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Home My WebLink AboutMiscellaneous - 747 FOREST STREET 4/30/2018mhisiffi 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. tab Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 747 Forest Street Property Address Adel Dressel Owner's Name North Andover MA 01845 06/14/13 Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form.=�- RECEIVED A. General Information Inspector: JUL 012013 TOWN OF NORTH ANDOVER John J Soucy r HEALTH DEPARTMENT Name of Inspector Soucy's Sewer Service, Inc. Company Name 78 North Broadwav Company Address Salem CityFrown 603-898-9339 Telephone Number B. Certification NH State 13397 License Number 03079 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ ed Further Evaluation by the Local Approving Authority A -kC.C� L Insp o s rigniture Date TOX system inspector shall submiKa copy of this inspection report to the Approving Authority (Board o Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 1 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °w 747 Forest Street Property Address Adel Dressel Owner Owner's Name information is North Andover MA 01845 required for every page. City/Town State Zip Code B. Certification (cont.) 06/14/13 Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old" or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 747 Forest Street Property Address Adel Dressel Owner's Name North Andover MA 01845 06/14/13 City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ❑ distribution box is leveled or replaced Needs replacing, falling apart. ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 747 Forest Street Property Address Adel Dressel Owner's Name North Andover City/Town B. Certification (cont.) MA _01845 06/14/13 State Zip Code Date of Inspection 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 747 Forest Street Property Address Adel Dressel Owner Owner's Name information is required for every North Andover MA 01845 06/14/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts _ d Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 747 Forest Street Property Address Adel Dressel _ Owner Owner's Name information is North Andover MA 01845 required for every page. City/Town State Zip Code C. Checklist 06/14/13 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 -- DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 330 t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form — Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 747 Forest Street Property Address Adel Dressel _ Owner Owner's Name information is required for every North Andover page. City/Town D. System Information Description: MA 01845 State Zip Code 06/14/13 Date of Inspection 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: Gallons per day (gpd) ❑ Yes ® No Current Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No P t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Number of current residents: 2 ---- Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 9 ( Y 9 (gp ))� Private Detail: Well Water — 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: Gallons per day (gpd) ❑ Yes ® No Current Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No P t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 747 Forest Street Property Address Adel Dressel Owner Owner's Name information is North Andover required for every page. City/Town D. System Information (cont.) Last date of occupancy/use: Other (describe below): MA 01845 State Zip Code General Information Current Date 06/14/13 Date of Inspection Pumping Records: f f t Owner/Soucy's Sewer Service 2013 Source o In orma lone Was system pumped as part of the inspection? If yes, volume pumped: 1500 gallons How was quantity pumped determined? gage on truck Reason for pumping: Maintenance and In Type of System: ® Septic tank, distribution box, soil absorption system El Single cesspool ❑ Overflow cesspool El Privy on ® Yes ❑ No ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts ----W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments /y 747 Forest Street Property Address Adel Dressel Owner Owner's Name information is required for every North Andover MA 01845 06/14/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1990. orioinal Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): 28" Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: over 100' feet Comments (on condition of joints, venting, evidence of leakage, etc.) Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 10" feet ❑ Yes ® No ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: Sludge depth: ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^wa 747 Forest Street Property Address Adel Dressel Owner Owner's Name information is required for every North Andover page. City/Town t5ins - 3113 D. System Information (cont.) Septic Tank (cont.) MA 01845 _ 06/14/13 State Zip Code Date of Inspection Distance from top of sludge to bottom of outlet tee or baffle 38 — 2" Scum thickness Distance from top of scum to top of outlet tee or baffle 6 -------- — Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Tape and sludge tool Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 747 Forest Street Property Address Adel Dressel Owner Owner's Name information is North Andover MA 01845 06/14/13 required for every page. City/Town State Zip Code Date of Inspection D. System information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: --- Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: — - Alarm in working order: Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ❑ Yes ❑ No * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 747 Forest Street -- Property Address Adel Dressel Owner's Name North Andover MA 01845 06/14/13 City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): "D" box replaced prior to inspection see attached permit. _ Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts u ; Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 747 Forest Street Property Address Adel Dressel Owner Owner's Name information is MA 01845 required for every North Andover page- CityFrown State Zip Code D. System Information (cont.) Type 06/14/13 Date of Inspection ❑ leaching pits number: ❑ leaching chambers number: - ❑ leaching galleries number: ® leaching trenches number, length: (3) 40' long ❑ leaching fields number, dimensions: -- ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No signs of hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool -------- Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 747 Forest Street Property Address Adel Dressel Owner Owner's Name information is required for every North Andover page. City/Town D. System Information (cont.) MA 01845 06/14/13 State Zip Code Date 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.): t5ins • 3/13 - Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s7 Subsurface Sewage Disposal System Form Not for Voluntary Assessments 7d7 Fnract gtrPPt Property Address Arial nracsPl Owner Owner's Name information is North Andover required for every — page. city/Town D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below 71 rlrawinn attached separately MA 01845 State Zip Code 06/14/13 Date of Inspection t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Commonwealth of Massachusetts Q Title 5 Official Inspection Form S Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 747 Fnregt Street — Property Address Anal nrecgPl __ — Owner Owner's Name information is North Andover MA required for every State page. Cityrrown D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells 01845 06/14/13 _ Zip Code Date of Inspection 6' _ Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record 7/1999 If checked, date of design plan reviewed. Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Dug hole with auu er in low drop off area. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V 747 Forest Street Property Address Adel Dressel Owner Owner's Name information is MA 01845 06/14/13 required for every North Andover page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information — Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 15ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 . . ......... ..... ... . .... Commonwealth of Massachusetts t05.Ml 72 BOARD OF HEALTH • BHP-2013-0779 North Andover S125,00 F.L DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted J"1111 (Repair) an IIXIM(hlal Sewage Disposal Systerri, a -�,o "ET t 747 FORES�T S'l.'R.F its shown on the application for Disposal \V01-`s construction Permit yo. BIJ11-1-0 13-1077 [med . .1unc 10., 2013 Issued On: R111- 10201 3 a4 - R 1) OF H EA LA 11 • 111111 111 T1 k BILE COPS' •Tlip '-V PUBLIC PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 6/13/2013 This is to certify that the individual subsurface disposal system has been installed in accordance with the provisions of Title 5 of the State Environmental Code: D -Box Repair By: John Soucy At: 747 Forest Street Map 105D Lot 0172 North Andover, MA 01845 AThesuanceof th' ertificate ''hall not be construed as a guarantee that the system will function satisfactorily. UL ele Grant Public Health Agent 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com North Andover Health Department Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 747 Forest St. MAP: 105D LOT: 0172 INSTALLER: John Soucy DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS — DBox inspection 6/13/2013 TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS Comments: SEPTIC TANK ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port Comments: PUMP CHAMBER Comments: CONTROL PANEL Comments: DISTRIBUTION -BOX ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: D -Box is 27' deep. Installed on stable stone base H-20 D -Box Inlet tee (if pumped or >0.08'/foot) Hydraulic cement around inlet & outlets Observed even distribution Speed levelers provided (not required) Commonwealth of Massachusetts BOARD OF HEALTH North Andover P.I. Map -Block -Lot 105.DO172 ----------------------- Permit No BHP -2013-0779 ----------------------- FEE F.I. $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted -John -S-o-u-cy ---------------------------------------------------------------------------------------------- to (Repair) an Individual Sewage Disposal System. at No 747 FOREST STREET ---------------------------------------------------------------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. .13HP-20137077 --- Dated June 10, 20 - 13 -------- 110, - --------- --- - - --- ---- ---- Issued On: Jun -10-2013 O_Z50 RD OF HEALTH V -- ---------------------------------------------------------- Commonwealth of Massachusetts BOARD OF HEALTH North Andover CE %FICATE OF CO PL THIS IST 7CERTIFY, hat the Individual Sewag isposal Sy! John"S.oucy --- I \ / I-------- CE (Repair) Map -Block -Lot 105.DO172 ----------------------- at No 747 FOKST-STREET - ------------------------------------------------------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. _13HP-20137077 Dated ---June_ 10,-2013-------- ----------------------------------------------------------------- Printed On: Jun -10-2013 BOARD OF HEALTH ----------------------------- - --- - -------- ------------------------------------- Commonwealth of Massachusetts Map -Block -Lot 105.DO172 BOARD OF HEALTH ----------------------- Permit No North Andover BHP -2013- 07 79 ----------------------- FEE $125.00 DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted John -SOUCY ---------------------------------------------------------------------------------------------- to (Repair) an Individual Sewage Disposal System. b- box at No _747 FOREST -S-TREE-T ---------------------------------------------------------------- LEU --LE -copy as shown on the application for Disposal Works Construction Permit No. BHP -2013-077 Dated June 10, 2013 - -- --------- ----------------------------- Issued On: Jun -10-2013 ---------- ----------------------------------------------------------------- BOARD OF HEALTH Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Application for Septic Disposal System Construction Permit -TOWN OF AvOlcation is hereby made fora vermit to: Construct a new on-site sewage disposal system* RX9-0s�T $250.00- $125.00- 0 250.00- $125.00- ❑ Repair or replace an existing on-site sewage disposal system* i 6�yRepair or replace an existing system component - What? \1 A. Facility I nun Address or Lot # j n. R�a City/rown 2.- *TYPE OF SEPTIC SYSTEMA*: ❑ Pump 9Gravity (choose one) ***If pump system, attach copy of electrical permit to application*** (Conventional System (pipe and stone system) ❑ Infiltrator or Blodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D -Box Present) S.A.S. 2. Name Add (ff di rent frp/ ��above) 6011 (J 1 b City/I own Zip Code Telephone Number 3. Installer Information h Cel,- Namg � q Name of CQMoany mdress— e n, n 14 03_'-) 7�/ Cityrrown State Zip Code Telephone Number (Cell Phone # if possible please) 4. Des!ner Information Name /V/ fr Name of Company Address ' City/Town State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 RT �h Application for Septic Disposal System PAM a . 'Construction Permit —TOWN OF ORTH ANDOVER, MA 01845 s25o.00—Full Repair �9SSASEi�`i $125.00 -Component CNII PAGE 2OF2 A. Facility Information continued.... s. Type of Building:)OResidential Dwelling or []Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewage disposal system in accordance with the provisions of Title 5 of the EnvirqMAental Code, as well as the Local Subsurface Disposal Regulations for the Town of Norffi An over, and no o place the system in operation untifl a Certificate of Compliance has b en iss ed by this IWO of Health. -Name — i Date C A00lication Approved By: (BoarW of Health Representative) Name / /, / / Date Application Disapproved foythe following reasons: For Office Use Only: 1. Fee Attached. Yes " Z. Project Manager Obligation Form Attached. Yes No No 3. Pump System? Ifso, Attach copy ofElectrical Petmit Yes No 4. Foundation As Builta (hew construction ronly). (Same scale as approved plan) Yes No S. Floor Plans? (hew construction only). Yes No Application for Disposal System Construction Permit • Page 2 of 2 of NORTH 3y 6515 Town of North Andover HEALTH DEPARTMENT cHu CHECK #: �(n 1 DATE: ID 1 "i t LOCATION: H/O NAME: 1J 1 f::,> te` CONTRACTOR NAME:, Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ Septic Disposal Works Construction (DWC) ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ Title 5 Report $ ❑ Other: (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer =lam . 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. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 747 Forest Street Property Address Adel Dressel Owner's Name North Andover City/Town / V MA 01845 05/29/13 71� State Zip Code Date of Inspection Vi Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information Inspector: John J. Souc Name of Inspector Soucy's Sewer Service, Inc. Company Name 78 North Broadway Company Address Salem NH 03079 City/Town State Zip Code 603-898-9339 13397 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ :eeds sConditionally Passes ❑ Fails ❑ F rther Evaluationky the Local Approving Authority Date Tqe (ystem inspector shall submit a c?6py of this inspection reort to the Approving Authority (Board o ealth or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 747 Forest Street Property Address Adel Dressel Owner's Name North Andover MA 01845 05/29/13 CityFrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °w 747 Forest Street M Property Address Adel Dressel Owner information is required for every page. Owner's Name North Andover MA 01845 05/29/13 City[Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): Needs replacing falling apart. ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 747 Forest Street Property Address Adel Dressel Owner's Name North Andover MA 01845 05/29/13 City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/ day flow t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 747 Forest Street Property Address Adel Dressel Owner Owner's Name information is required for every North Andover MA 01845 05/29/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 747 Forest Street Property Address Adel Dressel Owner Owner's Name information is required for every North Andover page. City/Town C. Checklist MA 01845 State Zip Code 05/29/13 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® El the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? information The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 330 t5ins • 3/13 Title 5 Oficial Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 747 Forest Street M Property Address Adel Dressel Owner Owner's Name Yes ❑ No information is North Andover MA 01845 05/29/13 required for every Yes ❑ No page. City/Town State Zip Code Date of Inspection Yes ❑ D. System Information Description: 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Private Water meter readings, if available last 2 ears usage d 9 ( Y 9 (gp ))� Detail: Well Water Sump pump? ❑ Yes ® No Current Last date of occupancy: Date 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: Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 747 Forest Street Property Address Adel Dressel Owner Owner's Name information is required for every North Andover MA 01845 05/29/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Current Date Other (describe below): General Information Pumping Records: Sf information: Owner/Soucy's Sewer Service 2008 ource o Was system pumped as part of the inspection? If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): ❑ Yes ® No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 747 Forest Street M Property Address Adel Dressel Owner Owner's Name information is required for every North Andover page. City/Town D. System Information (cont.) MA 01845 State Zip Code 05/29/13 Date of Inspection Approximate age of all components, date installed (if known) and source of information: 1990. orioinal Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): 28" Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: over 100' feet Comments (on condition of joints, venting, evidence of leakage, etc.) Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 10" feet ❑ Yes ® No ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: Sludge depth: ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 747 Forest Street Property Address Adel Dressel Owner Owner's Name information is required for every North Andover page. City/Town t5ins • 3113 D. System Information (cont.) MA 01845 State Zip Code 05/29/13 Date of Inspection Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 38 Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Tape and sludge tool Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 747 Forest Street Property Address Adel Dressel Owner Owner's Name information is required for every North Andover MA 01845 05/29/13 page. CityFrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 747 Forest Street Property Address Adel Dressel Owner Owner's Name information is North Andover required for every page. City/Town D. System Information (cont.) MA 01845 State Zip Code 05/29/13 Date of Inspection Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 11 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): "D" box needs replacement Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 747 Forest Street Property Address Adel Dressel Owner Owner's Name information is required for every North Andover page. City/Town D. System Information (cont.) . Type State 01845 05/29/13 Zip Code Date of Inspection ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: (3) 70' long ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No sions of hvdraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 0 747 Forest Street 'M Property Address Adel Dressel Owner Owner's Name information is North Andover MA 01845 05/29/13 required for every page. CityFrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells 6' Estimated depth to high ground water: 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: Duq hole with auqer in low drop off area. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts -- v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 747 Forest Street r -I VlJeny r,aaress Adel Dressel Owner Owner's Name information is required for every North Andover MA 01845 05/29/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 747 Forest Street -M Property Address Adel Dressel Owner Owner's Name information is required for every North Andover MA 01845 05/29/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 747 Forest Street Property Address Adel Dressel Owner Owner's Name information is required for every North Andover MA 01845 05/29/13 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information — Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 TOWN OF �NORtH ANDOVER SYSTEM PUWING RECORD DATE SYSTEM OWNER & ADDRESS SYSTEM LOCATION Wires T- ST DATE OF PUMPING 1194 6, QUANTITY PUMPED j S6 (j &Z - CESSPOOL NO YES / NATURE OF SERVICE: ROUTINE y/ SEPTIC TANK NO YES t/ EMERGENCY OBSERVATIONS: GOOD CONDITION Y FULL TO COVER HEAVY GREASE BAFFLES IN LACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLID CARRYOVER OTHER EXPLAIN SYSTEM PUMPED BY 00, COMMENTS: A{ CONTENTS TRANSFERRED TO Oc-d i✓ �%'j I