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�roperty Record Card
Parcel ID :210/107.B-0039-0000.0 FY:2009 Community: North Andover
SKETCH
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75 BOSTON STREET
Location: 75 BOSTON STREET
Owner Name: CHAMPAGNE, JOHN
LUISI, DONNA L.
Owner Address: 75 BOSTON STREET
City: NORTH ANDOVER State: MA Zip: 01845
Neighborhood: 5 - 5 Land Area: 1.01 acres
Use Code: 101-SNGL-FAM-RES Total Finished Area: 1328 sqft
ASSESSMENTS CURRENT YEAR PREVIOUS YEAR
Total Value: 345,000 345,000
Building Value: 147,600 147,600
Land Value: 197,400 197,400
Market and Value: 197,400
Chapter Land Value:
http://csc-ma.us/PROPAPP/display.do?linkId=1465958&town=NandoverPubAcc 11/2/2009
6451
Of 4NORT .,M
O _ _ 9
Town of North Andover
HEALTH DEPARTMENT
�sswCHU
CHECK #: A A 010
�1 DATE: p�
,
LOCATION: I Po-,4tfA-,
H/O NAME:
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
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.
1 �I
Commonwealth of Massachusetts .
Title 5 Official Inspection
Subsurface Sewage Disposal System Form - Not for V�
75 BOSTON STREET
Property Address j
MARYELLEN MANTYLA ll
Owner's Name
NORTH ANDOVER, MA.
Cityrrown State
Inspection results must be submitted on this form. In!
way. Please see completeness checklist at the end of
A. General Information
1. Inspector.
BRIAN S. MURPHY
Name of Inspector
B & D SEPTIC INSPECTIONS
Company Name
P.O. BOX 47
Company Address
HULL,
City/rown
(781) 290-9942
Telephone Number
B. Certification
For
MA.
State
SI3675
License Number
02045
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
❑ Needs Further Evaluation by the Local Approving Authority
spectors Signature
1/11/13
Date
❑ FIs RECEIVED
MM, 21 2013
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
""This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
C 0 [P If
t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17
1$
Owner
information is
required for every
page.
Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
vel
Commonwealth of Massachusetts .
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
75 BOSTON STREET
Property Address
MARYELLEN MANTYLA
Owner's Name
NORTH ANDOVER, MA. 01845 1/11/13
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.
A. General Information
Inspector.
BRIAN S. MURPHY
Name of Inspector
B & D SEPTIC INSPECTIONS
Company Name
P.O. BOX 47
Company Address
HULL,
Citylrown
(781) 290-9942
Telephone Number
B. Certification
MA.
State
SI3675
License Number
02045
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
❑ Needs Further Evaluation by the Local Approving Authority
spectors Signature
1/11/13
Date
❑ Fils RECEIVED
MAI, 21 2013
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
C O P ly
t5ins • 11110 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
75 BOSTON STREET
Property Address
MARYELLEN MANTYLA
Owner's Name
NORTH ANDOVER, MA. 01845 1/11/13
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
LAUNDRY HAS BEEN CONNECTED TO SEPTIC SINCE LAST INSPECTION.
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):
l5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
75 BOSTON STREET
Property Address
MARYELLEN MANTYLA
Owner Owner's Name
information is
required for every NORTH ANDOVER, MA. 01845
page. Cityrrown State Zip Code
B. Certification (cont.)
B) System Conditionally Passes (cont.):
1/11/13
Date of Inspection
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if (with approval of Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
❑ distribution box is leveled or replaced
❑ Y ❑ N ❑ 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 • 11110 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
75 BOSTON STREET
Property Address
MARYELLEN MANTYLA
Owner's Name
NORTH ANDOVER, MA. 01845 1/11/13
cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
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 Y day flow
t5ins • 11/10 Title 5 Official Inspection Forth: 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
75 BOSTON STREET
Property Address
MARYELLEN MANTYLA
Owner Owner's Name
information is
required for every NORTH ANDOVER, MA. 01845 1/11/13
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.
El
®
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 If 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 • 11110 TWO 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
75 BOSTON STREET
Property Address
MARYELLEN MANTYLA
Owner Owner's Name
information is
required for every NORTH ANDOVER, MA. 01845
page. Cityrrown State Zip Code
C. Checklist
1/11/13
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?
El ® 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): N/A Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): N/A
t5ins • 11110 Title 5 Official 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
75 BOSTON STREET
Property Address
MARYELLEN MANTYLA
Owner Owner's Name
information is NORTH ANDOVER
required for every
page. City/Town
D. System Information
Description:
MA. 01845 1/11/13
State Zip Code Date of Inspection
Number of current residents:
Does residence have a garbage grinder?
Is laundry on a separate sewage system? [if yes separate inspection required]
Laundry system inspected?
Seasonal use?
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump?
Last date of occupancy:
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 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
Z
No
■
Yes
Z
No
■
Yes
0
No
■
Yes
0
No
APPX. 90 GPD
❑ Yes ® No
PRESENT
Date
❑
Yes
❑
No
❑
Yes
❑
No
❑
Yes
❑
No
l5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
75 BOSTON STREET
Property Address
MARYELLEN MANTYLA
Owner Owner's Name
information is NORTH ANDOVE
required for every
page. City/Town
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
Pumping Records:
Source of information:
MA. 01845 1/11/13
State Zip Code Date of Inspection
General Information
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Date
SYSTEM LAST PUMPED 9/11 - HOMEOWNER
gallons
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Yes ® No
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the IIA system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other (describe):
l5ins • 11/10 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
75 BOSTON STREET
Property Address
MARYELLEN MANTYLA
Owner Owner's Name
information is
required for every NORTH ANDOVER, MA. 01845 1/11/13
page. Cityrrown state Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
50+ YRS. SYSTEM INSTALLED 7/60 - D -BOX REPLACED 9/09 - LOCAL BOH RECORDS.
Were sewage odors detected when arriving at the site?
Building Sewer (locate on site plan):
Depth below grade:
Material of construction:
® cast iron ❑ 40 PVC ❑ other (explain):
Distance from private water supply well or suction line:
❑ Yes ® No
1411
feet
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 ❑ fiberglass
18"
feet
❑ polyethylene ❑ other (explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate)
Dimensions: 6'L X 5'W X 4'D
Sludge depth:
1"
❑ Yes ❑ No
t5ins - 11/10 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System - Page 9 of 17
Commonwealth of Massachusetts
lug
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
75 BOSTON STREET
Property Address .
MARYELLEN MANTYLA
Owner Owner's Name
information is NORTH ANDOVE
required for every
page. Cityfrown
D. System Information (cont.)
Septic Tank (cont.)
MA. 01845 1/11/13
State Zip Code Date of Inspection
Distance from top of sludge to bottom of outlet tee or baffle 17" (OUTLET @ 40")
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle 22
How were dimensions determined? MEASURED IN FIELD
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, CEMENT INLET BAFFLE AND SCH.40 OUTLET TEE IN GOOD CONDITION, LIQUID
LEVEL WITH OUTLET, TANK APPEARS SOUND NO SIGNS OF LEAKAGE, RECOMMEND
INSTALLING RISER ON CENTER COVER.
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:
t5ins - 11110
Date
Title 5 Official Inspection Forth: Subsurface Sewage Disposal System - Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
N 75 BOSTON STREET
Property Address
MARYELLEN MANTYLA
Owner Owner's Name
information is NORTH ANDOVER
required for every
page. City/Town
MA. 01845 1/11/13
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:
Design Flow:
Alarm present:
Alarm level:
gallons
gallons per day
❑ Yes ❑ No
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 - 11/10 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
75 BOSTON STREET
Property Address
MARYELLEN MANTYLA
Owner Owner's Name
information is
required for every NORTH ANDOVER, MA. 01845 1/11/13
page. Cityfrown 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 IN GOOD CONDITION, LIQUID LEVEL WITH OUTLETS DISTRIBUTION APPEARS EQUAL,
NO SIGNS OF CARRYOVER OR LEAKAGE, BOX 24" BELOW GRADE, RECOMMEND
INSTALLING RISER.
Pump Chamber (locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins - 11110 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 12 of 17
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
75 BOSTON STREET
Property Address
MARYELLEN MANTYLA
Owner- — -
Owner's Name
information is NORTH ANDOVER
required for every
page. City/Town
MA. 01845
State Zip Code
1/11/13
Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits
number:
❑ leaching chambers
number:
❑ leaching galleries
number:
® leaching trenches
number, length: 4 @ 50'- 1 @ 30'
❑ 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.):
SOIL CONDITIONS NORMAL, NO SIGNS OF HYDRAULIC FAILURE, VEGETATION NORMAL.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth — top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins • 11/10 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System . Page 13 or 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
75 BOSTON STREET
Property Address
MARYELLEN MANTYLA
Owner Owner's Name
information is
required for every NORTH ANDOVER, MA. 01845
page. Citylrown State Zip Code
t5ins - 11/10
1/11/13
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.):
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
75 BOSTON STREET
Property Address
MARYELLEN MANTYLA
Owner Owner's Name
information is
required for every NORTH ANDOVER, MA. 01845 1/11/13
page. Citylrown 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
A-1=13' A-4=24'6"
B-1=26' B-4=33'
A-2=15'
B-2=27'4"
A-3=17'6"
B-3=28'6"
A
321 75 BOSTON ST.
CAR
PORT
B FRONT
D
R
I
V
E
t5ins • 11/10 Title 5 Official Inspection Farts: Subsurface Sewage Disposal System • Page 15 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
75 BOSTON STREET
Property Address
MARYELLEN MANTYLA
Owner's Name
NORTH ANDOVER, MA. 01845 1/11/13
Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑
Check Slope
❑
Surface water
❑
Check cellar
❑
Shallow wells
Estimated depth to high ground water:
5'
feet
Please indicate all methods used to determine the high ground water elevation:
u
a
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:
GROUND WATER DETERMINED FROM DESIGN PLANS FOR ABUTTING PROPERTIES, # 85
BOSTON ST. ESHGW @ 64" ON PERK TEST (LESS THAN 150' FROM SYSTEM) DATED 5/21/12,
# 65 BOSTON ST. ESHGW @ 64" ON PERK TEST DATED 5/19/96, ALSO HAND AUGERED TO 2'
BELOW D -BOX NO WATER ENCOUNTERED.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins • 11/10 Title 5 01ficial 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
75 BOSTON STREET
Property Address
MARYELLEN MANTYLA
Owner Owner's Name
information is
required for every NORTH ANDOVER, MA. 01845 1/11/13
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 - 11/10 Title 5 Official Inspection Fonn: Subsurface Sewage Disposal System - Page 17 of 17
Summary Record Card generated on 16/2013 11:53:58 AM by Maureen McAuley
Town of North Andover
Tax Map # 210-1073-0039-0000.0
Parcel Id 18152
75 BOSTON STREET
KYLE MANTYLA
75 BOSTON STREET
NORTH ANDOVER, MA 01845
Page 1
Class 101 Single Family Property Type 1 Residential
Zoning2 1 Residential Zoning3 1 Residential
Size Total 1.01 Acres
FY 2013
UB Mailina Index
Name/Address
KYLE MANTYLA
75 BOSTON STREET
NORTH ANDOVER, MA 01845
CHAMPAGNE, JOHN
LUISI, DONNA
75 BOSTON STREET
NORTH ANDOVER, MA
01845
UB Account Maint.
Account No Cycle
Bldg Id. 13679.0 - 75 BOSTON STREET
1090357 01 Cycle 01
UB Services Maint.
Account No. 1090357
Service Code
MISCFEE ADMIN FEE
WTR WATER
UB Meter Maintenance
Account No. 1090357
Serial No Status
35445452 a Active
Date
10/23/2012
7/23/2012
4/23/2012
1/23/2012
10/24/2011
7/22/2011
4/22/2011
1/25/2011
10/21/2010
7/22/2010
4/22/2010
1/21/2010
11/13/2009
10/22/2009
7/23/2009
5/21/2009
5121/2009
4/24/2009
MSG
1/23/2009
10/22/2008
7/22/2008
4/23/2008
1/28/2008
10/23/2007
Type Loan Number
Owner
Previous Customer
Active/Inact. From
Inactive 2/12/2009
Occupant Name Active/Inactive
Last Billing Date 11/2/2012
Active
Rate Charge Multiplier/Users
0.635/8 7.82 1/
01 ALL METER SIZE 41.80 /1
Until
Location
Brand
Type Size
YTD Cons
00 ERT HH
b Badger
w Water 0.63 0.63
150
Reading
Code
Consumption
Posted Date
Variance
155
a Actual
11
11/9/2012
-1%
144
a Actual
11
8/14/2012
0%
133
a Actual
11
5/9/2012
10%
122
a Actual
10
2/13/2012
-6%
112
a Actual
11
11/14/2011
-3%
101
a Actual
11
8/15/2011
-4%
90
a Actual
11
5/16/2011
1%
79
a Actual
12
2/11/2011
14%
67
a Actual
10
11/12/2010
-29%
57
a Actual
14
8/16/2010
8%
43
a Actual
13
5/12/2010
-10%
30
a Actual
11
2/12/2010
251%
19
f Final Bill
1
11/13/2009
-68%
18
a Actual
13
11/11/2009
80%
5
a Actual
5
8/12/2009
0%
0
n New Meter
0
8/12/2009
0%
419
r Replacement
-1
8/12/2009
-134%
420
m Manual estimate
10
5/13/2009
2%
410
a Actual
10
2/10/2009
-18%
400
a Actual
12
11/12/2008
-47%
388
a Actual
22
8/15/2008
200%
366
a Actual
7
5/19/2008
32%
359
a Actual
6
2/19/2008
-90%
353
a Actual
56
11/16/2007
109%
f WCRTM 14Commonwealth of Massachusetts Map -Block -Lot
�Oo 107.60039
-----------------------
Board of Health
Permit No
BHP -2009-0695
t ; . North Andover -----------------------
FEE
F 'b..., ..,...�
MU$125.00
iy 35; SS
DISPOSAL WORKS CONISTRUCTIONI PERMIT
Permission is hereby granted John DiVincenzo
to (Repair -D -BOX ONLY) an Individual Sewage Disposal System.
at No 75 BOSTON STREET
as shown on the application for Disposal Works Construction Permit No. BHP -2009-069 Dated September 23, 2009
Issued On: Sep -23-2009
N
,�o�v►� Commonwealth of Massachusetts
Board of Health
North Andover
P.I.
\S.4ruu9�� F.I.
Map -Block -Lot
107.B0039
-----------------------
Permit No
BHP -2009-0695
FEE
DISPOSAL WORKS CONSTRUCTION PERMIT
Permission is hereby granted John-D1Vincenzo
to (Repair -D -BOX ONLY) an Individual Sewage Disposal System.
at No 75 BOSTON STREET
----------------------------------------------------------------------------------------------------------------------------------------------------------
as shown on the application for Disposal Works Construction Permit No. BHP -2009-069 Dated September 23,_ 2009
-------------------
Issued On: Sep -23-2009 I� . r.,amyt
$125.00
�oRrk Commonwealth of Massachusetts Map -Block -Lot
r°,•""° '"a�a4 107.60039
-----------------
r a
Board of Health
• North Andover
�►,S �•�19 •••� CERTIFICATE OF COMPLIANCE
SAcwuyf.
THIS IS TO CERTIFY, That the Individual Sewage Disposal System (Repair -D -BOX ONLY)
by John DiVincenzo
-- --------------------------------
Installer
at No 75 BOSTON STREET
has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the
application for Disposal Works Construction Permit No. BHP -2009-069 Dated September 23, 2009
--------------------------- --
Printed On: Nov -02-2009 Board of Health
396
MORTp
• : Town of North Andover
HEALTH DEPARTMENT
,SSACHUS�S
CHECK #: 519 xj DATE: i 3 07 -
LOCATION:
` -LOCATION: 7,5 13 . s
H/O NAME: G' 2--
CONTRACTOR NAME: a --k%
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
$
❑
TrashlSolid 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) $-
1719 1719
He Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
VQ
Application for Septic Disposal System
Construction Permit -TOWN OF
.TH
MA 0
Application is hereby made for a permit to:
❑ Construct a new on-site sewage disposal system*
TODAY'S DATE
$ 250.00 — Full Repair
$125.00 - Component
❑ Repair or replace an existing on-site sewage disposal system*
Repair or replace an existing system component — What? c�l — -9 1
A. Facility Information
C__ s 126,s7-6 k) S&
Address or Lot #
City/Town
2.- *TYPE OF SEPTIC SYSTEM*:
❑ Pump ❑ Gravity (choose one)
***If pump system, attach copy of electrical permit to application***
❑ Conventional System (pipe and stone system)
❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system.
❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement)
❑ Pressure Dosed (D -Box Present) S.A.S.
2. Owner Information
Name
Address (if different from above)
City/Town
3. Installer Information
JC7 'V 2- 0,V, j n C z & W
Name
Addd
4. Designer Information
Name
Address
City/Town
Name of Company
State
Zip Code
!ase)
Telephone Number (Best # to Reach)
�' �� ��✓i% �f�, Application for Disposal S stem Construction Permit • Page 1 of 2
Jahn i�. ;h
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
®u� u
Application for Septic Disposal System
Construction Permit -TOWN OF TODAY'S DATE
�qORTH ANDOVER, MA 01845 $ 250.00 — Full Repair
$125.00 - Component
Application is hereby made for a permit to:
❑ Construct a new on-site sewage disposal system*
❑ Repair or replace an existing on-site sewage disposal system*
Repair or replace an existing system component — What? z) — -9 �
A. Facility
-J-6 0 S! -
)VO,
i
Address or Lot #
/'OF /'y'N
City/Town
2.- *TYPE OF SEPTIC SYSTEM*:
❑ Pump ❑ Gravity (choose one)
***If pump system, attach copy of electrical permit to application***
❑ Conventional System (pipe and stone system)
❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system.
❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement)
❑ Pressure Dosed (D -Box Present) S.A.S.
2. Owner Information
Name
Address (if different from above)
City/Town
State Zip Code
Telephone Number
3. Installer Information
' ), i✓j�C_f�,�
S'��war �! ,pT_iC
Name
Name of Company
Address
47 date.
rn�c�
City/Town
State 3 7 y Zip c q
Telephone Number (Cell Phone # if possible please)
4. Designer Information
Name
Name of Company
Address
City/Town
State Zip Code
Telephone Number (Best # to Reach)
��_ �� ��✓f% �%>�, Application for Disposal System Construction Permit • Page 1 of 2
s �'.%' Application for Septic Disposal System
�r a onstruction Permit —TOWN OF
�� •t ORTH ANDOVER, MA 01845
PAGE 2OF2
A. Facility Information continued....
5. Type of Building: kesidential Dwelling or ❑Commercial
B. Agreement
TODAY'S DATE
$ 250.00 — Full Repair
$125.00 - Component
The undersigned agrees to ensure the construction and maintenance of the afore -described
on-site sewage disposal system in accordance with the provisions of Title 5 of the
Environmental Code, as well s the Local Subsurface Disposal Regulations for the Town of
Norti Ananver, and Rot to ace the system in operation until a Certificate of Compliance has
bee iss d bt�thisMar of Health.
7
9 p'�)_ 16
Date
Application Approved By: (Board of Health Representative)
Name
Application Disapproved for the following reasons:
For Office Use Only:
1. Fee Attached.
2. Project Manager Obligation Form Attached.
Date
Yes No
Yes No
3. Pump Sys tem? Ifso, Attach copy ofElectrical Permit Yes No
4. Foundation As -Built. (new construction ronly): Yes No
(Same scale as approved plan)
5. Floor Plans? (new construction only): Yes No
Application for Disposal System Construction Permit • Page 2 of 2
' SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at: A
251�
('address of septic system) For plans by
1
Relative to the application of Gc.H 20
(Installer's name) And dated
Dated
o ay s ate
With revisions dated
I understand the following obligations for management of this project:
(Engineer)
ngina ate
(Last revised date)
1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to
performing any work on a site. I must have the approved plans and the permit on site when any work is
being done.
2. As the installer, I must call for any and all inspections. If homeowner, contractor, project manager, or any
other person not associated with my company schedules an inspection and the system is not ready, then
item three shall be applicable.
3. As the installer, I am required to have the necessary work completed prior to the applicable inspections as
indicated below. I understand that requesting an inspection, without completion of the items in accordance
with Title 5 and the Board of Health Regulations may result in a $50.00 fine being levied against me and/or
MY c01n42anY_-
a. Bottom of Bed — Generally, this is the first (1'� inspection unless there is a retaining wall, which
should be done first. The installer must request the inspection but does not have to be present.
b. Final Construction Inspection — Engineer must first do their inspection for elevations, ties, etc.
As -built of verbal OK (or e-mail to: healthdel2t&townofnorthandover.com) from the engineer must
be submitted to the Board of Health, after which installer calls for an inspection time. Installer must
be present for this inspection. With a pump system, all electrical work must be ready and able to
cause pump to work and alarm to function.
c. Final Grade — Installer must request inspection when all grading is complete. Installer does not
have to be on-site.
4. As the installer, I understand that only I may perform the work (other than simple excavation) and I am required
to complete the installation of the system identified in the attached application for installation. I further
understand that work done by others unlicensed to install septic systems in North Andover can constitute
reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of
North Andover, significant fines to all persons involved are also possible.
5. As the installer, I understand that I must be on-site during the performance of the following construction
steps:
a. Determination that the proper elevation of the excavation has been reached.
b. Inspection of the sand and stone to be used.
c. Final inspection by Board of Health staff or consultant.
d. Installation of tank, D -Box, pipes, stone, vent, pump chamber, retaining wall and other
components.
6. As the installer, I understand that I am solely responsible for the installation of the system as per the
approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve
me of this obligation.
Undersigned Licensed Septic Installer:
L 0tl 'Y .w
ame —Print)
7c):
c
Z'
HOARD OF HEALTH
TOWN OF' NORTTi ANDOVERO h'1ASS.
1.
2.
1i�
NAmE .�C. _.tea 4- �--. �. U��. �/. 5.7.7-
....... DATEADDRESS� ). LOT N0. . . TEL. � .�1.7/0
N0. OF EEDROOK DEN YES . . . . . NO..�/ .
+4. GARBAGE GRINDEP
YES . . . W 0 NO..
5. SHOW DITENSIONS OF HOUSE
6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES
?. SHOW DIPENSIONS OF LOT
S. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL
9, NOPE LOCATION AND DISTANCE OF WELL FROM SSE SYSTEM Jv MiL-
10. SHOW LOCATION OF HROW l STREAK, DITCHES, LEDGE OUTCROP, ETC. 1VOI IC
L.1, SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE
NOTZs LOCAL REGULATIONS SHOULD IE READ CAREFULLY9
t 0 ' C , a :/t. /'1 a L 1 _ x r•.' I !`L " r :Jr ` Donald Clough
` 1 ` 1 -tOst',on St. `
APPLICATION FOR SEWAGE DISPOSAL INSTALLATION
HEALTH DEPARTMM--NORTH ANDOVER, MASS.
I hereby make application for a permit for a sewage disposal installation at
_,,,, B oston St. 1 will install this system in
accordance with all the laws of the Commonwealth of f&ssachusetts and regulations
of the Board of Health of the Town of North Andover.
Further, I will construct the house sever of bell and spigot pipe, the minimum
diameter being 4 inches, and will maintain a minimum grade of Zq until 10 feet
preceding the septic tank, where the grade shall not exceed 2%. I will install a
concrete septic tank of 600 gal,-.— in size. A manhole (s) permitting easy
cleaning will be provided with removable cover (s) of iron or concrete within 12
inches of the ground surface. I wilt, provide subsurface disposal field with open
Jointed bell and spigot Ackron pipe at least 4 inches in diameter and laid in a
series of trenches, the bottom of which will provide a minimum of goo lineal
(.feet of effective absorption area. The pipes will be laid on a 6
layer of washed gravel or crushed stone ranging in size from 3/4 to 1-1/2 inches
(dia.) and the pipes will be surrounded by similar material to a height of 2 inches
above the crown of the pipe. The joints of these pipes will be protected from
clogging and before filling the trench, 2 inches of gravel or stone 1/8tt to 1/411
(dia.) will be placed over the courseravel or stone. The disposal field will be
Installed at a grade of 4 to 6 inches/100 feet. No single tile line will exceed
100 feet in length and in any case, two lines of tile will be installed. A minimum
of 6 feet will be maintained between the center lines of the disposal field trenches
and the average depth of trench shall not exceed 36 inches. No part of the in-
stallation will be less than 100 feet from any private water supply, 25 feet from
any stream, 20 feet from any dwelling or 10 feet from any property line. I further
of icer, as provided below, and to incorporate any additional requirements that
may be attached to the permit. Plot Plans must be submitted with application.
DATE
Signature of Applicant
I hereby issue the above permit for the Board of Health of the Town of North
Andover, Massachusetts.
DATE
Si nature of Health Agent
I have inspected the uncovered system indicated above and find everything done
as des abed,
DATE
Signature of Ina eting Officer
Percolation Test
Garbage Grinder
BOARD OF HEALTH
T91 OF' NORTIi ANDOVER, MASS.
i
I
�J 70 �
�.N "TI p-----
T�
m
�61
C*4umc llpoies--5 JVDIW-)
Ave
Av
1. NALM ! -s)P 1�-"AL 7'. DATE N< !Ag4 H.. �.
1 HtAit� -rCL.. �F-. Zell&y L..cJtr`—L'
�i ,�,cis }�
2. ADDRESS �� T(; NcvK NO. . TEL .
3. N0. OF BEDROOM. . DEN YES . . . NO..
4. GARBAGE GRIMER YES NO..
5. SHOW DIIJENSIOMS OF HOUSE } o vj'\-'
6. SHM DISTANCES OF HOUSE TO ALL PROPERTY LINES
7. SHOW D31MIISIONS OF LOT j` -j 0
8. SHOW LOCATION AND SIZE OF SEPTIC TAI4K OR CESSPOOL
H J LZ IL9
9. NOTE LOCATION AND DISTANCE OF WELL FROr:1 SEV` ERAGE SYSTEM
10. SHOW LOCATION OF BROOKS V STR.ENZ O DITCHES, LEDGE OUTCROP, ETC. j,.J 0 k)
11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE '' N C Wli
NOTE: LOCAL REGULATIONS SHOULD HE READ CAREFULLY.
V/0 K .
V .
BOARD OF HEALTH
T91 OF' NORTIi ANDOVER, MASS.
i
I
�J 70 �
�.N "TI p-----
T�
m
�61
C*4umc llpoies--5 JVDIW-)
Ave
Av
1. NALM ! -s)P 1�-"AL 7'. DATE N< !Ag4 H.. �.
1 HtAit� -rCL.. �F-. Zell&y L..cJtr`—L'
�i ,�,cis }�
2. ADDRESS �� T(; NcvK NO. . TEL .
3. N0. OF BEDROOM. . DEN YES . . . NO..
4. GARBAGE GRIMER YES NO..
5. SHOW DIIJENSIOMS OF HOUSE } o vj'\-'
6. SHM DISTANCES OF HOUSE TO ALL PROPERTY LINES
7. SHOW D31MIISIONS OF LOT j` -j 0
8. SHOW LOCATION AND SIZE OF SEPTIC TAI4K OR CESSPOOL
H J LZ IL9
9. NOTE LOCATION AND DISTANCE OF WELL FROr:1 SEV` ERAGE SYSTEM
10. SHOW LOCATION OF BROOKS V STR.ENZ O DITCHES, LEDGE OUTCROP, ETC. j,.J 0 k)
11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE '' N C Wli
NOTE: LOCAL REGULATIONS SHOULD HE READ CAREFULLY.
V/0 K .
o'•
e�
k�o
b`=`
April 16, 1957
Miss Mary Sheridan R. N.
Health Agent
Board of Health
North Andover, Massachusetts
Dear Miss Sheridan:
An examination was made relative to the
suitability of the soil for the sub -surface disposal
of sewage on the proposed building lot of Mr. Donald
Clough. The lot is located on Boston Street.
A 2.5 minute percolation test was conducted
in clay and sandy soil.
It is recommended that a 600 gallon tank
be installed together with 200 lineal feet of drain
pipe.
Very truly yours,
Ernest F. Romano
-56
H/O NAME:
CONTRACTOR NAME:
T_yye
of Permit or License: (Check box)
❑
40
Town of North Andover
�'•�,,,,o .. �,
�sswcHust�
HEALTH DEPARTMENT
$
f
CHECK #:'"
DATE:
❑
Dumpster
LOCATION:
❑
H/O NAME:
CONTRACTOR NAME:
T_yye
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 'S syector
-'Title
$j �}
0
5 Report
$
❑ Other. (Indicate) $
14
L'A
o -
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
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
Sc�'-r�C i ANK , vt��2tisut cs,.t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assep
75 Boston St.
Property Address
John Champagne
Owner's Name
North Andover
Cityrr-ow n
MA _ 01845
State Zip Code
RECEIVED
SEP 18 2009
ANDOVER
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. General Information
1. Inspector:
Chad Jablonski
Name of Inspector
I�1,1^r%cV R gr%nq Inc
Company Name
167 Willow Ave.
Company Address
Haverhill
City/Town
978-360-9358
Telephone Number
B. Certification
MA
State
4574
License Number
01835
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 b cal Approving Authority
nsnector's I ture Date
The system inspector,,sKiaWgubmit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) WtldM days of completing this inspection. If the system is a shared system or
has a design flKii of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17
t5ins • 09/08
ot�=
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
75 Roston St
Property Address
John Champagne
Owner's Name
North Andover
City/Town
B. Certification (cont.)
MA 01845
State Zip Code
9/14/09
Date of Inspection
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 - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17
Commonwealth of Massachusetts
_- - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u 75 Boston St.
Property Address
John Champagne
Owner Owner's Name
information is North Andover MA 01845 9/14/09
required for every
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution 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):
Distribution box is cracked and unlevel due to corrosion.
❑ 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 - 09/08 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
75 Boston St.
Property Address
John Champagne
Owner's Name
North Andover
City/Town
B. Certification (cont.)
MA 01845
State Zip Code
9/14/09
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 coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes
No
❑
®
Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑
®
Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑
®
Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑
®
Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/z day flow
l5ins • 09/08
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17
moi=
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
75 Boston St.
Property Address
John Champagne
Owner's Name
North Andover
City/Town
B. Certification (cont.)
Yes No
MA 01845
State Zip Code
9/14/09
Date of Inspection
❑ ® 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 - 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
75 Boston St.
Property Address
John Champac
Owner Owner's Name
information is
required for every North Andover
page. City/Town
ne
C. Checklist
MA 01845 9/14/09
State Zip Code Date of Inspection
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
® ❑
Pumping information was provided by the owner, occupant, or Board of Health
❑ ®
Were any of the system components pumped out in the previous two weeks?
® ❑
Has the system received normal flows in the previous two week period?
❑ ®
Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑
Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑
Was the facility or dwelling inspected for signs of sewage back up?
® ❑
Was the site inspected for signs of break out?
® ❑
Were all system components, excluding the SAS, located on site?
® ❑
Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑
Was the facility owner (and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
❑ ®
Existing information. For example, a plan at the Board of Health.
® ❑
Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 330
t5ins • 09/08 Title 5 Official 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
75 Boston St
Property Address
John Champac
Owner Owner's Name
information is North Andover
required for every
page. City/Town
D. System Information
Description:
System and components in good working order with the exception of the distribution box which needs
to be replaced.
ne
MA 01845 9/14/09
State Zip Code Date of Inspection
Number of current residents:
Does residence have a garbage grinder?
Is laundry on a separate sewage system? [if yes separate inspection required]
Laundry system inspected?
Seasonal use?
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Normal water flow with no irrigation
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
®
Yes
❑
No
®
Yes
❑
No
❑
Yes
®
No
Attached
❑ Yes ® No
Occupied
Date
❑
Yes
❑
No
❑
Yes
❑
No
❑
Yes
❑
No
t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
75 Boston St.
Property Address
John Champagne
Owner Owner's Name
information is
required for every North Andover
page. City/Town
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
MA 01845
State Zip Code
Date
General Information
Pumping Records:
Source of information: North Andover BOH
Was system pumped as part of the inspection?
If yes, volume pumped: na
gallons
How was quantity pumped determined? na
Reason for pumping: na
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
9/14/09
Date of Inspection
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other (describe):
t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
75 Boston St.
Property Address
John Champagne
Owner Owner's Name
information is
required for every North Andover MA 01845 9/14/09
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:
Were sewage odors detected when arriving at the site?
Building Sewer (locate on site plan):
Depth below grade:
Material of construction:
® cast iron ❑ 40 PVC ❑ other (explain):
❑ Yes ❑ No
14"
feet
Distance from private water supply well or suction line: na
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Watertiaht at foundation
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
® concrete ❑ metal
If tank is metal lista e*
22"
feet
❑ fiberglass ❑ polyethylene ❑ other (explain)
na
g years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 5' deep with 4' radius
Sludge depth: 3
t5ins • 09/08 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
75 Boston St.
Property Address
John Champac
Owner Owner's Name
information is
required for every North Andover
page. City/Town
t5ins • 09/08
MA 01845
State Zip Code
9/14/09
Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
24
Scum thickness
`1
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined?
Measuring tape
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 structurally, tee's in good working 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
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�H 75 Boston St.
MA 01845
State Zip Code
9/14/09
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.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene
❑other (explain):
Dimensions:
Capacity:
Design Flow:
Alarm present:
Alarm level:
gallons
gallons per day
❑ Yes ❑ No
Alarm in working order:
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 - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17
Property Address
John Champagne
Owner
Owner's Name
information is
required for every
North Andover
page.
City/Town
MA 01845
State Zip Code
9/14/09
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.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene
❑other (explain):
Dimensions:
Capacity:
Design Flow:
Alarm present:
Alarm level:
gallons
gallons per day
❑ Yes ❑ No
Alarm in working order:
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 - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17
A Commonwealth of Massachusetts
--_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
ne
D. System Information (cont.)
MA 01845
State Zip Code
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert Box Leaking
9/14/09
Date of Inspection
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Box corroded and 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.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17
75 Boston St.
Property Address
John Champac
Owner
Owner's Name
information is
required for every
North Andover
page.
City/Town
ne
D. System Information (cont.)
MA 01845
State Zip Code
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert Box Leaking
9/14/09
Date of Inspection
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Box corroded and 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.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
75 Boston St.
Property Address
John Champagne
Owner Owner's Name
information is
required for every North Andover MA
page. City/Town State
D. System Information (cont.)
Type:
01845 9/14/09
Zip Code Date of Inspection
❑ leaching pits
number:
❑ leaching chambers
number:
❑ leaching galleries
number:
® leaching trenches
number, length: 5 - 30' to 50' long
❑ leaching fields
number, dimensions:
❑ overflow cesspool
number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure,
level of ponding, damp soil, condition of
vegetation, etc.):
No sign of hydraulic failure or oondino
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
15ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 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
75 Boston St.
Property Address
John Champagne
Owner's Name
North Andover MA 01845 9/14/09
CityFrown 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 • 09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 14 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
75 Boston St.
Nroperty Address
John Champagne
Owner's Name
North Andover MA 01845 9/14/09
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 - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
75 Boston St.
Property Address
John Champagne
Owner Owner's Name
information is
required for every North Andover _ MA 01845
page. City/Town State Zip Code
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
9/14/09
Date of Inspection
® Shallow wells
Estimated depth to high ground water: 64" - 79"
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: 5/8/2006
Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health - explain:
Neighboring Deep Hole Tests
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
Perc Test for 91 Boston St. on 3/15/06 performed by Gordon Rogerson witnessed by Paul Leblanc.
Perc Test at 65 Boston St.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17
M
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
— Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 75 Boston St.
Property Address
John Champac
Owner Owner's Name
information is North Andover
required for every
page. City/Town
ne
MA
State
E. Report Completeness Checklist
01845 9/14/09
Zip Code Date of Inspection
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information — Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17
Owner
information is
required for every
page.
Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
fab
:1
ram
l5ins - 09/08
2 "A—z- L�v��y 106 y G� TEa��
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
John Champagne
Owner's Name
North Andover
City/Town
MA 01845
State Zip Code
9/14/09
Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. General Information
Inspector:
Chad Jablonski
Name of Inspector
Company Name
167 Willow Ave.
Company Address
Haverhill
City/Town
978-360-9358
Telephone Number
B. Certification
MA
State
4574
License Number
01835
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,Eval5-59-h by the Local Approving Authority
Date
The syst inspe r shall submit a copy of this inspection report to the Approving Authority (Board
of He or ) within 30 days of completing this inspection. If the system is a shared system or
has desi n flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
rep o 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.
P it -7-
\le 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
75 Boston St.
Property Address
John Champagne
Owner's Name
North Andover MA 01845 9/14/09
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not
determined," please explain.
The septic tank is metal and over 20 years old" or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins • 09/08 _ 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
a
M 75 Boston St.
Property Address
John Champagne
Owner Owner's Name
information is North Andover MA 01845 9/14/09
required for every
State Zip Code Date of Inspection
page. City/Town
B. Certification (cont.)
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):
❑ 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 - 09/08 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
75 Boston St.
Property Address
John Champagne
Owner's Name
North Andover MA 01845 9/14/09
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 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
15ins • 09108
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17
.
Commonwealth of Massachusetts
W
Title 5
Official, Inspection Form
the system is within 400 feet of a surface drinking water supply
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM
75 Boston St.
❑
❑
Property Address
John Champagne
Owner
Owner's Name
information is
required for every
North Andover
MA 01845 9/14/09
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.
l5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
75 Boston St.
Property Address
John Champac
Owner Owner's Name
information is
required for every North Andover
page. City/Town
e
C. Checklist
MA 01845
State Zip Code
9/14/09
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): Greywater
leaching pit
t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17
Commonwealth of Massachusetts
r
Title 5 Official Inspection Form
y
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M
75 Boston St.
Property Address
John Champagne
Owner Owner's Name
information is
required for every North Andover
page. City/Town
D. System Information
Description:
MA 01845
State Zip Code
9/14/09
Date of Inspection
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
❑
Number of current residents:
❑
3
❑
Yes
Does residence have a garbage grinder?
❑
Yes
®
No
Is laundry on a separate sewage system? [if yes separate inspection required]
®
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 ))�
Attached
Detail:
Normal water flow with no irrigation
Sump pump?
❑
Yes
®
No
Last date of occupancy:
Occupied
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 • 09/08 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
caw 75 Boston St.
Property Address
John Champagne
Owner Owner's Name
information is North Andover MA
required for every
page. City/Town State
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
01845 9/14/09
Zip Code Date of Inspection
Date
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Type of System:
neverpumped
na
gallons
na
na
❑ Yes ® No
❑ Septic tank, distribution box, soil absorption system
® Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other (describe):
t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17
4� Commonwealth of Massachusetts
-- Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
75 Boston St.
Property Address
John Champagne
Owner Owner's Name
information is
required for every North Andover MA 01845 9/14/09
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:
Were sewage odors detected when arriving at the site?
Building Sewer (locate on site plan):
Depth below grade: 5
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other (explain):
Distance from private water supply well or suction line: na
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Watertight at foundation
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal
no tank
feet
❑ Yes ❑ No
❑ fiberglass ❑ polyethylene ❑ other (explain)
If tank is metal, list age: na
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
t5ins - 09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System - Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a
-- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
75 Boston St.
Property Address
John Champagne
Owner Owner's Name
information is North Andover MA
required for every
page. City/Town State
D. System information (cont.)
t5ins • 09/08
01845 9/14/09
Zip Code Date of Inspection
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
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
❑ fiberglass
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17
feet
❑ polyethylene ❑ other (explain):
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w 75 Boston St.
Property Address
John Champac
Owner Owner's Name
information is
required for every North Andover
page. CitylTown
e
MA 01845 9/14/09
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 . 09/06 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
75 Boston St.
Property Address
John Champagne
Owner Owner's Name
information is North Andover MA 01845 9/14/09
required for every _
page. 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 no d -box
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber (locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
l5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17
. Commonwealth of Massachusetts
- : Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M
75 Boston St. _
Property Address
John Champagne
Owner Owner's Name
information is
required for every North Andover MA 01845
page. City/Town State Zip Code
D. System Information (cont.)
Type:
9/14/09
Date of Inspection
®
leaching pits
number: 1 - 4' radius
❑
leaching chambers
number: —
❑
leaching galleries
number:
❑
leaching trenches
number, length:
❑
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.):
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 - 09/08 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
75 Boston St
Property Address
John Champac
Owner Owner's Name
information is North Andover
required for every
page. City/Town
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
ne
MA 01845
State Zip Code
9/14/09
Date of Inspection
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 • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
-- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,.. 75 Boston St.
ne
MA 01845
State Zip Code
9/14/09
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
F-1 drawin4 attached separately
15ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17
h'roperty Aaaress
John Champac_
Owner
Owner's Name
information is
North Andover
required for every
page.
City/Town
ne
MA 01845
State Zip Code
9/14/09
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
F-1 drawin4 attached separately
15ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form.- Not for Voluntary Assessments
75 Boston St.
Property Address
John Champagne
Owner Owner's Name
information is
required for every North Andover MA 01845
page. City/Town State Zip Code
D. System Information (cont.)
Site Exam:
®
Check Slope
®
Surface water
®
Check cellar
®
Shallow wells
Estimated An th to hi In round water'
64" - 79"
9/14/09
Date of Inspection
F, g g 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. 5/8/2006
Date
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health - explain:
Neiohborina Deer) Hole Tests
Checked with local excavators, installers - (attach documentation)
Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
Perc Test for 91 Boston St. on 3/15/06 performed by Gordon Rogerson witnessed by Paul Leblanc.
Perc Test at 65 Boston St.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins - 09/08 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
75 Boston St.
Property Address
John Champagne
Owner Owner's Name
information is
required for every North Andover MA 01845 9/14/09
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 - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17
Summary Record Card generated on 9/15/2009 1:32:46 PM by Lisa Evans
Town of North Andover
Tax Map # 210-1073-0039-0000.0
Parcel Id 18152
75 BOSTON STREET
CHAMPAGNE, JOHN
LUISI, DONNA
75 BOSTON STREET
NORTH ANDOVER, MA
01845
Page 1
Class 101 Single Family Property Type 1 Residential
Size Total 1.01 Acres
FY 2010
UB Mailina Index
Name/Address
CHAMPAGNE, JOHN
LUISI, DONNA
75 BOSTON STREET
NORTH ANDOVER, MA
01845
UB Account Maint.
Account No Cycle
Bldg Id. 13679.0 - 75 BOSTON STREET
1090357 01 Cycle 01
UB Services Maint.
Account No. 1090357
Service Code
MISCFEE ADMIN FEE
WTR WATER
UB Meter Maintenance
Account No. 1090357
Brand
Serial No Status
YTD Cons
35445452 a Active
b Badger
Date
Reading
7/23/2009
5
5121/2009
0
5/21/2009
419
4/24/2009
420
MSG
0
1/23/2009
410
10/22/2008
400
7/22/2008
388
4/23/2008
366
1/28/2008
359
10/23/2007
353
7/20/2007
297
4/19/2007
271
1/29/2007
266
10/25/2006
261
7/28/2006
243
5/2/2006
211
1/30/2006
205
10/26/2005
199
7/25/2005
192
4/22/2005
186
2/1/2005
180
10/25/2004
172
7/29/2004
166
Type Loan Number
Payor
Active/Inact. From
Occupant Name Active/Inactive
Last Billing Date 8/5/2009
Active
Rate Charge Multiplier/Users
0.635/8 7.82 1/
01 ALL METER SIZE 15.20 /1
Until
Location
Brand
Type Size
YTD Cons
00 ERT HH
b Badger
w Water 0.63 0.63
0
Code
Consumption
Posted Date
Variance
a Actual
5
8/12/2009
0%
n New Meter
0
8/12/2009
0%
r Replacement
-1
8/12/2009
-134%
m Manual estimate
10
5/13/2009
2%
a Actual
10
2/10/2009
-18%
a Actual
12
11/12/2008
-47%
a Actual
22
8/15/2008
200%
a Actual
7
5/19/2008
32%
a Actual
6
2/19/2008
-90%
a Actual
56
11/16/2007
109%
a Actual
26
8/15/2007
352%
a Actual
5
5/21/2007
20%
a Actual
5
2/20/2007
-74%
a Actual
18
11/16/2006
-45%
a Actual
32
8/18/2006
464%
a Actual
6
5/16/2006
4%
a Actual
6
2/13/2006
-17%
a Actual
7
11/9/2005
18%
a Actual
6
8/10/2005
-15%
a Actual
6
5/13/2005
-7%
a Actual
8
2/15/2005
19%
a Actual
6
11/15/2004
-37%
a Actual
9
8/25/2004
29%
Town of North Andover Licensed Septic System Installers (Disposal Works Installer's)
Last Updated: 7/7/2008
Five or more
installations
within the last
Name 18 months # of
Affiliated Company
R.T. Amo_ r
Bateson Enterprises, Inc.
Phone #
978 887-5468
1
2Bateson,
3
4
5
6
7
Amor, Robert 0
978-475-1474
Todd 20
603.893.9189
Beaulieu, Serge R. 0
Roadway Excavators _
Breen Excavating, Inc___
Daniel R. Briscoe_
Busby Construction Co., Inc.
Ramey Construction _
978-682-7774
Breen, Peter 0 _]Peter_
978-372-2200
Briscoe, Daniel R. 1
603-362-6015
Busby, Philip A. Jr. 0
978-633-6791
Carr, John 0
8
Colosi, Philip A. 0
Colosi Construction LLC T _
Kevin Coyle _ _ _
James H. Currier Construction Co_, In
Robert K. Daigle, Jr. _
Frank DeLucia & Son, Inc.
978-777-5679
603-944-8501
Coyle, Kevin 0
978-774-6685
_9_
10
Currier, James H. 1
11
12
Daigle, Robert K. 1
978-887-3703
978-686-8200
DeLucia, Rocci Jr. 0
13
14
15
DiVincenzo, John L. 2
Andover Septic/J&S Dev. Corp.
Daniel A. Giard Septic Service _
Bill Hall, Inc_ _ _ _._
978-372-7471
Giard, Daniel
978-686-7653
978-689-3711
Hall, Bill, Inc.
40JamesHartigan
16
Hartigan, James
_
Bruce Hoehn;
978-766-0087
978-372-8274
17
Hoehn, Bruce 0
18
19
Hutton, Arthur 0
Hutton's General Construction, Inc_
978-685-2667
978-663-6006
Innis, Robert L. 0
R.L.I. Corp_ _ _
Jablonski & Sons rt _ _
978-360-9358
20
Jablonski, Chad 0
21
Kellett, James 3
Kellett Excavating _
781.953.7146
22
23
Marsh, Steve 0
The We Co._ __
Maynard Construction _
978-742-9778
Maynard, Dave 0
978-375-7228
24
Murray, David 1
Ranger Development Corp. _
978-360-8506
25
Osgood, Ben 1
New England Engineering_ _
Pearce Construction _
Angelo Petrosino _
978-686-1768
978-664-5264
26
27
28
Pearce, Warren 0
978-664-2030
Petrosino, Angelo 0
978-457-0528
Quinlan, Timothy 0
Quinlan & Rand Builders _
29
30
31
Reilly, Mike 0
F.P. Reilly & Sons
978-475-1237
603-642-8910
Sawyer, William T. 1
Arco Excavators, Inc_ _ _
Wildwood Excavation, Inc.
Soucy's Sewer Service _
978-474-8088
Shaw, John III 0
32
Soucy, John J. 8
800.541.9379
33 _
_ 34
35
36
37
38
39
Sullivan, Jack 0 Jack Sullivan, _ 978-352-7871
Surianello, Joseph 0 Ralph Surianello, Ino 617-799-3900
Todd, Charles R. 0 Charles R. Todd Contractor, Inc__ 978-667-4270
Waelty, Craig(Skip) 0 Craig Waelty _ _ 978-664-2126
Watson, Joseph 0 JW Watson, Jr. 978-475-8581
Zaher, Charles 0 Charles Zaher 978-804-7786
Zaloga, Dave 0 1 Dave Zaloga 603-765-9296
Total Installations 111/07 - 717/08 39
Note: The Septic Installer Exam is held in January March. May, July and September of each year_
T ----
You must call the Health Department to sign up for the exam at 978.888.9540.
The testing fee is $25. Last Updated: 7/7/08
Last Updated: 7/7/2008
WILLIAM F. WELD
Governor
COMMONXWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL -
ONE H'I'TTER STREET. BOSTON. MA 02108 617-29
ARGEO PAUL CELLUCCI
Lt. Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION
t PART A
CERTIFICATION
NOV .0 1998
--� TRU Y CORE
Secretary
DAVIL 1,.eSTRUHS
Commissioner
Property Address:/Address of Owner:
Date of Inspection. /y (If different)
Name of Inspector: . U
I am a DEP aoved system inspecto pursuant to Section 15.340 of Title 5 (.310 CMR 15.000)
p r
Company Name: P Li U t o a �–�
Mailing Address: <,/ A I G. > in S !'
Telephone Number: f – 7t— '6 0 - 2 y �T
CERTIFICATION STATEMENT
1 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 sews disposal systems. The system:
_1 Passes
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: J 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, of D:
AI SYSTEM PASSES: Va
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.
COMMENTS:
BI SYSTEM CONDITIONALLY PASSES:
tiL
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 conforming septic tank
as approved by the Board of Health.
(rovisad 04/25/97) Pago l of 10
DEP on the World Wide Web http:/twww.magnet.state.ma.us/dep
0 Printed on Recycled Paper
Property Address:
Owner:
Date of Inspection:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
07 905"11-A4 A
01110 e-7� I/,
.,
BJ SYSTEM CONDITIONALLY PASSES (continued) f
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). Describe observations:
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:
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 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 to 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 I 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
less than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
(revised 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (cont' d)
Property Address:
Owner: �� tO
Date of Inspection: f!
DI SYSTEM FAILS: % /- A
You must indicate either "Yes' or "No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
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. ,
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day floe.
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: H. .
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The -system serves a facility WA-adesign fl6'w of ]0,000 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 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 0{/25/97) Paye 3 of 10
e
Property Address:
Owner:
Date of Inspection:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
fol
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes/ No
�/' _ Pumping information was provided by the owner, occupant, or Board of Health.
f
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. ) Nr
As built plans have been obtained and examined. Note if they are not available with N/A.
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:
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub -Surface Disposal System.
_ Existing information. Ex. 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) [15.302(3)(b))
r
(zaviaad 04/25/97) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner:
Date of Inspection
FLOW CONDITIONS
RESIDENTIAL:
Design flow: g.p.d./bedroom for S.A.S.
Number of bedrooms: - .4
Number of current residentsi(yes
f
Garbage grrr der (yes or no):!or
Laundry connected to syst no):O
Seasonal use (yes or no):d
Water meter readings, if avail ble (last two (2) year usage (gpd): /W",/ (AA rr�-
Sump Pump (yes or no):�1 '
,.•• U K iy. a i +; 4 .a,
Last date of occupancy:(Y (/l
V
COMMERCI.AUINDUSTRIAL• f `
Type of establishment:
Design flow:_ga►lons/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
System pumped as part of inspection: (yes or no).V-e-)
If yes, volume pumped:�1��allons
Reason for pumping / r C c %µ✓s�/(
TYPE OF S7�EM
Septic tank/distribution box/soil abso ptiJn system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information:%
Sewage odors detected when arriving at the site: (yes or no)',6/d
(revised 04/25/97) Page 5 of 10
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: v �' /fir^ Ci►
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
Depth below grade: r /
Material of construction: _ iron _ 40 PVC _ other (explain)
Distance from private water supply well or suction lir-f,
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
t
Depth below grader
Material of construction: _oncrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list ague _ Is age confirmed by Certificate of Compliance _ (Yes/No)
Dimensions:
Sludge depth: ry
Distance from top of sludge dto bottom of outlet tee or baffler
Scum thickness:_ 'e,
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:IV
How dimensions were determined:
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;_
(locate on site plan) 't
j� / Ii � • t. t r / � � �r t
f F
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 04/2S/97) Papa 6 of 10
e°
Property Address:
Owner:
Date of Inspection:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
5/)
TIGHT OR HOLDING TANK: (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;L gallons
Design flow: gallons/dav
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:
GO1 /
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
U � llt�,ii C � i1 /� s T /! .�-•-� �x > .. _ s-"/ �+�� � c w'�'*�s. -r
PUMP CHAMBER:_
(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 04/25/97) Page 7 of 10
T SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: /? f (f%rl
Date of Inspection:
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
teaching pits, number:_
leaching chambers, number _
leaching galleries, number
/leaching trenches, number,length: W"
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
5614 -
CESSPOOLS: G1G--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)
E is
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 04/23/97) Page a of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: S
Owner: t G fir
Date of Inspection: 6—
f l
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
T
I.
a
f
(revised 04/25/97) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: ,rf�A
Date of Inspection:12
( !y f
Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
—;0b,servation of Site (Abutting property, observation hole, basement sump etc.)
too Deigrm'ine it from loc t,conJition
Check with local Board of health
Check FEMA Maps
-"'Check pumping records
``Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. Must be completed) €
�2 013 SPy,a`' ``
1011
Ai t t.
F
(revised 04/75/97) Page 10 of 10
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: 1 -JG ►_ roti, -C�fpA-��RV 6,4 ��'"��
,l).c�rloyP C �c01��' 4a �,0 �
Owner's Name: ..C(-Ln
Owner's Address:
Date of Inspection: g- 03
Name of Inspector: (please print) SQM
Company Name: V, Ce A6
Mailing Address: � I
f- aRj�fck
Telephone Number:
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:
X Passes
777 T Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
ails
Inspector's Signature: Date: d"k,:-031
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
Pagp 2 of 11
` OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: -}'
Owner: a00f Ul: n
Date of Inspection: 1 y — $ — a2
Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D
A. System Passes: Y6
.I have.notfound 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: 14
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 sewagebackup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
ND►explain:
® The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
ND explain:
Pdge 3 of 1 l
d'
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
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, safetyor 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.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,�performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
03. Other:
U
Pape 4 of 11
d
0 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: G=Ar
Owner: isna f i l ra
Date of Inspection: 1 C)�& - 03
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or "no" to each of the following for all inspections:
Yes . No
-"B—ackup 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
logged 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''I/ day flow
�equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
hof times pumped
Any portion of the SAS, cesspool or privy is below high ground water elevation.
_ _� y 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.
✓Ay 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.]
(Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:,:
To be considered 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.4ach of the following:
(The following criteria apply to large systems in addition to the criteria above)
ye$ no
_ the system is within 400 feet of a surface drinking water supply
C
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 Il 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
Page 5 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: ``;t - ee
Owner: GM f
. r_
Date of Inspection: n — S — c. -
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes o 1 t.
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)
J — Was the facility or dwelling inspected for signs of sewage back up ?
Was the site inspected for signs of break out ?
T
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
e b
of thaffles 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 locition of the Soil' Absorption System (SAS) on the site has been determined based on:
Yes no
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) [3 10 CMR 15.302(3)(b)]
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OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: g, ACZ6 113, i-1eJ
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design):Number of bedrooms (actual):
CMR 1 .3
DESIGN flow based on 310 5.203 (for example: 110 gpd x # of bedrooms):
Number of current residents:
Does residence Have a garbage grinder (yes or no): (�vr -FU
Is laundry on a separate sewage system (yes or no): [if yes separate inspection required]
Laundry system inspected (yes or no): _
Seasonal use: (yes or no): � 14
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump (yes or no): _pI U
Last date of occupancy: Q« a
COMMERCIALANDUSTRIAL
Type of establishment: j
Design flow (based on 310 CMR 15.203): gpd
Basis of design flow (seats/persons/sqft,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:
Was system pumped as part of the inspection (yes or no):
If yes, volume pumped: f _ p-, rt+ gallons -- How was quantity pumped dete#nined?
Reason for pumping: Tom— '
TYPE SYSTEM
eptic tank, distribution box, soil absmrptium system
_ Single cesspool
_ Overflow cesspool
Privy
Q 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
o'-b—tained 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: L/
3 -/'-
Were
`
Were sewage odors detected when arriving at the site (yes or no): //V
Pagee8of11
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OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 16
IV
f _
Owner: U—r C'1
Date of Inspection: k 11�1 — 6
TIGHT or HOLDING TANKf r'/' (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: ),
Material of constriction: concrete metal 'fiberglass polyethylene other(expldin):
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: Y,15 (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: d /
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:` . Aocate on site plan)
Pumps in working order (yes or no):. g
Alarms in working order (yes or no):
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Page 7 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: ?� Yl)
Owner: �•'CriaE
Date of Inspection: i en — 6 - 0-�
BUILDING SEWER (locate on site plan)
Depth below grade: 0
Materials of construction: _ t iron p_40 PVC _other (explain):
Distance from private water supply well or suction line:
Comments (on condition of joints, venting, evidence of leakage, etc.):
SEPTIC TANKf�locate on site plan)
Depth below grade: /
Material of construction: L,�oncrete _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) If
Dimensions: s A
Sludge depth: S` ,r
Distance from top of sludge to bottom of outlet tee or baffle: 3cF `'
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: U.-/ 5/ T c.
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related,to outlet invert, evidence of leakage, etc.):
GREASOTRAP: _(locate on site plan)'
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Page 9 of 11
r
r OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: nS-�rv��.►-(may'
Owner Cy-raf LT -r- C')
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS): �5(ocate 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: 4� ' 5'� Ca&4 .
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.):
SIM 6/-' �!'/p /�vLlc ,� /amu e
14
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 or no.): i ;(
Comments (note conditionbf 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.):
9
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OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM'INFORMATION (continued)
Property Address:-79�-
Owner: (fvn r14T6
Date of Inspection: (n --g —o3
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 flet. Locate where public water supply enters the building.`{
Sp 3
Th
D t%
I
10
Pate 11 of 11
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OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: Y1, �4r
ClfeA _LA�Pe-1
Owner: C=,-nf Ix,t: n
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar j
Shallow wells v r t t Nil
Estimated depth ts,gr`ound water feet
Please indicate check) all methods used to determine the high ground water elevation:
) btained 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)
Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
r
a
11
a
0