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HomeMy WebLinkAboutMiscellaneous - 72 SAW MILL ROAD 4/30/2018 (2)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. _Q S Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Saw Mill Road Property Address Doree Scarmoutzos Owner's Name North Andover City/Town MA 01845 State Zip Code ECEI D APR 29 20113 TOWN OF NORTH ANDOVER HEALTH PARTMF:NT 4/23/2013 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: Neil J. Bateson Name of Inspector Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover City/Town 978-475-4786 Telephone Number B. Certification MA State SI 15 License Number 01810 Zip Code 5 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 ❑ Nee Mrtherf-valuation by the Local Approving Authority (� 4/23/2013 Inspe or' 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. t5ins • 3/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Saw Mill Road Property Address Doree Scarmoutzos Owner's Name North Andover MA 01845 4/23/2013 City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with. a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ® N ❑ ND (Explain below): Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Saw Mill Road Property Address Doree Scarmoutzos Owner - information is required for every page. uwners Name North Andover MA 01845 4/23/2013 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ 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 system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 3 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 72 Saw Mill Road Property Address Doree Scarmoutzos Owner's Name North Andover MA 01845 4/23/2013 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for 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: Outlet tee in septic tank & d -box with riser. D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than % day flow t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 72 Saw Mill Road Property Address Doree Scarmoutzos Owner Owner's Name information is North Andover required for MA 01845 4/23/2013 every 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: F-1® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sew Disposal posal System •Pape 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments rt 72 Saw Mill Road Owner information is required for every page. t-ropeny AaareSS Doree Scarmoutzos Uwners Name North Andover MA 01845 4/23/2013 Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) Z ❑ 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 bedroomsn desi : 4 ( 9) Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): A t5ins • 3/13 Title 5 Official inspection Forth: Subsurface Sewage Disposal System •Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 72 Saw Mill Road Property Address Doree Scarmoutzos Owner Owner's Name information is required North Andover MA 01845 every page. City/Town State Zip Code D. System Information Description: Number of current residents: 4/23/2013 Date of Inspection Does residence have a garbage grinder? Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) 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 15.203): Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: 4 ❑ Yes ® No ❑ Yes ® No ❑ Yes ❑ No ❑ Yes ® No Yes ❑ Yes ® No Current Date Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 3113 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 t " 72 Saw Mill Road Property Address Doree Scarmoutzos Owner information is required for every page. Uwner's Name North Andover MA 01845 4/23/2013 Cityrrown 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: Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: _Pumped August 2011 1500 gallons Measured tank. Inspect tankk & tees. ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ® Yes ❑ No ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' 72 Saw Mill Road Property Address Doree Scarmoutzos Owner information is required for every page. owners Name North Andover MA 01845 4/23/2013 Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 30 years old, 11/14/1983, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 2 feet Material of construction: ® cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" cast iron through wall to septic tank. 3" PVC in house, no leaks visible Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal ❑ fiberglass 1 feet ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 10'x 5'x 4' Sludge depth: t5ins - 3113 4" ❑ Yes ❑ No Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 t5ins - 3/13 Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts -k Title 5 Official Inspection Form rl Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Saw Mill Road Property Address Doree Scarmoutzos Owner information is required for every page. Owner's Name North Andover MA 01845 4/23/2013 City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle N/A Scum thickness 4" Distance from top of scum to top of outlet tee or baffle N/A=Outlet tee has hole at liquid level Distance from bottom of scum to bottom of outlet tee or baffle N/A How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumped septic tank. Inlet tee ok. Inlet baffle ok. Outlet tee has corrosion hole, needs to be replaced. Depth of liquid at outlet invert. No evidence of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal El fiberglass ❑ polyethylene El other (explain): t5ins - 3/13 Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M " 72 Saw Mill Road Owner information is required for every page. t5ins • 3/13 Property Address Doree Scarmoutzos Owner's Name North Andover City/Town MA 01845 4/23/2013 State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Owner information is required for every page. t5ins • 3113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Saw Mill Road Property Address Doree Scarmoutzos Owner's Name North Andover Cityrrown 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 L 4/23/2013 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.): D -box level & distribution not equal, two lines lower. D -box has corrosion hpoles, needs to be replaced. Evidence of leakage. Evidence of carryover, pumped d -box to clean Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetaion ok. No sign of ponding to surface Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments "t 72 Saw Mill Road Property Address Doree Scarmoutzos Owner Owner's Name information is required for North Andover MA 01845 4/23/2013 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1 field 30'x 50' ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetaion ok. No sign of ponding to surface Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 . � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r< 72 Saw Mill Road Owner information is required for every page. rroperty Aadress Doree Scarmoutzos Owner's Name North Andover MA 01845 4/23/2013 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 • 3/13 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 14 of 17 Owner information is required for every page. t5ins • 3113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Saw Mill Road Property Address Doree Scarmoutzos Uwners Name North Andover MA 01845 4/23/2013 Cityfrown 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 r Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �•'r 72 Saw Mill Road Property Address Doree Scarmoutzos Owner Owner's Name information is required for North Andover MA 01845 4/23/2013 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope Z Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: >4feet 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: 5/25/1983 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Design plan ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Test pit data on design plan shows water at 7' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 72 Saw Mill Road Owner information is required for every page. t5ins • 3113 Property Address Doree Scarmoutzos Owners Name North Andover Cityrrown MA 01845 4/23/2013 State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked Z 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 Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 Class Zoning2 Size Total FY 101 Single Family 1 Residential 1 Acres 2013 Town .of North Andover Tax Map # 210-104.A-0085-0000.0 Parcel Id 16312 72 SAW MILL ROAD DOREE SCARMOUTZOS 72 SAWMILL ROAD NORTH ANDOVER, MA 01845 UB Mailina Index Namelkdress Type DOREE SCARMOUTZOS Owner 72 SAW MILL ROAD NORTH ANDOVER, MA 01845 DOREE ROUND Payor 72 SAWMILL ROAD NORTH ANDOVER, MA 01845 UB Account Maint. Accou'nYNo Cycle Bldg Id. 18140.0 - 72 SAW MILL ROAD 3180168 03 Cycle 03 UB Services Maint. Account No: 3180168 Property Type Zoning3 Loan Number Active/Inact. From Inactive Occupant Name Last Billing.Date 4/10/2013 Service Code Rate MISCFEE ADMIN FEE 0.635/8 WTR WATER 01 ALL METER SIZE UB_Meter Maintenance Account. No. 3180168 Type Size YTD Serial No Status w Water 0.63 0.63 Location .18736633 a Active Posted Date 00 Date Reading Code 3/26/2013 845 , a Actual 12/13%2012 830 a.Actual 9/19/2012 817 a Actual 6/18/2012 800 a Actual 3/20/2612 785 a Actual 12/19/2011.: 770 a Actual 9/16/2011 754 a Actual 6/13/2011 738 a Actual 3/15/2011 723 a Actual 12/15/2010 706 a Actual 9/16/2010 687 a Actual 6/14/2010 530 a Actual 3/18/2010 506 a Actual 12/14/2009 494 a Actual 9/16/2009 481 a Actual 6/10/2009 .465 a Actual 3/18/2009 452 a Actual 12/15/2008 442 a Actual 9/15/2008 428 a Actual 6/10/2008 394 a Actual 3/14/2008 377 a Actual 12/17/2007 367 a Actual 9/14/2007 343 a Actual 6/21/2007 292 a Actual 3/16/2007 278 a Actual 12/13/2006 268 a Actual 1/301/2006 . Active/Inactive Active Charge Multiplier/Users 7.82 1 / 57.00 /1 1 .Residential 1 Residential Until Brand Type Size YTD METE METE w Water 0.63 0.63 .Cons 468 Consumption Posted Date Variance 15 4/22/2013 1 13. 1/9/2013 -16% 17 10/15/2012 10% 15 7/16/2012 26/6 15 4/14/2012 -4% 16 1/17/2012 1 % . 16 10/13/2011 1 % 15 7/20/2011 -12% 17 4/13/2011 -11% 19 1/12/2011 m87%, 157 10/15/2010 512% 24 7/15/2010 114% 12 4/14/201:0 -13% 13 1/12/2010 11% 16 10/15/2009 5% 13 .7/20/2009 44% 10 4/29/2009 -30% 14 1/20/2009 -56% 34 10/10/2008 81% 17 7/16/2008 70% 10 4/11/2008 X55% 24 1/22/200 -57% 51 10/12/2007 316% 14 7/20/2007 34% 10 4/16/2007 2%. 9 1/10/2007 -52% Commonwealth of Massachusetts up City/Town of System Pumping Record Form 4 DEP has provided this form for us&by local Boards of Health. Other forms may be used, but the Information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left/ Right front of house,a / Right MOM'Left / right side of house, Left / Right side of building, Left / Right front of building, Left / Right rear of building, Under deck AUTO= K) �A P4A K)ONA& A4� City/Town ` state 2. System Owner. Name Zip Code Address (if different from location) Citytrown state Zip Code B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): Telephone Number pate 2. Quantity Pumped: Cesspool(s) eptic Tank `S --d4-1 Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yee O If yes, was it cleaned? (] Yes ❑ No 5. Condition of System: 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc, Company 7. Location where contents were disposed: t5form4.doc• 06/03 F5821 Vehicle License Number Data System Pumping Record • Page 1 of 1 Jos- rrrFn, Commonwealth of Massachusetts Map -Block -Lot BOARD OF HEALTH --------------------- Permit No North Andover BHP -2013-0816 ----------------------- FEE $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd Bateson - ------------------------------------------------------- to (Repair) an Individual Sewage Disposal System. at No 72 SAW MILL ROAD as shown on the application for Disposal Works Construction Permit No. BHP-2013-00 I'COP ate L— ------------------ ssue On: Jul -18-2013 ----------------------------------------------------------------- TV) nur) nF user Tu %+ L Application for Septic Disposal Svstem '7� t3 'S Construction Permit - TOWN OF TODAYDATE NORTH ANDOVER, MA 01845 $;25.00 — Full Repair Component Important: Application is hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on the computer, use ❑ Repa' or replace an existing on-site sewage disposal system* only the tab key epair to move your or replace an existing system component — What? i-t,��•� T T� �-� cursor - do not use the return A. Facility Information key. Address or Lot # V 9;1j roG (( � Cityrrown -P , JUL 8 2013 2.- *TYPEF T *• O SEPI SYSTEM . TOWN OF NORTH ANDOVER ➢ ❑ Pump Egaravity (choose one) IHEALTH DEPARTMENT ***If puM)Lsy4Wm, attach copy of electrical permit to application*** ➢ L%ff, Conventional System (pipe and stone system) ➢ ❑ Infiltrator or Biddiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system.) ➢ ❑ Pressure Distribution S.A.S. (No D -Box) ➢ ❑ Pressure Dosed (D -Box Present) S.A.S. ➢ ❑ Does the system require an effluent filter? Yes No If yes, does plan specify make and model of filter? YES = (no further info. needed) NO = (installer must specify brand of filter before DWC issuance) What is the Make? What is the Model. 2. Owner Information Name Address (if different from above) City/Town State Zip Code Telephone Number 3. Installer Information Name Name ofC mpany ILLA ROAD C/f f - Address / I OWn A64CI r City/Town State Zip Code rS— A, -U :3 Telephone Number (Cell Phone # if possible please) 4. Designer Information Name Name of Company Address City/Town State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 Application for Septic Disposal System Construction Permit - TOWN OF NORTH ANDOVER, MA 01845 PAGE 2OF2 A. Facility Information continued. 5. Type of Building: B eesidential Dwelling or ❑Commercial B. Agreement '7-1 "7—I TODAY'S DATE $ 250.00 - Full Repair $125.00 - Component 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. I understand that until a final Certificate of Compliance has been issued by this Board of ea/th, the installed system is not approved. 4 '7- °�- Name Date Application Approv : (Board of Health Representative) J Name Date Application Disapprove r the following reasons: For Office Use Only; L Fee Attached. Yes No 2. Project Manager Obligation Form AttachedP Yes No J. Pump System? If so. Attach copy of Electrical Permit Yes_ No 4. Reviewed approvalletter, all paperwork received. Yes No Missing:' 5. Foundation As -Built. (new construction only): Yes_ No (Same scale as approved plan) 6. Floor Plans? (new construction only): Yes No Application for Disposal System Construction Permit • Page 2 of 2 SEP"�'IC SYSTEM. INS ALS E 'PROJE MANAgMENT-OOBLIGATIONS As the North Andover licensed installer for the construction f¢r!the septic systenn­fot.the property at: r7a•- S��w1 �ll �• . For plans by (Address of septic system) (Engineer) Relative to tht.application of !�` 'QS`�0`� (ia'staller's name) Acid dated nguia date . Dated o a s ae With revisions dated (bast revised date) I understand the following obligations for management of -this project: 1. 2. 3. lo 4. 5. G. As the installer, I atn .obligated t o obtain. all permits and Board of:Health approved plans g or to :performing any'work on a site: must have the' Wroved glans and the permit: on site when my work is being As the installer,.I mWt••call -for any and Ainspe'ctions: I£ homeowner, contractor, .proj ect mauagex, or any schedules an'inspection and the sgstern is not ready, then other person not associated with my company item three. sha2 bri.applicable. As tli► rtstaller, I atzs• required tio. have .the oecessary work comp eted,prior to the .applicable inspections as a.:.Bo6m of B.ed generally, this -is the, 'spectiou•pnless. there is a�retaining Wall, which shotild.be��dt�ac<first: The:uist4rk:tnust equest th inspectiort but doe's.hot have to be presenx: . b. final. �o'nstiucti'ori.Itispeetioii - EnOr- Cer must first; do their~ irtsj ection for elevations; ares, 'etc. --, -T. As-bdilt of.verbg OK(or e-nuilxo: . a lthd;gtZtownof46rthandover.com): from the engineer must be subniifted-to .the.Bo'ard•ofHealth., aftei'.;w li installer.calls f•or•an inspection time. 'Installer must be present for this.inspection, with •a pump system, a31 electrical wQtk;must ;be ready and able to cause ;p.w3v t6 ^ai'ork arid• alarm..to funC C. on.. c. Fin ; � • : d : •- installer must 3request inspection tvheii'4 •gmding-is' complete.; . Installer. does' not have to be •on4ite. As -the installer,'I ung dsUnd that only Iv aey perform the work' (other than :eimple extavation) an -1m' required to complete the •installation of the system identified in the atiachea .applicatYoa for. installation: 'I furrhier As the.inst filler, •I understand t . on=;site during tho•per &nn once of the following construction. s eps. .: • S. Determinatios� that.tbe prioper elevadon of a vcaradon has been reached b. Inspection ofthe sand and stone to be used. c. Finalimspecdorr byBoard ofHealtb swffor consultant d. Ins don oftank, D Box pipes, stone, vent, pump chambet, rctarurrg wall and other components.1. . . Undersigned tcensed 'c.Tn$tallex PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 7/30/2013 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Repair of D -box and outlet tee By: Todd Bateson At: 72 Saw Mill Road Map 104A Lot 0085 North Andover, MA 01845 The Issuanpe'tyf this certificate shall not be construed as a guarantee that the system will function satisfactorily. ub'lic Health Aunt MCOPY 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com North Andover Health Department (ommunity Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 72 Saw Mill MAP: 104A LOT: 0085 INSTALLER: Todd Bateson DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: 7/30/13 D -Box 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 1 � � Comments: PUMP CHAMBER Comments: CONTROL PANEL Comments: DISTRIBUTION -BOX ❑ 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 ❑ 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 ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement X Installed on stable stone base X H-20 D -Box ❑ Inlet tee (if pumped or >0.08'/foot) X Hydraulic cement around inlet & outlets ❑ Observed even distribution X Speed levelers provided (not required) Comments: Called Neil — adjust speed levelers on left side rA //- /y - 7— -� Z A . nIt / ��-- �•til/�ar e�'t Ev�T-/off r' /a N k / /V lox iENO LtNt 1-47.0 _jAfq.0 72 Saw Mill Road Leslie & Veronica Hudson North Andover. Ma 01845 Owners Subsurface Sewage Disposal System Insprect ion Report Title 5 Town of North Andover Board of Health Copy Service Pumping & Drain Co., Inc. P. 0. Box 498 Wakefield, Ma 01880 (617) 245-7576 (800) 794-9265 Fax (617) 245-7590 C William F. Weld Commonwealth of Massachusetts Governor Executive Office of Environmental Affairs Trudy Coxe Secretary, EDEA Department of Environmental Protection David B. Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 72 Saw Mill Road, North Andover, Ma 01845 Address of Owner Date of Inspection: January 23, 1996 (if different) Name of Inspector: John B. Nicholas Company: Service. Pumping & Drain Co,, Inc,, P.O. Box 498, Wakefield, Ma 01880 (617) 245-7576 CERTIFICATION STATEMENT I certify that i have personally inspected the sewage disposal system at this address and that the information reported below is true accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _X Passes ___ Conditionally Passes __- Needs Further Evaluation By the Local Approving Authority Fails inspector's Signature:--- ---„----- /l/_/--------------- Date: _ / 46 ' ------ The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection, If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection, The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY check A, B, C, or D: A] SYSTEM PASSES: X_ I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303, Any failure criteria not evaluated are indicated below, B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, Passes inspection. indicate yes, no, or not determined (Y, N, or NO). Describe basis of determination in all instances, if 'not determined". explain why not. --- The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of BealtL (revised 8/15/95) One Winter Street # Boston, Massachusetts 02108 # Fax (617) 556-1049 Telephone (617) 292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 92 Saw Mill Road, North Andover, Ma 01845 Owner: Leslie & Veronica Hudson Date of Inspection: January 23, 1996 B] SYSTEM CONDITIONALLY PASSES (continued) ___ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipes) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health): _____ broken pipes) are replaced obstruction is removed _____ distribution box is levelled or replaced ___ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): _____ broken pipe(s) are replaced obstruction is removed 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A BANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: ___ Cesspool or privy is within 50 feet of a surface water ___ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: ___ The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply, ___ The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. ___ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. ___ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more form a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D) SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. ___ Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. ___ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. (revised 8{15{95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 72 Saw Will Road, North Andover, Ma 01845 Owner: Leslie & Veronica Hudson Date. of Inspection: January 23, 1946 D] SYSTEK FAILS (continued): ___ 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ---- . ___ Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ___ Any portion of a cesspool or privy is within a Zone I of a public well. ___ Any portion of a cesspool or privy is within SO feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the welt has been analyzed to be acceptable, attach copy of welt water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen, E) LARGE SYSTER FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: ___ the system is within 400 feet of a surface drinking water supply ___ the system is within 200 feet of a tributary to a surface drinking water supply ___ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 315 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 72 Saw Mill Road, North Andover, Ma 01845 Owner: Leslie & Veronica Hudson Date of Inspection: January 23, 1996 Check if the following have been done: _X Pumping information was requested of the owner, occupant, and Board of Health. _X None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection _X As built plans have been obtained and examined. Not if they are not available with N/A. _X The facility or dwelling was inspected for signs of sewage back-up, _X The system does not receive non -sanitary or industrial waste flow. The site was inspected for signs of breakout. _X All system components, excluding the Soil Absorption System, have been located on the site. _X The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum, _Y_ The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non -intrusive methods. _X The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Subsurface Disposal System. (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 12 Saw Mill Road, North Andover, Ma 01845 Owner: Leslie & Veronica Hudson Date of Inspection: January 23, 1996 FLOW CONDITIONS RESIDENTIAL: Design flow:_600 gallons Number of bedrooms: 4 Number of current residents: 2 Garbage grinder (yes or no):__N Laundry connected to system (yes or no):__Y Seasonal use (yes or no):__N _ Water meter readings, if available: See Last date of occupancy:_Occupied COMMERCIAL/INDUSTRIAL: Type of establishment: ------------------------------- Design flow:_____ gallons/day Grease trap present: (yes or no)_____ Industrial Waste Holding Tank present: (yes or no)____ Non -sanitary waste discharged to the Title 5 system: (yes or no) Water meter readings, if available.: Last date of occupancy: OTHER: (Describe)______ Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: __________________December/94 per owner, ------------------------------------------------------------------------------------- System pumped as part of inspection: (yes or no) _Y _ If yes, volume pumped:_1500 gallons Reason for pumping: ------- Customer request ------------------------------------------------------------------------ TYPE OF SYSTEM Y Septic tank/distribution box/soil absorption system _____ Single Cesspool _____ Overflow cesspool ----- Privy N Shared System (yes or no) (if yes, attach previous inspection records, if any) ----- Other (explain)________________ APPROXIMATE AGE of all components, date installed (if known) and source of information: --------- 11/14/83 per plans. Sewage odors detected when arriving at the site: (yes or no) __N (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 72 Saw Mill Road, North Andover, Ma 01845 Owner: Leslie & Veronica Hudson Date of Inspection: January 23, 1996 SEPTIC TANK:—Y (locate on site plan) Depth below grade: 12"_ Material of construction: ](_concrete ___metal ___FRP _--other(explain) Dimensions—: ----------------------'— ---------------------------------------------------------------------------------------------------------- Sludge depth: ... I' ---- Distance from top of sludge to bottom of outlet tee or baffle: 2' Scum thickness:_ 1/4' _—_ Distance from top of scum to top of outlet tee or baffle: 4" _ Distance from bottom of scum to bottom of outlet tee or baffle: 2' Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) All OL No visable signs of failure. GREASE TRAP: N (locate on site plan) Depth below grade:_____ Material of construction: concrete metal _ FRP--other(explain) Dimensions: ---------------------------------------------------- Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc,)__________________________ (revised 8/15(95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 72 Saw Mill Road, North Andover, Ma 01849 Owner: Leslie & Veronica Hudson Date of Inspection: January 23, 1996 TIGHT OR HOLDING TANK: N (locate on site plan) Depth below grade:_____ material of construction: concrete metal FRP other(explain) Dimensions: ---------------------- Capacity: .......... gallons Design flow: ---------- gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:—Y (locate on site plan) Depth of liquid level above outlet invert: 0 Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)_________ ------ Box OL No visable signs of failure, ----- PUMP CHAMBER: N_ (locate on site pian) Pumps in working order: (yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc,) (revised 8/19/99) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 72 Saw Mill Road, North Andover, Ma 01845 Owner: Leslie A Veronica Hudson Date of Inspection: January 23, 1996 SOIL ABSORPTION SYSTEM (SAS):_Y (locate on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number:_____ leaching galleries, number: leaching trenches, number, Iength:__________ leaching fields, number, dimensions: --I R 50' x 30' overflow cesspool, number: _ Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) ____ All OK. No visable signs of failure. -------------------- CESSPOOLS: N (locate on site plan) Number and configuration:__ --------------------------------------- Depth -top of liquid to inlet invert: ----------------------------- Depth of solids layer: ------------------------------------------- Depth of scum layer: Dimensions of cesspool: Materials of construction: --------------------------------------- Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc,) Privy: N_ (locate on site plan) Materials of construction: Dimensions: Depth of solids: _ ----------------------------------------------------------------------------- Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)___ (revised 8%15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address; 72 Saw Mill Road, North Andover, Ma 01845 iiwners: Leslie @ Veronica Hudson Date of Inspection: January 23, 1996 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' W 0 AD qI, !3 D 6`l sof DEPTH TO GROUNDWATER Depth tc groundwater: 8 feet Method of determination or approximation: --------_--- Per plans, �re'rised Y;`1/9S1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION ADDENDUM I Property Address: 72 Saw Mill Road, North Andover, Ma 01845 Owner: Leslie & Veronica Hudson Date of Inspection: January 23, 1996 (No Comments) Initial Service Pumping Fi Drain Co,, Inc, has been retained by the owner to provide an inspection of the on site sewage disposal system as defined by 310 CMR 15,303, D,E,P, guidance instructs the inspector to make an evaluation of the systems performance on the day of the inspection, The Title 5 inspection is not designed to provide information to demonstrate that the system will adequately serve the use to be placed upon it by the new owner as stated in 15,302. This inspection is not a warrantee or guarantee of the systems future performance, and does not either express or imply that, 14112 G.B. >'l T -F�� (�'TT'i.'1"''"TS'TX7 i T� j? !.1 �� •!,- � � :...i .� � � a} rt! v5. in r {4 cz Ul ,i•� i r, :D D- m E f > J !13 u3 ct3 r i� AV A ro tA ! � r -r ; � �3 X •(4G�i "w Gi W M ! z ©. rn tn - � �. v.+ ! l '6k• Rs t J.,..3 7 .alt 1; ;r! 7 1 Wi..! ... 1 m m . `. i .•. ' N i : rLE' Re as ( I { r !19 r� ro fj ro i } . � I • � i _ Y"� y¢ ar � � �'t ` � el� ill Lj: Li y h � jj` P mm TO: NORTH ANDOVER, MASS tle-V 19 493 BOARD OF HEALTH FROM: DESIGN ENGINEER Re: Soil Absorption Sewage System Inspection This is to certify that I have inspected the construction of the said disposal system at L T 442 A SA W AP // Rrj 19 L) North Andover, Mass. SITE LOCATION The grades and construction are as specified in *Ay plans and specifications dated P� �S IVNors nitarian SOIL PROFILE & PEACOLATION TEST DATA North Andover, Mass. Street No Sk-wo-, t l ItZ-a ' lot No 4Z A Loc/Subdiv. Pland Owner 4g�;4be--r e Investigator Iry E Observer 11S2 - SOIL PROFILE DATES l.�F,l.ev 2.Elev 3.Elev 4.Elev 0 0 1 1 2 T� S 2 3 1 3 4 5 6 7 8 2W-JD 4 5 6 7 8 -n%\ I uOZY Start Saturation B 0 1 2 3 4 5 6 7 8 1-10 9 9 9 10- 10 , 10 B la 5 Location Elevation Datum PERCOjATION TESTS DATES 411 (,Ie% 0 1 2 3 4 5 6 7 8 9 10 Tiles toPits est Pit Number t, C 'g C4�3 4 Start Saturation °� : SS `'►.: to Soak -Minutes p : t o Start, a �S 33 Drop of 3" -Time Drop of 6" -Time Mams.lst 3" drop Mins.2nd " Drop Percolation to 1(0 Board of Health Nez-ti::�ndover,?Sasa APPROVED DATE .' : providedr; Title V Reg 2.5 r3�a//es NMI EME O SUBSURFACE DISPOSAL DFMGN CHECK LIST LOT # A -L 4 Sbwµ"lA DISAPPROVED DATE Reasons: submitted plan =t show as a Minimum! the lot to be served -area, dimensionslot #, abutters location and log deep observation hoes -distance to ties location and results percolation tests -distance to ties design calculations & calculations sluywing required leaching area location and dimensions of system -including reserve area existing and proposed contours location any vet areas within 140' of sewage disposal system or disclaimer -check wetlands mapping surface and subsurface drains within 100' of sewage disposal system or disclaimer location any drainage easements vithin 140' of swage disposal system or di.sclairer-P arming Board files kno= sources of water supply within 200 of serge disposal e stem or disclaimer -lo-cation of any -proposed-well -to serve 10t=10Q' from leaching faeili location of kater lines on property -10' from leaching facility location of benchmark �ivev-a�ys image disposals /no PVC to be used in construction pro a of system -elutions of basement, plurb, pipe, septic tank, bution box inlets and outlets, distribution field piping and ther elevations m yJ-xsm ground meter elevation in area se -;.-age disposal system plan mast be prepared by a Professional Engineer or other professional authorized by lax to prepare such plans Reg 6� s - tic Tanks (a capacit es -150 of flog, meter table, tees, depth of tees, 4 access, n piing cleanout 10, from cellar imll or inground s- .-ng pool d) 25+ from subsurface drains Reg 10.2 Distribution Faxes (a) slope greater than 0.08 Reg 10.4 I ) sures R��E QBE oo' AaA-Tb C•� . �t +��T�ll&i� Qf plaN ��of-� 14 0� �� spit jopcp- 0N� ti 0 Subsurface_ Design Check List ' Fad, .2 FAIL I M Leaching Pits Leaching pits are preferred where the installation is possible Reg 11.2 a) calculations of leaching area-minilmhm 500 eq ft ll.lt b) spacing 11.10 c) surfff a 2% 11.11 d) cove e) 21z2pad f) g) be Brom d -box to pipe L Ching Fields seg 15.1 a seater than 20 minutes/inch -minim= 900 sq fit 15•t� c c struction of field 15.8 surface drainage 2 % 3.7e) 202 Brom cellar van or inground sArzdng pool LeachinR fir. cnes ,eg 1}x.1 14.3 14.4 3-4.6 14.7 2 .10 .eg 9.1 9.6 a) c c on of -leaching area -min 500 sq ft b) spacing- ft min 6 ft with reserve between c) diva as d) co ction e) s ne f) surface drainage 2% Dounhill Slo e a) slope y x = to be shownn) b) y/x x 1500 = (to be sho�.yn) _ Purz�s a) approval star -by power 'rte T�'C o tC �►.JE '�� rte'© `�'"'�� ' Jb) n 0 N Sew►-1�1 �