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2eptic Tank
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4 Effluent Tea Fllter present? . ❑ Yes ❑ No ' If yes, was It cleaned?
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t5forrn4.doa X03 System Pumping Record • Page 1 of t
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North Andover Board of Health
120 Main St.
North Andover Ma.01845
Haul Lic. #151 -OOH
Install Llc. # 128-0
Date Address
11/1/2000 303 Chester St
11/1/2000 50 Willow Rd
11/1/2000 160 Carelton Ln
11/1/2000 165 Bridal Path
11/4/2000 174 Ingals St
11/4/2000 1062 Salem St
11/6/2000 373 Raligh Tavern Ln
11/6/2000 252 Boxford St
11/6/2000 150 Liberty St
11/6/2000 149 Osgood St
11/7/2000 255 Haymeadow
11/7/2000 850 Winter St
11/8/2000 25 Windsor Ln
11/9/2000 249 Carlton Ln
11/9/2000 767 Johnson St
11/10/2000 56 Academy Rd
11/14/2000 Sugar Cane Ln
11/14/2000 250 Abbott St
11/15/2000 195 Winter St
11/15/2000 187 Winter St
11/16/2000 85 Laconia Cir
11/16/2000 86 Willow Ridge
11/17/2000 2135 Turnpike St
11/20/2000 203 Grandville Ln
11/20/2000 391 Pleasant St
11/20/2000 124 Tucker Farm Rd
11/22/2000 394 Boston_ Rd
11/22/2000 728 Forest St 7
11/22/2000 18 Johnney Cake St
11/24/2000 106 Rockey Brook Rd
11/24/2000 258 Rea St
11/28/2000 1815 Great Pond Rd
11/28/2000 1420 Great Pond Rd
11/29/2000 266 Lacy St
11/29/2000 155 Laconia Cir
Andover Septic
47 Railroad St.
Bradford Ma. 01835
Gallons Comments
1000
1000
1500
1500
1000
1250
1000
1000 Leachfield Run Back/ Ex. Solids
1500
1000
1500
1250
1500
1500
1500
1500
1500
1000 Extra Solids
1500
1500
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1000
1500
1000 Flooded
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TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSL SYSTEM FORM
PART A
CERTIFICATION A'
Property Address: 728 Forest Street
North Andover, MA 01845 2
Owner's Name: Thomas & Laurie O'Connor , r.
Owner's Address: 728 Forest Street
North Andover, MA 01845
Date of Inspection: December 9, 2003
Name of Inspector: (please print) George Norris
Company Name: D.F. Clark, Inc.
Mailing Address: P.O. Box 265, Ipswich, MA 01938
Telephone Number: (978) 356-5638
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is
true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and
experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system
inspector pursuant to Section 15.340 of Title 5 (31.0 CMR 15.000). The system:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approval Authority
Fails0-7
n
Inspector's 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.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that time. This
inspection does not address how the system will perform in the future under the same or different conditions of use ' '
Title 5 Inspection Form 6/15/00
page 1
0
Page 2 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 728 Forest Street
North Andover, MA 01845
Owner: Thomas & Laurie O'Connor
Date of Inspection: December 9, 2003
Inspection Summary: Check A, B, C, D or E / ALWAYS complete all of Section D
A. System Passes:
X I have not found any information which indicates that any of the failure conditions 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.
Answer yes, no or not determined (Y, N, ND) in the for the following statements. If "not determined" please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound,
exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing
tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating
that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
_ broken pipe(s) are replaced
_ obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass
inspection if (with approval of the Board of Health):
ND explain:
broken pipe(s) are replaced
obstruction is removed
2
Page 3 of I1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 728 Forest Street
North Andover, MA 01845
Owner: Thomas & Laurie O'Connor
Date of Inspection: December 9, 2003
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.
System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system
is not functioning in a manner which will protect public health, safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is
functioning in a manner that protects the public health, safety and environment:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface
water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private
water supply well". Method used to determine distance
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and
volatile organic compounds indicates that the well is free from pollution from that facility 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:
Page 4 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 728 Forest Street
North Andover, MA 01845
Owner: Thomas & Laurie O'Connor
Date of Inspection: December 9, 2003
D. System Failure Criteria applicable to all systems:
You must indicate either "yes" or "no" to each of the following for all inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s)
Number of times pumped
X Any portion of the SAS, cesspool or privy is below the high ground water elevation
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply
X Any portion of a cesspool or privy is within a Zone 1 of a public well
X Any portion of a cesspool or privy is within 50 feet of a private water supply well
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates
that the well is free from pollution from the facility and the presence of ammonia nitrogen and nitrate
nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of
the analysis must be attached to this form.]
No (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described in
310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to
determine what will be necessary to correct the failure.
E. Large Systems:
To be considered large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either "yes" or "no" to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped
Zone 11 of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in
Section "D" above the large system has failed. The owner or operator of any large system considered a significant threat
under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
4
f S
Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 728 Forest Street
North Andover, MA 01845
Owner: Thomas & Laurie O'Connor
Date of Inspection: December 9, 2003
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 600
Number of current residents: 7
Does residence have a garbage grinder (yes or no): No
Is laundry on a separate sewage system (yes or no): No ; [if yes, separate inspection required]
Laundry system inspected (yes or no):
Seasonal use: (yes or no): No
Water meter readings, if available (last 2 years usage (gpd)): Well Water
Sump Pump (yes or no): No
Last date of occupancy: Currently Occupied
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow (based on 310 CMR 15.203): gpd
Basis of design flow (seats/persons/sgft, etc.):
Grease trap present (yes or no):
Industrial waste holding tank present (yes or no):
Non -sanitary waste discharged to the Title 5 system (yes or no):
Water meter reading, if available:
Last date of occupancy/use:
OTHER: (Describe)
GENERAL INFORMATION
Pumping Records
Source of information: Svstem was last Dumped Snrinv/Summer 2003 accordiniz to owner
Was system pumped as part of inspection (yes or no): No
If yes, volume pumped: _gallons — How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
X Septic tank, distribution box, soil absorption system
Single cesspool
Overflow cesspool
Privy -
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract
(to be obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other (describe):
Approximate age of all components, date installed (if known) and source of information:
System was installed in 1984 according to homeowner
Were sewage odors detected when arriving at the site (yes or no): No
6
Page 7 of I 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 728 Forest Street
North Andover, MA 01845
Owner: Thomas & Laurie O'Connor
Date of Inspection: December 9, 2003
BUILDING SEWER (locate on site plan)
Depth below grade: 25"
Material of construction: X cast iron 40 PVC —other (explain):
Distance from private water supply well or suction line: 18'
Comments: (on condition of joints, venting, evidence of leakage, etc.):
Building sewer pipe is in good condition no evidence of leakage.
SEPTIC TANK: Yes (locate on site plan)
Depth below grade: 16"
Material of construction: X concrete _metal _ fiberglass_polyethylene
_other (explain)
If tank is metal list age _ Is age confirmed by a Certificate of Compliance (yes or no): (attach a copy of
certificate)
Dimensions: 5'W x 8'L x 4'D
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or baffle: 33"
Scum thickness: 0"
Distance from top of scum to top of outlet tee or baffle: N/A
Distance from bottom of scum to bottom of outlet tee or baffle: N/A
How were dimensions determined: Measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Inlet and outlet baffles are in dace liquid level is normal tank is in good condition with no sign of leakage.
GREASE TRAP: No (locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments: (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related
to outlet invert, evidence of leakage, etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 728 Forest Street
North Andover, MA 01845
Owner: Thomas & Laurie O'Connor
Date of Inspection: December 9, 2003
TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass _polyethylene _other (explain):
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present (yes or no):
Alarm level: Alarm in working order (yes or no):
Date of last pumping:
Comments (condition of alarm and float switches, etc.):
DISTRIBUTION BOX: Yes (if present must be opened)(locate on site plan)
(Depth below grade = 25")
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.):
Distribution is equal no evidence of solid carryover, d -box is in good condition.
PUMP CHAMBER: No (locate on site plan)
Pumps in working order (yes or no): _
Alarms in working order (yes or no):
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc):
Page 9 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 728 Forest Street
North Andover, MA 01845
Owner: Thomas & Laurie O'Connor
Date of Inspection: December 9, 2003
SOIL ABSORPTION SYSTEM (SAS): Yes (locate on site plan, excavation not required)
If SAS not located explain why:
Type
_leaching pits, number:
_leaching chambers, number:
leaching galleries, number:
X leaching trenches, number, length: 7 leach trenches — 50' long
_leaching fields, number, dimensions:
_overflow cesspool, number:
innovative/alternative system Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.):
SAS is under side yard and under snow, inspected SAS with a video inspection camera and found no sign of
hydraulic failure
CESSPOOLS: No (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth - top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow (yes or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRIVY: No (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.):
d
Page 10 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 728 Forest Street
North Andover, MA 01845
Owner: Thomas & Laurie O'Connor
Date of Inspection: December 9, 2003
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.
Locate all wells within 100 feet. Locate where public water supply enters the building.
F4
Forest Street
10
Page 11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 728 Forest Street
North Andover, MA 01845
Owner: Thomas & Laurie O'Connor
Date of Inspection: December 9, 2003
SITE EXAM
Slope
Surface water
Check Cellar
Shallow wells
Estimated depth to ground water _ feet
Please indicate (check) all methods used to determine the high ground water elevation:
X Obtained from system design plans on record — If checked, date of design plan reviewed:
_ Observed Site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health -explain:
Checked local excavators, installers — (attach documentation)
Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Bottom of SAS is 41" below grade According to design plan by GeoTechnical Consultants of Masschusetts Inc. dated
April 1984 bottom of SAS is 4' above the groundwater elevation
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Commonwealth of MassachusettsWei
[R:
Cp '13.2010
City/Town,of ORTH ANDOVERMUSETT
System Pumping Record NEALTHflepgRTMENT R
F 4
DEP has provided this form for use by loyal Boards of Health. The System Pumping Record mug
be submitted to the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1.
forms on the
computer, use
only the tab key
to move your
cursor -. do.not
use the return
key,. 2
City/Town State Zip Code
Address (if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pum
Data Y ped
3.., Type of system: ❑ Cesspool(s) j;--S*eptic Tank
,
Other (describe):
http://ww.rhas;
: 1 '5' 9
Gallons
❑ . Tight Tank
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,'was it cleaned? ❑ Yes ❑ No
5. Condition of System:
8.. System Pumped By:
me Vehicle License Number
Company
7. Locatlo where contents were disposed:
®U
t5fomti4.doa 06/03 System Pumping Record • Page 1 of 1
i