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Miscellaneous - 76 BOSTON HILL ROAD 4/30/2018 (2)
l 4 North Andover Health Department (ommunity Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 76 Boston Hill Rd. MAP INSTALLER: Mike Reilly DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS D- Box INSPECTION: 11/13/14 DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS Comments: SEPTIC TANK LOT: ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port VA Comments: PUMP CHAMBER Comments: CONTROLPANEL Comments: DISTRIBUTION -BOX Comments: ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Installed on stable stone base H-20 D -Box Inlet tee (if pumped or >0.08'/foot) Hydraulic cement around inlet & outlets [� Observed even distribution Speed levelers provided (not required) Schedule 40 PVC Pipe Board of Health North 1,,ncioveriN.aaa. - -- -- CNID DATE SEPTIC STSTEH INSTALLATICK CHIDCS LISP easPnst LOT ;# (Ot�1Sr0iv _._._._ LEXCAVATIN Old FAIL 1. Distance Tot a. Wetlands b. Drains c, Well 2. Water Line Location 3. No PPC Pipe 4. Septic Tank a. Tees -_Length & To . Clean Out Covers b. Cement Pipe to Tank - On Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All bines Flo -,;Ing Equal Amoimts C. No Back Flow b. Leach Field or Trench a. Dimensions b. Stone Depth c. Capped lads d. Clean Double Washed Stone 7. Leach Pits a. Dimensions b. Stone Depth c. Splash Pads d. Tees e. Cenent Pipe to Pit - Both Sides f. Clean Double Washed Stone 8. No Garbage Disposal 9. Final Grading Inspection 10. Barricading Covered System 11. As Built Submitted a. Lot Location b. Dimensions of System C* Location with Regard -to Perc Test d. Elevations e.' Water Table or 1 I ag facil tic tal*,.v 1 s - C s, - -- - - _ . ia: r � � A` on 0,C) '10 t I 1 or 1 I ag facil tic tal*,.v 1 s - C s, - -- - - i ELEVATIONS 'r -,,P FNU 2�S.2G N8g•16'4CE __, S' VICT 24J•37 ST 0.: LET 246-:B n.�pX I,,LT i D -BOX OUTLET 245.71 TRENCH 1 24523 2 2.44.10 3 24Z-.79 4 241.39 5 23577 N CP .w "-G— 147�- s v L) D u, ELEVATIONS 'r -,,P FNU 2�S.2G t 10 _ - F O�� L.I.. i 24 5.98 S' VICT 24J•37 ST 0.: LET 246-:B n.�pX I,,LT 2v`� 51 D -BOX OUTLET 245.71 TRENCH 1 24523 2 2.44.10 3 24Z-.79 4 241.39 5 23577 zor l .GSD 'b05 i©l-- � "Gtliurs F G r -I -ZC, -jf f 187-5`;•4� :'• 1 ' c h�•F � Tl+� `.r.�.'" � �`�-T�,i. 1'.f+��'.:.i''A,! [F(.•f, i '�.+i:i:�f� rf+lrF-;�1i. A V-14v4AN `) OF TNF ` Y ,TT C_+ j VRFNAR�:7 1 1 J NACE I` 1I a `I u.1 - CQ s ELLIt.G r r� v• - ,w D -BOX }c+LFT 245.91 D-2:; < C,;—LET 255-71 2 241-13 Commonwealth of Massachusetts Map -Block -Lot 107.B0083 BOARD OF HEALTH - ------ No Permit N ------------ North Andover BHP -2014-1285 P.I. FEE F.I. $125.00 -------- --------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Peter F.-Re11ly---------------------------------------------------------------------------------------- to (Repair) an Individual Sewage Disposal System. at No L ----76--BOSTON-----------------HILROAD ----------------------------------------------------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. BHP -2 I4-' 128 i" DaaTed'"No bn4ber 10, 2014 ............ ----------- ----------------------------------------------------- Issued On: Nov -10-2014 BOARD OF HEALTH ------------------------------------------------------------------------------- •9oT , 7153 ? 4 + , 9 Town of North Andover '�°'•'� HEALTH DEPARTMENT ,'SSACHUSE� CHECK #: DATE: I W11r* LOCATION: H/O NAME: L CONTRACTOR NAME: Type of Permit or License: (Check box) J ❑ 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 $ "6 Title 5 Report 1 5() .1 ❑ Other. (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer #. r OF NORTH 4H ti0 x y �4SSAC HU - Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. ray rerun Aaalication for Seatic Disaosal Svstem A/a/6,04) ba- l°/ 20iy Construction Permit - TOWN OF TODAY'S DATE NORTH ANDOVER, MA 01845 $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* '/ g'Repair or replace an existing system component — What? r 11 A. Facility Information �, Address or Lot # I/, =1ArWVAWrjAW1 UFA I �IM 2.- *TYPE OF SEPTIC SYSTEM*: ONP�j"�` ➢ ❑ Pump Gravity (choose one) ***If pumps tem, 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) ➢ ❑ Pressure Dosed (D -Box Present) S.A.S. ➢ ❑ Does the system require an effluent filter? Yes No If yes, does plan specify make and model of filter? YES = (no further info. needed) NO = (installer must specify brand of filter before DWC issuance) What is the Make? What is the Model? 2. Owner Information r u Name '74 Address (if different from above) mzrA A 4�t? City/Town State Zip Code q78^ to 7570 Telephone Number 3. Installer Information Name Name of Company AddZ City/Town State Zip Code I7� yl?/ / Telephone Number (Cell Phone # if possible please) 4. Designer Information Al Name Name of Company Address City/Town State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 • '° •. Application for Septic Disposal System A/ev, leo 2-0,111 Construction Permit - TOWN OF TODAY'S DATE NORTH ANDOVER MA 01845 $ 250.00 - Full Repair , $125.00 -Component PAGE 2OF2 A. Facility Information continued.... 5. Type of Buildinq:)krResidential Dwelling or ❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover. I understand that until a final Certificate of Compliance has been issued by this Bd of Health, the installed system is not approved. 76 UD I l/-/ o/ Name VDate Application Approved By: (Board of Health Representative) Name Application Disapproved for the following reasons: For Office Use Only: L Fee Attached? 2. Project Manager Obligation Form Attached? 3. • Pump Sys tem? If so, Attach co�y ofElectrical Permit Applicant received copy of "Electrical Inspection Notes for Septic Systems" Handout? 4. Reviewed approval letter, all paperwork received. Missing: 5. Foundation As -Built? (new construction only). (Same scale as approved plan) Date Yes No Yes No Yes No Yes No Yes No Yes No G. Floor Plans? (new construction only): Yes No Application for Disposal System Construction Permit • Page 2 of 2 Ct NORTN ,� f `I Gr 3 F in . . Town of North Andover 'o'• HEALTH DEPARTMENT /n� ' (, CHECK #:'D �A �11�I� DATE:. 1 J 11J 101) hf' LOCATION:' ! U/ L H/O NAME: C CONTRACTOR NAME: Type of Permit or License: (Check box) J ❑ 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. return Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 76 Boston Hill Road Property Address Eugene P. Willis Owner's Name North Andover City/Town MA 01845 November 7, 2014 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: Peter F. Reilly Name of Inspector Peter F. Reilly Company Name 136 Andover Street Company Address Andover MA City/Town State 978-375-3750 S11955 Telephone Number B. Certification License Number ;�SE:IK 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 Furthe valuation by the Local Approving Authority November 7, 2014 Ins tor's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 11/10 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 76 Boston Hill Road Property Address Eugene P. Willis Owner's Name North Andover MA 01845 November 7, 2014 Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 76 Boston Hill Road Property Address Eugene P. Willis Owner's Name North Andover MA 01845 November 7, 2014 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 ❑ obstruction is removed ® distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): Inspection subject to replacement of deteriorated d -box. ❑ 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c,M 76 Boston Hill Road Property Address Eugene P. Willis Owner Owner's Name nformation is required for every North Andover MA 01845 November 7, 2014 for page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ❑ i than Y2 day flow t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17 ❑ 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 Y2 day flow t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 76 Boston Hill Road Property Address Eugene P. Willis Owner Owner's Name information is required for every North Andover MA 01845 November 7, 2014 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17 Commonwealth of Massachusetts F W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 76 Boston Hill Road C. Checklist RAA 114 6Ac November 7, 2014 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? ® ❑ Property Address Eugene P. Willis Owner Owner's Name information is required for every North Andover page. City/Town C. Checklist RAA 114 6Ac November 7, 2014 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): 4150 gpdd Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 600 t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 76 Boston Hill Road Property Address Eugene P. Willis Owner Owner's Name information is North Andover MA 01845 November 7 2014 required for every , page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 1,500 gallon septic tank / d -box / SAS (5 trenches). Original system installed in 1985. Grease trap present? ❑ Yes ❑ Number of current residents: 1 ❑ 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 9 ( Y 9 (gP ))� N/A - well water Detail: Single occupant. Dwelling is on a domestic well that is greater than 1 00'from all system components. Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: — - - t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 76 Boston Hill Road _ Property Address Eugene P. Willis Owner Owner's Name information is North Andover MA 01845 November 7 2014 required for every , page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: 2012 Date Other (describe below): General Information Pumping Records: Source of information: owner said about 3 years since last pumping - no pumping records on file at BOH Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: How was quantity pumped determined? Reason for pumping: gallons Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 76 Boston Hill Road Property Address Eugene P. Willis _ Owner Owner's Name information is required for every North Andover MA 01845 November 7, 2014 _— page. CityTTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Original system installed in 1985. As built and design plans on file at BOH. 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 rivate water su I well ors t' li ���Fdm 1.5 feet >100' p pp y uc Ion ine. feet Comments (on condition of joints, venting, evidence of leakage, etc.): Building sewer was watertight and appeared sound at the foundation. Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 1.0 feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: rectangular approx. 6' x 12' Sludge depth: 1"-2'• t5ins • 11/10 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 76 Boston Hill Road Property Address Eugene P. Willis Owner Owner's Name information is required for every North Andover MA 01845 page. City/Town State Zip Code D. System Information (cont.) 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 26" 0"-1 " 7° 15" November 7, 2014 Date of Inspection How were dimensions determined? estimation / measurement Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was watertight and appears to be functioning properly. Baffles,intact. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness N/A 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 • 11/10 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 76 Boston Hill Road Property Address Eugene P. Willis Owner Owner's Name information is North Andover MA 01845 November 7, 2014 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 I Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 76 Boston Hill Road Property Address Eugene P. Willis Owner's Name North Andover MA 01845 November 7, 2014 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 a 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.): Five lines leading to SAS were accepting effluent fairly evenly. Minimal solids carryover evident. The box cover was 12" - 18" below the surface, depth varied due to sloping topography. 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 - 11/10 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 76 Boston Hill Road Property Address Eugene P. Willis Owner Owner's Name information is required for every North Andover page. City/Town D. System Information (cont.) MA 01845 November 7, 2014 State Zip Code Date of Inspection Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system 5 - 50' trenches per "as built" plan Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soils in the area of the SAS appeared normal, no signs of breakout. 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 Form: Subsurface Sewage Disposal System • Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 76 Boston Hill Road Property Address Eugene P. Willis _ Owner Owner's Name information is required for every North Andover MA 01845 November 7 2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins • 11/10 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 7 76 Boston Hill Road Property Address Eugene P. Willis Owner Owner's Name information is required for every North Andover MA 01845 November 7. 2014 page Gity[Town State Zip Code Date of Inspection . .. .. ........... .. D. System Information (cont.) Sketch Of Sewage Disposal SystemProvide 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 5R5 50, +rcmc�(5 !;ms - "1:U 1 ! , 0-,E?! fnswmo, Fox, S,bs,Alac, 1,0,a,?a [M*,,v system - PJge 13.:x• , laic 57 C4 2_2-5" R 4ti D -fox 31,41 - -- - ------- ---- ------ -- C V- box 30°0 5R5 50, +rcmc�(5 !;ms - "1:U 1 ! , 0-,E?! fnswmo, Fox, S,bs,Alac, 1,0,a,?a [M*,,v system - PJge 13.:x• , Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 76 Boston Hill Road Property Address Eugene P. Willis Owner's Name North Andover _ MA 01845 November 7, 2014 City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: >1' below bottom of SAS - 1984 design plan shows adequare separation Please indicate all methods used to determine the high ground water elevation: // El // // 104 Obtained from system design plans on record If checked, date of design plan reviewed: 1984 Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: information on file. Checked with local excavators, installers - (attach documentation) Accessed USGS database - explain: USGS data not specific to site. You must describe how you established the high ground water elevation: Soils, grade changes, and lack of sump pump indicates adequate groundwater separation. Howwever, the precise ground water elevation cannot be determined for certain without a soil evaulation test. NOTE: Soil evaulation is the recognized method for determining or establishing the high groundwater elevation. Since I am not a licensed or certified soil evaulator, I am not qualified to determine or establish the high groundwater elevation beyond the public information available, such as recent design plans of the site or the nearby area. My estimation of the high groundwater elevation is based on a due diligence effort to obtain all available information both on and off the site and my experience as a certified septic system inspector. (see attached Discliamer) Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 76 Boston Hill Road State Zip Code E. Report Completeness Checklist November 7, 2014 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 Property Address Eugene P. Willis Owner Owner's Name information is required for every North Andover page. City/Town State Zip Code E. Report Completeness Checklist November 7, 2014 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 DISCLAIMER This passing septic inspection under Massachusetts Title V is in no way a guaranty or warranty of the inspected septic system. The inspection is a "snapshot in time" and does not constitute a complete assessment of the quality or potential longevity of the septic system. The pass/fail criteria are specific and outlined in detail in this report. Under the limited criteria of a Title V inspection, it is impossible to determine how long any septic system will last. The inspector made a diligent effort to certify the septic system based on the criteria required under Title V. Under Massachusetts Title V, soil evaluation is the accepted method of determining the high groundwater elevation. This inspector is not a certified soil evaluator and is therefore not qualified under Title V to determine or establish the high groundwater elevation. The method used to estimate the high groundwater for this inspection was based on the public records and methods of observation described on the previous page. Groundwater levels can vary greatly from season to season, year to year and soil evaluation is considered the most reliable method of groundwater determination under Title V. Peter F. Reilly Inspector November 7, 2014 , / ' . 11M�2 E� _ . . / '. ' ' / / Z CO (Tt u c � / � / CY� -- l ` ` MO r1i 4 1 0 ITI 1� 0 —E- 34 Co N — rt Fr cc I 4 1 7 LM t.N 0 ip cc rn CP Ln I rn CP T-1. no I CP