 cross / Applicant: Frances Estates 'oor': r r Town of North Andover, Massachusetts Farm No.3 NORTIy BOARD OF HEALTH t F 9 DISPOSAL WORKS CONSTRUCTION PERMIT ,SSACMUSEt Applicant . NAME �ADDRESS TELEPHONE Site Location �G '7" i�%(�.�'+-�.�) � C3`� Permission is hereby granted to Construct ( ) or Repair (-Kan Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CHAIRMAN, BOARD OF HEALTH Fee D.W.C. No. /--,9 .. V Town of North Andover Health Department Date: fe Location: (Indicate Address,if Residential,or Name 9f Busir��ess) Check#: Type of Permit or License:(Circle) ➢ Animal �� $ ➢ Dumpster $ ➢ Food Service-Type: $ ➢ Funeral Directors $ ➢ Massage Establishment _ ,$ ➢ Massage Practice $ ➢ Offal(Septic)Hauler $ ➢ Recreational Camp $ ➢ SEPTIC PERMITS: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC)$ ❑ Septic Disposal Works Installers(DWI) $ ➢ Sun tanning $ ➢ Swimming Pool $ ➢ Tobacco $ ➢ TrashlSolid Waste Hauler $ ➢ Well Construction $ ➢ OTHER(Indicate) 611 V' Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer a I of I I / COMMONWEALTH OF MASSACHUSETTS �✓ EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS J DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 64 North Cross Rd North Andover,MA 01845 Owner's Name: Salina Sbaw Owner's Address: 64 North Cross Rd North Andover,MA 01845 Date of Inspection: February 6,2006 Name of Inspector: (please print) Benjamin C.Osgood,Jr.Certified Title 5 Inspector Company Name: New England Engineering Services Inc. Mailing Address: 60 Beechwood Drive North Andover,MA 01845 Telephone Number: 978-686-1768 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 the on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15340 of Title 5(3 10 CMR 15.000).The system: f Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 2 L6 [Ob The system inspection shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 2of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 64 North Cross Rd North Andover,MA 01845 Owner's Name: Salina Shaw Date of Inspection: February 6,2006 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: `1 F-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: & System Conditionally Passes: N J One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): Broken pipe(s)are replaced Obstruction is removed Distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): Broken pipe(s)are replaced Obstruction is removed ND explain_ t 3of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 64 North Cross Rd North Andover,MA 01845 Owner's Name: Salina Shaw Date of Inspection: February 6,2006 C. Further Evaluation is Required by the Board of Health: A)0_Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and (SAS)Soil Absorption System and the(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 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 organize 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 5ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: T 4o€11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 64 North Cross Rd North Andover,MA 01845 Owner's Name: Salina Shaw Date of Inspection: February 6,2006 D. System 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 overload or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overload or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than''/s day flow U 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. L11 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 nitrogen is equal to or less than 5ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) .620 — (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The fo wing criteria apply to large systems in addition to the criteria above) Yes No The system is 400 feet of a surface drinking water supply The system is within 200 a tributary to a g water supply The system is located in a nitrogen area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you answered"yes"to any que . in Section E the system is consider ignificant threat,or answered"yes"in Section D above the large system has failed a owner or operator of any large system conside significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system o er should contact the appropriate regional office of the Department. 5of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 64 North Cross Rd North Andover,MA 01845 Owner's Name: Salina Shaw Date of Inspection: February 6,2006 Check if the followine 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 an 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 sign of break out? Were all system components,excluding the SAS,located on site? Were all 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 difference from owner)provided with information on the proper maintenance of the 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- Determined ealthDetermined 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)] 6 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 64 North Cross Rd North Andover,MA 01845 Owner's Name: Salina Shaw Date of Inspection: February 6,2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design)_Number of bedrooms(actual): y DESIGN flow based in 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): L b O Number of current residents: S Does residence have a garbage grinder(yes or no): m F6 Is laundry on a separate sewage system(yes or no): N O [if yes separate inspection required] Laundry system inspected(yes or no): /V/A . Seasonal use: (yes or no): N 0 . Water meter readings,if available(last 2 years usage(gpd): )-10 6-f`_t:> Sump Pump (yes or no): ti� Last date of occupancy c. t--c.ti i COMMERCIAL/INIDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): god Basis of design flow(seats/persons/sgft,etc Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Tide 5 system(yes or no) Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: a I 1 �_os ,F&Z n u1 r►e 5 rc c c pA Was system pumped as part of the inspection(yes or no):,.N< If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM L Septic tank, distribution box,soil absorption system ,j rrt-c -?v^n.? 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 Attached a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 63<kaL-i t A 1,120 Were sewage odors detected wen arriving at the site(yes or no): 7of11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 64 North Cross Rd North Andover,MA 01845 Owner's Name: Salina Shaw Date of Inspection: February 6,2006 BUELDING SEWER(locate on site plan) Depth below grade: i 2 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.): F1i e J-0 C, Ks (Z-?C)Z> Ln-) SEPTIC TANK: (locate on site plan) Depth below grade: /9 Material of construction:—concrete metal fiberglass polyethylene Other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: Iso es-6L-cam A r s Sludge depth: 41 Distance from top of sludge to bottom of outlet tee or baffle: 3 0 Scum thickness: Z-- 1 Distance from top of scum to top of outlet tee or baffle: S Distance from bottom of scum to bottom of outlet tee or baffle /0- How 0How were dimensions determined: _g e a s Q 6 u< Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): MgN►l 1ti1 Cr00� ca,. p TI)o N. �G5 1 6-00 cON0/70/1, �e c0/µC/-Z> /NS'T`A L L_!N Gr P-l's&-a-5 -Toy j rl/AJ 69-k"c 4-LG- 0PEM 1".1 G-S GREASE TRAP:�(locate on site plan) Depth below grade: Materials of construction: concrete metal fiberglass polyethylene other (eXplainj Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of sludge 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. 8of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 64 North Cross Rd North Andover,MA 01845 Owner's Name: Salina Shaw Date of Inspection: February 6,2006 TIGHT OR HOLDING TANK: A�1.4 (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Materials of construction: concrete metal fiberglass polyethylene other (explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: d Comments(note if box is level and distribution to outlets equal,any evidnence of solids carryover,any evidence of leakage into or out of box,etc.): _ OFrnNE 4�1 3 7tH go X153. ST rt-)— of ,2`©-1-3 P(on� 7�oX avfe Cp-A -KcD 2econ�iP�O P-ef 4c�: ivc�112 F-OJAL-, No `i�' '-" N c?2 OC ,. - PIC-, PUMP CHAMBER (locate on sire plan) Z <,ts lox �— G2Rp�e oae/L eu�- Pumps in working order(yes or no) G 5 7VnnR)tip �`e cu f�o n Alarms in working order(yes or no) LLL 5 ez;'s'o c_2. Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): -FO M,:F' ►Ad �,j o P.u,I,v b- 0 2 D r\e- 9of11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 64 North Cross Rd North Andover,MA 01845 Owner's Name: Salina Shaw Date of Inspection: February 6,2006 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required If SAS not located explain why TYPE leaching pits number leaching chambers, number leaching galleries number beaching trenches,number in length ro 3.3 w ti C— -7-Keo c F2 C S leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure.Level of ponding,damp soil,condition of vegetation,etc) �E1A i7 1 reVh(H&s bN-au.S N0",4 A/O F0,UD /V 6--. f-,70 0/91-P yD�l� DfZ i�NJSyr9 066-c7yq--Vo"� P-cc01Ae,4.> C07ny 6— A 6f 6 f}ilJJ�jL(�/ y)eep _Ooeos6? 191uD —j72 ec_ pDz) 1�- f::�aoA4 IAJ(>AD),�,� - �XfS Gt.�cl1 7Yz2nC hCs� CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of Construction Indication of groundwater inflow(yes or no) Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: ILI]k(locate on site plan) Material of construction: Dimensions: Depth of solids Comments(note condition of soil signs of hydraulic failure,level of ponding,condition of vegetation,etc. 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 64 North Cross Rd North Andover,MA 01845 Owner's Name: Salina Shaw Date of Inspection: February 6,2006 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. Zo`o Pµ 3� U 3q o�fl SssM� 2a` T2E6 Z PJM I-wc /Y1 a5 civ kTa I-'Triad 2- ! Acv){ 1 F,a` crtnnngG,� 2 - PQM? �•S TFC sl►►- f J�^1� T� T L?N i� ag I Oe- of tiL iT 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 64 North Cross Rd North Andover,MA 01845 Owner's Name: Salina Shaw Date of Inspection: February 6,2006 SITE EXAM Slope Surface water Check cellar s a ? Shallow wells NOI N u Estimated depth to ground water 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: _Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health—explain: Checked with local excavator,installers—(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: PS i2-b L)e- CT J N D ` NEW ENGLAND ENGINEERING SERVICES INC �rG 1 9 /p December 18, 2002 North Andover Board of Health Town Hall Annex 27 Charles Street North Andover, MA 01845 RE: TITLE V REPORT: 64 North Cross Road,North Andover, MA Dear Sirs:. Enclosed is a copy of the Title V report for the above referenced property. The system PASSED our inspection. If there are any questions please call me at my office, 686-1768. Sincerely BeOsgood, Jr. 60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: &1j No 2 fK Ci2o S s ,Zo No QT1 N v�2 MH Owner's Name: Owner's Address: N©0_-n f c,2 o sS 2p d 711 A ,&)D a�jt5-R 44A Date of Inspection: , 2I 1( z Name of Inspector:(please print) .vim�aii•<<,v C ©S Go d D 1� Company Name: Neu j Mailing Address: G.c�, RL-�a�lc„���n pi2tvC N01UW Telephone Number. 9,- 8(v I Z 6 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 15340 of Title 5(310 CMR 15.000 The system: asses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: J�_ 0__ Date: Z:;t `Zc, 2 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) PropertyAddress:_ & f 00/1-11{ CaoS& 9-o 4r) `N o ant e 2 MR Owner: pi-ao P TSfEi Date of Inspection: ►Z l it./OZ- Inspection oZInspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: V1 I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be r9placed or repaired Th em,upon completion of the replacement or repair,as approved by the Board ealth,will pass. Answer yes,no or not etermined(Y,N,ND)in the for the following.statem .If"not determined"please explain. The septic tank is metal d over 20 years old*or the septic (wheer metal or not)is structurally unsound,exhibits substantial infixration or exfiltration or tank fail a is imminent.System will pass inspection if the existing tank is replaced with a complAng septic tank as appro by the Board of Health. *A metal septic tank will pass inspection' it is structurall und,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years o�d is avail e. ND explain: Observation of sewage backup eak out or hi static water level in the distribution box due to broken or obstructed pipe(s)or due to a brok ,settled or uneven di str ution 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 repla ND explain: e system required pumping more than 4 times a year due to broken or o ed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page! of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 4,!jNo 2T't-( c,Q.c.cs goon }. 0b- -f A^-)-O 0,A%2 •401 Owner: PHI t..) P TS&:v Date of Inspection: 1-2-X tb(v 7— 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. temwill pass unless Board of Health determines in accordance with 310 C 15.303(l)(b)that the is not functioning in a manner which will protect public health,sa and the environment: or privy is within 50 feet of a surface water — Cesspool or 'vy is within 50 feet of a bordering vegetated w d or a salt marsh 2. System will fail unless the Board of e th(a Public Water Supplier,if any)determines that the system is functioning in a manner that prot a public health,safety and environment: _ The system has a septic tank 11 it absorp ' system(SAS)and the SAS is within 100 feet of a surface water supply or tributary t surface water s ly. — The system has a septi and SAS and the SAS is in a Zone 1 of a public water supply. _ The system has tic tank and SAS and the SAS is within feet of a private water supply well. _ The syst as a septic tank and SAS and the SAS is less than 100 but 50 feet or more from a private wat upply well**.Method used to determine distance **Th' system passes if the well water analysis,performed at a DEP certified la tory,for coliform ba eria and volatile organic compounds indicates that the well is free from pollution om that facility and e presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,pr ded that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: W1 IkjQ2Ti-( CQoss I'Z3 1,�90U A Av -Do ,) 2 AAA Owner: k i' s Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or`oro"to each of the following for ail inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool r 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'/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. 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.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large_Systems: To be consi a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 l?d You must indicate either `�+ "or`oho"to each of the following: (The following criteria apply to a systems in addition to the cri�a above) yes no i the system is within 400 feet of a s ' g water supply _ the system is within 200.�feel of a tr' ributary to a ace drinking water supply — _ the system is 1� n a nitrogen sensitive area(Int ellhead Protection Area–IWPA)or a mapped Zone II "public water supply well If you have answered"yes"to any question in Section E the system is consider ,a,significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: No Q j l-( e^a0S51Z0 iv o an Ati D ex)E2 Owner: PHIL- )P �5}gra. Date of Inspection: Check if the following have been done.You must indicate`ycs"or"no"as to each of the following: Yes No %/' _ Pumping information was provided by the owner,occupant,or Board of Health 1/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? v***-_ 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 taffies 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. / — 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(3)(b)) Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: (,41 1V o R�� f 2b ss fLt� 0 0 2T1i An1 D av f(Z n^A Owner: Fl" Date of Inspection:_ 12-1 )6.1() Z FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 640 Number of current residents: _ Does residence have a garbage gander(yes or no): t Is laundry on a separate sewage system(yes or no):A0_ [if yes separate inspection required] Laundry system inspected(yes or no):— Seasonal use:(yes or no):&0 Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):9 Last date of occupancy: C,r G COMIKERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): ____gpd Basis of design flow(se ats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):T Non-sanitary waste discharged to the Title 5 system(yes or no):— Water meter readings,if available: . Last date of occupancy/use: OTIIER(describe): GENERAL INFORMATION Pumping Records Source of information: Pr6,71- t Y{ 09- A(so Was system pumped as part of the inspection(yes or no): If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool —Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval —Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): � Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: (o 1J02'N e,/1os5 R.17 -N o 2T,1 AN'1-)oy62 to A Owner- Pill L'iP TSRj- Date of Inspection: j;7,11G/a 2 BUILDING SEWER(locate on site plan) Depth below grade: I Z4 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.): �l`�SGrYL�N ) SEPTIC TANK:_(locate on site plan) Depth below grade: //P.. Material of construction: i/concrete metal— fiberglass_polyethylene other(explain) — If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: 1,6-o o 6-A L I-OA) s Sludge depth: 4.1 Distance from top of sludge to bottom of outlet tee or baffle: 3o" Scum thickness: L/`- Distance from top of scum to top of outlet tee or baffle: 'C , Distance from bottom of scum to bottom of outlet tee or baffle:_1,9 How were dimensions determined: i►a CAS LjZ C S i)C/4 Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): PYPE /3C-Twrcti Tratix A,vj) Pd.AP Cw >6-6FJ R/A wits C_A-CA1vEn aA.1 P -J-A.V A /5 f�Al c 77 p,yl A/ (.- ND 2 i✓1 A t-v PRO^ Qs,:�/ts v E,., ,771/A, 6'' OF 6-aAo p,v t�vL OP12-10V 6--S GREASE TRAP:locate on site plan) Depth below grade:— Material of construction: concrete_metal—fiberglass_polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: loy AJo277{ C/L0.ss R,> Owner:_ 12-1 (,, / 0 Z Date of Inspection: P 141 L�1 P ff1 TIGHT or HOLDING TANK-.,V#4(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be openedxlocate on site plan) Depth of liquid level above outlet invert: E) 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.): f�D X i N Co,--0 r-70 PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): �S Alarms in working order(yes or no):y�S Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): I�v...t2 , n1 t.io21�+�+✓ Lr �,2DG2 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 64 N o 2 i 1! C/Z4W s " i2O 2TY A0,POLJE 2 AAA Owner- PHIL-)P 7311 Date of Inspection: 1 2h6.1J2 SOIL ABSORPTION SYSTEM(SAS): (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: L oN G- T2rucrTEs leaching fields,number,dimensions: overflow cesspool,number: innovativetalternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): Ry>' il-CEOCHC-5 s.W 143 Ala Pc)aD,,v G- I)A.K? soi L. OQ S)/IIUScI A4. lJLGG AT)o0 Rr-60'H NP G✓i 77 Al L_DN�T fLAsS, $APS JN (rS 4"9 $P-VSX E)A/ 4A/ f} oAL- 6Asis 'Tb F,2Evi 1vT l.v7 ,ZVS/a,V err N L= CESSPOOLS:A(cesspool must be pumped as part of mspectionXlocate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:N&(locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: &9 No RTi-1 c gois 7.7> N b 2Tif AwP ou%2 M/q Owner: F H (a 1? '1's 6:a Date of Inspection: 2,11(,10 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. U E IV 3�' fob PU MP I-W c /V165 Qu%T1- 13 I --T fjAJ A 2_ 1 Av)4 )b'� Pati. TA#JIi PJ�^►� T� TAnil�. g f y� O� Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: �--y 15o/yn-f C2oss Rp N 6 gn-f "D o✓r 2 .v A Owner: PHILIP TSA- Date of Inspection: Z� i bT2 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design planreviewed: Observed site(abutting propertylobservation 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: - S�_�Tc r►n ncs_�nL� N` R$� F G.It.o�.�� �g�r 2. S�STi:M (C�41SFrpj�"LtNT 1JVL/L14A.)� �h&J fl B ago)4. Commonwealth of Massachusetts City/Town of kpr.k 4napUe,f OCT 2 000 System Pumping Record 2 5 Form 4 { M 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 Location: forms on to the / A 1..�j�_ �+ x`Dss Q� computer,use (p ��/[J�_�V� C� only the tab key Address to move your NOVA AAn cursor-do not City/Town State Zip Code use the return key. 2. System Owner: VkA S-Ina k 1 Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record / 1. Date of Pumping �` �s 2. Quantity Pumped: 1�� Date Gallons 3. Type of system: ❑ Cesspool(s) [oleptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes Ny"No If yes, was it cleaned? ❑ Yes ❑ No 5. ,,Cnnondition of System: l - '66b 6. System Pumped By: 4X t,hae° t ��Ul L NaKiVehicle License Number Company 7. Location where contents were disposed: IAI- /- 1/; -* �'/6� Signature Haul Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts / City/Town of C� dv System Pumping Recor Form 4 • M 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 Location: forms on to the �d Q /� � 1� Z-4\„ computer,use ] �l d `^4\ only the tab key Address to move your 41. & f�,lj'�VP l- tg17 cursor-do not City/Town �N State Zip Code use the return key. 2. System Owner: COIACO'14, Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumpingate 2. Quantity Pumped: G15 e 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes El'lqo If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: &lee ��� N e Vehicle License Number Company 7. Location where contents were disposed: Signature uler Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of �' System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Loca on: forms on the computer,use 64 1z only the tab key 4Aress _ to move your cursor-do not City/Tow `n to ee Zip Code use the return key. 2. Sys caner: tea Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Q ntity Pumped: Gallon 3. Type of system: ElCesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. Syste Pum Red By: e Vehicle License Number C ny 7. Location where contents were disposed: i ature f Hauler Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 0 N zz7.z4% "'���CCC -oMQr�o + x `- Q� v . - m w LOT 9 n ` • N v 5-5,71 2 5, P-. I n� �s 35"10 =G3•Z7 IZ �.4 STEL ET SEPTIC SYSTEM AS BUILT PLAN IN _ ��Of�T►-f ,�-lel D0�1 G�:'�. AS DRAWN FOR 3CALE r , j,,G G�1 Tr o ti� DEED BOOK PAGE AREA PLAN R06 ALAN ASSES50RlNIAPS h (Z } t l Dov } A iso 2's174 BOCK �,� R.A.M. ENGINEERING LCT 160 MAIN STREET ./ ''i NAVERHLLMA. Form 4 -- System Pumping Record Commonwealth of Massachusetss : Massachusetts System Pumping Record System Owner System Location Type: Emergency Routine Cesspool: No i.a Yes Septic tank: No Yes Er Date of Pumping: ©s•0-7^(91 Quantity Pumped: I�5LY) Gallons System Pumped By: Wind River Environmental, LLC Permit#: Contents transferred to: / V Contents Disposed at: 6:5- L � Date: Pumper Signature: Condition of System/Other Comments Dep Approved From - 12/07/95 Form 4 -- System Pumping Record Commonwealth of Massachusetss : Massachusetts System Pumaina Record System Owner System Location Cc, .t q /V, . C Type: Emergency Routine Cesspool: No Yes Septic tank: No E]Yes Date of Pumping: Quantity Pumped: r. Cs� Gallons System Pumped By: Wind River Enwommtoi, LLC Permit#: Contents transferred to: Contents Disposed at: Date: Pumper Signature: Condition of System/Other Comments Dep Approved From - 12/07/95 Form 4 -- System Pumping Record Commonwealth of Massachusetss : Massachusetts System Pumping Record System Owner System Location rA,J ov c/-- Type: Emergency Routine yes -6ermr7 mt: w yes Date of Pumping: ( eu Quantity Pumped: S00 Gallons S System Pumped By: Wind River Environmental, LLC Permit#: Contents transferred to: Contents Disposed at: Date: Pumper Signature: Condition of System/Other Comments Dep Approved Front - 12/07/95 _ Form 4 -- System Pumping Record Commonwealth of Massachusetss : Massachusetts System Pumping Record System Owner System Location Type: Emergency Routine Cesspool: No Yes Septic tank: No Yes U Date of Pumping: Quantity Pumped: lions System Pumped By: Wind River Enwrwwwnta/, LLC Permit#: Contents transferred to: Contents Disposed at: Date: Pumper signature: Condition of System/Other Comments l 3 ZOOt Dep Approved From - 12/07/95 Town of North Andover, Massachusetts Form No.3 f NORTH BOARD OF HEALTH _ O tt��o ie 11.O `ut� DISPOSAL WORKS CONSTRUCTION PERMIT CINI Applicant__ NAME /ADDRESS A TELEPHONE Site Location Permission is hereby granted to Construct ( ) or Repair ( an Individual Soil, Absorption Sewage Disposal System as shown on the Design Approval S.S. No. ,:,• ,✓i" CHAIRMAN, BOARD OF HEALTH Fee D.W.C. No. �=� BOARD OF HEALTH NORTH ANDOVER, MA 01845 978-688-9540 APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: - CURRENT INSTALLER'S LICENSE# LOCATION: 1 no, fLj- LICENSED INSTALLER: SIGNATU E: TELEPHONE# 97772 SIGNATU dE�� T CHECK ONE: REPAIR: X NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUILT. Administrative Use Only 446VWFee Attached? Yes No Foundation As-Built? Yes No Floor Plans? Yes ' No X Approval Date: \ ' .. N SU�J`M�vV,R,MASS O9' N if GRAS `�' � V N v�p A• MPG\-AMpSS• ��� 3 2 W ►� .�/ a A '� pvE 168'1 0 pNp -�L NpRp �� O '�2'/ \ ti �a ' \ co WERp�SPSEMEN ' � \ � • � sE /� Off\ // �;,✓ 55-Tt2 GF 4t/ Ca ry � fV b 10) oL \ 1 1.- .0 8 S(V 3 \ -1 4-, \ �,1,•"' �0 .•� �..r `��' 10 6E R Y., �. r" /� 0 oo - a X60• :.� ' o� t r p• 4 r 2 �r NORTH ba p0' S I O X51 D• 2g�.�� X9'0 SS tii0 F 30 N i LOZ 6 � 4 O 3 ern v, �h 5 -�O � R '25'1 OO4' � -5-1.004 1 -'Si" 6� , L • 6'34. 25.25' � p• 06 _ i z. X8•_19. - . -01. ......r_<.!.,VWitiw'^t'f..t.N1`N'aM:.+'.r...+r.�.....+rn.'.aysa...-w .a........n.�—..aiwr... ...._..w.arw.W.+r'rw..w..aw..... ..—.. w.........,. FAL SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION Address of property 64 NORTH CROSS tO Owner ' s name BETH & JOE HABES Date of Inspection 5/24/95 `3 PART A CHECKLIST Check if the following have been done: Pumping information was requested of the owner, occupant, and 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. As built plans have been obtained and examined. Note if they are not available with N/A. r The facility or dwelling was inspected for signs of sewage back-up. The site was inspected for signs of breakout. All system components, excluding the SAS , have been located on the J 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. l The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. The facility' owner (and occupants, if different .from owner) were provided with information on the proper maintenance of SSDS. 8 SUBSURFACE SEWAGE `..DIS.POSAL SYSTEM .INSPECTION- FORM' PART B §`, n SYSTEM -INFORMATION., .: FLOW. :CONDITIONS If. residential' number of bedrooms _ number of,:current residents ;_&,L)_ garbage grinder, yes or no' _ jJ/_ laundry connected to system, yes or no :,seasonal -use, yes or no. Yf' nonresidential, cAlcu.latad flow. Water ,meter readings, 'f ava"�la.ble ^ w�Nht Last date of , occupancy N,ERAL- INFORMATION Pumping records ' and'source of information: l �v✓„'.,- Q -.,w�i a erd�v'f o.,e 44 1 System" pumped as >part of inspection, yes or 'no �.f yes:; .:volume' pumped G:./ Reason forpumpingi " f / I.t.S DCS/' /rt74 t'.1`r'✓✓� ('eh'►'Y)�YOHe✓� e7P �N (yam _ Typp�--Qf system ✓ Septi.c tank/distribution box/soil absorption system Y .' Single cesspool ,viirf•low"'cesspool Privy... Shared system ^(yes or` no)' {if yes,; attach previous`.-inspection records, -.:if 'any) Other:: (explain): Approximate ageof all .components.. :Date installed, � f":known. Source of ;information: ` fAs � , � AIG.; c�1c.�•e 9 9 I2 � g2 / 6f Sewage..odors detected when. arriving . at the site; .yes or no: 1 • 9: SUBSURFACESEWAGE DISPOSAL SYSTEM INSPECTION FORM ,I PART. B SYSTEM 'INFORMATION Continued :. SEPTIC. TANK: (iocate, on site plan) I de p th belo w grade: /8 material of construction: .—Zoncrete - metal FRP other(explaln). :dime`nsions IA-00 C _ siud.ge depth" y" ',distance from. top of sludge to bottom, -of outlet tee orraffle thickness "distance: from top of scum: to top of outlet:" tee or baffle 'd; stance from'" bottom, of :scum, to bottom of outlet tee .or: baffle, commen°ts d (recommenation .for .pump�ng, o.ondit-ion of.- in let. and outlet tees: or baffles, depth of liqul.d" level : in 'rela-tion' to.: outlet invert, structural -integrity, evidence of leakage, recommendations, `for repairs, etc ) .', n r. DISTRIBUTION'' BOX: (locate ",on site plan) ' depth of liquid' lev el above outlet invert Comments : (note `if '-level and distribution is":=equal, ;evidence ,of solaids ca zyover, evidence`'of 'leakage 'into or `out of`box, recommendation for" repairs, 'etc.)' . 6 A; 10 .oIpe PUMF�; CHAMBER (1-oca e oni,site. plan)•: cS pumpsin working order., yes or no 'Comments: (note condition. of pump chamber, condition of pumps and°appurtenances, recommendations :for maintenance' or repairs=,etc. ) v:iia` w P c } o SUBSURFACE. SEWAGE DISPOSAL SYSTEM INSPECTION .FORM PART .B:: SYSTEM INFORMATION continued .SOIL ABSORPTION .•SYSTEM. (.SAS). ' (locate :on-'site` pf. pos ieexca.vati`onotrqrbmay be" ,.app.roximated by non-intrusive methods) I f• not' determined .to be present;` explain`; Type leaching pits; .and number leaching chambers and :number, leacng galleries; and number leach• ngtr.encYies,` number, length leagbing, •fields; number, d-imensions overf'1ow• cesspool number Comments (note condition of ,$oil., signs of hydraulic failure, level, of ponding, condition of vegetation, recommendations6 ' or 'maintenance-or" re air$';etc:) eo, ire r e ter. N ! V b r 7'D F.,v "'.-CESS P00.•LS -(locate on site ,plan) c ca2i2y o�ht,2 nuinber. and`:conf iguration depth=top '`of. liquid to inlet invert depth ,of solids layer` depth "vf scum layer - dmens' ons 'of cesspool . m-ateraaas of •construction indication of' goundwater z inflow`, (cep pool m'u'st `bee pumped -as ' part of inspe:ction') Comments• _ (note condition of soil; signs of`' hydraulic failure, level of ponding, 6o'nd1 tiq of vege'tation',, recommendationsfor. maintenance or: repairs;etc.') PRVX (locate , on,.site .-plan)` material's of construction d]mensions F- depthrof. solids Comments (note condition of soil,-, signs of. hydraulic failure" : level . of ponding, conditxon 'of, vegetation, recommendations for maintenance. or-rdpai,rs �.1. SUBSURFACE SEWAGE':DISPOSAL.-SYSTEM INSPECTION :FORM PART : B : SYSTEM INFORMATION continued SKETCH OF '-SEWAGE .DTSPOSAL SYSTEM:: include tles to. at least two permanent, references'. 1andmarks or benchmarks locate all `we11S within 1001. -x..24' n(RK �°2c� • �r vGvT : PIPE 3n\� � • �4 :: •fir,-�� : a . : o�� Yak t C.a�t7u) +501'/�TFD wC T,. .��'LEA /9Quv�ty .vi►�}rvrlo OF Cfevsr :BY. ►Jr4TE1Z.. co;t� �ivc_ SA•WE..R: 'Cc9JEl2 : *'" Chabt�. Cr Aw TAN x l /pvcGS •Dtsr ,— ��`,,JL o i- A • l2 � , DEPTH TO. GROUNDWATER 2 1$.� ' depth to groundwater methodof determination or approximation: ILGM 11�3�4�:.r f,rA At f 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM. INSPECTION .FORM . .PART; :C FAILURE CRITERIA Indicate -yes, :,no, or not .determ'ined (Y, N, or, ND) . Describe basis ,of d;eteermination in all:' instances. If:, "not determined'". explain, why .not) Backup of sewage into facility? Discharge.,or ponding :of effluent to the surf ac"f t.re- ground or _ surface waters? .'scE' !4s- - gvr l T PLA&t r-vRSNFr�' ire wr.'T. RQPrq :Static liquid level 'in: the,.distrib.ution box aboveoutlet. znv;ert? Liquid depth -in ,cesspoo1:,<6" below invert or aya�lable volume< 1/2 day fWow? ^ Require d_.,pumpi.ng '4 times or mare in the las"t..-year? number of -tim es pumped ,:. Septic tank is metal?:.'cracked? structurally „unsound? substantial n'filtrat:ion? substantial ex.fihtration?. tank falur'e,:imminent? . Is ,any portion of`,the SAS, .;cesspool or privy.: �f below the hi4h groundwater'elevation? within 50:.feet `of a surface water? within :100 ,feet of a surface water ,supply or tributary to a surface water`, upply- wi�thim a Zone '.I of a public wehl? ith.in' 50 feet ' of a bordering vegetated wetland or salt mars2i Iw :(cesspools and priv-iesFonly, not the SAS) ' � V within 50 feet of a private water supply well? less than` 106 feet but greater than 50 feet., from a private water supply, well with ,no acceptable water quality analysis? If the we11 has. beeri: analyze,d to be acceptable; attach copy :of well water, analysis for coliform bacteria, volatile .organic compounds; ammonia nitrogen and �ni,trate. nitrogen. 13 { SUBSURFACE SEWAGE DISPOSAL =SYSTEM INSPECTION FORM PART ,D CERTIFICATION Name of. Inspector (7�'rr ofyp�� Sn Company Address, 33 w�,t � a i2� ,S�; c 3 N- A,vnc+�rz �+a: 018 k3 Certif'icition Statement I `certfy that"`I have personally• inspected the sewage disposal system at this address .and 'that .th' information reported is',true, .accurate and com lete as of "the' tl.me: of inspection., �' The' inspection was -performed, and P. any recommendations regard ng `upgrade, maintenarice-and repair. are consistent with- my. training and °experience in the'proper'`function and manitenan'ce of -oh'site-sewage :disposal ':systems Che c ane I have not found any information which indicates that the system f:als to adequately protect public health or he environment as:.def`ined".in 310 CMR Anyl-tiure criteriot . vehuated are, as .$tated ;in the FAILURE CRITERIA' sectiori of this form. I have , determined Vthat the "system fails to protect public : health, and the environment as defined" in 310"CMR '15. 30`3: " The basisforth is determination_ is provided in' the' FAILURE CRITERIA section of this form. Inspector' s . Signature bate s/zs/sr - Ori= anal to, system; ow' COpleS t0 Buyer `(if'`appi'icable) Approving ..authority ,va►�Tf-� gti�ov�1�, MA. « ,. �QP�i Cgti I , �4i�f� ��P�t-7 bwrJ O WE(..c._ ,�P ouCDIYJTC _ l vest c-uJ i�PYizovCD D,�r� lU-Z�-�� /J�i�I�ovi�G fury--fo��ry �� Ca�Df"��v�5 :RANI 5/ov �15APPRUVEp p�}C -rte �►� Dc� r-7Ani FJ/JS ��� $CPT(C SYSTEM t,v 5l%J l LrdT+n�J ®ire nIA-e f USp��lo� PIPE S t-tvcY i T/J r Fl Pry R)L �PPI�C�vE17 IQ/,TC /JP1'K��J►/v� Zvi�tOI�1Ty I NSlifllt-; DtS,�P��ovE� DA T RUAL APPROVAL pl7 1/ nv' 1 A,069r, 44. 4'ur 4 Allier l?, R.A.M. ENGINEERING ROBERT A. MASYS, P.E. ONE MASYS WAY HAVERHILL, MA 01 930 PHONE: (61 7) 372-0449 September 12 ,1990 Mike Rizzati North Andover Board of Health North Andover, MA Dear Mike, As you requested, we have prepared a set of specifications for the effluent pump required for the proposed septic system on Lot 1 North Cross Road. Both this office and the manufactures representative feel that the proper pump for this system is the ABS Inc. model SESH 5W, or approved equal . This pump should be installed in a 500 gallon concrete pump chamber. If you have any other questions about this pump system please feel free to contact me. Very truly yours, Robert A. Masys, P.E. COMPLAINT NUMBER DATE: #24 MAY 6, 1993 COMPLAINTANT: TIM OULETTE CLOSE DATE: ADDRESS: DPW PHONE: OWNER: PHONE #: ADDRESS: 64 NORTH CROSS ROAD INSPECTION DATE: ORDER L DATE: COMPLAINT: LEACHATE COMING FROM SEPTIC SYSTEM ACTION: J4- �,ttAA AT-Low Pr Town of North Andover, Massachusetts Form No. 1 NORTH BOARD OF HEALTH F qti �? `,`ED 16 6ab °0 19- 0 9O oYa T ,} R � ' APPLICATION FOR SITE TESTING/INSPECTION LIP 38 7 ADRATED 9SSACHUS / `V Applicant NAME ADDRESS TELEPHONE Site Location _ G/2 v SS Engineer � ' l - NAME ADDRESS TELEPHONE Test/Inspection Date and Time CHAIRMAN,BOARD OF HEALTH Fee Test No. ALI-to S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. O cg�Z� jD `76 or 3 TOWN OF NORTH ANDOVER-,-- , SYSTEM PUMPING RECORD' ` 1 203 DATE: CJ L4A 03 SYSTEM OWNER& ADDRESS SYSTEM LOCATION �N o% h n (example: left front of house) to v3 v, DATE OF PUMPING: -1I L 02 QUANTITY PUMPED W- 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: 1 � COMMENTS: CONTENTS TRANSFERRED TO: ���� MMI ��... ch.0.e .iTt.�. ' ulS•:'�n�••I�. .Nyr•: •:•'•r.•l:•,.�..':�.;ir:'7;l::Y3��!+'•:•!F.7 ::.• AIDOVER� MASSACHUS �S• a .m •� E'1"i'S�. . , f > ,1 Gln.g cord' . ' . . ``I'•. 1, .. .'I•. .dr(Ctn,h •t�'✓( y1:::•�I,�ij 'r��l rll.;n:t, ') 4„'•n.li�r1:�W Yiir;,: .. ! {,h'�,,',l.htjl i.o !k'C'iFT,)F''!i,M y:,4'4v�';f,.? .:�. ��•�' ' DEP has rovlded jh p !s form for use by local Boards of Health.. The System Pumping Recorc .T.; be submi. to the,►ocal'Board of Health or other a r:? pproving authority, A ..Faclllty .Infortl t(on . 'arWl�en'NMQ out 1.. System Location; only lhCOMDUetab key' Address to move your Cursor.• o a rOtufil`Yi''r',.�::�?�:;,VitY!IOWA ,'i ' .,;. . .r,'... •r: � $ate �r 7�/� � !,hl t�'1'''%r/.�tlrl•'Ij '•t(��l:,l:Iv n;..! �,.'"�r a �'�, :1 .. zip. ode y'; 4.Si,'�.;f.r:. 7t'• 11., r.' 4;' is C r ow :.••i'•J;II'.i'w•, %'�'.i{';•'•: :t*.�:i:•i..,. • ::�.� •:1sr!r: .:li`y17�::.`�;)'',f,�;�'Nams,'�J,i:4r.1"•'..•J••O"�r�rd•''.v,.•p•, ^ • .t ''� ''•111:' Fj.r.'.r,.,:�'' rLJt:r�' '!i. � V ''Q G- `0 r N c r Address(It dlNerenl from bcadon) ' `... , �� :CtprRown.°M: ' ':I;.•:1;::'� ,•.! .. Sia Lp Code .. •. ., �;� •.;� ,,. ��-��3 930 Telephone Number pumplt�g .Re.C:ord: 1i t. of Pum Llj� �.— pinq pale 2, Quantlty Pumped: . .�' �'3� ,� '{'.�r,';;��,.; .. ;,,.��; .•:. v. G tong Type 9 ,aystam;'; ' '❑ Cesspooi(s) ❑ Septic Tank . ;: •.• •.•.�!,'• ; ;, '•J. ❑ Tight Tank !.Other(de3Cflb@) o..s Yes N E�ffluat.Tee Flits{+pi ) ❑ if yes, was It oleaned? Yes ❑ No . �'•�';:.�';:•; .:;9-�r, ,1�'Co�dl�lon.Q(,;•8Y m.:,'�.• :,:�:; Ij .. ... - ''i4'-a.e'•.r;i�i���•,r'iu�•!J•il .f6�i7r 1•w�i.,.l� 11�.,r.�:."�,:� - ' .. ,tea .�,'; '�:� Ilrr'4�i1'•f!i�ilt�rl'j+:r il�4r•.I.';!):i!�y�r. �Itfir'1�:'�`�:L;; .. M.r� 1 r`^ •jyrl�:.!l,,t"!?i 4.►�++—�-�—LTi '(4, ="—i•------�.��. . ��; ,r. � �•61�;;�'SY �P,limped Byi�'::. : :. . �'l..>r' •`'��ij"t'„`':'':K;','�ii�'' �ar�W,i�t1:i'� ��j�• �r��}� 11i�.1 .tI)';, Ucen�e Number i.,•.a•„��;•':,,�,v. J +�rl))Yu�((((1l+�; S1 { I��eJ,rr,,=,�y(.r•+,, µmi . ..�:.•1r,. ,I•.•!• J'•.{' �::�\�{W i{ , 1�••'t4I) �\/_� �.frl 1',:7.�''' � .. . �'•�„� f'flr t.1','M.rN'3,7J1J! ,Y.�hr�if71����,jit�'', a on.where contents wsra:dl;3posed; (f,!;.:.::.:ai'�'.•..:. . .r,j}r1.f' :rl.,yirl<l' !�I!,Y.” �' Ni . w:. .r�;� t}.7p 5�:i!'.'rt.(.��i:;�:bd:�y�e.F.,'t •'ti: �J�fr. ♦, \. •��!` �r.� ;! ,J"•; �•!..o:'i.'•Vii• :�Y.. /l;^ • '`�� i{�+.i�•n�'.v'!�Ji;•F� Ni`t!,i�: 1;r• •r' '�1 I'�'1 � � ' ;.;::, '�'r:;�:c ';''�:r:•'`;:Signa n of Haulal�Yi;rti�<•t,';,<:,:.{:.. Date h ltirtiwr,mass.gov/dapV.w ar/apprGva)s/tb(orms,htm inspect e Sytlem Purnpinp Record Pa e II Lt .CioP��J Commonwealth of Massachusetts Town of:, From:Soucy's Sewer Service.Inc. Month: 6 �&) Date Address Owners Name Gallons um d " H,G,C,D,S Contents tranfered to Condition of s em '36 Go L. SD `r 3 fQ 17PY1 Vs' i2 6 7 8 —� 9 10 JUL % '1 11 TOWN OF NORTH AM OVER 12 SENT 13 14 , .15 16 17 18 - - 19 *C= Cesspool, D= Drywell. S= Sentirt