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HomeMy WebLinkAboutMiscellaneous - 703 MIDDLETON STREET 4/30/2018Commonvtreallth of Massachusetts RECEIVED Title 5 official Inspection Forms Ar fi Subsurface Sewage Disposal.System For, - Not for Voluntary A nis �T 2011 0 � � 2 H AND 6) 1 1 e-� J� E� NDEPARTM OVER Pro rty Address ENT Owner dCl-() `-- information is ZAesame required for 0 everU_e Y--- every page. City/Town ----' � Smote Zi Code ---1---_._.._ P Date of Inspection Inspection resulls must be submitted on this form. Inspection forms may not: way. Please see completeness checklist Y be altered in any at the end of the i form. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. AL— t5ins • o7/12. A. ueneral information 1. Inspector. Name of Inspector Company Name Company Address 60 CitylToyvn- - �J' 1TK-4— be -Q �� o- Teleph ne Numr B. Certification 0, _ M State Zip Code —'-- License Number 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 ;it sewage sewage disposal s!/stems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 115.000). The system: [� Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority ctoes SlgnaE ; e —/)��_" A1,- Date — The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DE=P. 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 undler the same or dlifferent conditions of use. Title 5 ofTidel Inspec�dw FOrm Subsurk" Sewage Dlspa w system • page 1 or 17 Owner Information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 C� 140 v1 <3 ' Property A dress Owner's Name Cityrrown B. Certification (cont.) State Zip Code Date of Inspection Inspection Summary: Check A,B,C,D or E: / always complete all of Section D A) System Passes: (7 I have not found any information which indicates that any of the failure criteria described in 310 CIMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: A 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 We following statyements. If "not determined, " please explain. The septic tank is metal and over 20 years old' or the s tic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration o exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced ith a complying septic tank as approved by the Board of Health. " A metal septic tank will pass inspection0s, structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is �gs than 20 years old is available. ❑ Y C] N ❑,ND/ (Explain below): t5ins • 03113 Title 5 Official Inspection FormSubsurface Sewage Disposal Systern • Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner _ Information is Owner's Name — --- required for every page.City/Town —�'— State -- Zip Code Date of Inspection B. Certification (cont.) ---- B) System Conditionally Passes (cont.); ❑ Observation of sewage backup or break out or high static water level in the distribution boy: 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 ❑ D (Explain below): ❑ The System required pumping more than times a year due to broken or obstructed pipe(s). The system will pass inspectio/replace oval of the Board of Health ❑ brokenpipe(s)ar)❑ Y ❑ N ❑ ND (Explain below): obstruction is rem ❑ 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 Hea determines in accordance with 310 CMR 15.303(1)(b) that the system is not fu coning in a manner which will protect public health, safety and the environment: / ❑ Cesspool or pr/w*ith 50 feet of a surface water ❑ Cesspool or pr50 feet of a bordering vegetated wetland or a salt march 15ins - 03113 Tile 5 Official InsoWion Fnrm R��tie�..r,.e c...._.,_ 11__ Owner Information is required for every page. t5ins - 03/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sell wage Disposal System Form - Not for Voluntary Assessments D �l Ot C��'P'I J 6 Y) % Property Address Owner's Name City/Town B. Certification (cont.) State Zip Code Date of Inspection 2. System will fail unless the Board of Health (and Public Water Supplier, if any) deterimes 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 w' in a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the S is within 50 feet of a private water supply well. ❑ The system has aseptic tank and SAS and a 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 nalysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the pr enc of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no her 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 ❑ 0" Static liquid level in the distribution box above outlet invert: due to an overloaded or clogged SAS or cesspool O�rA ❑ Liquid depth in cesspool is less than 6" below inve than % day flow rt or available volume is less Owner Information is required for every page. [Sins - 03/13 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewag2 Disposal System Form - Not for Voluntary Assessments a 3 /�, d ol! 46.0 � 4 - Property Address Owner's Name City/Town B. Certification (cont.) State Zip Code Date of Inspection Yes No ❑ L� Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Elf 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. ❑ Cr Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ C]/ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ El 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. [chis system passes if the well water analysis, performed ata 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.] ❑ ❑� This system is a cesspool serving a facility with a design flow of 2000gpd- 10, 000gpd. ❑ d 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" t questions in Section D. each of the following, in addition to the / Yes No �i El El the system is within 44/00"feet of a surface drinkiing water supply ❑ 11 the system is wit ' 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system i ocated in a nitrogen sensitive Area -1'�PA r a mapped Zone 11 of a public water supply weejihead Protection If you have answered " e to any y question in Section E the system is condidererl a significant threat, or answered "yes" in S ction D above the large system has failed. The owner or operator of any large system considered 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. Title 5 Oficial Insoer.6nn.- (� Commonwealth of Massachusetts Title 5 Official Inspection Form P. Subsurface Sewage Disposal System Form Not for Voluntary Assessments w % d lir 1 0Y) 5 y Property Address Owner _ Information is 5wner's Name required for every page. City/Town State Z( Code -- P 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 iNo ❑ 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? ❑ I� Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ Were as builtlans of the system ystem obtained and examined? (If the were riot available note as N/A) y 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? C� 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 C� scum? Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? This 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)1 D. System Ilnformation Residential Flow Conditions: Number of bedrooms (design): A � ' Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): t5ins - 03/13 Title 5 Oficial Inspection Form Subsurface Sewage Disposal System • Page 6 of 17 0 Owner information is required for every page. t5ins • 03/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments d � , j 0 �b )q 5�, Property Address Owner's Name City/Town D. System Information Description: State Zip Code Date of Inspection Number of current residents: Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes 0"No Laundry system inspected? Seasonaluse? Water meter readings, if available (last 2 years usage (gpd)): Detail: i I N ` I vC) Sump pump'? Last date of occupancy: Commercial/Industrial Flow Conditions:. Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft.,etc. Grease trap present? Industrial waste holding tank present? A❑ Yes ❑ No r� ❑ Yes 12� No � i-);, l () EJ/Yes ❑ No �t Cru L{'� Date Gallons per day (gpd) ® Yes ❑ No ❑ Yes ❑ No Non -sanitary waste discharged to Ke Title 5 system? ❑ Yes ❑ No Water meter readings, if avail le: nae s omaei insr-4,_ r— Owner information is required for every page. Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments D�Z-1 a n , Property Address Owner's Name City/Town D. System Information (cont.) Last date of occupancy/use: Other (describe below): State Zip Code General Information Date Date of Inspection Pumping Records: Source of information: Was system pumped as part of the inspection? FA v ❑ es No If yes, volume pumped: How was quantity pumped determined? gallons y h p YP Reason for pumping: 1 / tc� �tK k ru�1 I Type of System: 2 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): 15ins - 03113 Title 5 Official Inspection Forth Subsurface Sewage Disposal System • Page 8 0117 Owner information is required for every page. Commonwealth of Massachusetts Title 5Official Inspection Form Subsurface Sewage Des osaI System Form -Not for Voluntary Assessments o�� a Property Address s Name Cityrrown D. System Information (cont.) State Zip Code Date of Inspection Approximate: age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: Mate' I of construction: l.� Feet cast iron ❑ 40 PVC ❑ other (explain) Distance from private water supply well or suction line: A Con condition feet omments 1,( on of�oints, venting, evidence of leakage, etc.): Yes ® No Septic Tank (locate on site plan): Depth below grade: Material of construction: l � concrete ❑ metal ❑ fiberglass If tank is metal, list age: feet � Gi ❑ polyethylene ❑ other (explain) years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth t5ins • 03113 1106 5 Offldat Inspection Forth Subsurface Sewage Disposal System • Pape 9 of 17 F • a i; Owner Information is required for every page. i5ins - 03113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner's Name Citylrown State Zi Code ZIP Date Of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 �1J How were dimensions determined? S� Ud Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid liquid levels as related to outlet invert, evidence of leakage, etc.): rP :g Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness; Distance from top of scum to Distance from bottom of Date of last pumping: l g cp— — ftnn1 1-e _q 45 feet ❑ fibergl s ❑ polyethylene ❑ other (explain) of outlet tee or baffle to bottom of outlet tee or baffle nate Z a - a Owner information is required for every page. Commonwealth of Massachusetts' Title 5 'Official Inspection Form Subsurface Sevvage Disposal System Form - Not for Voluntary Assessments Al Properly Address Owner's Name Cityfrown 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 ❑ polyeti�ene ❑ other (explain) Dimensions: Capacity: Design Flow: gallon Ions per day Alarm present: ® Yes ❑ No Alarm level: -77/ Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date ---- Comments (condition of alarm float switches, etc.): Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins - 03113 'nle 5 Of ciai Inspection Form Subsurface Sewage DISoosai Svstam . PAMA 11 At 17 h a Owner Information is required for every page. t5ins . 03/13 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewiage Disposal System p m � � ( Ole y Forrn -Not for Voluntary Assessments �� Property Address Owner's Name City/Town Do System Information (cont.) State Zip Code — Date of Inspection C Distribution Box (if present must be opened) (locate on s plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber,ZDumpsdappurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Title 5 Official Inspection Form Subs fa, ca,,,,,e R 0 Owner Information is required for every page. t5ins - 03/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 6-� A, L Property Address r Owner's Name 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: leaching fields number, dimensions:91. -�'� - x q ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: _ Comments (note condition of soil, signs of hydraulic failure, vegetation, etc.): level of ponding, damp soil, condition of -- ��p by) � � Y) (-�' A /0' ( , +J i `HC? t I ur ,P-- - Cesspools (cesspool must be pumped as part of inspection) Number and configuration Depth - top of liquid to inlet invert Depth of solids layer f / Depth of scurn layer Dimensions of cesspool Materials of constructio Indication of groun water inflow LJ Yes LJ No Title 5 official Inspection on site plan): Owner Information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form m Subsurface Se /wage Disposal System Form -riot for Voluntary Assessments Property Ad ress --- ----- Owner's Name Citylrown D. System Information (cont.) State Zip Code Date of Inspection Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegeltation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of by ulic failure, level of ponding, condition of vegetation, etc.): t5ins - 03113 Title 5 Official Inspection Form Subsurface Sewaae DlSnosal Svslem • Paan td M 17 Z\ Owner Information is required for every page. [Sins - 03113 Commonwealth of Massachusetts Title 5 Official Inspection Form m Subsurface Sewage DispDsal System Form - Not for Voluntary Assessments JP2LA Property Address Owner's Name City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand -sketch in the area below ❑ drawing attached separately I 'f 7.a io.R L4 Title 5 Official Inspection Form Subsurface Sewage Disposal System - Pape 15 of 17 0 Owner Information is .required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner's Name CitylTown D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: State Zip Code Date of Inspection 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: U Checked with local excavators, installers - (attach documentation) ❑ Accessed USG$ database - explain: You must describe how you established the high ground water elevation: - t Before filling this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 03113 Title 5 Official Inspection Form subsurface Sevrage Disposal System • Pape 16 of 17' Commonwealth of Massachusetts Title 5 Official Inspection For - p m Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address Owner Information is Owner's Name ----- required for every page. City/Town State-- Zip Code Date of Inspection E. Report Completeness Checklist 0 Inspection Summary: A, B, C, D, or E checked Inspection Summary D (System Failure Criteria Applicable to All Systerris) completed System Information - Estimated depth to high groundwater L►� Sketch of Sewage Disposal Systern either drawn on page 15 or attached in separate p ate file t5ins - 03113 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 17 of 17 �L\ Commonwealth of Massachusetts W City/Town of NORTH ANDOVER S -P U g 2014 a System Pumping Record TDVvlvu�-NUKIMA14UUVER Form 4 HEALTH DEPARTMENT GM Syey DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out forms 1. System Location: on the computer, use only the tab 703 MIDDLETON STREET key to move your Address cursor - do not NORTH ANDOVER use the return key. City/Town 2. System Owner: SCOTT LOYALL Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 6/24/14 Date MA State State Telephone Number 2. Quantity Pumped: 3. Component: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Observed condition of component pumped: GOOD CONDITION 6. System Pumped By: JAMES H CURRIER II Name X SEPTIC & DRAIN Company 7. Location where contents were disposed: GLSD Signature a; Signature of Receiving Facility (or attach facility receipt) 01845 Zip Code Zip Code 1000 Gallons ❑ Grease Trap If yes, was it cleaned? ❑ Yes ❑ No H79 406 Vehicle License Number 6/24/14 Date Date t5form4.doc• 11/12 System Pumping Record • Page 1 of 1 Owner information is required for every page. Important; When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. v �I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Asses; 703 MIDDLETON STREET Property Address SCOTT LOYALL Owner's Name NORTH ANDOVER City/Town MA 01845 State Zip Code RECEIVED Sip 0 3 2013 VN Or NORTH ANDOVER EALTH DEPARTMENT 06/18/13 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. A. General Information 1. Inspector: JAMES H. CURRIER II Name of Inspector J'S SEPTIC & DRAIN Company Name 131 FOREST ST vv„ Nal y -VU CJD MIDDLETON City/Town 978-774-6685 Telephone Number B. Certification I certify that I have personallv insnarrtot4-•-•- information reported belc was performed based on sewage disposal system; r 1 Title 5 (310 CMR 15.000; �l ® Passes ❑ Needs Furth Ev Inspector's Signature MA State S12327 License Number 01949 Zip Code is address and that the f the inspection. The inspection i and maintenance of on site uant to Section 15.340 of ❑ Fails The system inspector,, Approving Authority (Board of Health or DEP) withi Item is a shared system or has a design flow of 10 1 owner shall submit the report to the appropriat ie sent to the system owner and copies sent to the I _. . 'w -Li tcapproving 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. return Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Asses; 703 MIDDLETON STREET Property Address SCOTT LOYALL Owner's Name NORTH ANDOVER Cily/Town MA 01845 State Zip Code RECEIVED SIP 0 3 2013 N OF NORTH ANDOVER ALTH DEPARTMENT 06/18/13 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. A. General Information Inspector: JAMES H. CURRIER II Name of Inspector J'S SEPTIC & DRAIN Company Name 131 FOREST ST MIDDLETON city/Town 978-774-6685 relephone Number B. Certification MA State S12327 License Number 01949 Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Furth Evaluation by the Local Approving Authority inspector's Signature 8/23/13 Date The system inspector shall submit a copy.of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments t 703 MIDDLETON STREET SCOTT LOYALL Owner Owner's Name information is uired for every ry NORTH ANDOVER MA 01845 page. City/Town State Zip Code B. Certification (cont.) 06/18/13 Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins • 11/10 Title 5 0ffcial Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 703 MIDDLETON STREET Property Address SCOTT LOYALL Owner's Name NORTH ANDOVER Gity/Town B. Certification (cont.) B) System Conditionally Passes (cont.): MA 01845 State Zip Code 06/18/13 Date of Inspection ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required purt}�ping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspecti 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 Requked 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 tsins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. t5ins - 11/10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 703 MIDDLETON STREET Property Address SCOTT LOYALL Owner's Name NORTH ANDOVER city/Town B. Certification (cont.) MA 01845 06/18/13 State Zip Code Date of Inspection 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/z day flow Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e` wM 703 MIDDLETON STREET Property Address SCOTT LOYALL Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 06/18/13 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. ❑ ❑�\p` Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ❑ NAY Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ El \AAny 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 syst is wi In 400 feet of a surface drinking water supply ❑ ❑ the system � within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the syst is to . ted in a nitrogen sensitive area (Interim Wellhead Protection Area — PA) 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 703 MIDDLETON STREET Property Address SCOTT LOYALL Owner's Name NORTH ANDOVER MA 01845 06/18/13 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? ❑ ❑ 4 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): NA Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): A t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17 Commonwealth of Massachusetts N Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 5 703 MIDDLETON STREET Property Address SCOTT LOYALL Owner Owner's Name information for is eve ry NORTH ANDOVER MA required fo page. City/Town State D. System Information Description: Number of current residents: Does residence have a garbage grinder? 01845 06/18/13 Zip Code Date of Inspection Is laundry on a separate sewage system? [if yes separate inspection required] Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15. 3): Basis of design flow (seats/persons/sq.ft., etc. . Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Ti e 5 system? Water meter readings, if available: A ❑ Yes ® No ❑ Yes ® No l� ❑ Yes ❑ No ❑ Yes ® No WELL ® Yes ❑ No CURRENT Date Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 703 MIDDLETON STREET Property Address SCOTT LOYALL Owner Owner's Name information is NORTH ANDOVER required for every MA 01845 06/18/13 page. CityTTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other (describe below): General Information Pumping Records: Source of information: LPD 8/15/07 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 703 MIDDLETON STREET '1M vBy` [-IUNcny MUUttlSS SCOTT LOYALL Owner Owner's Name information is NORTH ANDOVER required for every page. City/Town u. System Information (cont.) MA 01845 06/18/13 State Zip Code Date of Inspection Approximate age of all components, date installed (if known) and source of information: HOUSE BELIEVED TO BE BUILT IN 1960 Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: 15" feet 26' ❑ Yes ® No feet Comments (on condition of joints, venting, evidence of leakage, etc.): PLUMBING IN GOOD CONDTION Septic Tank (locate on site plan): Depth below grade: 12" feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene El 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: 5'X8' 1000 GALLON Sludge depth: 3" - 6" t5ins • 11110 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 703 MIDDLETON STREET D. System Information (cont.) Septic Tank (cont.) MA 01845 State Zip Code Distance from top of sludge to bottom of outlet tee or baffle 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 NA 0 NA NA 06/18/13 Date of Inspection How were dimensions determined? SLUDGE JUDGE Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): TANK DOES NOT NEED PUMPING AT THIS TIME. INLET BAFFLE IN PLACE, LIQUID LEVEL CORRECT. OUTLET BAFFLE REPLACED WITH PVC TEE. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet fiberglasA ❑ polyethylene ❑ other (explain): Distance from top of scum to top of outlet tee or I Distance from bottom of scum to bottom of outlet Date of last pumping: t5ins • 11/10 or baffle Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17 Property Address SCOTT LOYALL Owner Owner's Name information is required for every NORTH ANDOVER page. City/Town D. System Information (cont.) Septic Tank (cont.) MA 01845 State Zip Code Distance from top of sludge to bottom of outlet tee or baffle 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 NA 0 NA NA 06/18/13 Date of Inspection How were dimensions determined? SLUDGE JUDGE Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): TANK DOES NOT NEED PUMPING AT THIS TIME. INLET BAFFLE IN PLACE, LIQUID LEVEL CORRECT. OUTLET BAFFLE REPLACED WITH PVC TEE. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet fiberglasA ❑ polyethylene ❑ other (explain): Distance from top of scum to top of outlet tee or I Distance from bottom of scum to bottom of outlet Date of last pumping: t5ins • 11/10 or baffle Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 703 MIDDLETON STREET Nroperty Address SCOTT LOYALL Owner Owner's Name information fo is every NORTH ANDOVER required for eve MA 01845 page. City/Town State Zip Code 06/18/13 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: Design Flow: gallons gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ❑ Yes ❑ No " Attach copy of current pumping contract (rg ggired). Is copy attached? ❑ Yes ❑ No t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,a 703 MIDDLETON STREET D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert N 06/18/13 Date of Inspection 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.): LIQUID LEVEL CORRECT, NO EVIDENCE OF CARRYOVER. BOX WAS REPLACED WITH NEW H2O CONCRETE DISTRIBUTION BOX, BOX IS 11" BELOW GRADE. Pump Chamber (locate on site plan): Pumps in working order: Alarms in working order: ❑ Yes ❑ No ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17 Property Address SCOTT LOYALL Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 page. City/Town State Zip Code D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert N 06/18/13 Date of Inspection 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.): LIQUID LEVEL CORRECT, NO EVIDENCE OF CARRYOVER. BOX WAS REPLACED WITH NEW H2O CONCRETE DISTRIBUTION BOX, BOX IS 11" BELOW GRADE. Pump Chamber (locate on site plan): Pumps in working order: Alarms in working order: ❑ Yes ❑ No ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 703 MIDDLETON STREET t-roperry Haaress SCOTT LOYALL Owner Owner's Name information is NORTH ANDOVER required for every page. City/Town D. System Information (cont.) Type: leaching pits leaching chambers leaching galleries leaching trenches leaching fields overflow cesspool innovative/alternative system MA 01845 06/18/13 State Zip Code Date of Inspection number: number: number: number, length: number, dimensions: number: (1) 25'X45' Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SOILS DRY, NO SIGN OF HYDRAULIC FAILURE, VEGITATION NORMAL. USED CAMERA AND LOCATOR TO DETERMINE LENGTH, WIDTH, AND DEPTH. 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 - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 703 MIDDLETON STREET rroperty Address _ SCOTT LOYALL Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 06/18/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Y '1 703 MIDDLETON STREET Property Address SCOTT LOYALL Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 06/18/13 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 1J.., 0 Wt // -7+ Z / 2,6 3/ t�11 To 5 <s/-�m �4ppry 1070, ins-9lf8 TA85 OMCM bqmcfta Fbanc "''Mist Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 703 MIDDLETON STREET vpvlLy nuuress SCOTT LOYALL NORTH ANDOVER CirylTown D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: MA 01845 State Zip Code feet 06/18/13 Date of Inspection 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: THE HOUSE HAS A SUMP PUMP WHICH IS APPROX 6' BELOW GRADE. THE HOUSE HAS A LEACH FIELD WHICH IS APPROX 2' BELOW GRADE. THEREFORE, THERE IS A SEPERATION BETWEEN BOTTOM OF SYSTEM AND HIGH GROUND WATER. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r ti 703 MIDDLETON STREET Property Address SCOTT LOYALL Owner Owner's Name information is NORTH ANDOVER required for every page. City/Town MA 01845 State Zip Code E. Report Completeness Checklist 06/18/13 Date of Inspection ® 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 703 MIDDLETON ROAD property Address SCOTT LOYALL Owner's Name NORTH ANDOVER MA 01845 State Zip Code Cityfrown inspection results esubmitted on this form. Inspection forn way. Pease e ccompletness checklist at the end of the form. Important: When A. General Information filling out forms on the computer, use only the tab 1. Inspector key to move your cursor - do not JAMES H. CURRIER II use the return Name of Inspector key. J'S SEPTIC & DRAIN Company -Name 131 FOREST ST �--- -� Company Address MA MI N State '�---" Cilymown lrown S12327 978-774-6685 License Number Telephone Number B. Certification 6/18/13 Date of Inspection AUG 26 2013 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 01949 Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 8/23/13 Alore,s n re Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""*"This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Official ftmec ion Fmm: Subsurface Sewage Dtsoosai Svstem 'Pam 1 of 17 t5ins • 11110 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 703 MIDDLETON ROAD Property Address SCOTT LOYALL owners Name NORTH ANDOVER MA 01845 cityrrown State Zip Code B. Certification (cont.) 6/18/13 Date of Inspection Inspection Summary_ Check A,B,C,D or E 1 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, NO) 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 hank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is sb ucturaliy 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 tsins -1 ino Tilb5 Offic i ikon £wnrr. SubswraW sewage Disposal system - Page 2 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 703 MIDDLETON ROAD Property Address SCOTT LOYALL Owner's Name NORTH ANDOVER MA 01845 Citylrown State Zip Code B. Certification (cont.) B) System conditionally Passes (cont.): 6/18/13 Date of Inspection ❑ 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 ❑ Y ❑ N ❑ NO (Explain below): ❑ Y ❑ N ❑ NO (Explain below): ❑ Y ❑ N ❑ NO (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 obstruction is removed ❑ Y : `❑ Y ❑ N ❑ N ❑ ❑ NO (Explain below): NO (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 Trft 5 offiml Insoac ion form: Subsurface .*AMSW Disposal SvMem • Pam 3 of 17 f5ins • 11110 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 703 MIDDLETON ROAD Property Address SCOTT LOYALL Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 6/18/13 page. citYrrown State Tp Code Date of lnspec ion B. Cer#fication (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 fess 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,p ed 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 "Ne to each of the following far 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 6a below invert or available volume is less than % day flow t5ins -11/10 Tdte5 oftM mon Few &AMuiam sewage Disposal &MM • Page 4 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form ants Subsurface Sewage Disposal System Foran - Not for Voluntary Assessor 703 MIDDLETON ROAD Property Address SCOTT t_UYKL�- owner . Owners Name MA 01845 _ 6118113 information isDOV NORTH ANER S co a Date of inspection required for every CitylTown page- B. Certification (cont-) Yes Noed Required pumping more than 4 times in the last year NOT due to clo99 or ❑ ® obstructed pipe(s). Number of times pumped: ❑ 10 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. ❑ 00 Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ M-1,10 Any portion of a cesspool or privy is within 50 feet of a private water supply well. [] ❑ 0 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet supply well with no acceptable water quality analysis. [This from a private water system passes if the well water analysis, performed at a DEP certified indicates absent and the presence laboratory, for fecal coliform bacteria Of ammonia nitrogen and nitrate nitrogen is equal to or lesseean a atysis A copy provided that no other failure criteria are triggered. custody moist be attached to this form.) and chain of 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 in 310 CMR 15.303, therefore the system fails. The arteria exist as described owner should contact the Board of Health to determine what will be system 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 1o,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 w in 400 fleet a surface drinking water supply ❑ C7 the system is within 2 t of a tributary to a surface drinking wafer supply ❑ ❑ the system is to n a n n sensitive area (interim Wellhead Protection Area — IWPA) or a apped Zone t 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 ar operator of any large system considered a signif cant threat under Section E or fatted under Section D shall upgrade he system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Title 5 ot6 w Uupec6an r -a: Suhswt" sewage D-SpOsEd System- Page 5 d 17 t5iro - t U10 Domlll>lonwreafth of Massachusetts Title 5 Official Inspection Farm - _ Subsurface Sewage Disposals System Form - Not for Voluntary Assessments r� 703 MIDDLET©N ROAD Property Address SCOTT LOYALL Owner Ownees Name information is required for every NORTH ANDOVER MIA 01845 _ 6118113 page. Ciiyfrvwn state Zip Code Date of inspection C. Check -list 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 W/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: ❑ N Existing information. For example, a plan at the Board of Health, Z ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) 1310 CMR 15.302(5)) D. System Information Residential Flow Conditions - Number of bedrooms9 desi n : NA 4 ( )- Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): NA t5ms • 11110 Title 5 Ofirciel trtsaec tion Form. Subsurface Seweoe Oisoosel Svstem • Pace 6 of 17 Commonwealth of Massachusetts Title ciao Inspection Farm Subsurface Sewage Disposal System Form - Not for Voluntary Assessments - f< ' 703 MIDDLETON ROAD Property Address SCOTT LOYALL owner ownefs Name information is required for every NORTH ANDOVER MA 01845 6/18/13 page. C4/Tom state Zip Code Date of tnspeetion D. System Information Description: Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required) :Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Detait Sump pump? Last date of occupancy: CommerciaYindustrial=Flow Conditions: Type of Establishment: Design flow (based on Basis of design flow Grease trap present? 15.203): Industrial waste holding tank present? Non -sanitary waste discharged to Water meter readings, if per day (gpd) , etc_): 1 ❑ Yes ® No ❑ Yes ® No 'VVY0 Yes ❑ No ❑ Yes ® No WELL 0 Yes ❑ No CURRENT Date ❑ Yes ❑ No or ❑ Yes ❑ No 5 system? ❑ Yes ❑ No t5ins • 11110 Fine 5 of cta4 PWPectlon Fora[ SUDSWace Sewage ©isPosat System - Page 7 of 17 Commonwealth of Massachusetts z title 5 Official Inspection Form Subsurface Sewage Disposal System Form -riot for Voluntary Assessments .N 5 703 MIDDLETON ROAD Property Address SCOTT LOYALL Owner Owner's Name information is NORTH ANDOVER required for every page. Cityrrown D. System Information (cont.) Last date of occupancy/use: Other (describe below): nse State 01845 Zip Code Date Information Pumping Records: Source of information: LPD 8/15/07 Was system pumped as part of the inspection? If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool 6/'18/'13 Date of trispecfion ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Altemative 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): 15ins • 11110 Tide 5 Official WPectm forth Subsurface Sewage Disposal System . Page 8 of 17 commonwealth of Massachuseft _- Title 5 Oficial Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 703 M€DDLETON ROAD Property Address SCOTT LOYALL Owner Owner's Name information is NORTH ANDOVER MA 09845 6118193 required for every page Cityfravun State Zip Code Date of Inspection D. System 1n€OrmaflOn (W1tt-) Approximate age of all components, date installed (if known) and source of information: HOUSE BELIEVED TO BE BUILT IN 1960 _. Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: Material of construction: ® cast iron 0 40 PVC ❑ other (explain): Distance from private water supply well or suction line: ❑ Yes ® No 15" feet M feet Comments (on condition of joints, venting, evidence of leakage, etc.): PLUMBING IS IN GOOD CONDITION Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal If tank is metal, list age: Q fiberglass 12" feet ❑ polyethylene ❑ other (explain) years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 5'X& 1000 GALLON Sludge depth: 3" - 6" t5ins - 11/10 TM-_ 5 €1SSciat htsoection Farm; SUbmfam Sewaae Disposal Svstem • Paae 9 of 17 Commonwealth of Massachusetts _ Tine 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 703 MIDDLETON ROAD rropeRy Haaress SCOTT LOYALL Owner Owner's Name information is NORTH ANDOVER required for every page. City/Town D. System Information (cont.) MA 01845 6/18/13 State Zip Code Date of Inspection Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? NA 0 NA NA SLUDGE JUDGE Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc_): TANK DOES NOT NEED PUMPING AT THIS TIME. INLET BAFFLE IN PLACE. LIQUID LEVEL CORRECT, OUTLET BAFFLE REPLACED WITH PVC TEE. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass 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: 15ins . 11/10 feet ❑ polyethylene ❑ other (explain): Date Title 5 Official Insneotion Form: Subsurface Sewaae oisoosal Svstem • Paae 10 of 17 Commonwealth of Massachusetts viTit e 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments l703MIDDLETON ROAD Property Address SCOTT LOYALL Owner Owner's Name information is NORTH ANDOVER required far every page_ City/Town MA 01,845 6/18/13 State Zip Code Date of inspection D. System Information (cont.) Comments (on pumping recommendations, Inlet and liquid levels as related to outlet Invert, evidence of le tee or baffle condition, structural integrity, etc.). Tight or Holding Tarok (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass Dimensions: Capacity: Design Flow: Alarm present Alarm level: Date of last pumping: Comments (condition of alagq and float gallons polyethylene ❑ other (explain): gallons per day ❑ Yes [_J No Alarm in working order: ❑ Yes ❑ No " Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins - 11110 I Me 5 offidW irtspection Form: Subsurface Sewage Disposal System . Page 11 of 17 Owner information is required for every page. toms - 11!10 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 703 MIDDLETON ROAD r —Fvfly nlN{G�b SCOTT LOYALL Owner's Name NORTH ANDOVER Cityfrown D. System Information (cont.) MA 01845 State Zip Code Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 6/18/13 Date of Inspection 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.): LIQUID LEVEL CORRECT, NO EVIDENCE OF CARRYOVER. BOX WAS REPLACED WITH NEW H2O CONCRETE DISTRIBUTION BOX, BOX 11" BELOW GRADE. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Title 5 Official fnscection Form: subsurtace sewace Dlslosal Svstem - Pace 12 of 17 Commonvream of Massarhuse s Ora tie 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments kv-_ Is wi-A nntnnt t- rrIN ROAD property eaooress SCOTT LOYALL Owner Owner's Name information is NORTH ANDOVER required for every page City/ Town D. System Information (cont-) MA State 01845 +6/18113 Zip Code Hate of inspection Type: ❑ leaching pits number. ❑ leaching chambers number: ❑ leaching galleries number. ❑ leaching trenches number, length: ® leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system 11 25' X 45' Type/name of technology: - Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp_ soil, condition of vegetation, etc.): SOILS DRY. NO SIGN OF HYDRAULIC FAILURE, VEGITATION NORMAL. USED CAMERA AND LOCATOR TO DETERMINE LENGTH, WIDTH, ARID DEPTH_ Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth -top of liquid to i Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of constructioi Indication of groundwater inflow t5ins • 11!10 ❑ Yes ❑ No Title S of ttoal k�Tec on Form: subsurface Sewage Disposal System • Page 13 or 17 owner information is required far every page. G®rn am eat of Massachusetts Ti t o officialInspectionForm meas Subsurface Sewage MSPOSal System Foy -Not for Voluntary Asses 703 M1D1?t.ETO1'R RT D Property Address SCOT LOYALL owner's Name NORTH AND©VER MA 64- TO" State D. System Information (cont-) Comments (note condition of soil, signs of hydraulic etc.): privy (locate on site pian): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of etc.): 01845 6/18/13 Zip Code Rate of inspection of ponding, condition of vegetation, failure, level of ponding, condition of vegetation, Title 5 O C1W lnspeaion Form. Subsurface Seg _te Disposak System - Page 1 a of 17 5ns - 11110 com Monweafth of Massachusetts Title 5 Official Inspection Form Subsurftce SewageI)Isposal System Form - Not for Voluntary Assessments 703 MIDDLE rm ROAD Property address SCOTT LOYALL Owner Owners Name information is NORTH ANDOVER... MA 01846 6118/13 required for every state Zip Code Date of Inspection Page - D. D. SystBm InfOrnatiOn (cGnO 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 attached separately M11 Tc) 57�Ae-,rn /0 7 Owner information is required for every page. Commonwealth of Massachusetts Title .5 Official Inspection Form Subsurface Sevrage Disposal System Foran - Not for Voluntary Assessments 703 MIDDLETON ROAD Property Address SCOTT LOYALL Owner's dame NORTH ANDOVER citytrown D. System Information {conk} Site Exam: ❑ Check Slope ❑ Surface water (� Check cellar ❑ Shallow wells Estimated depth to high ground water: MA 01845 6/18/93 Slate Zip Cade Date of Inspection Chi test Please indicate all methods used to determine the high ground water elevation-- obtained levation_ Obtained from system design plans on record if checked, date of design plan reviewed: tate ❑ Observed site (abutting property/observation hole within 150 feet of SAS) D 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. THE HOUSE HAS A SUMP PULP WHICH IS APPROX 6` BELOW GRADE_ THE HOUSE HAS A LEACH FIELD WHICH IS APPROX 7 BELOW GRADE_ THEREFORE THERE IS A SEPERATION BETWEEN BOTTOM OF SYSTEM AND HIGH GROUND WATER. Before filing this inspection Report, please see Report Completeness Checklist on next page. TfUe 5 ofioal insoe€ UGn Fam Substdace Sewage rhsoosal system - Page 16 of'? t5ins • 11/10 Commonwealth of Massachusetts Title 5 Officialinspection Form Subsaeiace Se�nrage Ctisp©saI system Fo m - Not for Voluntary Assessments m 703 MIDDLETON ROAD Property Address SCOTT LOYAt_t- Owner Owners Name information is NORTH ANDOVER MA 41845 6/18/13 required for every Cityl6own State Zip Code Date of inspection page. E. Report Completeness Checklist j� inspection Summary: A, 8, 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 Title 5 official ft1pearon Fenn: Subs ftm Sewage DtSIMal System' Page 17 of 17 t5ins • 11110 Ot HOFTM 1y h 9 SACMUSt CHECK #: LOCATIO H/O NAN CONTRA( 6529 Town of North Andover HEALTH DEPARTMENT 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 Sustems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ Title 5 Report $� ❑ Other. (Indicate) $ (6 Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer I Commonwealth of Massachusetts RECEIVED v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessme its JUN 2 6 2013 703 MIDDLETON ROAD TOWN OF NORTANDOVER , Property Address SCOTT LOYALL Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 6/18/13 page. City/rown State Zip Code Date of Inspe 'on Inspection results must be submitted on this form. Inspection forms may not be alteredl a way. Please see completeness checklist at the end of the form. Important: When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor -do not JAMES H CURRIER II use the return key. Name of Inspector J'S SEPTIC & DRAIN 3� Company Name 131 FOREST ST Company Address MIDDLETON MA 01949 City/ rown State Zip Code 978-774-6685 S12327 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15:340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 6/20/13 Iffspectors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board., of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins - 11/10 Title 5 Official Insoection Form: Subsurface Sewaae Disoosal Svstem - Paae 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 703 MIDDLETON ROAD Property Address SCOTT LOYALL Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 6/18/13 page. Cityfrown 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 703 MIDDLETON ROAD Property Address SCOTT LOYALL Owner's Name NORTH ANDOVER City/Town B. Certification (cont.) B) System Conditionally Passes (cont.): MA 01845 6/18/13 State Zip Code Date of Inspection ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): THE D BOX HAS DETIORATED AND NEEDS TO BE REPLACED, ALSO THE OUTLET BAFFLE NEEDS REPLACING. ❑ 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): ❑ obsbuQtion is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluatio s Required by the Board of Health: ❑ Conditions exist hich require further evaluation by the Board of Health in order to determine if the system is faZi in 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 - 11/10 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 703 MIDDLETON ROAD Property Address SCOTT LOYALL Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 6/18/13 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, provls(ed 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 ❑ 1:10 Liquid depth in cesspool is less than 6" below invert or available volume is less than % day flow t5ins - 11/10 Tithe 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 5a''r 703 MIDDLETON ROAD Property Address SCOTT LOYALL Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 6/18/13 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. ❑ E] kA Any portion of cesspool or privy is within 100 feet of a surface water supply or 1'` tributary to a surface water supply. ❑ ❑o Any portion of a cesspool or privy is within a Zone 1 of a public well. El ❑\"�` 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 w in 400 feet a surface drinking water supply ❑ ❑ the system is within 2 et of a tributary to a surface drinking water supply ❑ ❑ the system is locate n a nitr n sensitive area (Interim Wellhead Protection Area — IWPA) or a apped Zone I 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 • 11/10 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 703 MIDDLETON ROAD Property Address SCOTT LOYALL Owner Owner's Name information is NORTH ANDOVER MA required for every page. City/Town State C. Checklist 01845 6/18/13 Zip Code Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out 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): NA Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): NA t5ins - 11/10 Title 5 Official Insoection Form: Subsurface Sewaae Disoosal Svstem - Paae 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 703 MIDDLETON ROAD Property Address SCOTT LOYALL Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 6/18/13 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required] Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 31 Q MR 15.203): Basis of design flow (seats/perso sq. etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to t itle 5 system? Water meter readings, if available _---- - per day (gpd) 1 ❑ Yes ® No ❑ Yes ® No vkh❑ Yes ❑ No ❑ Yes ® No WELL ® Yes ❑ No CURRENT Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins - 11/10 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 s 703 MIDDLETON ROAD Property Address SCOTT LOYALL Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 6/18/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Date LPD 8/15/07 ❑ Yes ® No gallons 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 - 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 703 MIDDLETON ROAD 01845 6/18/13 Zip Code Date of Inspection Approximate age of all components, date installed (if known) and source of information: HOUSE BELIEVED TO BE BUILT IN 1960 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 15"feet Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: 26 feet Comments (on condition of joints, venting, evidence of leakage, etc.): PLUMBING IS IN GOOD CONDITION Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 12" feet ❑ 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: 5'X8' 1000 GALLON 3-1-6" Sludge depth: t5ins - 11110 Title 5 Official Insoection Form: Subsurface Sewaae DisDosal Svstem • Paae 9 of 17 Property Address SCOTT LOYALL Owner Owner's Name information is required for every NORTH ANDOVER MA page. Citylrown State D. System Information (cont.) 01845 6/18/13 Zip Code Date of Inspection Approximate age of all components, date installed (if known) and source of information: HOUSE BELIEVED TO BE BUILT IN 1960 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 15"feet Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: 26 feet Comments (on condition of joints, venting, evidence of leakage, etc.): PLUMBING IS IN GOOD CONDITION Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 12" feet ❑ 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: 5'X8' 1000 GALLON 3-1-6" Sludge depth: t5ins - 11110 Title 5 Official Insoection Form: Subsurface Sewaae DisDosal Svstem • Paae 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 703 MIDDLETON ROAD Property Address SCOTT LOYALL Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 6/18/13 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 NA Scum thickness 0 Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA t5ins • 11/10 How were dimensions determined? SLUDGE JUDGE Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): TANK DOES NOT NEED PUMPING AT THIS TIME. INLET BAFFLE IN PLACE, OUTLET NEEDS PVC TEE INSTALLED, LIQUID LEVEL CORRECT Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ Dimensions: Scum thickness Distance from top of scu740 top of outlet tee or baffle\ Distance from bottom of (scum to bottom of outlet tee or baffle Date of last pumping: Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 feet ❑ polyethylene ❑ other (explain): Commonwealth of Massachusetts a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 703 MIDDLETON ROAD Property Address SCOTT LOYALL Owner Owners Name information is required for every NORTH ANDOVER MA 01845 6/18/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and OUtlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of I age, 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: Design Flow: Alarm present: Alarm level: gallons gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins - 11/10 Title 5 Oficial 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 703 MIDDLETON ROAD Property Address SCOTT LOYALL Owner Owner's Name information is NORTH ANDOVER required for every page. City[Town D. System Information (cont.) MA 01845 6/18/13 State Zip Code Date of Inspection 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.): THE BOX NEEDS TO BE REPLACED, LIQUID LEVEL CORRECT, NO EVIDENCE OF CARRY OVER. BOX IS 14" BELOW GRADE. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order\oump El Yes ❑ No Comments (note conditichamber, con ' ion of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 11/10 Title 5 Official Inspection Gone: 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 703 MIDDLETON ROAD Property Address SCOTT LOYALL Owner Owner's Name information is NORTH ANDOVER required for every page. City/Town D. System Information (cont.) leaching pits leaching chambers leaching galleries leaching trenches leaching fields overflow cesspool innovative/alternative system State 01845 Zip Code number: number: number: 6/18/13 Date of Inspection number, length: number, dimensions: number: 1)25'X45' Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp, soil, condition of vegetation, etc.): SOILS DRY. NO SIGN OF HYDRAULIC FAILURE, VEGITATION NORMAL, USED CAMERA AND LOCATOR TO DETERMINE LENGTH, WIDTH. AND DEPTH. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration / Depth — top of liquid to i Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow t5ins • 11/10 ❑ Yes ❑ No 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 703 MIDDLETON ROAD Property Address SCOTT LOYALL Owner Owner's Name information is NORTH ANDOVER MA required for every page. Cityrrown State D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failt etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of etc.): 01845 6/18/13 Zip Code Date of Inspection of ponding, condition of vegetation, failure, level of ponding, condition of vegetation, t5ins - 11/10 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 M 703 MIDDLETOh ROAD Property Address SCOTT LOYALL Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 6/18/13 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. Nhand-sketch in the area below fat.°tg' attached separately firms.3m , I Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 703 MIDDLETON ROAD Property Address SCOTT LOYALL Owner's Name NORTH ANDOVER Citylrown D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: MA 01845 6/18/13 State Zip Code Date of Inspection feet Please indicate all methods used to determine the high ground water elevation: ❑■ u 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: THE HOUSE HAS A SUMP PUMP WHICH IS APPROX 6' BELOW GRADE. THE HOUSE HAS A LEACH FIELD WHICH IS APPROX Z BELOW GRADE. THEREFORE THERE IS A SEPERATION BETWEEN BOTTOM OF SYSTEM AND HIGH GROUND WATER. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins - 11/10 Title 5 Official Insoection Fonn: Subsurface Sewaae Disposal Svstem - Paae 16 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 703 MIDDLETON ROAD Property Address SCOTT LOYALL Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 page. CityrFown State Zip Code E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked 6/18/13 Date of Inspection ® 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 - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 OF NORTH qti p CO SSACH11s� PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 8/21/2013 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Repair of Outlet Baffle and D -Box By: James Currier At: 703 Middleton Street Map 109.0 Lot 0043 North Andover, MA 01845 3ic / 'suance of thisc�tificat sha 1 not be construed as a guarantee that the system will function satisfactorily. hble Grant Public Health Agent 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com r� r North Andover Health Department (ommunity Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 703 Middleton St. MAP: 109.0 LOT: 0043 INSTALLER: James Currier DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS OUTLET BAFFLE & D -BOX: 8/21/13 TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS Comments: SEPTIC TANK ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered ❑ 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: 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 EF Inlet tee (if pumped or >0.08'/foot) Hydraulic cement around inlet & outlets Observed even distribution Speed levelers provided (not required) Comments: ........................................................................................................................................................................... 703 MIDDLETON STREET Reference No: BHJ-2013-000062 ................................... Department: Permit No: BHP-2013-0862 ................................... North Andover BOARD OF HEALTH ......................................................................................... Fee Type: Account No: 1001001.1.5.0510.00 ....................... DWC-Component Repair PERMIT ......................................................................................... Receipt No: REC-2014-000191 Paid By: LOYALL, SCOTT J E SUE LOYALL Paid in Full On: ................................ Thu Aug 15,2013 .................................... ......................................................................................... Received By: Check No: 3224 Lisa Blackburn ......................................................................................... DEPARTMENT'S COPY Amount: $125.00 L .............................................................................................................................................. .......... ...... " ........................ • 4tn: , Commonwealth of Massachusetts Map -Block -Lot r �-^. • 109.00043 ----------------------w BOARD OF HEALTH North Andover �' CERTIF C TE OF COMPAA THIS IS TO CERTIF ,That the I dividual Sewage Disposct) by J _--- es Lu >er ------------ ---------------------- ------------------------- ----------------------- \�Lj ----------------------------------------- staller at No 703 MIDDLETON STREET ------------------------------------------------------------------------------------------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. BHP -2013-086 Dated August 15, 2013 ----------------------- --- AV- ----- ---------------------------------------------- Printed On: Aug -15-2013 BOARD OF HEALTH • �w ' W-1- Commonwealth of Massachusetts Map -Block -Lot ,, sw• 109.00043 r� BOARD OF HEALTH ----------------------- --------- Permit No North Andover BHP -2013-0862 ------------ - ------- o „«.» �• FEE rsBA$125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted James -Currer --------i-------------------------------------------------------------------------------------------- to (Construct) an Individual Sewage Disposal System.„ BU1 �- �aTl at No 703 MIDDLETON STREET F I LE-------------------------------------- -----------------------------J-COPY as shown on the application for Disposal Works Construction Permit No. BHP -2013-086 Dated August -1-5,-2-0-1-3 ------------ - ------------------------------------------- Issued On: Aug -15-2013 BOARD OF HEALTH 57 Application for Septic Disposal System Yae ,a 71a AConstruction Permit -TOWN OF Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return keys�----�� VIXA! VER. MA Application is hereby made for a permit to: ❑ Construct a new on-site sewage disposal system* TODAY'S DATE $ 250.00 — Full Repair $125.00 - Component Vepair or replace an existing on-site sewage disposal system* pair or replace an existing system component — What? 1/-oy A. Facility Information 2 ®3 Address or Lot # V17 44 4V41- City/Town 2.- *TYPE 017,89PTIC SYSTEM*: Zp QGravity (choose one) pump system, attach copy of electrical permit to application***entional 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) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D -Box Present) S.A.S. 2. Owner Information Name � Address (if different from above) City/Town 3. Installer Information State Telephone Number Zip Code a --e- z s 9e_P ";L_ t 0^ Name Name of Company 13 1 Address City/Town State Zip Code t�ke97,f 127 61 cl '5_ `(Telephone Number (Cell Phone # if possible please) 4. Designer Information 9?P'Lie Z3 &f& j Name Address City/Town Name of Company State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 r °RrM Application for Septic Disposal Svstem TODAY'S DATE - Construction Permit -TOWN OF NORTH ANDOVER, MA 01845 $ 250.00 - Full Repair $125.00 - Component PAGE 2 OF 2 A. Facility Informationcontinued.... 5. Type of Building:Residential 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 Andover, and not to place the system in operation until a Certificate of Compliance has been " ed by this Bo d of Health. N e Date Applicatio pproved B (Board of Health Representativ ) / ell Nam Date pplication Dis pproved for the following reasons: For Office Use Only: 1. Fee Attached. 2. Project Manager Obligation Form Attached. 3. Pump Svstem? If so, Attach copy of Electlical Permit 4. Foundation As -Built? (new construction ronly): (Same scale as approved plan) 5. Floor Plans? (new construction only): Yes No Yes No Yes No Yes No Yes No Application for Disposal System Construction Permit • Page 2 of 2 SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer f r the construction for the septic system for the property at: IV (Address of septic system) For plans by Relative to the application of elks L ) U ``-Q, (Installer's name) Dated - I (o a = s ate) And dated With revisions dated I understand the following obligations for management of this project: (Engineer) (Original ate (Last revised date) 1. As the installer, I am obligated to obtain all permits and Board of Health approved plans pjior 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 reauesting 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 company. a. Bottom of Bed — Generally, this is the first (V5 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(c�7�,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. s the installer, I understand that only I may perform the work (other than simple excavation) and I am required tc 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 sustiension of my license to operate in the Town of North Andover, significant 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. As the installer; I understand that I am solely responsible for the installation of the system as per the appr�plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Undersigned Licensed Septic Installer: �-� S N ame — Print (Today's Date) ?I l '5l L Commonwealth of Massachusetts City/Town of NORTH ANDOVER, MASSACHUSETT System -Pumping Record Form 4 N v DEP has provided this form for use by local Boards of Health. The System Pu be submitted to the local Board of Health or other approving authority. A. Facility Information mportant: NOV 0 2 200 When filling out 1. System Location: ? forms on the �Q computer, use C o� V� �" TOI,,aJN C:' INCTH AND only the tab key Address [__t EA H to move your if C!"� cursor - do not lry — use the return City/Town State Z key. 2. System Owner: rab _+� a y' ct(( S C -o f� — Name iemm Address (if different from location) City/Town State Z _� Telephone Number B. Pumping Record (�(/ 1. Date of Pumping pate C5 © � 2. Quantity Pumped: 3. Type of system: ElCesspool(s) Septic Tank El Tight Ta ❑ Other (describe): 4. Effluent Tee Filter present? E] Yes No If yes, was it cleaned? El5. Condition of System: &c) ed 6. System Pumped B r'0 s: H Name Vehicle License Number Company S m ping Record must 7 OVER L 7. Location where contents were disposed: Signature -of Hauler Date f r http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect /0 /of --D t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 N I- _ t-(,� ip Code ip Code s D allo ns nk Yes ❑ No 7. Location where contents were disposed: Signature -of Hauler Date f r http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect /0 /of --D t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetss MassachusettskECEIV System Pumping Record SFEP 13 System Owner Type: Emergency Routine Cesspool: No Yes / Date of Pumping: 5-6,c— System Pumped By: Wind River Environmental, LLC Contents transferred to: Contents Disposed at: mLoc�tionHEr�L' U -"r Form 4 -- System Pumping Record Septic tank: W Yes Quantity Pumped: /&® Gallons Permit #: Date: 6 Pumper Signature: rUw' Condition of System/Other Comments r Dep Approved Form - 12/07/95 C Form 4 -- System Pumping Record Commonweakh of Massadwsetss MassachusettsRECEIN (stem Puma�RecordPuma�Record I SEP 13 n Owner ee. VI''11' L .. ".•1 tj? U r. 2 Type: Emergency Routine Cesspool: No / Yes Date of Pumping: System Pumped By: Wind River Enwrw neenta/, LLC Contents transferred to: Contents Disposed at: 1 / 1 Date: c'3 ►S C�+j Pumper Signature: 1Zw'\ Condition of Systen✓Other CommaMs m LocationHEAILT Uc`:'N 7 r l ei:y.ti r j ,.t Dep Approved Form - 12/07/95 Septic tank: No =Yes 0 Quantity Pumped: I&j© "Ions permit #: C Commonwealth of Mossachusetss : Massachusetts System Pumping Record System owner L : i LO'YA!.L tk' 111 .HN2. ,(LP . r 01,j i.i• r,, :1 #7E -f 7Z ,1, Location Ott � s ;111 Lr iC" 1 Pi 7 Foran 4 -- Sys m Pumping Record 7 2001 ::JF'M ANi UVE. tt', I l J 4 6. .q. h3..- X 4 5 Type: Emergency � Routine Cesspool: No Yes Date of Pumping: Aja- ?—j - d 1 System Pumped By: Wind River Environmental, LLC Contents transferred to: Contents Disposed at: Date: of System/Other Comments Pumper signature: Dep Approved From - 12/07/95 Septic tank: IVo r7Yes Ef Quantity Pumped: 1500 Gallons Permit #: FORM 4 - SYSTEM PUMPING RECORD CURRIER SEPTIC & DRAIN SERVICE 107 FOREST STREET; MIDDLETON, MA 01949 (978) 774-2772 COMMONWEALTH OF MASSACHUSETTS / %�� s , MASSACHUSETTS SYSTEM PUMPING RECORD SYSTEM OWNER: SYSTEM LOCATION: Ce7^ Z) DATE OF PUMPING:' �U %QUANTITY PUMPED:y �� GALLONS CESSPOOL: NO YES 0 SEPTIC TANK: NO 0 YES JZ SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE CONTENTS TRANSFERRED TO: C(�// DATE: - INSPECTOR: 114 OF 1 � r � 1 1999