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HomeMy WebLinkAboutMiscellaneous - 743 WINTER STREET 4/30/2018 (2)N 0 o� A ;P Z M -+ m CilM wcn S� m m o '+ w � 2 � � A \ Q a } } k % \ 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. �I r� MKI Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Asses; 743 WINTER STREET Property Address ANDREW MAUL RECEIVED MAR 16 2009 UN OF NORTH ANDC HEALTH DEPARTM& Owner's Name Noirth Andover MA 01845 1-23-09 City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 1. Inspector: Benjamin C. Osgood, Jr. Name of Inspector Company Name 224 High Street Company Address Newburyport City/Town 508-328-4633 Telephone Number B. Certification MA State 870 License Number 01950 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 /-2_4,7 (�� &?) - 3 -0 9 Yn—speclIrfs Signature Date The system inspectr 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 Inspection Blank Form • 08106 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 743 WINTER STREET Property Address ANDREW MAUL Owner's Name Noirth Andover MA 01845 1-23-09 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass.. 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 Title 5 Inspection Blank Form - 08106 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 743 WINTER STREET Property Address ANDREW MAUL Owner's Name Noirth Andover MA 01845 1-23-09 Citylrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: 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 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. Title 5 Inspection Blank Form - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 743 WINTER STREET Property Address ANDREW MAUL Owners Name Noirth Andover MA 01845 1-23-09 City[rown State ., Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 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 '/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 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. Title 5 Inspection Blank Form • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 15 Commonwealth of Massachusetts u Title 5 Official Inspection Fo Subsurface Sewage Disposal System Form - Not for Voluntary 743 WINTER STREET Property Address ANDREW MAUL Owner Owners Name information is required for Noirth Andover MA 0184 every page. City/Town state Zip Co B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ E 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. Title 5 Inspection Blank Form • 08106 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 15 rm Assessments 5 1-23-09 de Date of Inspection Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ E 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. Title 5 Inspection Blank Form • 08106 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 15 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 743 WINTER STREET Property Address ANDREW MAUL Owner Owners Name information is required for Noirth Andover MA 01845 1-23-09 every page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? Z ❑ 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)] Title 5 Inspection Blank Form • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 743 WINTER STREET D. System Information Residential Flow Conditions: 01845 1-23-09 Zip Code Date of Inspection Number of bedrooms (design): 4 Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 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)): 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: Last date of occupancy/use: Other (describe): 4 ® Property Address ❑ ANDREW MAUL Owner Owner's Name information is required for Noirth Andover MA every page. Cityrrown State D. System Information Residential Flow Conditions: 01845 1-23-09 Zip Code Date of Inspection Number of bedrooms (design): 4 Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 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)): 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: Last date of occupancy/use: Other (describe): 4 ® Yes ❑ No ❑ Yes ® No ❑ Yes ® No ❑ Yes ® No ❑ Yes ® No current Date Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Date Title 5 Inspection Blank Form • 08/06 Tide 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 743 WINTER STREET Property Address ANDREW MAUL Owner's Name Noirth Andover MA 01845 City/town State Zip Code D. System Information (cont.) 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: 1-23-09 Date of Inspection unknown ❑ 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): Approximate age of all components, date installed (if known) and source of information: 25 vears Were sewage odors detected when arriving at the site? ❑ Yes ® No Title 5 Inspection Blank Form • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 15 Commonwealth of Massachusetts N - Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM •''� 743 WINTER STREET Property Address ANDREW MAUL Owner Owner's Name information is required for Noirth Andover MA 01845 1-23-09 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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: n/a feet Comments (on condition of joints, venting, evidence of leakage, etc.): pipe looks good in basement Septic Tank (locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1500 gallons Sludge depth: 2 Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 2 Distance from top of scum to top of outlet tee or baffle 7 Distance from bottom of scum to bottom of outlet tee or baffle 14 How were dimensions determined? 30 Title 5 Inspection Blank Form • 081G6 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 743 WINTER STREET Property Address ANDREW MAUL Owner's Name Noirth Andover MA 01845 City1rown State Zip Code 1-23-09 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.): Tank in good condition. Concrete tees in Good condition. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 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): Title 5 Inspection Blank Form - 08106 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 15 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 743 WINTER STREET Property Address ANDREW MAUL Owner Owner's Name information is required for Noirth Andover MA 01845 1-23-09 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) 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 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.): Box in good condition. Equiped with flow levelers and distribution equal. No evidence of leakage in or out. No evidence of carryover. Pump Chamber (locate on site plan): Pumps in working order: Alarms in working order: ❑ Yes ❑ No ❑ Yes ❑ No Title 5 Inspection Blank Forth - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 743 WINTER STREET Owner information is required for every page. Property Address ANDREW MAUL Owner's Name Noirth Andover Cityrrown State 01845 1-23-09 Zip Code Date of Inspection D. System Information (cont.) 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: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields 1900 sq. ft. 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.): Area of field snow covered. Title 5 Inspection Blank Form • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 15 ' Commonwealth of Massachusetts u r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 743 WINTER STREET Property Address ANDREW MAUL Owner information is required for every page. Owners Name Noirth Andover City/Town State 01845 Zip Code 1-23-09 Date of Inspection D. System Information (cont.) 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 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.): Title 5 Inspection Blank Form • 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 15 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 743 WINTER STREET Property Address ANDREW MAUL Owners Name Noirth Andover City/Town MA State 01845 1-23-09 Zip Code Date of Inspection D. System Information (cont.) 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. D t> r AnICV^S t2-,- 30' 7A"d K—W*M I" 9 Title 5 Inspection Blank Form - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 15 ="�EE� Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 743 WINTER STREET Property Address ANDREW MAUL Owner's Name Noirth Andover MA 01845 1-23-09 City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to ground water: 3 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Soil testing done downslope of system indicated water table at elevation 97.46. Bottom of system is 2.5 feet below ground at the distribution box where the finished grade is 100.39 putting the bottom of the system at elevation 97.89 which is .4 feet above ground water. System is located on a hill. The nearest wetland is at the rear of the property approximately 10 feet lowe than the elevation of the syste. Basement is dry and the basement floor is 6 feet below the bottom of the system. Basement does not have a sump pum. Title 5 Inspection Blank Form - 08/06 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 15 ,-4 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: '7Y3 k/ /tiM., 0— 5r ,V,0472V 198X ICR, Owner's Name: 4 U011 Owner's Address: Date of Inspection: � 16 -Ir Name of Inspector: (please print)-IoA741 d USS Company Name: /l,t7r:a7i�fjST �/d/t2a�vM�M7�L Mailing Address: Is w4r!s7 :7A/ ST Z>AWvZ2S J %;f,4 j723 Telephone Number: --S-Vos- Ccs RECEIVE MAY 19 2005 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 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 (310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: —5A ZE 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 6/15/2000 page 1 -Wage 2 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: `7113 wivr�rz. ST A"i2.,r7-�L i¢itv,G *VL., , Owner: L uc, Date of Inspection: yyo S - 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. Commenntts: C,aG,O e,0"41 T 70Al 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 ves, 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 pipes) are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY. ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: M%�.3 Gcl/ti7`Q S% Owner: Date of Inspection: O C. Further Evaluation is Required by the Board of Health: l% 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 is 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 1.00 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: 3 �. Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ?,13 &,y" 7T R S7 - "A -'7-N Owner: ( / Date of Inspection: 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 i� Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool te" 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 '/2 day flow I�Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ,// Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50.feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] /VQ (YeOcribed he system fails. I have determined that one or more of the above failure criteria exist as 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:j7" To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either "yes" or "no" to each of the following: (The 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 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. 4 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 71X.3 lull -IM Q- S7 - Owner: LvG/ Date of Inspection: Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes Noi V _ Pumping information was provided by the owner, occupant, or Board of Health LS Were any of the system components pumped out in the previous two weeks ? jZ _ Has the system received normal flows in the previous two week period ? L//_ Have large volumes of water been introduced to the system recently or as part of this inspection ? V' _ 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: YZ-0 Existing information. For example, a plan at the Board of Health. t — Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)) 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: :�ZIV2 k//A/r R ST' R/o2.7N 4¢ eV oy,Fi,_ Owner: LuC. Date of Inspection: O FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: l 10 gpd x # of bedrooms): Number of current residents:_ Does residence have a garbage grinder (yes or no): Al Is laundry on a separate sewage system (yes or no): k/ [if yes separate inspection required] Laundry system inspected (yes or no): ZIA Seasonal use: (yes or no): W Water meter readings, if available (last 2 years usage (gpd)): Sump pump (yes or no):. /1/ Last date of occupancy: Gya gAIr COMMERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): _ gpd Basis of design flow (seats/persons/sgff,etc.): Grease trap present (yes or no): Industrial waste holding tank present (yes or no): _ Non -sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER (describe) - GENERAL INFORMATION Pumping Records Source of information: STS �r4lL T Was system pumped as part of the inspection (yes or no): If yes, volume pumped: f SUU gallons -- How was quantity pumped determined? 6 y4 G <,, Reason for pumping: IA.,;r7%1z X L 11t)S/Cr_C77oV TYP&OF SYSTEM _ZSeptic 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: z.v yes We re sewage odors detected when arriving at the site (yes or no): /v© • Page 7 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: `,7113 Ly/A,-1175�e Sr Owner: L116lb Date of Inspection: Q BUILDING SEWER (locate on site plan) Depth below grade: Materials of construction: ,r-LTst iron_L�,4410 PVC other (explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: ,�roncrete _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) . l Dimensions: 4C' -A//# !o Sludge depth: "y" Distance from top of sludge to bottom of outlet tee or baffle: 17 d 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: '.r:1EZ-6 OgS-E'avT-z> Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): GREASE TRAP: _(locate on site plan) 41V 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 I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ",,-r14vDat2 Owner: L u Date of Inspection: 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/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: �f present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 011 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)�11A 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.): 8 + ,. A. Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 71/3 4.//A/ rj2 57' .iGfO�Li~1`a' A�vlJ�t�� Owner: C t&lh Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: _ leaching chambers, number: leaching galleries, number: leaching trenches, number, length: , :leaching fields, number, dimensions: Zo ,c 3o ' 41— 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.): 6,000 G o A"0 T7yrt) CESSPOOLS:011 cesspool must be pumped as part of inspect ion)(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: ocate on site plan) Materials o , construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 9 r R � Page 10 of 1 l OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM'INFORMATION (continued) Property Address: 7 y3 laml 75i -4 57- Owner: %Owner: LUGlb Date of Inspection: izehs— 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. A -C- - /y 3-C- = 2Z A -D = 3 9- *D - ✓ 7 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: 7y3 fit//iv7F-4Q.. sr �(IOiZr-l* Owner: LJJGI h � Date of Inspection: ly jqAS— SITE EXAM Slope 0-3Z 54C1 -?7-7 L f/1-lov5C Surface water >c/Gd t Check cellar alai --po Pum'o. Shallow wells >-7 5— Estimated depth to ground water feet 44e,4 3!-15-1 Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record - If checked, date of design plan reviewed: Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Checked.with local excavators, installers- (attach documentation) _LZAccessed USGS database -explain: 461. ,4 IV/� So /L /yi4 Q r You must describe how you established the high ground water elevation: Ae ChM v F/ B 1—D 4 T 3. 5 0 /4- r I �4 l�5 9)> 6 3 r� Zvi M c�w1 5 Z,,ag ZA 770A) COMMONWEALTH OF MASSACHU. SETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 99-:6 6' TRUDY COXE - i � 1 SeEYCtA2y ARGEO PAUL CELLUCCI DAVID $ ST&UiiS Commisroner Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM j PART A j CERTIFICATION Property Address: 7A13 Name of Owner S%1GG6Y G"Av /� L �/91ei? 4,1. ANDOV,!�2, MA AddressofOwner: -7113 INt^' Date of Inspection: 9l..q9/99 Name of Inspector: (please Print) Benjamin C. Osgood, Jr. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.0001 Company Name: New England Engineering SPrvi ros, Inc. MaXng Address: 60 Beechwood r, MA 01845 Telephone Number 686-1768 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true• accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-sitesewage disposal systems. The system: _V Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: � C) Date: C� 1141, The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)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 oftEnvironmental Protection. The original should'be sent to'ttw system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 Pace 1 of 11 `� VnMcd on R<cycicd P,pc. 121993 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: —71P3 W r �✓ �i2 ST/IEC ?.� Al 441 L{d ✓r 2 Owner: sJ-Jci.Ly CAVAL -a -192c) Date of Inspection: .71.74%q9 . ( INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: ` 1 have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If 'not determined', explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumphig-Tnam then four -times is yeardue to broken or obvructed pipe(s). The system wit. Vass" inspection if (with approval of the Board of Health): - - broken pipe(s) are replaced obstruction is removed revised 9/2/98 Page 2of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: S1yai-V 019019"4120 Owner: 7113 btir'L' 2 ST tip- A t'DU �lG 2 Date of Inspection: '? C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: r i Conditions exist which require further evaluation by the Board of Health in"order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 (1)(151 THAT THE SYSTEMA IS NOT FUNCTIONING IN A MANNER WHICKYALL PROTECT THE PUBUC HEALTH AND SAFETY AND THE ENVJBONMEKT: _ Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEMA 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone 1 of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or lass than 5 ppm. Method used to determine distance (approximation not vafid). 3) OTHER revised 9/2/98 rogeiefII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 71/3 W1-72�2 tT/1e"C� ,(.r.. f}NOL`✓c 2 Owner: SNL LLY coq .%4 LL►920 r Date of Inspection: D: SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into 4aci6tror-sTtitem component dueao on overlooded omiggged 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 112 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 50 feet o1 a private water supply well. Any portion of a cesspool or privy is less -than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable. attach copy of well water analysis for –coliform bacteria, volatile organic -compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: 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: The system serves a facility with a design flow of 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: Yes No the system is within 400 feet of a surface drinking water supply the system is -with 200 feet of-o4tibtAery-4ea sur4o"Anki"-water-w&uWY the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION f-0RM PART B CHECKLIST Property Address: % �/3 1NiN� i2 Si /'C r % /1/- fJti 00✓� 2 Owner: Shl LLY CALM i-141ZV Date of Inspection: ! r r r Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes/ No or Board of Health. _✓ _ Pumping information was provided by the owner, occupant, None of the system:componenu.14 ti^,.n pampe"orstleast two ureekc and -the system has 1— =ecaiaiog wrrwaal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. LZ__ _ The facility or dwelling was inspected for signs of sewage back-up. ✓^ _ The system does not receive non -sanitary or industrial waste flow. V� The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. V___ 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. The size and location of the Soil Absorption System on the site has been determined based on: Existing information. For example, Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) 115.302(3)(b)) / _✓ - _ The facility owner (and.occupaou,il different from-owned.were.prauidad.with iafnunation.on lhATpLa er mgiruonsac."f SubSurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: '7 y3 W 1 V : !Z S % /CCG-%; Owner: 5/IELC %' CHV4if t I a a Date of kupection: q�2ry�c c r ROW CONDITIONS RESIDENTIAL: . Design flow: g.p.d./bedroom. r Number of bedrooms (design): = Number of bedrooms (actual): Total DESIGN flow — Number of current residents: Z Garbage grinder (yes or no):Lit S Laundry (separate system) (yes or no): IVIf yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no):/VL' Water meter readings, if available (last two year's usage (gpd); Sump Pump (yes or no): NC, Last date of occupancy: cL:r-r&,vT COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: qpd ( Based on 15.2031 Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non -sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: F'v pe- n 3 yC--,/23 fto System pumped as part of inspection: (yes or no)_ If yes, volume pumped: gallons 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, ii any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed{if known) -end source o(4"fomVetion: Sewage odor detected when arriving at the site: (yes or no)�`i revised 9/2/98 Page 6ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Prop" Address: 7 �/3 ✓-1i v7T'/1 S1—Y1 C�%, ti. fli.t/Qv✓r /L Owner: C4iJA tL'4r2G Date of Inspection: ( BUILDING SEWER: (Locate on site plan) r r Depth below grade: Material of construction: ►cast iron _ 40 PVC _ other (explain) r Distance from private water supply well or suction line Diameter I` Comments: (condition of joints, venting, evidence of loakage,-etc.) _ C�>N 0, it4 N l •L SCM tri) SEPTIC TANK:_ (locate on site plan) Depth below grader Material of construction: E/Concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is (metal, list age _ Is.age.confumed by Certificate of Compliance _ (Yes/No) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 2.59 Scum thickness:Orr 11 Distance from top o[ff Scum to top of outlet tee or baffle: S_ 1, Distance from bottom of scum to bottom of outlet tee or baffle: 2V How dimensions were determined: MtA csv KE 5%JC iC Comments: (recommendation for pumping, condition of inlet and outlet tees or -baffles. depth of liquid level in relation to outlet invert, structur,&14ntegrity, evidence of leakage. etc.) 7-AAIA NJ/17O D ti� lvNvr'T7vN GREASE TRAP:A/.W (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: (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 9/2/98 Page 7ofII 0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 71/3 W/ ,V S % 2 C c ! r N •. 4A/ ae) ✓G Owner: .5 '/9vAl-L09,2O Date of kupection: /z1e/f9 TIGHT OR HOLDING TANK -,d/2 (Tank must be, pumped prior to, or at time -of, inspection) (locate on site plan) Depth below grade:_ Material of construction: _concrete —metal _Fiberglass _Polyethylene _other(explain) � Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order: Yes _ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) - /%,r iw,' i.tl Cu ✓J/Ti0•t/ J�NS%h'LLt/J J �t �ti L-� L.- _I- /4' 1914 JI. - PUMP CHAMBER:A�4 (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.) revised 9/2/98 Page 8ofII SUBSURFACE $SWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEMA INFORMATION (continued) Property Address: si �ci , .9��i) Owner' s}.{rLL-Y V1 12C) Date of kupection: y12f/ I , SOIL ABSORPTION SYSTEM (SAS): (locate on site plan..if possible: excavation not required, location may be approximated by non -intrusive methods) If not located, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number - leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) /i/2 c�F ii<<D i -or ►C� �/yR.s1 i9L /y POA,'01,t,' Fr c�Ntitp seg, t 0 /2 - CESSPOOLS: ./V CESSPOOLS:./V e't (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 inspecti Comments: (note condition of soil, signs of hydraulic failure, level of polling, condition of,vegetation, etc.) PRIVY: /_✓A (locate on site plan) Materjals of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation; etc.) revised 9/2/98 Page 9ofII ' I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART G SYSTEM INFORMATION (continued) I Property Address: 7 y3 w r N; Owner: SNtt`y a.4V.9 Lt420 Date of Inspection: r SKETCH OF SEWAGE DISPOSAL SYSTEM: r include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) I c revised 9/2/98 Pagc 10 of II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION, FORM PART C SYSTEM INFORMATION (continued) Property Address: 71/3 w f N I E R 5 % /�G �, .v f� ✓ D OVC �2 Owner: S}1ELcy ('/%dfl t Lr9l Date of knpection. NRCS Report name Sv/L s" ,ZUi V tss C X ��..� TY -f iV L) r?/Wr ta— t Soil Type C gA.JIVl Typical depth to groundwater i iv -c2 t USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderato Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater 3 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed.Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers _ Used USGS (data Describe how you established the High Groundwater Elevation. (Must be completed) I� Lv R't"C2 7 r1$ lL t LL' � �'� 0 .v /'S2J.v� p,v c i 4 yq sc t) c. ��`..4N / ,✓ ,? / C /t i�S L'✓�RT�/L ir+t3LGJI;V �/% i% /3D770/✓ OF SCh LF -BEV revised 9/2/98 Page 11ortt NEW ENGLAND ENGINEERING INC North Andover Board of Health Town Hall Annex 27 Charles Street North Andover, MA 01845 RE: TITLE V REPORT: 743 Winter Street, North Andover SERVICES October 7, 1999 Enclosed is a copy of the Title V report for the above referenced property. The systemap sses our inspection. If there are any questions please call me at my office, 686-1768. Sincerely Aenj 'n C. Osgood Jr.,.LT. President 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 STEWART'S SEPTIC TANK SERVICE 47 RAILROAD STREET - BRADFORD, MA 01835 Board of Health of North Andover CARr� � f q 3 Gv lkirtrL- s J-/42T/L x-10 dv*v To whom it may concern: At request of owner at 743 Main Street, we come back to re-examine the D -Box. We now find the D -Box at normal levels, no ponding. They had the pipes cleaned with water jetting by Drain King, which has unplogged the pipes. We monitored the D -Box for several months and it has maintained level. We are submitting a new Title V passing all criteria's Respectfully yours, /4� Sam Busa William F. Weld Gmmor TrudyCoxs S�erMary, ft David B. Struhs Commissioner Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION 5T /9)q�iaU�v Property Address: 74-3 Go 1,#�ei-,' Address of Owner: Date of Inspection: ! ,� C (If different) Name of Inspector: SS, 9- Company Name, Address and Telephone Number: t-� S rEw �.A- f IJ44�o� .S ��. en X7,e-,44,e-,44C /L/ S r CERTIFICATION STATEMENT �T1 � ( f 3 7� 7Y-7 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: /S Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: �/'' Date: 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: 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: N 4 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 ND). 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 Health. (revised 8/15/95) 1 One Winter Street • Boston, Massachusetts 02108 • FAX (617) 556-1049 • Telephone (617) 292-5500 %D Printed on Recycled Paper Property Address: Owner: Date of Inspection: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) '773 AIIJIrI-I& s >' ,A -I. I;Ztlfjlr vP v 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 pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: t( J 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 MANNER .WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM 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 from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D] SYSTEM FAILS: I have determined ttiat,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. It (revised 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: y 3 !� ��� r��- Sr •/��� U�°{2 Owner: Date of Inspection: (/r t - -e D) SYSTEM FAILS (continued) Static liquid lev 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 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: PA. 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 a mapped Zone II of a public water supply welh The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 Property Address: Owner: Date of Inspection: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL: Design flow: stallons Number of bedrooms. --401/ Number of current residents: y Garbage grinder (yes or no):�t Laundry connected to system (yes or no): --N--( Seasonal use (yes or no): /J Water meter readings, if available: /u /i• Last date of occupancy:—&tJ1/ r COMMERCIAUI N DUSTRIAL: Type of establishment: an, Design flow:allons/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: N. 4. System pumped as part of inspection: (yes or no) If yes, volume pumped �allons Reason for pumping: TYPE qT-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) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: / 4. Sewage odors detected when arriving at the site: (yes or no) ,U(j (revised 8/15/95) Property Address: Owner.: Date of Inspection: SEPTIC TANK:—Y^ (locate on site plan) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 5/9 V/rirrA, Sf , /,gtrn yrh '' C/a tmeo--1 '°v ! -IC ,V /r Depth below grade: I Material of construction: _concrete _metal _FRP —other(explain) Dimensions: r"'1 ` .{'" x ! d' Sludge depth:4 Distance from top of sludge to bottom of outlet tee or baffle: 7-�? .Scum thickness: L, 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.) ovr� GREASE TRAP:_ AA (locate on site plan) 9.4.- 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 From to bottom of outlet tee or battle: 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: 7 (13 ivj }/ Owner: j Date of Inspection: 0,4"P+A_ TIGHT OR HOLDING TANK:_ y• (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 BOXYPS (locate on site plan) Depth of liquid level above outlet invert: L yU ? Comments: (note if level and distribution i� equal, evidence of solidi carryover, evidence of leakage into or out of box, etc.) -e PUMP CHAMBER:_ (locate on site plan) / Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) 1 (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) i v�V Property Address: -) y3 yrcn. 5>~ �/ HD U Owner: Date of Inspection: �% P/,� '� e i - SOIL ABSORPTION SYSTEM (SAS): -PS (locate on site plan, if possible; excav ion 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,length: % eo'k leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) CESSPOOLS: _' . (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: (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) s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 2 �/� SYSTEM INFORMATION (continued) Property Address: r7a l 14 %Al�� M /�4 ,Oq4 v P h - Owner: Date of Inspection: IlAk&4te !/' 7 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' DEPTH TO GROUNDWATER Depth to groundwater:f 4('- feet - method of determination or approximation: C P c G %1 G w / 5 (/ /�-� 17 ✓ 0— 1 j ( �► Gv /I-- -I—e— ✓ 6 g Pr Ae -� G V 4 f' / S' i? 1+E i ♦ n la caq -f —i" % s Td] o c.,0— (revised 8/15/95) 9 V Commonwealth of Massachusetts ExecuWe Office of Emdronmental Affairs Department of Environmental Protecti William F. Weld r t3ovemor ` Trudy Coxe Secretary, EDEA David B. Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR1�A PART A ` CEBJIFICATION 17 WIN, Property Address: Address of Owner: Date of Inspection: J. � � % � (If different) Name of Inspector: Company Name, Address an -16 �eph�V Nu�e�[r�l 4V jZ17 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: Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: �" 7. r The System Inspe or 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: , f /J. 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: A1.4 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 ND). 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 Health. (revised 8/15/95) One Winter Street a Boston, Massachusetts 02108 a FAX (611) 556-1049 a Telephone (611) 292 -SSW ice, Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 77 .� CERTIFICATION (continued) P�/ Property Address: //3 Owner: C}2 Date of Inspection: 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 pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed Cl 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 MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM 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 fee! 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 from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D] SYSTEM FAILS: 10 S 1 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. failure. ilii Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. r. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. (revised 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: z13 �v/hl r r/z— 5T' /V. 411 Do Owner: 0,4 0 PA Date of Inspection: D] SYSTEM FAILS (continued): IkS Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. M #' 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. Alk Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. l Any portion of a cesspool or privy is within a Zone I of a public well. i� Any portion of a cesspool or privy is within 50 feet of a private water supply well. 4 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: �14 r The following criteria apply to large systems in addition to the criteria above: The design flmv 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 a 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 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: j Owner: L,�, 4 it' k-- Date of Inspection: ) f~ (P Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. _None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. r As built plans have been obtained and examined. Note if they are not available with N/A. V/The facility or dwelling was inspected for signs of sewage back-up. ✓The system does not receive non -sanitary or industrial waste flow -/The site was inspected for signs of breakout. " All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. 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. The facility o,�ner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub - Surface Disposal System. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C /,{/ �(f SYSTEM INFORMATION / Property Address: 7'7 3 o" III rr/a :5r /i • �qH 0 0 v P Owner: tS 14 A/ 10`if /? Date of Inspection: / f 7. 9 t/. ci nw rn►.inrnnkJc RESIDENTIAL: Design flow: Gallo s Number of bedrooms: 6 Number of current residents:_ Garbage grinder (yes or no):_ Laundry connected to system (yes or no):—Jd Seasonal use (yes or no):i�a Water meter readings, if available: Last date of occupancy: IV COMMERCIAUI N DUSTRIAL: 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: " i System pumped as part of inspection: (yes or no)_ If yes, volume pumped gallons 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) Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) _ (revised 8/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 7q3 3 r.4`1z 5 f %-'i/. %4".V 0® v e N Owner: Date of Inspection: f^� SEPTIC TANK:_ (locate on site plan) of Depth below grader Material of construction: _oncrete _metal _FRP —other(explain) Sludge depth: _ h Distance from top of sludge to bottom of outlet tee or baffle:, Scum thickness: / ►` 7 ,t Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: t `'1 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.) GREASE TRAP:_ k1h, (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 �ct)m t- bottom of outlet tee or battle:_ Comments: (recommendation for pumping, condition of inlet and outlet tees or integrity, evidence of leakage, etc.) (revised 8/15/95) 6 depth gjjgpid level in relation to outlet invert, structural SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: 1/ r i t+ C t✓ Date of Inspection: / -;L i- T 4 TIGHT OR HOLDING TANK:_ (locate on site plan) A, 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:1- (locate on site plan) Depth of liquid level above outlet invert: G 4v a� f1 fir' Comments: (note if level and distributor. ; equa!, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER:_ Al (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) 1 (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ��• SYSTEM INFORMATION (continued) Property Address: 7Y P,4 1v �, .1 re /z Owner:jet J E`71., '.#.. Date of Inspection: ,r SOIL ABSORPTION SYSTEM (SAS): (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,length: fit teelr S `�'B leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) CESSPOOLS:_ Ji 1, W (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: _ (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) s y • r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continuer!) Property Address: Owner: Date of Inspection: F' SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' TAmq 80 X I) Iu r• / l t r 4 l Aj'r4;1� DEPTH TO GROUNDWATER Depth to groundwater: feet method of determination or approximation: (revised 8/15/95) 9 IN, O'Neill Associates Civil Engineers and Land Surveyors 246 Main Street, Suite 7 NORTH READING, MA 01864 (508) 664-8141 Fax (508) 664-8142 TO S � t�0_,t, Q F1 1 -4z V,�PNN.v Z5'TZ` eT eta, V-='ttj�C_-� QcZ+ t--{ p i 8d S WE ARE SENDING YOU ❑ Shop drawings ❑ Copy of letter DATE 8- LIQ - "►b JOB NO. ATTENTION �-(S , � �►., D Zia S ► ai2. RE: Nc� . A�7AoV�.Z ►U N OF I�pAT'H AnJDO "1 VER/ BOARD FNfi.+:rT•�_, kAttached ❑ Under separate cover via rints X Plans EP❑ SAMRS ❑ Change order ❑ the following items: Specifications COPIES DATE NO. DESCRIPTION S of STc M 43 lnl t rm-tt s>ov e iZ- I V_- NPr-'v�c(2at- 1)ST,"Pe zK�- 1 THESE ARE TRANSMITTED as checked below: )<For approval ❑ Approved as submitted ❑ Resubmit copies for approval ❑ For your use ❑ Approved as noted ❑ Submit copies for distribution ❑ As requested ❑ Returned for corrections ❑ Return corrected prints XFor review and comment ❑ ❑ FORBIDS DUE 19 ❑ PRINTS RETURNED AFTER LOAN TO US REMARKS T%—*,S `� i r+ t S V P�2 V6- c ;=�Q S +c�,w, 'B'F5 CA,j S_­SiI—nzz -10.Q4E- V-N-ms c TJ ti -2q lit ti- l J t f-- CE Gee-tr-c-za0�_) s , _i_ V�t� �cyK�tvA3 L� i St- -,k4 COPY TO SIGNED: If enclosures are not as noted, kindly notify us at once. V NORTH ANDOVER BOARD OF HEALTH DESIGN REVIEW REPORT FEE: PERMIT ## DATE RECEIVED / APPLICANT 11/1Z6 MAP PARCEL ADDRESS LOT ## STREET # ENG. �"/ //(��� �"' STREET ENG. ADDRESS 5U/% 7 ,� PLAN DATE CONDITIONS OF APPROVAL APPROVED. REV. DATE 0 DISAPPROVED REASONS FOR DISAPPROVAL: a /� )01 . IUo 5701V 19 C DD RU D r AL'4eAf o/c j�G� aF roPSo/G SUC3Sc5/� >14 �1 �TE2� s /-J AGS O T/�G�� 1���(//DUS ��G 11f/JU //U c 116` S Tv T/fes /l/ATvrc°!� G 1 S 7 , �iJ�i�r l s 'tea lT6 /Lj EC ' C)Jcp, U���" <5/UcJ /f/�U� 56267 -EA-). O'Neill Associates Civil Engineers and Land Surveyors 246 Main Street, Suite 7 October 23,1996 North Reading, MA 01864 (508) 664-8141 FAX (508) 664-8142 TOWN OF Ms. Sandra Starr, R.S. BOARC i Health Administrator t Town of North Andover ? COT 2 9 jg Office of Community Development and Services 146 Main Street North Andover, MA 01845 t Re: 743 Winter Street Dear Ms. Stan, Enclosed please find three sets of plans titled, Proposed Subsurface Septic Disposal System, 743 Winter Street, North Andover, Massachusetts, latest revision date 10-8-96. The plans have been revised to reflect the comments in your letter dated October 4, 1996: Comment 1. Sheet 1, See General Notes, Note 4 Comment 2. Sheet 1, See General Notes, Note 12 Comment 3. Sheet 2, See Detail of Leaching Facility Comment 4. Six inches of stone has been provided. A variance from Section 18.05 of the Town of North Andover regulations requiring a minimum of 12 inches underneath the system is requested. The system is designed and the proposed grading meets Title 5 requirements regarding providing the break out set backs. Because of the site area limitations, raising the grade an additional 6 inches to allow for 12 inches of stone would require installing reinforced concrete retaining walls to meet Title 5 requirements. This will add substantially to the cost of replacement of the existing system proposed. The estimated cost of the replacement is $10,000 prior to making the current revisions to the plans. Comment 5. See Pump System Detail, Note 4. No check value or bleeder hole has been provided since the back flow to the pump chamber after each cycle is only 7 gallons. See Note 1. Comment 6. See Sheet 1, General Notes, Note 1. Comment 7. See Sheet 2, Soils Testing Comment 8. See Sheet 2, Vent Svstem Detail. vt� v Enclosed is a check for the amount of $25.00 for reviewing the resubmitted plans'� � G�0 �' �\ If you have any further questions please do not hesitate to call. } U`T, Very Truly Yours, Michael O'Neill P.P.E. John Hancock Mutual Life Insurance Company Corporate Compensation John Hancock Place P.O. Box 111 Boston, Massachusetts 02117-0111 Telephone (617) 572-6783 Fax(617)572-6336 Lynette D. Carpenter Executive Compensation Consultant October 25,1996 Sandy Starr, Environmental Engineer Board of Health - Town of North Andover 146 Main Street North Andover, MA 01845 Dear Ms. Starr: Financial Services We have delayed the signing of our Purchase and Sale agreement on our residence, pending approval of the engineering drawings for the repair of our septic system. We still see no evidence of failure and hope that the diagnosis is correct. Mike O'Neill, the engineer we hired, appears to be very knowledgeable, but is not very thorough in following through on commitments. You originally visited our property in April, did not see any evidence of a proposed drawing until August, and are now reviewing revised drawings in October. We are scheduled to close on the sale of our residence on December 31,1996. We hope to have the repairs of the septic system done prior to the closing. Sandy, can you issue a satisfactory Title V certificate if the lawn is not seeded and loomed. Does the weather this time of year prevent seeding and looming? We appreciate your review and approval of the revised plans. Our delayed P & S date is scheduled for the 31th of October. Either myself or our engineer will attempt to reach you on October 30th. Our engineer had promised he would have the revised plans to you last week. I guess you know how that goes! Sandy, thanks for your help. Sincerely, ette D. Carpenter PITS MIN 660 LEACHING MIN 1 (131x16') PIT MANHOLE/PIT GW MIN 4' BELOW BOTTOM EXC 2x EFF W OR D 12"-48" STONE BOT + SIDE x LOAD = TOTAL (L x W x #) (2x(L+W) xD x #) (G/ft2) CHAMBERS 3 MIN 660 LEACHING GW MIN 4" BELOW COVER >3 FT - VENT MANHOLES 12"-48" STONE SPLASH PADS SLOPE .005 BED/TRENCH (Bed max. 60' X 601) MIN 13' X 16' PIT BOT (L x W x #) FIELDS MIN 660 GPD_Z + SIDE X LOAD = TOTAL (2 x (L+W) XD x #) (G/ft2) 900 ft2 BED GW MIN 4' BELOW BOTTOM OF FIELD PIPE ENDS JOINED? 4" PEA STONE? DIST LINE SLOPE > 3 ' COVER-VEN�LX�1" WP 9CH 4 0 MIN 12 " COVER RATE'�,�/ LDG X 660 = ,� QQ X TOTAL G66 G/ft2 REQ'D (ft2) LXW 1" 5 rOiu6; UAAD 6:- . DOSING TANKS AND PUMPS DIMENSIONS X X = PUMP CAPACITY 9Pm L W D Vol. DISCHARGE SIZE �M % r/ DISCHARGE RATE 17• b DISCHARGE TIME 9Pm MANHOLES TO GRADE ALARM SEP. CIRC. L*-� GW (Min. 1' below inlet HWL LWL CHECK VALVE BLEEDER HOLE MANUAL OP . SWITCH AAD l 6G�r Copyright `D 1995 by S.L. Start PLAN REVIEW CHECKLIST ADDRESS ENGINEER 0 GENERAL p� 3 COPIES v/ STAMP Z- / LOCUSZ NORTH ARROW SCALE c/ CONTOURS v PROFILE v SECTION BENCHN[ARK ` SOIL & PERCS ELEVATIONS WETS. DISCLAIMER WELLS & WETS WATERSHED?j DRIVEWAY (E1ev) WATER LINE FDN DRAIN SCH40 ✓ TESTS CURRENT? SOIL EVAL SEPTIC TANK MIN 150OG .17 INVERT DROP GARB. GRINDER(+200% EDF) 25' TO CELLAR MANHOLE ELEV GW # COMPS. D -BOX SIZE # LINES FIRST 2' LEVEL STATEMENT INLET �bJ.V` - OUTLET lDi 3 % ( 2" OR .17 FT) TEE REQ' D? �S LEACHING MIN 660 GPD?'z RESERVE AREA 4' FROM PRIMARY? 2% SLOPE ✓- 100' TO WETLANDS 100' TO WELLS, 4' TO S.H.GW (5'>2M/IN) 35' TO FND & INTRCPTR DRAINS 325' TO SURFACE H2O SUPP 4' PERM. SOIL BELOW FACILITY MIN 12" COVER FILL? (25' if above natural elev; 10'if below) BREAKOUT MET? TRENCHES 1 MIN 660 gpd SLOPE (min .005 or 6"/100') SIDEWALL DIST. 3X EFF. W OR D (MIN 61) RESERVE BETWEEN TRENCHES? IN FILL? MUST BE 10' MIN. 4" PEA STONE? VENT? (>3' COVER; LINES >50') BOT + SIDE X LDNG = TOT (L x W x #) (DxLx2x,#) (G/ft2) Copyright'0 1995 by S.L. Suir 11 FORM 11 - SOIL EVALUATOR FORM Page 1 of 3 No. Date: Commonwealth of Massachusetts i r=> F1Ntu3=,o\/ Ew, r... oilassachuSeus u OuttuutilcY r>Z)sesmitvia �%ur un -sue Sewage Msposci Performed By: ... ....C��_.`....N4..1.....,.�. Date: Witnessed By: _ .............. S 1.z.+ __...... .7. ..... ...... ....... .. . ....................................................... - ..... ...... Location Address or Owrcr•s Name,��--�—�— c CAS PCN T�� La I -�7 bJ 1 �iT 5 Address, and Talcphorc / fiJ o t2 -� A tv �o v iZ * C, ,Amt ©v c'g t-4 New construction ❑ Repair X, 6 2 —.4 e Zy OfFiice Review, Published Soil Survey Available: No ❑ Yes RI Year Published • t981 ... Publication Scale 640 Drainage Class tom- ........ Soil Limitations `... Surficial Geologic Report Available: No R Yes ❑ Year Published Publication Scale •.,ec, :ogic l .ateria ('Alap Uni ) ................................................................ Landform............................................................................. .......................................... Flood Insurance Rate Map: Above 500 year flood boundary No ❑ Yes V Within 500 year flood boundary No 10 Yes ❑ Within 100 year flood boundary No 1J Yes ❑ Wetland Area: > t oo F r, National Wetland Inventory Map (map unit) ...................... Wetlands Conservancy Program Map (map unit) ......... Current Water Resource Conditions (USGS): Month Range :Above Normal El Normal El Below Normal ❑ Other References Reviewed: DPP APPROVED FORM - 12/07/95 Soil Map Unit Cbb t FORM 11 - SOn, EVALUATOR FOR -NJ Page 2 of 3 Location Address or Lot No. -14- -:-2> 1 :�1:5 7r, On-site Review Deep Hole Number Time: Weather Location (identify on site plan' A C e. Land Use Slope Surface Stones TZA-=---k -7 4 Itt. W k re re- --.r, Vegetation Landform Position on landscape (sketch on the back) Distances from: Open Water Body — feet Drainage way feet Possible Wet Area — feet Property Line to feet Drinking Water Well feet Other DEEP OBSERVATION HOLE LOG* Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface (inches) (USDA) (Munsell) Mortlina (Structure..Stones, Boulders, Consistency, % Gravel) 4 liz qL (:—;I iz qZ IF:, CLV4k C=1 CV r. e -Sk-q V% Z S. k kK&014-S 4_-A l' MINIMUM Ur Z NULt,) f1tUU1t1tU A I tVtKY FKUVU6l:U, U16PUSAL AKLA Parent Material (geologic) gfm- 1_f --.,c k (Z" t-- 1 Depthto8edrock: J)epth to Groundwater: Standing Water in the Hole: V..) a QZ Weeping from Pit Face: Estimated Seasonal High Ground Water: DFP APPROVED FOUM - 12/017/95 x FORM 11 - SOIL EVALUATOR FORM Page 3 of 3 Location Address or Lot No. 'Sr. two, AN�av,�2 Determination far Seasonal High Water Table 1'eir-10%,J Usa , ❑ Depth observed standing in observation hole .............. inches ❑ Depth weeping from side of observation hole ................. inches .Depth to soil mottles z.'Z inches ❑ Ground water adjustment ................... feet Index Well Number ................. Reading Date .................. Index well level ........... Adjustment factor .................. Adjusted ground water level .................................................. Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? mitts If not, what is the depth of naturally occurring pervious material? Certification I certify that on IS ­8 -9s (date) I have �assed the soil evaluator examination approved by the Department of Environments Protection and that the above analysis was performed by me consistent with the required -training, expertise and experience described in 310 CMR 15.017. c'...,gt , \ D ..�gure ..ate 8-Z2-91. DFP APPROVED FORM - 12/07/95 No. THE COMMONWEALTH OF MASSACHUSETTS FEE MASSACHUSETTS �yyltirnttivu for Construction 16utit Application is hereby made for a Permit to Construct ()() or Repair ( ) an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name, Address and Tel. No. V` -'A5. -4 "eT;z lz os 2 RC1 tesla , c> Vv S> 0'j (=8 z — 41B2 -j Installer's Name, Address, and Te1.No. Designer's Name, Address and Tel. No. M �C N ACS ®, !jekt._L �Ctt„_1._S tr',:cS 24c� laaAt%..,'$ i. i-90 • ZC-_=r1s>cam , Type of Building: Dwelling Other -'>Q tZ i_–ba-- — V-� ' 4 I No. of Bedrooms 4 Garbage Grinder (tom) Type of Building 2,c�7 2 No. per Persons Showers ( ) Cafeteria ( ) Other Fixtures Design Flow 4 +<=� gallons per day. Calculated daily flow Plan Date 6 2—" S L Number of sheets Revision Date Title :5 1� = �•r c css��s€�,� � 5 ck -1 W % a kcz Description of Soil d — c l c -,-zA Nature of Repairs or Alterations (Answer when a plicable) iZci��caC� "c ► n r n v= Date last inspected: P gallons. Agreement: The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed _ Application Approved by Application Disapproved for the following reasons Permit No. Date Date Date Issued THE COMMONWEALTH OF MASSACHUSETTS , MASSACHUSETTS C�exttttrate of (ICIIxitylian ce THIS IS TO CERTIFY, that the On-site Sewage Disposal System installed( ) or repaired/replaced ( ) on by for at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit .No. dated . Use of this system is conditioned on compliance with the provisions set forth below: The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. This Certificate expires on nATF. __ Inspector SEPTIC PLAN SUBMITTALS LOCATION: NEW PLANS: OYES $60.00/Plan` 4 REVISED PLANS: YES $ .07Plan DATE:—&.Qk I lq , L DESIGN ENGINEER: 0 % n &� U rx� C , 'L'—� When the submission is all in place, route to the Health Secretary f MORTly o � p •^SAI as�cHusEt Town of North Andover, Massachusetts BOARD OF HEALTH Form No. 2 DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant 0 n I _L,UC Q0-d'� Test No. Site Location I L{ —� l I )ti T 1t SA —( A. Reference Plans and Specs.l E DA Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. IK Fee CHAIRMAN, BOA R13 OF HEALTH Site System Permit No. / v