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HomeMy WebLinkAboutMiscellaneous - 67 STONECLEAVE ROAD 4/30/2018 (2) Health File 210/104.13-0142-0000.0 67 Stonecleave Road I a a I. �• l 1 l V � s �AA l "2 �y AQ + z2cc PUBLIC HEALTH DEPARTMENT Town of North Andover Community and Economic Development Division CERTIFICATE OF COMPLIANCE As of: April 18, 2017 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: D-Box Repair By: SoucySewer Service Inc. At: 67 Stoneeleave Road Map 104.B Lot 142 North Andover, MA 01845 J-hoo-issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. Michele Graffi Public Health Agent 120 Main St.,North Andover,Massachusetts 01845 Phone 918.688.9540 Fax 918.688.9542 Web www.northandoverma.gov NUMBER COMMONWEALTH OF MASSACHUSETTS BHP-2017-0340 North Andover FEE $175.00 BOARD OF HEALTH John Soucy --------------------------------------------------------------------------------------------- NAME 67 STONECLEAVE ROAD ------------------------------------------------------------------------------------------------------------ ADDRESS IS HEREBY GRANTED A PERMIT D-box repair This permit is granted in conformity with the Statutes and ordinances relating thereto, and expires ---------------June 282-2017---------------unless sooner suspended or revoked. March 28, 2017 ---------------------------------------------------------------- BOARD OF -------------- -------------- --- ------------ HEALTH LUi -CO ----------------------------------------------------------------- BOARD OF HEALTH CHAIRMAN r � t � NUMBER COMMONWEALTH OF MASSACHUSETTS BHP-2017-0340 North Andover FEE $175.00 BOARD OF HEALTH John Soucy -------------------------------------------------- -------------------------------------------------- NAME 67 STONECLEAVE ROAD ------------------------------------------------------------------------------------------------------------ ADDRESS IS HEREBY GRANTED A PERMIT Disposal Works Construction I D-box repair This permit is granted in conformity with the Statutes and ordinances relating thereto, and expires ----------------June-2-81- 201-7- __- -_---_--unless sooner suspended or revoked. - ---- - - - --------------------------------------- ------------------------ BOARD OF March 28, 2017 HEALTH �r ------------------------ --- - ----------------------------------------------------------------- BOARD OF HEALTH CHAIRMAN i Application for Septic Disposal System 3/27/17 Construction Permit - TOWN OF TODAY'S DATE $350.00 -Full Repair NORTH ANDOVER, MA 01845 $175.00 -Component Important: Application is hereby made for a permit to: When filling out ❑Construct a new on-site sewage disposal system* forms on the computer, use ❑Repair or replace an existing on-site sewage disposal system* only the tab key to move your Repair or replace an existing system component—What? D BOX cursor-do not use the return A. Facility Information key. 67 STONECLEAVE RD Address or Lot# RECEIVED tali N. ANDOVER City/Town MAR 2 8 2017 2.-*TYPE OF SEPM SYSTEM*: TOWN OF NORTH ANDOVER ❑ Pump ravity(choose one) HEALTH DEPARTMENT ***If pumps tem, attach copy of electrical permit to application*** ➢ [�Conventional System (pipe and stone system) ➢ ❑ Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system.) ➢ ❑ Pressure Distribution S.A.S.(No D-Box) ➢ ❑ Pressure Dosed(D-Box Present)S.A.S. ➢ ❑ Does the system require an effluent filter? Yes No_j/ If yes, does plan specify make and model of filter? YES =(no further info. needed) NO=(installer must specify brand of filter before DWC issuance) What is the Make? What is the Model. 2. Owner Information THERESA PETRIE Name 67 STONECLEAVE RD Address(if different from above) N.ANDOVER MA 01845 City/Town State Zip Code PETRIE67@VERIZON.NET 978-771-3679 Email address Telephone Number 3. Installer Information JOHN SOUCY SOUCY SEWER SERVICE INC. Name Name of Company 78 N. BROADWAY Address SALEM NH 03079 Cityrrown State Zip Code 603-216-7175 Telephone Number(Cell Phone#ifpossible please) 4. Designer Information Name / , 14 Name of Company Address City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 k . •F - Application for Septic Disposal System AI7 1 Construction Permit - TOWN OF TO AY'SATE -Full Repair NORTH ANDOVER, MA 01845 $75 00-Component PAGE 2OF2 A. Facility Information continued.... 5. Type of Building: $IResidential Dwelling or❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North AndeVip. I understand that until a final Certificate of Compliance has been issued by this B rd o Health, t nstalled system is not approved. 3/27/17 Name Date ka s on Approv i (Boa o ea/th Representative) Date Application Disapproved for the following reasons: For Office Use Only: L Fee Attached. Yes No 2. Project Manager Obligation Form Attached. Yes No 3. Pump Svstem? Ifso,Attach cog ofElectrical Permit Yes No Applicant received copy of "Electrical Inspection Notes for Septic Systems" Yes No Handout? 4. Reviemed a royal letter allpaperwork . s No PP � erwork receivedYe P P M1SSing; 5. Foundation As-Built?(new construction only): Yes No (Same scale as approved plan) 6. Floor Plans?(new construction only): Yes No Application for Disposal System Construction Permit•Page 2 of 2 SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction for the septic system for the property at: d7 c L/42 � (Address of septic system) For plans by (Engineer) Relative to the aLpplication of TQt.. /^ (Installer's name) And dated /j/•A rigina ate) Dated ( o ay s ate) With revisions dated (Last revised date) I understand the following obligations for management of this project: 1. As the installer,I am obligated to obtain all permits and Board of Health approved plans pdor to performing any work on a site. I must have the approved plans and the permit on site when any work is being done. 2. As the installer, I must call for any and all inspections. If homeowner,contractor,project manager,or any other person not associated with my company schedules an inspection and the system is not ready, then item three shall be applicable. 3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection,without completion of the items in accordance with Title 5 and the Board of Health Regulations may result in a$50.00 fine being levied against me and/or my comp an'. a. Bottom of Bed—Generally, this is the first (1'� inspection unless there is a retaining wall,which should be done first. The installer must request the inspection but does not have to be present. b. Final Construction Inspection—Engineer must first do their inspection for elevations,ties, etc. As-built of verbal OK (or e-mail to: healthdept@townofnorthandover.com from the engineer must be submitted to the Board of Health,after which installer calls for an inspection time. Installer must be present for this inspection. With a pump system,all electrical work must be ready and able to cause pump to work and alarm to function. c. Final Grade—Installer must request inspection when all grading is complete. Installer does not have to be on-site. 4. As the installer, I understand that only I may perform the work (other than simple excavation)and I am required to complete the installation of the system identified in the attached application for installation. I further understand that work done by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of North Andover, sip�2ificant fines to all persons involved are also possible. 5. As the installer, I understand that I must be on-site during the performance of the following construction steps: a. Determination that the proper elevation of the excavation has been reached. b. Inspection of the sand and stone to be used. c. Final inspection by Board of Health staff or consultant. d. Installation of tank, D-Box, pipes, stone, vent,pump chamber, retaining wall and other components. 6. As the installer, I understand that I am solely res le for the installation of the system as per the approved plans. No instructions by the ho wne eneral contractor,or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: CC o ay's Date) ame—Print i ame— ign f�ORTN 1 7796 ti p Town of North Andover ' '••;;.o:: HEALTH DEPARTMENT �Ss�cNusEt CHECK#: 332 DATE: 3/.),8 Lo% LOCATION: 0/r-V �,.1�, H/O NAME: CONTRACTOR NAME: 5e, w� 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 , r $ Other:(Indicate) Lo Hea gent Initials White-Applicant Yellow-Health Pink-Treasurer • Sw�TL'F,D y�c � v North Andover Health Department (ommunity and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 67 Stonecleave Road MAP: 104.13 LOT: 142 INSTALLER: John Soucy 603-898-9339 DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION.- DATE NSPECTION:DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ [Exist g septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged F-11500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port y ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION-BOX ® Installed on stable stone base ® H-20 D-Box ❑ Inlet tee (if pumped or >0.08'/foot) ® Hydraulic cement around inlet & outlets ® Observed even distribution ® Speed levelers provided (not required) ® Schedule 40 PVC Pipe Comments: Michele Grant told John to bed the pipes properly. SOIL ABSORPTION SYSTEM (General) ❑ Bottom of SAS excavated down to C soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 40 Mil HDPE barrier installed ❑ Laterals installed and ends connected to header (and vented if impervious material above) ❑ Elevations of laterals and chambers installed as on approved plan ❑ Retaining wall (boulder/ concrete /timber/ block) ❑ Final cover as per plan Comments: SOIL ABSORPTION SYSTEM (Gravel-less Chambers) ❑ Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ❑ Number of chambers per row: ❑ Number of rows (trenches): Comments: Total Chambers = FINAL GRADE ❑ Loamed ❑ Seeded ❑ Cover per plan Comments: DOCUMENTS NEEDED ❑ Certification of Installation Form submitted By engineer and signed and dated by Engineer and installer ❑ As-Built Plan I BM = HR = HI = SYSTEM ELEVATIONS ROD AS-BLT INVERT DESIGN INVERT ELEVATION ELEV ELEV Benchmark Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 TOP Lateral 1 INVERT Lateral 2 TOP Lateral 2 INVERT Lateral 3 TOP Lateral INVERT Lateral 4 TOP Lateral 4 INVERT Lateral 5 TOP Lateral 5 INVERT Lateral 6 TOP Lateral 6 INVERT Top of Chamber Bottom of Bed/Chamber SKETCH PLAN CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback Tank SAS Sewer ® Property line 10 10 -- ® Cellar wall 10 20 -- ® Inground pool 10 20 -- ® Slab foundation 10 10 -- ® Deck, on footings, etc 5 10 -- ® Waterline 10 10 101 ® Private drinking well 75 1002 50 ® Irrigation well 75 100 ® Surface Water 25 50 ® Bordering Vegetated Wetland , Salt Marsh, Inland/Coastal Banka 75 100 ® Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ® Trib. to surface water supply 325 325 ® Public well 400 400 ® Interim Wellhead Prot.Area ® Reservoirs 400 400 ® Drains (wat. supply/trib.) 50 100 ® Drains (intercept g.w.) 25 50 ® Drains (Other)Foundation 10(5) 20(10) ® Drywells 20 25 ' Suction line 222(2) Z 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance(NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54,and 10.30,respectively,pursuant to 15.211(3),also by NA wetland bylaws C3' � North Andover Health Department fommunity and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 67 Stonecleave Road MAP: 104.13 LOT: 142 INSTALLER: Soucy DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: d© �0� 5,140/ INSPECTIONS Ca 6 TANK INSPECTION: -� DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: I CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION-BOX Installed on stable stone base H-20 D-Box Inlet tee (if pumped or >0.08'/foot) Hydraulic cement around inlet & outlets I� Observed even distribution Speed levelers provided (not required) Schedule 40 PVC Pipe t Comments: J r • V i North Andover Health Department Community and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 67 Stonecleave Road MAP: 104.13 LOT: 142 INSTALLER: Soucy DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port ` b ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: i CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped j ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION-BOX Installed on stable stone base H-20 D-Box Inlet tee (if pumped or >0.08'/foot) Hydraulic cement around inlet & outlets I� Observed even distribution Speed levelers provided (not required) Schedule 40 PVC Pipe f Comments: J v} j SOIL ABSORPTION SYSTEM General ❑ Bottom of SAS excavated down to C soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 40 Mil HDPE barrier installed ❑ Laterals installed and ends connected to header (and vented if impervious material above) ❑ Elevations of laterals and chambers installed as on approved plan ❑ Retaining wall (boulder/ concrete /timber/ block) ❑ Final cover as per plan Comments: SOIL ABSORPTION SYSTEM (Gravel-less Chambers) ❑ Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ❑ Number of chambers per row: ❑ Number of rows (trenches): Comments: Total Chambers = FINAL GRADE ❑ Loamed ❑ Seeded ❑ Cover per plan Comments: DOCUMENTS NEEDED ❑ Certification of Installation Form submitted By engineer and signed and dated by Engineer and installer ❑ As-Built Plan I ,Y 1 BM = HR = HI = SYSTEM ELEVATIONS ROD AS-BLT INVERT DESIGN INVERT ELEVATION ELEV ELEV Benchmark Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 TOP Lateral 1 INVERT Lateral 2 TOP Lateral 2 INVERT Lateral 3 TOP Lateral 3 INVERT Lateral 4 TOP Lateral 4 INVERT Lateral 5 TOP Lateral 5 INVERT Lateral 6 TOP Lateral 6 INVERT Top of Chamber Bottom of Bed/Chamber SKETCH PLAN F f V CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback Tank SAS Sewer ® Property line 10 10 -- ® Cellar wall 10 20 -- ® Inground pool 10 20 -- ® Slab foundation 10 10 -- ® Deck, on footings, etc 5 10 -- ® Waterline 10 10 101 ® Private drinking well 75 1002 50 ® Irrigation well 75 100 ® Surface Water 25 50 ® Bordering Vegetated Wetland , Salt Marsh,Inland/Coastal Banka 75 100 ® Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ® Trib. to surface water supply 325 325 ® Public well 400 400 ® Interim Wellhead Prot.Area ® Reservoirs 400 400 ® Drains (wat. supply/trib.) 50 100 ® Drains (intercept g.w.) 25 50 Z Drains (Other)Foundation 10(5) 20(10) ® Drywells 20 25 ' Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance(NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54,and 10.30,respectively,pursuant to 15.211(3),also by NA wetland bylaws Commonwealth of Massachusetts Title 5 Official Inspection F R .R ubsurface Sewage Disposal System Form -Not for Voluntary Assessments tJ 67 Stonecleave Road N� Property Address Theresa Petrie Owner Owner's Name information is required for every North Andover MA 01845 3/20/17 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information ,on the computer, ,: 18 2011 use only the tab 1. Inspector: key to move your T(�i,t!OF NORTH ANDOVER cursor-do not John J. Soucy f.,;,AjH[) .pARTMENT use the return Name of Inspector key. Soucy's Sewer Service Inc. i Company Name 78 North Broadway Company Address Salem NH 03079 City/Town State Zip Code 603-898-9339 13397 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 ❑ Ne s rther Evaluation by the Local Approving Authority , /2 3/20/17 nspe is Sign ure Date The system inspector shall s/ays a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30f 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•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 1 of 17 ` � L�'' � � , a t_��Ubl i I t ` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Stonecleave Road Property Address Theresa Petrie Owner Owner's Name information is required for every North Andover MA 01845 3/20/17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 67 Stonecleave Road Property Address Theresa Petrie Owner Owner's Name information is required for every North Andover MA 01845 3/20/17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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): D box is highly corroded and must be replaced. ❑ 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•3/13 Title 5 Official Inspection Form: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 wM 67 Stonecleave Road Property Address Theresa Petrie Owner Owner's Name information is required for every North Andover MA 01845 3/20/17 page. City/Town 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 r , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Stonecleave Road Property Address Theresa Petrie Owner Owner's Name ' information is required for every North Andover MA 01845 3/20/17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts IJ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Stonecleave Road Property Address Theresa Petrie Owner Owner's Name information is North Andover MA 01845 3/20/17 required for 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): 440 t5ins-3/13 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 67 Stonecleave Road Property Address Theresa Petrie Owner Owner's Name information is required for every North Andover MA 01845 3/20/17 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 5 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: Well 100'+ Sump pump? ® Yes ❑ No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: 1 Design flow(based on 310 CMR 15.203):03)' 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•3/13 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 M 67 Stonecleave Road Property Address Theresa Petrie Owner Owner's Name information is required for every North Andover MA 01845 3/20/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Current Date Other(describe below): General Information Pumping Records: Source of information: Soucy's Sewer Service Inc Was system pumped as part of the inspection? ® Yes ❑ No If yes,volume pumped: 1000 gallons How was quantity pumped determined? Gauge on truck Reason for pumping: Maintenance and Inspection Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract to be obtained from system owner)and a cop of latest ( Y Y � inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 17 a , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 67 Stonecleave Road Property Address Theresa Petrie Owner Owner's Name information is required for every North Andover MA 01845 3/20/17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 22"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.): No evidence of leakage Septic Tank(locate on site plan): Depth below grade: 12"feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8'6"x 4'8" Sludge depth: 3" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Stonecleave Road Property Address Theresa Petrie Owner Owner's Name information is North Andover MA 01845 3/20/17 required for every page. CitylTown 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 35" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape &Sludge tool Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet baffle, outlet tee good, tank structure is sound, no apparent leaks, pump tank annually due to age of leaching system. 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 67 Stonecleave Road Property Address Theresa Petrie Owner Owner's Name information is required for every North Andover MA 01845 3/20/17 page. CitylTown 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-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 67 Stonecleave Road Property Address Theresa Petrie Owner Owner's Name information is North Andover MA 01845 3/20/17 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): "M box needs replacement 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.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Stonecleave Road Property Address Theresa Petrie Owner Owners Name information is required for every North Andover MA 01845 3/20/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: (2)3'x 60' ❑ 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.): No signs of hydraulic failure Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 67 Stonecleave Road Property Address Theresa Petrie Owner Owner's Name information is North Andover MA 01845 3/20/17 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 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 w 67 Stonecleave Road Property Address Theresa Petrie Owner Owner's Name information is required for every North Andover MA 01845 3/20/17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately A _ t�A+A�Cu IGNST 00• . r Na, AA100V5,Q t,,/✓r7 I`o m } I EX, 7-/N G, i j r/ov.« SFtnt";i!A+ss ftPPRcX i 11/ /f4 !7 A— _ Tpnl" OrtiT 1444L C'OY ,V a x opt 1=N0 L-N 1W3l2 w O I f51% C2 D F MAS&I f.UP ------ 0,Z 0%rt �OArssionP` /ooG C/ "A Of hf4s4 2� lOSEPN SG m. E s BAABAGAItU 'OQFCISTEP Grp G" f'4'0NA151.� L.. t5ins•3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 • r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 67 Stonecleave Road Property Address Theresa Petrie Owner Owner's Name information is required for every North Andover MA 01845 3/20/17 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: 5 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Dug hole in low drop off area, left of driveway, no water at 4', 18"elevation difference from SAS location. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 J Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Stonecleave Road Property Address Theresa Petrie Owner Owner's Name information is North Andover MA 01845 3/20/17 required for 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 L • Commonwealth of Massachusetts 2 L - Title 5 Official Inspection Form M Subsurface Sewage Disposal System Form Not for Voluntary Assessmen wM 67 Stonecleave Road Property Address Theresa Petrie Owner Owner's Name information is required for every North Andover MA 01845 4/13/17 page. City/Town State Zip Code Date of Inspection w Inspection results must be submitted on this form. Inspection forms may0tered0�r�any way. Please see completeness checklist at the end of the form. 1$`1, Important:When filling out forms A. General Information of N �Qp� on the computer, use only the tab 1. Inspector: key to move your cursor-do not John J. Soucy use the return Name of Inspector key. Soucy's Sewer Service Inc. rmi Company Name 78 North Broadway Company Address n Salem NH 03079 City/Town State Zip Code 603-898-9339 13397 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 ❑ ;eeF hedva ion by the Local Approving Authority <� x � 3/20/17 Inspna re Date Theinspector 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 it f �I �q r 1 t �� y "- �.�.� i i if Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Storiecleave Road Property Address Theresa Petrie Owner Owner's Name information is required for every North Andover MA 01845 4/13/17 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 67 Stonecleave Road Property Address Theresa Petrie Owner Owner's Name information is required for every North Andover MA 01845 4/13/17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page3 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 67 Stonecleave Road Property Address Theresa Petrie Owner Owners Name information is required for every North Andover MA 01845 4/13/17 page. City/Town 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than Y day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Stonecleave Road Property Address Theresa Petrie Owner Owner's Name information is required for every North Andover MA 01845 4/13/17 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 67 Stonecleave Road Property Address Theresa Petrie Owner Owner's Name information is required for every North Andover MA 01845 4/13/17 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5ins-3/13 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 67 Stonecleave Road Property Address Theresa Petrie Owner Owner's Name information is required for every North Andover MA 01845 4/13/17 page. City/Town . State Zip Code Date of Inspection D. System Information Description: Number of current residents: 5 V Does residence have a garbage grinder? ElYes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Well 100'+ Sump pump? ® Yes ❑ No Last date of occupancy: CurrentDate 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•3/13 Title 5 Oficial 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 M 67 Stonecleave Road Property Address Theresa Petrie Owner Owner's Name information is required for every North Andover MA 01845 4/13/17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Current Date Other(describe below): General Information Pumping Records: Source of information: Soucy's Sewer Service Inc Was system pumped as part of the inspection? ® Yes ❑ No If yes,volume pumped: 1000 gallons How was quantity pumped determined? Gauge on truck Reason for pumping: Maintenance and Inspection Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 67 Stonecleave Road Property Address Theresa Petrie Owner Owner's Name information is required for every North Andover MA 01845 4/13/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 22"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.): No evidence of leakage Septic Tank(locate on site plan): Depth below grade: 12"feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8'6"x 4'8" Sludge depth: 3" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 67 Stonecleave Road Property Address Theresa Petrie Owner Owner's Name information is required for every North Andover MA 01845 4/13/17 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 35" Scum thickness 3 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape&Sludge tool Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet baffle, outlet tee good,tank structure is sound, no apparent leaks, pump tank annually due to age of leaching system. 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form =, a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 67 Stonecleave Road Property Address Theresa Petrie Owner Owner's Name information is required for every North Andover MA 01845 4/13/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 67 Stonecleave Road Property Address Theresa Petrie Owner Owner's Name information is required for every North Andover MA 01845 4/13/17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): T" Box replaced prior to inspection. See attached permit 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.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 67 Stonecleave Road Property Address Theresa Petrie Owner Owner's Name information is required for every North Andover MA 01845 4/13/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: (2) 3'x 60' ❑ 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.): No signs of hydraulic failure Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Stonecleave Road Property Address Theresa Petrie Owner Owner's Name information is required for every North Andover MA 01845 4/13/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5ins-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 ®fficial Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 67 Stonecleave Road Property Address Theresa Petrie Owner Owner's Name information is required for every North Andover MA 01845 4/13/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately E _ i}AyC� o 6c.uS7' Cao � /I(�STWl}RD L°Xz �aREST S7-• _ o, b i IV— Nun/OaVER GR n/ P-2 A 7� + �c i EEX /NG r i ,AIM Qkk ly4.4•l- i 6oY L=;V lW3 !1 w 6r.c F MAS$F�yL� 4o' ------I 3� 105EpN N i EPR .6P Or �Da0010\'' IOaGC�I SALT/C 7'11N11 i I OF M.1$ PH 5G i s BPRBAGPLlO Nn 464 6o Q2 2gFC'5(Ea�!Q T F'sS/ONP\SPS 1_ l5ins-3/13 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 67 Stonecleave Road Property Address Theresa Petrie Owner Owner's Name information is required for every North Andover MA 01845 4/13/17 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: 5'feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Dug hole in low drop off area, left of driveway, no water at 4', 18"elevation difference from SAS location. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 67 Stonecleave Road Property Address Theresa Petrie Owner Owner's Name information is required for every North Andover MA 01845 4/13/17 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary:A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information—Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 j . COMMONWEALTH OF MASSACHUSETTS NUMBER BHP-2017-0340 North Andover FEE BOARD OF HEALTH $175.00 -------------------------------------------John Soucy Som 5 � -C NAME 1 67 STONECLEAVE ROAD. ----- -------------------------------------- ----------------------------------------------------------- ADDRESS IS HEREBY GRANTED A PERMIT I D-box repair_ This permit is granted in conformity with the Statutes and ordinances relating thereto, and expires June 28, 2017 unless sooner suspended or revoked. March 28, 2017 ---------------------------------------------------------------- BOARD OF ------- HEALTH -------------------------- -------------- ------------ ------ - -------- - -- - -- ----- ----- l BOARD OF HEALTH CHAIRMANz ---z ----------------- ---------------------------- ---------- Y 7 �yy� 1 Of NQRTN 1t, I V L 1 o •. O Town of North Andover . 4sAt ' HEALTH DEPARTMENT SACNUSt CHECK#: 36 q DATE: y /8 Lo LOCATION: 6 7 Jc- /P /ea 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 $ .5'c� A-7 ❑ Other(Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer ZZ aCa Ca,ST C'a A1a 7' S �R .S 7' Ala , AA1l) t? I1ER , cp FX15 r11vC< l� /f 4!C7 err' 1. lax d u. � �� � • . �� • W Ar- �- qk SOF MAS&q w I 3� 1�S�PH N a ). SPRBPG46 O 0o No• 4�Q R � � A9CFf SIOtA SPS /000 0 F MgSs�cyG p JOSEPH Z` J 13ARBAGALLO No.464 Q ! /ST��� SS/DNAL SPS ZZI I - I Of 11 4 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 67 Stonecleave Road,North Andover,MA 01845 Owner's Name: Tracy Flanders RECEIVED Owner's Address: 67 Stonecleave Road,North Andover,MA 01845 Date of Inspection: February 20,2006 FEB 2 3 2006 Name of Inspector:(please print) Benjamin C.Osgood,Jr.Certified Title 5 Inspector Company Name: New England Engineering Services Inc. TOWN OF NORTH ANDOVER Mailing Address: 60 Beechwood Drive North Andover,MA 01845 HEALTH DEPARTMENT 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: --,ZPasses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: (9 Date• z z� 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: 67 Stonecleave Road,North Andover,MA 01845 Owner's Name: Tracy Flanders Date of Inspection: February 20,2006 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: '�I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: V O 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 exfil=on 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: 4of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 67 Stonecleave Road,North Andover,MA 01845 Owner's Name: Tracy Flanders Date of Inspection: February 20,2006 D. System Criteria applicable to all systems: You must indicate"yes or Nd'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'/z day flow —LZ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times Pumped JZ Any Portion of the SAS,cesspool or privy is below high ground water elevation. L,-' 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 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.) (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 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 of a tributary to a surfa g water supply The system is located in a nitroge five area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water sup 1 If you answered " any question in Section E the system is consid significant threat,or answered"yes"in Section D above the large system has failed The owner or operator of any large system conside ' cant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system o should contact the appropriate regional office of the Department. i 5ofll OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 67 Stonecleave Road,North Andover,MA 01845 Owner's Name: Tracy Flanders Date of Inspection: February 20,2006 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 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 onsite? Were all the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the bales or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? y 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 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)] i I 6ofll OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 67 Stonecleave Road,North Andover,MA 01845 Owner's Name: Tracy Flanders Date of Inspection: February 20,2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design) — Number of bedrooms(actual): DESIGN flow based in 310 CMR 15.203(for example: 110 gpd x #of bedroomsj Number of current residents:_ Does residence have a garbage grinder(yes or no): 1U0. Is laundry on a separate sewage system(yes or no): 410[if yes separate inspection required] Laundry system inspected(yes or no): -- Seasonal use:(yes or no): 1 a . Water meter readings,if available(last 2 years usage(gpd): V1 C L Sump Pump (yes or no):u S . Last date of occupancy L,, r�c� COMIERCIALANDUSTRUL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgfl,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: Z 0 Z Was system pumped as part of the inspection(yes or no): . If yes,volume pumped: eallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank, distribution box,soil absorption system Single cesspool Overflow cesspool Pri 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: 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: 67 Stonecleave Road,North Andover,MA 01845 Owner's Name: Tracy Flanders Date of Inspection: February 20,2006 BUILDING SEWER(locate on site plan) Depth below grade: VZ" Materials of construction: V-"cast iron 40 PVC other(explain) Distance from private water supply well or suction line: N6 Comments(on condition of joints,venting,evidence of leakage,etc.): -P/ 1-0 D KS C-D v SEPTIC TANK: (locate on site plan) Depth below grade: (� Material of construction: `/concrete metal fiberglass polyethylene Other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: /.S2 o G- L(o ej S Sludge depth: .3 Distance from top of sludge to bottom of outlet tee or baffle: 2"� , Scum thickness: /1' a Distance from to of scum to to of outlet tee or baffle: P P � Distance from bottom of scum to bottom of outlet tee or baffle z How were dimensions determined: -n ERsy,2.0 LsT1t rL Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): T�1.v/� �v G-oc),p t-�A-7P(i7 r on co,.,c�2 - l ti (-7 iX/ CDnJJ->iT-7ndl< GREASE TRAP: V/ .0ocate on site plan) Depth below grade: Materials 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 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. l 8.4 11 - OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 67 Stonecleave Road,North Andover,MA 01845 Owner's Name: Tracy Flanders Date of Inspection: February 20,2006 TIGHT OR HOLDING TANK: Nle (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) Cf Depth of liquid level above outlet invert:_ 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.): 1N 101_i2 2 PUMP CHAMBER:-IV14— ocate on sire 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.): 90f11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 67 Stonecleave Road,North Andover,MA 01845 Owner's Name: Tracy Flanders Date of Inspection: February 20,2006 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 leaching trenches,number in length 3 cF-f E 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) h-te# 7a�iE L-p C>(914S .v0 4vl-,AL. /yo f-AJ C,r- 09zr' Soy rDs 0/L t-E�-,q-l< Irl/ ✓L ©cam% CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of Construction Indication of groundwater inflow(yes or no) Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) 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: 67 Stonecleave Road,North Andover,MA 01845 Owner's Name: Tracy Flanders Date of Inspection: February 20,2006 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. wE:L- 0 Y\ Imu G 11 of 11= OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 67 Stonecleave Road,North Andover,MA 01845 Owner's Name: Tracy Flanders Date of Inspection: February 20,2006 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 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: Sysi�M t_nca-,-Lr-r7 (Ki ,,e-EA T-RWT Ff VA> 6(fe ui'> Z 1D FC A S3 D JL' O L D E XIS—1 (,j (r- + J s.G s /✓1 ft S f n l t7 1 f KYR W 14-1(1� -So VA-c -2- Z NEW ENGLAND ENGINEERING SERVICES INC RECOVED February 21, 2006 FEB 2 3 2006 T�HEA1-TH DEPAftTM NTWN OF NORTH ER Ms. Susan Sawyer North Andover Board of Health 400 Osgood Street North Andover, MA 01845 RE: TITLE V REPORT: 67 Stonecleave Road,North Andover,MA Dear Ms. Sawyer: Enclosed is the Title 5 Report for the above referenced property. The system PASSES the inspection. If there are any questions please call me at my office, 686-1768. Sincerely, GO BenjaminC. Osgo , Jr. Certified Title 5 Inspector 60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 S t { COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION s•• TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: .(-,'7 AD 0 ova 2 Owner's Name: t'jZ Owner's Address: �„ 7 S 7b.✓ c.L E�Jc` p� - --"5F _Y,�._ -- -. No(L-) fW 17 oJ0�. .+^✓4 Te"VAN OF NOR=H A�lt�v / BOARD 04 NEPI'Ci H D f o Z) - ' .' Date o inspection: 2 Name of Inspector:(please print) Beni amin C. Osgood, Jr. ! MAR 3 0 CompanyName: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 on site sewage disposal systems.I am a DEP approved system inspector pursuant too Section 15.340 of Title 5(310 CMR 15.000 The system: p/ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: S---..-7- _ Date: 3 Z 0 t� The system inspector shall submit a copy of this' ion 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) Property Address: 7 GLL A u c- ►2-; /1)0o,�c/2- Owner: L NAJN e Date of Inspection:_ =0 . Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ES I have not found any information which indicates that any of the failure cxiteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure aiteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following.statements.If`not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distn'bution 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 pipes).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND.explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 67 5 vNc G G�4y� r2o Owner: LG r9 M IV t,4 c A[.LIQ 12, Date of Inspection: 3 12 f y C. ./ Further Evaluation is Required by the Board of Health: V 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(l)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface.water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**.Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility aad 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: Page 4 of 11 OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: &- 7 Slap c u-6q�� 2fl tiF(Zi i /'nom D�� �►�+ Owner: 1-L5-f A1A1(T Date of Inspection: ,TZ-,,/b y D. System Failure Criteria applicable to all systems: You must indicate"yes"or`no"to each of the following for alt inspections: Yep 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 logged SAS or cesspool Static liquid level is the distn'bution box above outlet invert due to an overloaded or clogged SAS or cesspool _ iquid 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 _ z Any portion of the SAS,cesspool or privy is below high ground water elevation. Z/Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface meter supply. _ _✓ An ion of a 1 or is within y port cesspool privy a Zone 1 of a public well. _ : _ y 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 15303,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 ltd 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.iswithin 400 feet of a surface g water supply — the system is within 200 -of a tributary to a surface drinking water supply — — the system isjocated in a nitrogen seaisitiye area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II.of a public water supply well If you ha a answered"yes"to any question in Section E the syste& considered a significant threat,or answered "yes'in Section D above the large system has failed.The owner or open or 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: 6 AAA Owner: Date of Inspection: Z-0&y Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Y� 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 the system received normal flows in the previous two week period? ZHavelarge volumes of water been introduced to the system recently or as part of this inspection? Y Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ _ Was the facility or dwelling inspected for signs of sewage back up? ✓ _ Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no/� Existing information.For example,a plan at the Board of Health. 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)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 6 Owner: l•E/9NNL /_441-AlloS72�4 Date of Inspection: 31 z,;,/o y FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMRR5.203(for example: 110 gpd x#of bedrooms): Number of current residents: S Does residence have a garbage grinder(yes or no): IUO Is laundry on a separate sewage system(yes or no)g Q[if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no)/V0 Water meter readings,if available(last 2 years usage(gpd)): c.J E j-L Sump Pump(yes or no).:,,jfS Last date of ancy (rG -------------------------------- COMMERCIAIJINDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Bpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):— Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(descri GENERAi.INFORMATION -Pumping Records Source of information: Z ay 0 a7 2 Was system pumped as part of the inspection(yes or no):A10 IfYvolume P�P ___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: (+p /Lo x 15^ w C114-.S 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: & 7 Owner: G-CtWNe Al AL-J-!S-1 Date of Inspection: 3 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:Zcast iron 40 PVC other(explain): Distance from private water supply well or suction line: 17'0 ' Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_(locate on site plan) Depth below grade: ��:c Material of construction:Tooncrete metal fiberglass 1 eth enc — 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: ,,52>o Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: y 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: Z ` How were dimensions determined: .i1-7eA.5 a/L G C X, Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc:): CNK 1N 6-C' e� GREA.SF TRAP: (locate on site plan) . Depth below grade:_ Material of construction:_concrete metal fiberglass_polyethylene_other (explain),.— Dimensions: 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: 7 S725 N Nva-itt f�n� �oyG2 Owner: L e�-A�.vC /W Date of Inspection: 3 2-f TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of const uctiow. concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallonstday Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping- Comments umpingComments(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: U 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.): / 0 yA /1l CJ,-OIANC C or /_CftjiAC>-E l /U C, (- a CU r o LwiG I+rL a Y©j t%9- ;� Eu "c-4,5 0-- Fj t+L)(N Cs- R-L C N PUMP CHAMBER:UA(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.): Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address-. a A vlVc A c e s—L 2 L-7 Owner: Date of Inspection: 3 f Z o/zy 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: ;Zt REocKE S leading fields,number,dimensions: overflow cesspool,number: innovativelalternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): J J JLc D. �/La c3 e Aj Cr— F3A-/L alo fvoi e2e"cJcfit A�� ,��nJo.,v !� 'YLE.ycf�cS CESSPOOLS: (cesspool must be pumped as part of inspectionxlocate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimcesions 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:AIA 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: (,,7 2z> NO &I}-t A,-.y DOU c�2 Owner: Date of Inspection: cj 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. ujEt.Lr Iv Jf. 4- ► 55sre r� i-t 5�sG i ji 4 i F F_11 ft{ t ii F€F EEt tt( tt { t ` Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 6-7 �V 0 2j7? A-AJ D 6 U IL- Owner: t E1�NN� qLc s dL- Date of Inspection: 2-/v Y SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all me&ods used to determine the high ground water elevation: Obtained from system design plans on record-If decked,date of design plan reviewed: Observed site(abutting property/observation hole within ISO 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: irt-- tJ5 G-S SPS r , y NEW ENGLAND ENGINEERING SERVICES INC rovai of-NORTH AWnt:`�i;R� BOARD OF HEALTH MAR 3 0 2004 March 29, 2004 North Andover Board of Health Town Hall Annex 27 Charles Street North Andover, MA 01845 RE: TITLE V REPORT: 67 Stonecleave Road,North Andover, MA Dear Sir or Madam: 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 Benjamin C.Z/d,/Jr. Certified Title 5 inspector 60 BEECHWOOD DRIVE-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 c r �Lk COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET,BOSTON,MA 02108 (617)292-5500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 67 Stonecleave Rd.. N. Andover, MA 01845 Property Owner: Steve Casey Date of Inspection: April 7, 2000 Name of Inspector: (Please Print) Paul G. Jenner I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(3 10 CMR 15.000) Company Name: PAUL G. JENNER ASSOCIATES, Inc. Mailing Address: 31 RILEY AVENUE Telephone Number: EAST WEYMOUTH, MA 02189 (781) 337-8617 Fax (781) 337-1802 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 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: X Passes Conditionally Passes Needs Further Ev tion y the ppro ng Authority Fails Inspector's Signature: Date: April 8,2000 The System Inspector shall submit a copy of this i ection ort to the Approving Authority(Board of Health or DEP) within thirty(30)days of completing this inspect' If 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. - NOTES AND COMMENTS APR 1 PAUL G. JENNEKASSOCUTES (Revised 9/2/98) -Pago 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 67 Stonecleave Rd. N. Andover, MA 01845 Property Owner: Steve Casey Date of Inspection: April 7, 2000 INSPECTION SUMMARY: Check A,B,C,or D: A. SYSTEM PASSES: YES X I have not found any information within indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. B. SYSTEM CONDITIONALLY PASSES: N/A 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 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. 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). 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 PAUL G. JENNEB ASSOCIATES (Revised 9/2/98) -Page 2 ' r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 67 Stonecleave Rd. N. Andover,MA 01845 Property Owner: Steve Casey Date of Inspection: April 7,2000 C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: NO 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 IN ACCORDANCE WITH 310 CMR 15.303 (10) 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 WELL FAIL UNLESS THE BOARD OF HEALTH(AND THE PUBLIC WATER SUPPLIER, IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT 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 pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.Method used to determine distance (approximation not valid). 3) OTHER: PAUL G. JENNER ASSOCIATIES . (Revised 9/2/98) -Page 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 67 Stonecleave Rd. N. Andover,MA 01845 Property Owner: Steve Casey Date of Inspection: April 7,2000 D] SYSTEM FAILS: NO s You must indicate either"Yes"or"No"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 eluent to the surface of the ground 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 1R 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 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.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. E] LARGE SYSTEM FAILS: N/A You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the above criteria: The system serves a facility with a design flow of system is 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or moreof 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 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 The owner or operator of any such system shall bring the system in accordance with 310 CMR 15.304(2).Please consult the local regional office of the Department for further information. PAUL G. JENNER ASSOCIATES (Revised 9/2/98) -Page 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 67 Stonecleave Rd. N. Andover, MA 01845 Property Owner: Steve Casey Date of Inspection: April 7, 2000 Check if the following have been done: You must indicate either"Yes"or"No"as to each of the following: Yes No Y _ Pumping information was requested of the owner,occupant,and Board of Health. Y _ 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 volumesof water have not been introduced into the system recently or as part of this inspection. Y _ As built plans have been obtained and examined. Note if they are not available with N/A. Y _ The facility or dwelling was inspected for signs of sewage back-up. Y _ The system does not receive non-sanitary or industrial waste flow. Y _ The site was inspected for signs of breakout. Y _ All system components,excluding the Soil Absorption System,have been located on the site. Y _ The septic tank manholes were uncovered,opened,and the interior of the 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: Y _ Existing information.Ex.Plan at B.O:H N 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)] Y _ The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal System. PAUL G. JENNER ASSOCIATES (Revised 9/2/98) -Page 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART:C SYSTEM INFORMATION Property Address: 67 Stonecleave Rd. N. Andover, MA 01845 Property Owner: Steve Casey Date of Inspection: April 7, 2000 FLOW CONDITIONS RESIDENTIAL: Design flow 110 g p.d./bedroom Number of bedrooms(design): 4 Number of bedrooms(actual): 4 Total DESIGN flow: 440 Number of current residents: 5 Garbage grinder(yes or no): Yes-Recommend Disconnect Laundry(separate system)(yes or no):No If yes,separate inspection required Laundry system inspected(yes or no) N/A Seasonal use(yes or no): No Water meter readings,if available(last two(2)year usage(gpd):Well->100'from SAS Sump Pump(yes of no):No Last date of occupancy: Current COMIVIERCIAL/INDUSTRIAL: NO Type of establishment: Design flow: gallons/day(Based on 15.203) Basis of design flow 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)"/Owner System pumped as part of inspection(yes or no) NO If yes,volume pumped gallons Reason for pumping: Not pumped at time of inspection,System on yearly maintenance schedule TYPE OF SYSTEM: X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool F: Privy Shared system(yes or no).If yes,attach previous inspection records,if any. I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components,date installed(if known)and source of information:78/BOH records Sewage odors detected when arriving at the site:(yes or no NO PAUL G. JENNER ASSOCUTES (Revised 9/2/98) -Page 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:. 67 Stonecleave Rd. N. Andover, MA 01845 Property Owner: Steve Casey. Date of Inspection: April 7,2000 BUILDING SEWER (Locate on site plan) Depth below grade: 15" Material of construction: _cast iron X 40 pvc _ other(explain) Distance from private water supply well or suction line:N/A Diameter.:6" Comments:(condition of joints,venting,evidence of leakage,etc.)No abnormal signs observed SEPTIC TANK: YES (Locate on Site Plan) Depth below grade: Material of Construction: X Concrete _ Metal _ Fiberglass _ Polyethylene _ .Other(explain): If tank is metal,list age _ Is age confirmed by Certificate of Compliance _ (Yes/No) Dimensions: 8'L z 4'W z 416"D Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 33" Scum thickness: 1" Distance from " m top of scum to to of outlet tee or baffle: 6 P Distance from bottom of scum to bottom of outlet tee or baffle: 14" .How dimensions.were determined: measuring stick 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) No abnormal signs observed at time of inspection, all tees and baffles in place. Liquid levels,structural integrity OK . No leakage GREASE TRAP: NO (Locate on Site Plan) Depth below grade:_ Material of Construction: _ Concrete _Metal _ Fiber lass _ 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: g Comments(recommendation for pumping, condition o inlet and outlet tees or es .1� baffles, depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage, etc.): PAUL G. JENNER ASSOCIATES (Revised 9/2/98) Page 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 67 Stonecleave Rd. N. Andover,MA 01845 Property Owner.: Steve Casey Date of Inspection: April 7,2000 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or 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: Alarm level: Alarm in working order: (Yes/No) Date of previous pumping: Comments(condition of inlet tee, condition of alarm andfloat switches, etc.) DISTRIBUTION BOX: YES (Locate on Site Plan) Depth of liquid level above outlet invert: 0 Comments(note if level and distribution is equal evidence of solids carryover, evidence of leakage into or out of box, etc.) D-Box was level with no signs of solids carryover,no signs of leakage in or out of box PUMP CHAMBER: NO (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.) PAUL G. JENNER ASSOCIATES (Revised 9/2/98) -Page 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 67 Stonecleave Rd. N. Andover, MA 01845 Property Owner: Steve Casey Date of Inspection: April 7,2000 SOIL ABSORPTION SYSTEM(SAS): YES (locate on site plan, if possible;excavation not required, but may be approximated by non-intrusive methods) If not located,explain: TYPE: leaching pits and number leaching chambers and number leaching galleries and number X leaching trenches,number,length 2—60' each leaching fields,number,dimensions . overflow cesspool,number Alternative system: Name of Technology: Comments(note condition of soil,signs of hydraulic failure, level ofponding, condition of vegetation,etc.)No abnormal signs ` observed at time of inspection, no ponding, abnormal vegetation or hydraulic failure observed. CESSPOOLS: NO (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(cesspool must be pumped as part of inspection): Comments(note condition of soil,signs of hydraulicfailure,level ofponding, condition of vegetation,etc.) PRIVY: NO (Locate on Site Plan) materials of construction dimensions depth of solids 'Comments(note condition of soil,signs of hydraulic failure,level ofponding, condition of vegetation,etc.): PAUL G. JENNER ASSOCIIATES (Revised 9/2/98) -Page 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 67 Stonecleave Rd. N. Andover, MA 01845 Property Owner: Steve Casey Date of Inspection: April 7,2000 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) `SEE ATTACHED AS-BUILT DRAWING' PAUL G. JENNER ASSOCIATES (Revised 9/2/98) -Page 10 a. a -- ;As- / A.1 '"/0 ' EXISTINCt' 7Jw.2 /NC JQ � 1e I Al 4 .C y T r ►� .gL _ GJ OX wJl 3 y y 3 . OE MASS,4C i`s )OSEpN N . �° sSIONP�S _ /000 OF 4144 y gyp'' JOSEPH G� J. BARBAGALLO v' 4,40 7-o NAL SPS\ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 67 Stonecleave Rd. N. Andover, MA 01845 Property Owner: Steve Casey Date of Inspection: April 7,2000 DEPTH TO GROUNDWATER NRCS Report name: Soil Type: Typical depth to groundwater: USGS Date website visited: Observation Wells checked: Groundwater depth: Shallow Moderate Deep SITE EXAM Slope none Surface water none Check Cellar dry Shallow wells n/a Estimated Depth to Groundwater >7.5 Feet Please indicate all the methods used to determine High Groundwater Elevation: X Obtained from Design Plans on record _Observation of Site(Abutting property,observation hole,basement sump,etc.) _Determine it from local conditions _Check with local Board of Health _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) Design plans and perk test results on file @ Board of Health PAUL G. JENNER ASSOCIATES (Revised 9/2/98) -Page 11 V " ' ATTENTION THIS REPORT DOES NOT CONSTITUTE A GUARANTEE, WARRANTY OR REPRESENTATION THAT THE SYSTEM WILL CONTINUE TO OPERATE AND FUNCTION IN GOOD WORKING ORDER. THIS REPORT IS SOLELY LIMITED TO REPORTING WHETHER THE SYSTEM MEETS THE CRITERIA SET FORTH IN 310 CMR 15.303; THERE MAY BE LOCAL LAWS OR REGULATIONS APPLICABLE TO THE SYSTEM WHICH THIS REPORT DOES NOT ADDRESS. THIS REPORT CONSTITUTES THE ENTIRE REPORT. THIS REPORT WAS PREPARED ON BEHALF OF THE PERSON NAMED ON THE FRONT PAGE OF THE REPORT AND THE ONLY PERSONA UTHORIZED TO RELY UPON THE CONTENTS OF THIS REPORT IS SAID PERSON; ANY MATTERS WHICH SAID PERSON INTENDS TO RELY UPON MUST BE CONTAINED IN WRITING IN THIS REPORT AND SAID PERSON ACKNOWLEDGES THAT THEY ARE NOT RELYING UPON ANY ORAL COMMUNICATIONS OR DISCUSSIONS CONCERNING THIS REPORT. PAUL G.:JENNER ASSOCIATES (Revised 9/2/98) =Page 12