HomeMy WebLinkAboutMiscellaneous - 76 GRANVILLE LANE 4/30/2018r
North Andover Board of Assessors Public Access
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Parcel ID: 210/106.C-0070-0000.0 Community: North Andover
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Location: 76 GRANVILLE LANE
Owner Name: MELAKU, JORDAN G
MAKONNEN MELAKU
Owner Address: 76 GRANVILLE LANE
City: NORTH ANDOVER State: MA ZIP: 01845
Neighborhood: 6 - 6 Land Area: 1.11 acres
Use Code: 101- SNGL-FAM-RES Total Finished Area: 2711 sqft
ASSESSMENTS CURRENT YEAR PREVIOUS YEAR
Total Value: 539,000 503,400
Building Value: 328,500 308,600
Land Value. 210,500 194,800
Market Land Value: 210,500
Chapter Land Value:
LATESTSALE
Sale Price: 430,000 Sale Date: 12/20/2001
Arms Length Sale Code: Y -YES -VALID Grantor: FRANK JOHNSON III
Cert Doc: Book: 06563 Page: 0071
Page 1 of 1
http://csc-ma.us/NandoverPubAcc/jsp/Home.jsp?Page=3&Linkld=809098 9/21/2006
67�Q
Town of North Andover
HEALTH DEPARTMENT
rlf)CHECK #: DATE:
LOCATION:
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 Sustems:
❑ Septic - Soil Testing $
❑ Septic - Design Approval $
❑ Septic Disposal Works Construction (DWC) $
❑ Septic Disposal Works Installers (DWI) $
❑ Title 5 Inspector $�
Title 5 Report x $
❑ Other: (Indicate) $
J)
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
n
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
r 76 Granville Lane
Property Address
Makonnen Melaku
Owner's Name
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.
ou
IGS
t5ins - 3/13
North Andover
Cityrrown
MA 01845 3/19/2014
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
1. Inspector:
Neil J. Bateson
Name of Inspector
Bateson Enterprises Inc.
Company Name
111 Argilla Road
Company Address
Andover
City/Town
978-475-4786
Telephone Number
B. Certification
MA
State
S115
License Number
01810
Zip Code
14
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
❑ N[Pedsi Further. Evaluation by the Local Approving Authority
n
3/19/2014
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Foam - Not for Voluntary Assessments
76 Granville Lane
Property Address
Makonnen Melaku
Owner Owners Name
information is
required for North Andover MA 01845 3/19/2014
every page. City/Tbwn State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
Al 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 moresystem 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 • 3/13 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 Granville Lane
Property Address
Makonnen Melaku
Owner's Name
North Andover
Cityrrown
B. Certification (cont.)
JIM
OLCILU
01845 3/19/2014
Zip Code Date of Inspection
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if .
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or reak 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
❑ Y ❑ N ❑ ND (Explain below):
❑ 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 isnot functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17
Owner
information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
76 Granville Lane
Property Address
Makonnen Melaku
Owners Name
North Andover MA 01845 3/19/2014
Citylrown 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 invertdue to an overloaded
or clogged SAS or cesspool
❑
®
Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2 day flow
t5ins . 3113
Title 5 Official Inspection Forth: Subsurface Sewage Disposal System - Page 4 of 17
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
.For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area — IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17
Commonwealth of Massachusetts
lvTitle
5
Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
76 Granville Lane
Property Address
Makonnen Melaku
Owner
information is
Owner's Name
required for
North Andover
MA 01845 3/19/2014
every page.
Cityrrown
State. Zip Code Date of Inspection
B. Certification (cont.)
Yes
No
❑
® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑
® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑
® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑
® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑
® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑
® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
.For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area — IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
'u< 76 Granville Lane
Property Address
Makonnen Melaku
Owner Owner's Name
information is
required for North Andover MA 01845 3/19/2014
every page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
® ❑
Pumping information was provided by the owner, occupant, or Board of Health
❑ ®
Were any of the system components pumped out in the previous two weeks?
® ❑
Has the system received normal flows in the previous two week period?
❑ ®
Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑
Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑
Was the facility or dwelling inspected for signs of sewage back up?
® ❑
Was the site inspected for signs of break out?
❑
Were all system components, excluding the SAS, located on site?.
❑
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): Number of bedrooms (actual):
ALA
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms):
t51ns - 3/13 Title 5 Official Inspection Forth: 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
•30 76 Granville Lane
Property Address
Makonnen Melaku
Owner Owners Name
information is
required for North Andover MA 01845 3/19/2014
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents:
4
Does residence have a garbage grinder?
❑
Yes
®
No
Is laundry on a separate sewage system? (Include laundry system inspection
❑
Yes
®
No
information in this report.)
Laundry system inspected?
❑
Yes
❑
No
Seasonal use?
❑
Yes
®
No
Water meter readings, if available last 2 ears usage
( Y 9 (gpd))�
Yes
Detail:
Sump pump?
®
Yes
❑
No
Last date of occupancy:
Current
Date
Commercial/Ind4strial 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 - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17
N
Commonwealth of Massachusetts
Title 5:Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
76 Granville Lane
Property Address
Makonnen Melaku
Owner Owner's Name
information is
required for North Andover MA
every page. City/Town State
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
Pumping Records:
Source of information:
01845 3/19/2014
Zip Code Date of Inspection
Date
General Information
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Type of System:
Pumped two years ago,owner
1500
gallons
Measured tank.
Inspect tank & tees.
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
® Yes ❑ No
❑ 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 • 3/13 Tide 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
76 Granville Lane
Owner
information is
required for
every page.
Property Address
Makonnen Melaki
Owner's Name
North Andover
Cityrrown
D. System Information (cont.)
MA 01845
State Zip Code
3/19/2014
Date of I
Approximate age of all components, date installed (if known) and source of information:
Leach pits 32 years old, tank replaced 2006, d -box replaced 2011, as built plan & info at B.O.H.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer (locate on site plan):
Depth below grade: 3
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other (explain):
Distance from private water supply well or suction line: feet
Comments (on cond.ition,of.joints, venting, evidence of leakage, etc.):
4" PVC through foundation. 3" PVC in house, no leaks visible.
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal
2
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)
Dimensions: 10'x 5'x 4'
Sludge depth:
4"
❑ Yes ❑ No
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
y�< 76 Granville Lane
Owner
information is
required for
every page.
t5ins - 3/13
Property Address
Makonnen Melaku
Uwners Name
Korth Andover MA 01845 3/19/2014
Cityrrown State Zip Code Date of Inspection
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
29"
4"
8"
9.,
How were dimen$ions determined?
Tape Measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence
of leakage. Inlet cover has riser 8" deep.
Grease Trap (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal
Dimensions:
Scum thickness
feet
❑ fiberglass ❑ polyethylene ❑ other (explain):
Distance from top of scum to top of outlet tee or baffle
.Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17
Commonwealth of Massachusetts
I
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
76 Granville Lane
Owner
information is
required for
every page.
Property Address
Makonnen Melaku
Owner's Name
North -Andover MA 01845 3/19/2014
Cityfrown State Zip Code Date of Inspection
D. System Information (cont.).
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑metal ❑ fiberglass ❑ polyethylene ❑ other (explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract (required). Is copy attached? . ❑ Yes ❑ No
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17
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 Granville Lane
Property Address
Makonnen Melaku
Owner's Name
Korth Andover MA 01845 3/19/2014
CityRbwn State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid Ieyel 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 level & distribution equal. Evidence of carryover, pumped d -box to clean. No
evidence of leakage.
Pump Chamber (locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes. ❑ No`
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth — top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins • 3/13 Title 5 Official Inspection. Form: Subsurface Sewage Disposal System • Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection
Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
76 Granville Lane
Property Address
Makonnen Melaku
Owner
Owner's Name
information is
required for
North Andover MA
01845 3/19/2014
every page.
City/Town State
Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits
2
number:
❑ 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.):
Yard covered in snow, no sign of ponding to surface. Camera inside of pits through outlets in d -box,
no liquid to inverts.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth — top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins • 3/13 Title 5 Official Inspection. Form: Subsurface Sewage Disposal System • Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
76 Granville Lane
Property Address
Makonnen Melaku
Owner Owner's Name
information is
required for Forth Andover MA 01845 3/19/2014
every 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Film Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
76 Granville Lane
Owner
information is
required for
every page.
Property Address
Makonnen Melaku
Owner's Name
North Andover
MA 01845 3/19/2014
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
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0
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1 — ' 10 �-
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t5ins - 3/13 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
76 Granville Lane
,p
Owner
information is
required for
every page.
Property Address
Makonnen Melaku
Owner's Name
North Andover MA 01845 3/19/2014
Cityrrown 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: 4
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: 6/4/1982
Date
❑ Observed site (abutting. property/observation hole within 150. feet of SAS)
® Checked with local Board of Health - explain:
Design plan
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database - explain:
You must describe how you. established the high ground water elevation:
Test pit data on design plan.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�.' 76 Granville Lane
Property Address
Makonnen Melaku
Owner Owner's Name.
information is
required for North Andover MA 01845 3/19/2014
every page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
t5ins - 3113
® 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
Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17
IM
• . .� uommonweann of Massachusetts
City/Town of
System Pumping Record
Form 4
DEP has provided this form for use�by local Boards of Health. Other forms may be'used, but the
information must be substantially the same as that provided here. Before using -this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/ Right front of house, Left / I hgt rear of house Left / right side of house, Left/
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
Address
City/Town state nn ("Ma
2. System Owner.
It-e,lq�k
I v 0 w LcL,-ve_
Name'
Address (if different
State Zip Code
70
Telephone Number
B. Pumping Record `
1. Date of Pumping l
P 9 Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Y" 2-vo if yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
7.
Neil Bateson
Name `
Bateson Enterprises Inc
Company
contents were disposed:
Lowell Waste Water
F5821
Vehicle License Number
Date
t5fomr4.doc• 06/03 System Pumping record • Page 1 of 1
l
Town of North Andover
Tax Map # 210-106.C-0070-0000.0
Parcel Id 17705
76 GRANVILLE LANE
MELAKU, MAKONNEN
103 BLUE MEADOW LANE
SICKLERVILLE, NJ
08081
y
Class 101 Single Family
Property Type
1 Residential
Zoning2 1 Residential
Zoning3
1 Residential
Size Total 1.11 Acres
FY 2014
UB Mailing Index
Name/Address
Type Loan Number
Activellnact. From
Until
MELAKU; MAKONNEN
Payor
103 BLUE MEADOW LANE
SICKLERVILLE; NJ
08081
UB Account Maint.
Account No
Cycle
Occupant Name
Active/Inactive
Bldg Id. 17395.0 - 76 GRANVILLE LANE Last Billing Date 1/7/2014
3170065
03 Cycle 03
Active
UB Services Maint.
Account No. 3170065
Service Code
Rate Charge
Multiplier/Users
MISCFEE ADMIN FEE
0.635/8 7.82
1/
WTR WATER
01 ALL METER SIZE 109.30
/1
UB Meter Maintenance
Account No. 3170065
Serial No Status
Location Brand
Type Size
YTD Cons
36433711 a Active
ERT HH b Badger
w Water 0.63 0.63
458
Date
Reading
Code Consumption
Posted Date
Variance
3/10/2014
489
a Actual
21
-20%
12/9/2013
468
a Actual
26
1/17/2014
40%
9/10/2013
442
a Actual
19
10/15/2013
-6%
6/10/2013
423
a Actual
20
7/24/2013
-46%
3/11/2013
403
a Actual
38
4/22/2013
58%
12/7/2012
365
a Actual
22
1/9/2013
-8%
9/12/2012
343
a Actual
27
10/15/2012
21%
6/8/2012
316
a Actual
20
7/16/2012
-11%
3/14/2012
296
a Actual
25
4/14/2012
-100%
12/9/2011
.271
a Actual
0
1/17/2012
-100%
9/12/2011
271
a Actual
2
10/13/2011
-54%
6/6/2011
269
a Actual
4
7/20/2011
-79%
3/8/2011
265
a Actual
19
4/13/2011
-51%
12/10/2010
246
a Actual
41
1/12/2011
-69%
9/8/2010
205
a Actual
135
10/15/2010
143%
6/4/2010
70
a Actual
51
7/15/2010
77%
3/8/2010
19
a Actual
19
4/14/2010
-100%
1/9/2010
0
n New Meter
0
4/14/2010
-100%
1/9/2010
2756
r Replacement
9
4/14/2010
-19%
12/10/2009
2747
a Actual
34
1/12/2010
-25%
9/9/2009
2713
a Actual
48
10/15/2009
7%
6/4/2009
2665
a Actual
39
7/20/2009
32%
3/12/2009
2626
a Actual
34
4/29/2009
-12%
12/5/2008
2592
a Actual
35
1/20/2009
-38%
9/8/2008
2557
a Actual
62
10/10/2008
25%
6/4/2008
2495
a Actual
46
7/16/2008
34%
3/7/2008
2449
a Actual
34
4/11/2008
-9%
12/10/2007
2415
a Actual
41
1/22/2008
-4%
9/4/2007
2374
a Actual
36
10/12/2007
74%
Commonwealth of Massachusetts t:=
City/Town of
u System Pumping Record D-�� 2U12
Form 4 TOWN OF NORTH ANDOVER
HEALTH DEPART'..=NTS'
DEP has provided this form for us&by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left /Right front of house, Left fight rear of ,Left/right side of house, Left /
Right side of building, Left / Right front of building, a fight rear of building, Under deck
Address
Cityrrown State Zip Code
2. System Owner
e, f S
Name &fyl
Address (if different from location)
Cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping �� 2. Quantity Pumped: JC��
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes dNo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
Ro— 0 CL°
6. System Pumped By:
Neil Bateson
Name i
Bateson Enterprises Inc
Company
7. Locat p� ere contents were disposed:
Waste Water
F5821
Vehicle License Number
i (- Id—
Date
t5form4.doc• 06/03 System Pumping Recons • Page 1 of 1
DelleChiaie, Pamela
From: Sawyer, Susan
Sent: Thursday, June 30, 2011 10:09 AM,
To: DelleChiaie, Pamela
Cc: Grant, Michele
Subject: d - box
Michele, I put a file on your desk. Todd has a d -box that will be ready at 1PM. I personally cannot do the inspection
today. I could do it on Friday if your schedule is full today.
Thx, Susan
StliJatt SLY.Ivyu
Yub& ,7EeaO 291w tan
1600 Vagwod Stud
2t4 2U, unit 2-36
NodA Qndau", .MQ 01845
office 978 6SS-9540
f 978 6884476
All email messages and attached content sent from and to this email account are public
records unless qualified as an exemption under the
[ http://www.sec.state.ma.us/pre/preidx.htm ]Massachusetts Public Records Law.
Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records. For more
information please refer to: http://www.sec.state.ma.us/pre/preidx.htm.
Please consider the environment before printing this email.
PUBLIC HEALTH DEPARTMENT
Town of North Andover
Community Development Division
"FICA qJLE Off' C09W(PLJ
As of:
I 5 2011
This is to cert that the individuaCsubsurface disposaCsystem received a
SA`Z7SFAC701RT15VSPEM0Xof the:
ft&cement of a Ustri6ution Box for an
On Site Sewage 04osa[System
By.
ToddBateson
At:
76 GranvilTe .Gane
Wap -106. C^4Parre1-0070-
Parcel
ID :210/106.C-0070-0000.0
�1 Forth .Xndover, 9V X 01845
die Issuance opis certificate shat be construedas aguarantee that the system willfunction satisfactoriry.
T Sawyer,
3feafth Di
i0feafth (Director (Director
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
PUBLIC HEALTH DEPARTMENT
Town of North Andover
(ommunity Development Division
As of:
Lul-y 5, 2011
This is to cert that the individuafsu6surface diaposal system received a
SA`17SF3C`70RTIXS(ECYZ 0Xof the:
ft&cwwnt of a O stri6ution BoVor an
On Site Sewage 04osaCSystem
By:
ToddBateson
At:
76 granviffe Lane
Map-106.Co-tParceC-0070
Parcel ID :210/106.C-0070-0000.0
North . ndove v 5W,9 01845
The Issuance o)�fi?is certzcate shat be construedas aguarantee that the system wifffunction satisfactorify.
Zeafth
is 9feafth Director Director
1600 Osgood Street, North Andover, Massachusetts 01845
Phone 918.688.9540 Fax 918.688.8416 Web www.townofnorthandover.com
- _.
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� �� - - -
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� ��
4
North Andover Health Department
Community Development Division
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION i
ADDRESS: �f�/%, ��� MAP
INSTALLER:
DESIGNER:
PLAN DATE: j`� 1
BOH APPROVAL DATE ON PLAN:
INSPECTIONS
TANK INSPECTION:
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION:
SITE CONDITIONS
Comments:
LOT:
❑ Contractor reports any changes to design plan
E Existing septic tank properly abandoned
❑ Internal plumbing all to one building sewer
❑ Topography not appreciably altered
SEPTIC TANK
❑
Building sewer in continuous grade, on
compacted firm base
❑
Cleanouts per plan
❑
Bottom of tank hole has 6" stone base
❑
Weep hole plugged
❑
gallon tank has been installed
loading
❑
Monolithic tank construction
❑
Water tightness of tank has been achieved by
testing
❑
Inlet tee installed, centered under access port
4
❑ Outlet tee installed, centered under access port
Comments:
(gas baffle/effluent filter)
❑
inch cover to within 6" of final grade
installed over one access port
❑
Hydraulic cement around inlet & outlet
Comments:
PUMP CHAMBER
❑
Bottom of tank hole has 6" stone base
❑
Weep hole plugged
❑
gallon Pump Chamber installed
❑
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
Comments:
CONTROL PANEL
❑
Alarm & Pump are on separate circuits
�J/
❑
❑
Alarm sounds when float is tripped
Location of control panel: basement
/P G4 Q���/���
❑
Alarm signal located inside: basement
Comments:
DISTRIBUTION -BOX
Installed on stable stone base
b/
H-20 D -Box
F" -]Inlet
tee (if pumped or >0.08'/foot)
[✓]/
Hydraulic cement around inlet & outlets
Observed even distribution
[]/
Speed levelers provided (not required)
Comments:
SOIL ABSORPTION SYSTEM (General)
❑ Bottom of SAS excavated down to C soil layer,
as provided on plan
❑ Size of SAS excavated as per plan
❑ Title 5 sand installed, if specified on plan
❑ 40 Mil HDPE barrier installed
❑ Laterals installed and ends connected to
header (and vented if impervious material
above)
❑ Elevations of laterals and chambers installed as on
approved plan .
❑ Retaining wall (boulder / concrete / timber/ block)
❑ Final cover as per plan
Comments:
SOIL ABSORPTION SYSTEM (Gravel -less Chambers)
❑ Brand and Model of Chamber: Standard Quick
4 Infiltrator Chambers
❑ Number of chambers per row:
❑ Number of rows (trenches):
Comments: Total Chambers =
SYSTEM ELEVATIONS
ROD AS -BLT INVERT DESIGN INVERT
ELEVATION ELEV ELEV
Benchmark
Building Sewer OUT
Septic Tank IN
Septic Tank OUT
Pump Chamber IN
Pump Chamber OUT
Distribution Box IN
Distribution Box OUT
Lateral 1 TOP
Lateral 1 INVERT
Lateral 2 TOP
Lateral 2 INVERT
Lateral 3 TOP
Lateral 3 INVERT
Lateral 4 TOP
Lateral 4 INVERT
Lateral 5 TOP
Lateral 5 INVERT
Lateral 6 TOP
Lateral INVERT
Top of Chamber
Bottom of Bed/Chamber
SKETCH PLAN
4
CRITICAL SETBACK DISTANCES
Mark those distances checked in the field against the design plan and regulatory
setback
1 Suction line 222(2)
2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02).
3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA
wetland bylaws
Tank
SAS Sewer
®
Property line
10
10 --
®
Cellar wall
10
20 --
®
Inground pool
10
20 --
®
Slab foundation
10
10 --
®
Deck, on footings, etc
5
10 --
®
Waterline
10
10 101
®
Private drinking well
75
1002 50
®
Irrigation well
75
100
Z
Surface Water
25
50
®
Bordering Vegetated Wetland ,
Salt Marsh, Inland / Coastal Banka
75
100
®
Wetlands bordering surface
water supply or trib. (in Watershed)
150
150
®
Trib. to surface water supply
325
325
®
Public well
400
400
®
Interim Wellhead Prot. Area
®
Reservoirs
400
400
®
Drains (wat. supply/trib.)
50
100
®
Drains (intercept g.w.)
25
50
®
Drains (Other) Foundation
10 (5)
20 (10)
®
Drywells
20
25
1 Suction line 222(2)
2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02).
3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA
wetland bylaws
Cf 10FT `,�
0 9
Town of North Andover
`�'• HEALTH DEPARTMENT
,SSACMUSEt �j
CHECK #:�✓( D E:
LOCATION: 10
H/O NAME:
CO
AME:
5541
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 $
❑ Sept�ic - esign Approval $
lYSeptic Disposal Works Cons ctior)l'
)$❑ Septic Disposal Works Ins�Clllers $
❑ Title 5 Inspector $
Title 5 Report $
)then: (Indicate) $
Health Agent Initials
licant Yellow - Health Pink - Treasurer
r'.Of 4NORT X14 _ 5541
Town of North Andover
HEALTH DEPARTMENT
cmu
CHECK #: ,E:
LOCATION: /
H/O NAME:
AME:
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 ; 1f $
❑ Trash/Solid Waste Hauler $
❑ Well Construction $
r
SEPTIC Systems: '
❑ Septic - Soil Testing $
❑ Se/pticc --Design Approval $ / �
�.J-Ieptic Disposal Works Con ctio (D C) $�/(
L)
❑ Septic Disposal Works In llers ) $
❑ Title 5Inspector - $
i
❑ Title 5 Report $
❑ Other: (Indicate) $
Health Agent Initials
White - Applicant Yellow Health Pink - Treasurer
2T
Me
WO
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
Application for Septic Disposal System 6-,13-)l
Construction
,13 --
Construction Permit - TOWN OF TODArS DATE
$qORTH ANDOVER MA 01845 $ 250.00 — Full Repair
$125.00 - Component
Application is hereby made for a permit to:
❑ Construct a new onsite sewage disposal system*
❑ Repair or replace an existing on-site sewage disposal system*
E epair or replace an existing system component — What? 3�
A. Facility Information
Address or Lot #
R1
Cityrrown
2.- *TYPE OF SEPTIC SYSTEM*:
❑ Pump rav"Ity (choose one) JUN V Z011
***If pump system, attach copy of electrical permit to applicat iALTH
❑ Conventional System (pipe and stone system) DEpANDOVER
❑ 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
ni
Name ,
Address (if different from above)
OV ® A-& �lst
Cityfrown State ZipCode
—
3. Installer Information
Name
0 Atal'l
Address �� Q
Cityfrown
4. Designer Information
Name
Address
Cityfrown
q�k V1 �-
ul
Telephone Number
Name of Company 111 uwARQIL; A ROAD
•
kw...M ___
State
Zip Code
relephor►e Number (Cell Phone # if possible please)
Name of Company
Zip Code
Telephone Number (Best # to Reach)
Application for Disposal System Construction Permit • Page t of 2
' Y
-. "ORT 1ti Application for Septic Disposal System G -j3-1/ _
` 3r •`'°'- '- �' ' �°c
-Construction Permit - TOWN OF TODAY'S DATE
$ 250.00 - Full Repair
ORTH ANDOVER, MA 01845 $125.00 - Component
PAGE 2OF2
A. Facility. Information continued....
5. Type of Building:esidential 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, and not to place the system in operation until a Certificate of Compliance has
been issued b Board of Health.
Name Date
Applicati Appro By: (Board of Health Representative)
N Date
A lication Disappro d for the following reasons:
For Office Use Only:
1. Fee Attached.
2. ProjectManager Obligation Form Attached.
I Pump -Sy—stem? If so., Attach copy ofElectrical Permit .
4. Foundation As -Built? (new construction ronly);
(Same scale as approved plan)
5. Floor Plans? (new construction only):
Yest/
11
Yes
Yes
Yes
Yes
No
No
No
No
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:
'4 W
(Address of septic system)
Relative to theapplication of � . �¢ It s.-i,l/
(Installer's name)
For plans by
(Engineer)
And dated
ngina date) .
Dated �j _ 13 -- /I
o a s ate
With revisions dated
(Last revised date)
I understand the following obligations for management of this project:
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 reduesting'an inspection, without completion of the items in accordanc
MY eompan v v
a. Bottom of Bed.— Generally, this is the first (15) 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: healthdept@ttownofnorthaindover mm) 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, allelectrical work :must be ready and able to
cause :pump to cork 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 :rrmmle 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 toinstall sepfic systems in North And can constitute
reasons for dental of the system and/orrevocation or susuension 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 must be on-site during the. performance .of the following construction
steps:
a. Determination that.the proper elevation of the excavation has been reached.
A Inspection of the sand and stone to be used.
c. Final inspection by Board ofHealth staff or consultant.
d. Installation of tank, D -Box, pipes, stone, vent, pump chamber, retainingwall 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 anv other persons shall absolve
me of this obh tion.
Undersigned Licensed Septic. Installer:
(Today's Date)
G -A3-11
F
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.
VQ
IL
ISI
Commonwealth of Massachusetts IRECEIVED
Title 5 Official Inspection For JUL 29 2011
Subsurface Sewage Disposal System Form - Not for Voluntary Asses ments
TOWN OF NORTH ANDOVER
76 Granville Lane HEALTH DEPARTMENT
Property Address
Makonnen Melaku
Owner's Name
North Andover
Cityfrown
MA 01845
State Zip Code
6/30/2011
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
1. Inspector:
Neil James Bateson
Name of Inspector
Bateson Enterprises Inc.
Company Name
111 Arailla Road
Company Address
Andover
City/Town
978-475-4786
Telephone Number
B. Certification
MA
01810
State Zip Code
S115
License Number
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
❑ Nee Further Eval ation by the Local Approving Authority
l 6/30/2011
Insleforls Signatu 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
V
Owner
information is
required for
every page.
t5ins • 11/10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
76 Granville Lane
Property Address
Makonnen Melaku
Owner's Name
North Andover MA, 01845 6/30/2011
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
After permit from B.O.H., install new d -box , inspection from B.O.H., septic system now passes Title 5
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 0 N ❑ ND (Explain below):
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17
Cf NORTH ,� 5546
Town of North Andover
'+�'•°,,,,° .: HEALTH DEPARTMENT
,SSACNN54
CHECK #: 4 t 0 DATE,
LOCATION:
u
H/(
/
% OVA"CTOR ON 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 Sustems:
❑ Septic - Soil Testing $
❑ Septic - Design Approval $
❑ Septic Disposal Works Construction (DWC) $
❑ Septic Disposal Works Installers (DWI) $
❑ZTitleInspector $
WReportd, I J,
$
❑ Other: (Indicate) $
i r
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 retu_m
key.
Commonwealth of Mas �chusetts
Title 5 Officia Inspection Form
Subsurface Sewage Disposal System Form - Not for V
4
76 Granville Lane
Property Address JUN 1' 1 u 1 1
Makonnen Melaku IY f 1
Owner's Name TOWN OF NORTH ANDOVER
North Andover MA 04 H DEPAR' 01
Cityrrown State Zip Code Date ot 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:
Neil J. Bateson
Name of Inspector
Bateson Enterprises Inc.
111 Argilla Road
Company Address
Andover
City/Town
978-475-4786
Telephone Number
B. Certification
Ma
01810
State Zip Code
S11
License Number
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
❑ Passes ® Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
` 6/14/2011
Inspectors ignature 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 • 09/08 Title 5 Official. Inspection Form: Subsurface Sewage Disposal System - Page 1 of 17
Commonwealth of Massachusetts
m
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w 76 Granville Lane
Property Address
Makonnen Melaku
Owner
information is
required for every
page.
Owner's Name
North Andover MA 01845 6/14/2011
City(rown 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 • 09108 Tide 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17
U
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
76 Granville Lane
Property Address
Makonnen Melaku
Owner Owners Name
information is North Andover
required for every
page. Cityrrown
t5ins • 09/08
B. Certification (cont.)
B) System Conditionally Passes (cont.):
MA 01845 6/14/2011
State Zip Code 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
❑ 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:
FN -
70 I_
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
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
76 Granville Lane
Property Address
Makonnen Melaku
Owner's Name
North Andover MA 01845 6/14/2011
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 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 -box needs to be replaced.
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 '/z day flow
t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
76 Granville Lane
Property Address
Makonnen Melaku
Owner Owner's Name
information is
required for every North Andover
MA 01845 6/14/2011
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 • 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
76 Granville Lane
Property Address
Makonnen Melaku
Owner Owner's Name
information is North Andover MA 01845
required for every
page. City/Town State Zip Code
C. Checklist
6/14/2011
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): 450
t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17
I Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
76 Granville Lane
Property Address
Makonnen Melaku
Owner Owner's Name
Yes
❑
No
information is
required for every North Andover MA 01845 6/14/2011
Yes
❑
No
page. Citylrown State Zip Code Date of Inspection
Yes
❑
D. System Information
Description:
a
0
Number of current residents:
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 ))�
Yes
Detail:
Sump pump?
® Yes
❑
No
November 1,
Last date of occupancy:
2010
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?
Industrial waste holding tank present?
Non -sanitary waste discharged to the Title 5 system?
Water meter readings, if available:
❑
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
76 Granville Lane
Property Address
Makonnen Melaku
Owner Owners Name
information is North Andover
required for every
page. Cityrrown
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
MA 01845 6/14/2011
State Zip Code Date of Inspection
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Date
Pumped last year, owner
1500
gallons
Measured tank
Reason for pumping: Inspect tank & tees
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 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
a Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
76 Granville Lane
Property Address
Makonnen Melaku
Owner Owner's Name
information is North Andover MA 01845 6/14/2011
required for every �—
page. Cityfrown State Zip Code Date of Inspection
Ili
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Tank was replaced 4/20/2006, d -box & pits installed 12/3/1982, as built plan
Were sewage odors detected when arriving at the site?
Building Sewer (locate on site plan):
Depth below grade: 3feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other (explain): —
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
4" PVC thru wall. 3" PVC in house, no leaks visible.
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal
E
feet
❑ Yes ® No
❑ fiberglass 19 polyethylene ❑ other (explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate)
Dimensions: 10' x 5' x 4'
Sludge depth:
1"
❑ Yes ❑ No
t5ins - 09/08 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
76 Granville Lane
Property Address
Makonnen Melaku
Owner Owner's Name
information is North Andover
required for every
page. Cityrrown
D. System Information (cont.)
Septic Tank (cont.)
MA 01845 6/14/2011
State Zip Code Date of Inspection
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
24"
ill
811
20"
How were dimensions determined? Tape measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumped septic tank. Inlet has riser 8" deep. Inlet tee ok. Outlet tee ok. Depth of liquid at
outlet invert. No evidence of leakage.
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 - 09108
Date
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
76 Granville Lane
Property Address
Makonnen Melaku
Owner Owners Name
information is
required for every North Andover MA 01845 6/14/2011
page. City(rown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
* Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
76 Granville Lane
Property Address
Makonnen Melaku
Owner's Name
North Andover MA 01845 6/14/2011
Cityrrown 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 level & distribution equal. (Evidence of leakage, has corrosion holes in sides of box. D -box
needs to be replaced. Evidence of carryover.
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 • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17
Commonwealth of Massachusetts
M Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
76 Granville Lane
Property Address
Makonnen Melaku
Owner Owner's Name
information is North Andover
required for every
page. Cityrrown
D. System Information (cont.)
Type:
MA 01845 6/14/2011
State Zip Code Date of Inspection
®
leaching pits
number:
❑
leaching chambers
number:
❑
leaching galleries
number:
❑
leaching trenches
number, length:
❑
leaching fields
number, dimensions:
t5ins • 09/08
❑ 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 ok. Vegetation ok. No sign of ponding to surface. Camera inside of pits thru outlets in d -
box. No liquid to inverts of pits.
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
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
76 Granville Lane
Property Address
Makonnen Melaku
Owner Owners Name
information is
required for every North Andover MA 01845 6/14/2011
page. CityrFown 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
Commonwealth of Massachusetts
a
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�( 76 Granville Lane
Property Address
Makonnen Melaku
Owner Owner's Name
information is North Andover
required for every
page. Cityfrown
MA 01845
State Zip Code
6/14/2011
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.L?
S
5
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
M 76 Granville Lane
Property Address
Makonnen Melaku
Owner Owner's Name
information is North Andover
required for every
page. Cityrrown
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
MA 01845 6/14/2011
State Zip Code Date of Inspection
Estimated depth to high ground water: 4
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: 6/4/1982
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health - explain:
Design plan
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
As per design plan test pit data.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins • 09/08 Title 5 Offiicial.lnspection 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
76 Granville Lane
Property Address
Makonnen Melaku
Owner Owner's Name
information is
required for every North Andover MA 01845 6/14/2011
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
t5ins • 09/08
® 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
Title 5 Official Inspection Forth: Subsurface Sewage Disposal System • Page 17 of 17
"N Commonwealth of Massachusetts
City/Town of
System Pumping Record
form .4
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The. System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Le t -a ouse, right front of house, left side of house, right side of house, Left
rear of houses g t rear of hod"
, left side of building, right rear of building, under deck.
('civ ` Ue-.UA
City/Town
2. System Owner:
Name
Address (if different from location)
CitylTown
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
State
4,4,- - "I
Zip Code
Stat Zip ode
��-1`a-t-.. 1 fc�
Telephone Number
6 Date 2. Quantity Pumped: Gallons
Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes Lam" No
5. Condition of System:
��e Z�"
6. System Pumped By:
Neil J. Bateson
Name
Bateson Enterprises Inc.
Company
7. Location where contentsawere disposed:
of
t5form4.doc• 06/03
If yes, was it cleaned? ❑ Yes. ❑ No
F5821
Vehicle License Number
Date
System Pumping Record • Page 1 of 1
Summary Record Card g et;d on 618120112:51:09 PM by Karen Hanlon
Town of North Andover
Page'
Class 101 Single Family
Size Total 1.11 Acres
FY 2011
Tax Map # 210-106.C-0070-0000.0
Parcel Id 17705
76 GRANVILLE LANE
MELAKU, MAKONNEN
103 BLUE MEADOW LANE
SICKLERVILLE, NJ
08081
Property Type
1 Residentia
UB Mailing Index
Name/Address
Type Loan Number
Active/Inact. From
Unti
MELAKU, MAKONNEN
Payor
103 BLUE MEADOW LANE
SICKLERVILLE, NJ
08081
UB Account Maint.
Account No
Cycle
Occupant Name
Active/Inactive
Bldg Id. 1739,5.0 - 76 GRANVILLE LANE Last Billing
Date 4/6/2011
3170065
03 Cycle 03
Active
UB Services Maint.
Account No. 3170065
Service Code
Rate
Charge
Multiplier/Users
MISCFEE ADMIN FEE
0.635/8
7.82
1/
WTR WATER
01 ALL METER SIZE
72.20
/1
UB Meter Maintenance
Account No. 3170065
Serial No Status
Location Brand
Type Size
YTD Cons
36433711 a Active
ERT HH b Badger
w Water 0.63 0.63
25'.
Date
Reading
Code Consumption
Posted Date
Variance
3/8/2011
265
a Actual
19
4/13/2011
-510
12/10/2010
246
a Actual
41
1/12/2011
-690/(
9/8/2010
205
a Actual
135
10/15/2010
1430/(
6/4/2010
70
a Actual
51
7/15/2010
77%
3/8/2010
19
a Actual
19
4/14/2010
-1000/(
1/9/2010
0
n New Meter
0
4/14/2010
-1000/(
1/9/2010
2756
r Replacement
9
4/14/2010
-19%
12/10/2009
2747
a Actual
34
1/12/2010
-250/(
9/9/2009
2713
a Actual
48
10/15/2009
70/(
6/4/2009
2665
a Actual
39
7/20/2009
32°/<
3/12/2009
2626
a Actual
34
4/29/2009
-12%
12/5/2008
2592
a Actual
35
1/20/2009
-380/(
9/8/2008
2557
a Actual
62
10/10/2008
250/(
6/4/2008
2495
a Actual
46
7/16/2008
34°/<
3/7/2008
2449
a Actual
34
4/11/2008
-90/(
12/10/2007
2415
a Actual
41
1/22/2008
-40/(
9/4/2007
2374
a Actual
36
10/12/2007
74%
6/14/2007
2338
a Actual
23
7/20/2007
.40/c
3/15/2007
2315
a Actual
24
4/16/2007
-60/(
12/6/2006
2291
a Actual
22
1/19/2007
-200/(
9/12/2006
2269
a Actual
29
10/20/2006
28°/<
6/14/2006
2240
a Actual
25
7/10/2006
480/(
3/7/2006
2215
a Actual
13
4/17/2006
-480/(
12/21/2005
2202
a Actual
32
1/17/2006
270/c
9/14/2005
2170
. a Actual
25
10/14/2005
-140/(
6/9/2005
2145
a Actual
25
7/15/2005
860/c
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'C'\ Commonwealth of Massachusetts
City/Town of RECEIVED
a System Pumping Record
Form 4 ELI
8 2009
4�M
DEP has provided this form for use by local Boards of Health. Other forms may epi t,'T TN ENTER
information must be substantially the same as that provided here. Before using
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left side of house, Right side of house, Left front of house, Right front of house,
e r of hous Right rear of house.
Address
City/Town State Zip Code
2. System Owner:
C. V
Name
Address (if rent f om location)
City/Town Statee„
`Z3
2 -� t -�Code
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
Date 2. Quantity Pumped
Cesspool(s)Septic Tank
t<.5-ce�-
Gallons
❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes [No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L. 5. D Lowell Waste Water.
S#Ourfrof Haulr
t5form4.doc• 06/03
Vehicle License Number F5821
Date
System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
City/Town of ������
System Pumping Record AUG 3 i 2010
Form 4
M OWN Ni NORTH AN�OVM
DEP has provided this form for use by local Boards of Health. Other for
information must be, substantially the same as that provided here. Before using this form, check with your
local Board of Health tQ determine the form they use. The System Pumping Record must be submitted to
the local Board of Health of otfter approving authority.
A. Facility Information
1. S (mea-L.ocafin: Left side of house, Right side of house, Left front of house, Right front of house,
eft rear of a Right rear of house. Left rear of building. Right rear of building.
Address
city/Town State Zip Code
2. System Owner:
Name
Address (if different from location)
Cityrrown
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
Sta ^6� �Co!�
Telephone Number
912ruf _f a
Date 2. Quantity Pumped:
Cesspool(s)95`eptic Tank
Gallons
❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes D -N-0 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System, r
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Locatbfi'R�e contents were disposed:
G.L.S.D
Signature
F5821
Vehicle License Number
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
City/Town of 1 RECEIVEi
System Pumping Record
Form 4 JUL 2 5 2006
DEP has provided this form for use by local Boards of Health.. The 3�2 "F Tin n'Recor must
iiHtHrP� g::.:
be submitted to the local Board of Health or other approving authoh its .
A. Facility Information
Important:
When filling out 1. System Location:
forms the `�
�.I
computer. use
only the tab key Address `— I
to move your
cursor - do not
use thereturn Cdy/Town Sta a Zip Code
key.
2. System Owner: V60,
Name
Address (if different from location)
Cityfrown State�°j��y Zip Code
Telephone Number
B. Pumping Record
17
1. Date. of Pumping Date 2. Quantity` Pumped:
Gallons
.3. Type of system: ❑ Cesspool(s) eptic Tank ❑Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes Ej-lqo-- If yes, was it cleaned? ❑ Yes ❑ No
5. Conditi n of Sys em:
C�
6. Sys m P roped
Name Vehicle License Number
Company --
7. Locati where conte s wer disposed:
cq�22 -
Sig t e f Hauler Date
http://www.mass.gov/de. wa er/approvals/t5forms.htm#inspect
t5form4.doc• 003 System Bumping Record •Page 1 of 1
TOWN OF
SYST
DATE: `L S -®S
SYSTEM OWNER & ADDRESS
-- � garx �j ( ( (-f-- L�
ING RECO
RECEIVED
JUN 2 0 2005
TOWN OF NORTH ANDOVER
HEALTH DEPART` EEN_i
SYSTEM LOCATION
(example: left front of house)
ft.,,A- 6C
ko ut S --e-
DATE OF PUMPING: 0 QUANTITY PUMPED: r 5 o D GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.S.D\L Lowell Waste
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: -Q K -a J
SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING:5 -a'� -60- QUANTITY PUMPED5�
CESSPOOL: NO J YES SEPTIC TANK: NO
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SYSTEM PUMPED BY:
COMMENTS:
GALLONS
YES
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
CONTENTS TRANSFERRED TO: 91- f�< <) -
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: .(n --.,7q —0)
7 (Q groyvv i 1 1-e �AA .
(example: left front of house)
DATE OF PUMPING: (o—)9`01 QUANTITY PUMPED j SnO GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO
NATURE OF SERVICE: ROUTINE / EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SYSTEM PUMPED BY:
COMMENTS:
YES
Tc''�'r`
JUN
V/ 0
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
CONTENTS TRANSFERRED TO: (T] 2 b
O U)
U1 Q r -r
try
r :u k 1
C (l) �4
ri Ry •� Q)
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Commonwealth of Massachusetts
Board of Health
•
:. North Andover
L*b•...{.r`'t`P.I.
AcwuSG� F.I.
Disposal Works Construction Permit
Permission is hereby granted Todd -Bate -son
to (Repair -TANK ONLY) an Individual Sewage Disposal System.
at No 76 GRANVILLE LANE
Map -Block -Lot
106.C- 0070 -
----------------------
Permit No
BHP -2006-0741
-----------------------
FEE
$125.00
-----------------------
----------------------------------------------------------------------------------------------------------------------------------------------------------
as shown on the application for Disposal Works Construction Permit No. 13HP-20067074 Dated ___November 20, 2006
-----------------------------------------------------------------
Issued On: Nov -20-2006
Board of Health
at 59 qy Commonwealth of Massachusetts Map -Block -Lot
r y.• `�. aflt 106.C- 0070 -
---
Board of Health
North Andover
wc«u
{°ACWU ` Certificate of Compliance
'ssstt
THIS IS TO CERTIFY That the Individual Sewage Disposal System (Repair -TANK ONLY)
by Todd Bateson
------------------------------------------------------------------------------------------------------------------------------- -------------------------------
Installer
at No 76 GRANVILLE LANE
---------------------------------------------------------------------------------------------------------------------------------------------------
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-2006-074 Dated _ _ _ November 20,_ 2006
------------------ -----
Printed On: Nov -20-2006 Board of Health
1..
A ■
�10RT// j
of . � hyo •r
.- 9
t Town of North Andover
HEALTH DEPARTMENT
S CMUS!
CHECK #:
LOCATION:
H/ O NAME:
CONTRACTOR NAME: 7;" �z710
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 Sustems:
❑ Septic - Soil Testing $
❑ Septic -Design Approval $
❑.3,S tic Disposal Works Construction (DWC) $
❑ Septic Disposal Works Installers (DWI) $
❑ Title 5 Inspector $
❑ Title 5 Report $
❑ Other. (Indicate) $
2012
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
°HTS Armlic4tion for Septic Disposal Svstem
�pConstruction Permit — TOVN OF
NORTH ANDOVER, MA 01845
�Ss�cHuset
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
r,6
Application is hereby made for a permit to:
❑ Construct a new on-site sewage disposal system*
TODAY'S DATE
$ 250.00 — Full Repair
$125.00 - Component
❑ Repair or replace an existing on-site sewage disposal system*
�ir or replace an existing system component
A. Facility Information
76 01
Address or Lot #
City/Town
2.- *TYPE OF SEPTIC SYSTEM*:
❑ Pump ❑ Gravity (choose one)
***If pump system, attach copy of electrical permit to application***
❑ Conventional System (pipe and stone system)
❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system.
❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement)
❑ Pressure Dosed (D -Box Present) S.A.S.
2. Owner Information C J
i�r�4�t�✓ Z /,6- (i LA -
Name
Address (if different from above)
Citylfown
3. Installer
eaM 1!S
Name
r//14
State Zip Code
V'— 7 s..-
Telephone Number
N D), Tj?g8N
Address Argilla Road
q _
Andover, MA -0�$j�
City/Town State Zip Code
fills-- 0170 3
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)
Application for Disposal System Construction Permit • Page 1 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:
,7l
(Address of septic system)
Relative to the application of
(Installer's name)
Dated 1,7 - (o
1'o ay s ate
For plans by
And dated
With revisions dated
I understand the following obligations for management of this project:
(Engineer)
ngtna 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 company.
a. Bottom of Bed — Generally, this is the first'W) 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(Itoxvnofnorthandover.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 ofHealth 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:(Today's Date) �l— l %d, 4
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Town of North Andover
`ti'•,,,,, HEALTH DEPARTMENT
sscNuset
CHECK #: 4g
LOCATION: .ewelIz C
H/O NAME:o
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)
$
1801 Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
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: 76 Granville Lane
_ North Andover_
Owner's Name: _Jordan Melaku
Owner's Address: _76 Granville Lane
—North Andover, MA 01845_
Date of Inspection: 9/8/2006_
Name of Inspector: Neil J. Bateson_
Company Name: Bateson Enterprises Inc._
Mailing Address: _111 Argilla Road_
_Andover, MA 01810
Telephone Number: _( 978 ) 475-4786_
SEP 14 2006
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000 The system:
Passes
_X Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
F'
Inspector's Signature: 44;51 Date: 9/8/2006_
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.
Page 2 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 76 Granville Lane_
_ North Andover
-
Owner: _ Melaku
Date of Inspection: _9/8/2006 _
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:
X 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 . Septic Tank Leaking
y 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:
N Observation of sewage backup or break out or
high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or
uneven distribution box. System will pass inspection if (with approval of Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
N The system required pumping more than 4 times a
year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: _76 Granville Lane
Andover—
Owner: _Melaku_ _
North Andover_
Date of inspection: _9/8/2006_
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:
T Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the
system is functioning in a manner that protects the public health, safety and environment:
_ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 76 Granville Lane _
_ North Andover_
Owner: _Melaku_
Date of Inspection: _8/31/2006 _
1). System Failure Criteria applicable to all systems:
You must indicate `yes" or "no" to each of the following for all inspections:
No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
No Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_ No Liquid depth in cesspool is less than 6" below invert or available volume is 1/2 day flow.
No Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
No Any portion of the SAS, cesspool or privy is below high ground water elevation.
No Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
No Any portion of a cesspool or privy is within a Zone 1 of a public well.
—No7 Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_No_ 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.]
_No(Yes/No) The system fails. I have determined that one or more of the above failure criteria exist as described
in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to
determine what will be necessary to correct the failure
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either "yes" or "no" to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped
Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: _76 Granville Lane _
_ North Andover _
Owner: _Melaku_
Date of Inspection: _9/8/2006_
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
Yes_ — Pumping information was provided by the owner, occupant, or Board of Health
_No Were any of the system components pumped out in the previous two weeks?
Yes_ ` Has the system received normal flows in the previous two week period?
No Have large volumes of water been introduced to the system recently or as part of this inspection ?
_Yes_ ` Were as built plans of the system obtained and examined?
Yes — Was the facility or dwelling inspected for signs of sewage back up ?
Yes _ Was the site inspected for signs of break out ?
_Yes_ _ Were all system components, excluding the SAS, located on site ?
_Yes_ _ 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 ?
_Yes_ _ 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:
Yes No
_Yes_ _ Existing information.
_Yes _ 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)]
Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 76 Granville Lane
_ North Andover–
Owner: _Melaku_
Date of Inspection: 9/8/2006
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): 3_ Number of bedrooms (actual): 3_
DESIGN flow based on 310 CMR 15.203 _450 _
Number of current residents: _3
Does residence have a garbage grinder (yes or no): _No
Is laundry on a separate sewage system (yes or no): No
Laundry system inspected (yes or no): _
Seasonal use: (yes or no): No_
Water teeter reading: Yes _
Sump pump (yes or no): _No
Last date of occupancy: —
Current-COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow (based on 310 CMR 15.203): _gpd
Basis of design flow (seats/persons/sgft,etc.):
Grease trap present (yes or no): ____
Industrial waste holding tank present (yes or no):
Non -sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER (describe):
GENERAL INFORMATION
Pumping Records
Source of information: _Pumped last month, owner _
Was system pumped as part of the inspection (yes or no): –No_
If yes, volume pumped: _ gallons -- How was quantity pumped determined? —
Reason for pumping: _
TYPE OF SYSTEM
Septic tank, distribution box, soil absorption system
_ Single cesspool _ Overflow cesspool
_ Privy
_ Shared system (yes or no) (if yes, attach previous inspection records, if any)
_ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be
obtained from system owner)
Tight tank _ Attach a copy of the DEP approval
_ Other (describe): _---,
Approximate age of all components, date installed (if known) and source of information:_ 24 Years old, 12/3/1982,
as built plan_
Were sewage odors detected when arriving at the site (yes or no): _No_
Page 7 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 76 Granville Lane_
_ North Andover
Owner: _Melaku_ —
Date of Inspection: _9/8/2006_
BUILDING SEWER _ X _ (locate on site plan)
Depth below grade: _24"
Materials of construction: _ cast iron _X_40 PVC _other
Distance from private water supply well or suction line:
Comments (on condition of joints, venting, evidence of leakage, etc.) _ 4" PVC thru wall, 3" PVC in house, no
leaks.
SEPTIC TANKS: X
Depth below grade: _12" _
Material of construction: X_ concrete — metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: ` Is age confirmed by a Certificate of Compliance (yes or no): (attach a copy of
certificate)
Dimensions: 10' x 5' x 4'
Sludge depth —0" —
Distance from top of sludge to bottom of outlet tee or baffle: N/A _
Scum thickness: _0"_
Distance from top of scum to top of outlet tee or baffle: — N/AN/A= tank leaking
Distance from bottom of scum to bottom of outlet tee or affle: _N/A_
How were dimensions determined: jape Measure _
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc _ Inlet tee ok. Outlet tee ok. Depth of liquid below outlet
invert. Evidence of septic tank leaking. _
GREASE TRAP: _(locate on site plan)
Depth below grade: _
Material of construction: _concrete metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: _76 Granville Lane
_ North Andover
-
Owner: _Melaka_
Date of Inspection: _9/8/2006
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass _polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present (yes or no):
Alarm level: Alarm in working order (yes or no):
Date of last pumping:
Comments (condition of alarm and float switches, etc.):
DISTRIBUTION BOXS• _X_
Depth below grade _ 2011
1
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 level & distribution equal. No evidence of leakage no evidence of
carryover. D -Bog cover broken replaced it._
PUMP CHAMBER: _ (locate on site plan)
Pump in working order (yes or no): —
Alarm in working order (yes or no):
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Wage 9 of I 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: _76 Granville Lane _
_ North Andover
–
Owner: _Melaku_
Date of Inspection: _9/8/2006_
SOIL ABSORPTION SYSTEM (SAS): iX (locate on site plan, excavation not required)
If SAS not located explain why:
Type
,X leaching pits, number: 2_
leaching chambers, number:
leaching galleries, number:
leaching trenches, number, length:
leaching field, 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 ok. Vegetation oL No sign of ponding to surface. Camera inside of pits thru outlets in d -box. Both
pits empty _
CESSPOOLS:
Number and configuration: _
Depth – top of liquid to inlet invert: —
Depth of sludge layer: _
Depth of scum layer:
Dimensions of cesspool: _
Materials of construction:
Indication of groundwater inflow (yes or no): _
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRIVY: (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.):
-page 10 of 11
OFFICIAL INSPECTION FORM -- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 76 Granville Lane _
_ North Andover_
Owner: _Melaku_
Date of Inspection: —9/8/2006 _
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building
Ato1=
Ato2=
A to D-1
Bto1=
Bto2=
B to D -I
Page 11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: _76 Granville Lane _
_ North Andover—
Owner: _Melaka_
Date of Inspection: 9/8/2006_
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water > 4' _
Please indicate (check) all methods used to determine the high ground water elevation:
X_ Obtained from system design plans on record - If checked, date of design plan reviewed: _9/21/1982_
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: As per design plan , no water 4' deep_
Tel: (978) 475-4786
Fax: (978) 475-5451
BATESON ENTERPRISES, INC.
Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service
111 Argilla Road Andover, Mass. 01810
Title 5 Inspection Report
Property Address: 76 Granville Lane, North Andover
Owner: Melaku
Date of Inspection: 9/8/2006
My report contained herein does not constitute a guarantee of future usage and the functionality of the existing
septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further
operation of your current septic system.
Neil J. Bateson
Bateson Enterprises, Inc.
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: 76 Granville Lane
_ North Andover_
Owner's Name: _Mrs. Jordan Melaku
Owner's Address: 76 Granville Lane
_ North Andover, MA 01845
Date of Inspection: 12/14/206
Name of Inspector: _Neil J. Bateson_
Company Name: Bateson Enterprises Inc._
Mailing Address: _111 Argilla Road_
—Andover, MA 01810
Telephone Number: _( 978 ) 475-4786_
RECEIVED
JAN 10 2007
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system:
,X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fail
Inspector's Signature: �/ ! 0 Date: _12/14/2006_
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: After permit from B.O.H., install new septic tank, pipe to tank & pipe to d -box,
inspection from B.O.H., septic system now passes Title 5 Inspectio.
****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.
Page 10 of 11
Property Address: 76 Granville Lane
_ North Andover—
Owner: Melaku
Sketch of New Tank Installation
TGWN QF fvORi H A�NlDU4
e BQA�RL OF HEALTH
�
COMMONWEALTH OF MASSACHUSETTS F7AAUrjr,, 2001
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: 7%G k4Vtt-i ,
AN oc`-� lt-�st�t�� t t► r� o c �4tj
Owner's Name: ry
Owner's Address: 5;4Htr�
Date of Inspection: �, (C : t
Name of Inspector: (please print) _ 1Ro C3 M ny""-,
Company- Name:
Mailing Address:
Telephone Number: :44c� Ci C1 t
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 ofthe time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems -I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system:
✓ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: 1`o�4j,Date: Q 1
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.
Page 2 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 7Gr C. P1Q- tVW-S l 4�rTl�
,��td �H :�a2 �
Owner: F214t11C.t >scttQ k6y,kctn4
Date of Inspection: !�,k (, c i
Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the "Conditional Pass" section need to be replaced or
repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass.
Answer yes, no or not determined (;',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 exfi',tration 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.
*h metal septic tank will pass inspection if it is structu ally soured, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 tunes a year due to broken or obstructed pipe(s). The system will
pass inspection if (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: _-7(0 �cFttiV tice;V± p�-tl�c�'►�Z k MA c�{�
Owner: t4t'r 4C 5, 4 u o c+ Sct{
Date of Inspection: A . 6, • (ol
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the
system is not functioning in a manner which will protect public health, safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public `=
Vater Supplier, if any) determines that the
system is functioning in a manner that protects the public health, safety and environment:
_ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 7(� ��(�M�� (`.,OA&
"t-kcjos-T"tt Atv� v ,Mq �t�4S
Owner: F1'*K �- 5�5�1�1 ctirt.Sc
Date of Inspection: [; - c 1
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or `no" to each of the following for all inspections:
Yes No
tf 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 V2 day flow
t,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 groundwater 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 I of a public well.
,--Any portion of a cesspool or privy is within 50 feet of a private water supply well.
t/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.]
�4 0 (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 each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
_ the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
— _ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped
Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
Page 5 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: Ire 6r,-WVtw-r LA,,(e-
hor;.'ti+-t�d14 C't$4y
Owner: %�(LG c -I- `4,sa�rl .; vktKsc
Date of Inspection: P) . co . of
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 ?
+r _ Has the system received normal flows in the previous two week period ?
V 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 ?
v_ Was the site inspected for signs of break out
v _ Were all system components, excluding the SAS, located on site
_L/' _ 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:
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 CNIR 15.302(3)(b))
Page 6 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 7(� (tzkttvw, uw
hc�.cH �thoyt�P r.j�e; ��
Owner: eP_A1gC .k Scla4 ^GN eft
Date of Inspection: ;b C, CS
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): 3 Number of bedrooms (actual): 3 n
DESIGN flow based on 310 CMZ 15.203 (for example: 110 gpd x # of bedrooms): 4 '�_->L
Number of current residents: 1–
Does residence have a garbage grinder (yes or no): t4O
Is laundry on a separate sewage system (yes or no):'t iQ [if yes separate inspection required]
Laundry system inspected (yes or no):
Seasonal use: (yes or no): N O
Water meter readings, if available (last 2 years usage (gpd)): VZS = t I ci CA1Ov &
Sump pump (yes or no): HO
Last date of occupancy: C <-CQ. '7'0
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow (based on 310 CMR 15.203): gpd
Basis of design flow (seats/persons/sgft,etc.):
Grease trap present (yes or no): _
Industrial waste holding tank: present (yes or no): —
Non -sanitary waste discharged to the Title 5 system (yes or no): —
Water meter readings, if available:
Last date of occupancy/use:
OTHER (describe):
GENERAL INFORMATION
Pumping Records
Source of information: Q t; hkEAZ .} To W,0 LA SZ e- M � iA
Was system pumped as part of the inspection (yes or no): (�
If yes, volume pumped: gallons -- How was quantity pumped determined?
Reason for pumping:
TE OF SYSTEM
Septic tank, distribution box, soil absorption system
_ Single cesspool
_ Overflow cesspool
_ Privy.
Shared system (yes or no) (if yes, attach previous inspection records, if any)
_ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be
obtained from system owner)
_ Tight tank _ Attach a copy of the DEP approval
— Other (describe):
Approximate age of all components, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site (yes or no):�
Page 7 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: -N? 6Q-ATVt L („AKp
:.'(Et c h� v .¢�9 r`rle4 culQF S
Owner: e A ht1l- -'r !S,: SAI-(
Date of Inspection: T?, , G - 0 t
BUILDING SEWER (locate on site plan)
Depth below grade: i ( l
Materials of construction: _✓'cast iron _40 PVC _other (explain):
Distance from private water supply well or suction line:
Comments (on condition of joints, venting, evidence of leakage, etc.):
SEPTIC TANK: locate on site plan)
u
Depth below grade:
Material of construction: r/concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of
certificate)
Dimensions:
Sludge depth: o
Distance from top of sludge to bottom of outlet tee or baffle: 3 0
Scum thickness: — 0 -
Distance from top of scum to top of outlet tee or baffle: 7
Distance from bottom of scum to bottom of outlet tee or baffle: o �'
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.): r
�i'J k'Q lnU— EA.--
GREASE
A
GREASE TRAP: _(locate on site plan)
Depth below grade: _
Material of construction: —concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM — NOT FOR .VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 7w C- (OQ V.\ `Akt&
%tow.-rit ✓1r,�3 �n� ���
Owner: eaal yL
Date of Inspection: T.3 - (a, t
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: gallonslday
Alarm present (yes or no):
Alarm level: Alarm in working order (yes or no):
Date of lastpumping:
Comments (condition of alarm and float switches, etc.):
DISTRIBUTION BOX: V (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: - o
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.):
'P• -50is L—" il. NQS ,pLtap5
C,rft, 2Y A\/ 5 -42 -%JA C,A.Uc ^(! , an:! mz ,LLQ f2 /'hII
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.):
Page 9 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: gakt tu-v.-
DKK S ;sAyk :;�bywc {
Owner: _rA6P-1 4 A'*k'80V&A-
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS): Zoocate on site plan, excavation not required)
If SAS not located explain why:
Type
i/ leaching pits, number:
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 inspectionxlocate on site plan)
Number and configuration:
Depth — top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow (yes or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRIVY: (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.):
Page 10 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 7I (o G92A*Q.y\ju� LikNkti,
V` ups A- PRLAA n, t? M4
Owner: F V- -k 4_ 0 ,� e wt6co
Date of Inspection: G; • 01
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two -permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
A 60r tku- Cc H1`csV
6 6,'0,X*k cf- OcQS�-
7 Cr_-�-tt&2 G IJ Ek- 5GPikc.. 2ArCVQ
C_ c, zc - Sej;PAG�_, k( &_
A6 L
AAaG e0_o SicG 71-0
-7 G
-2, C5
p is F
C. 3-0 B }G F
SIS
��Ptte� Piz �
AAaG e0_o SicG 71-0
Ir
Page 11 of I 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: CA�46
Owner:Q + S�SPA4
Date of Inspection: S . G; _c�5 �
SITE EXAM
Slope
Surface water
C_hec_k cellar
Shallow wells
LOA
Estimated depth to ground water ' 6, feet
Please indicate (check) all methods used to determine the high ground water elevation:
Obtained from system design plans on record - If checked, date of design plan reviewed: (q �P- Z
tj
✓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:
M��zN�� 1 � Boil �i�,� t48 L �- 1��AEe►.�t�kSaC`C' �Li.WM� �'Ni.�(2
fa c
V:P2o M 64IMS&)
N q ' tea_ G'
�\ K1s1v '4 G Aot_
Commonwealth of Massachusetts
i
Massachusetts
System Pumping Record
System
Owner-
a (AASUn
System Location
"76 Gcanx4ul I�e,
Date of Pumping: ( L—a-3 —C/? Quantity Pumped: C�C3--j gallons
Cesspool: No (J Yes H Septic Tank: No
System Pumped by: Fetlre-dea 50&npaed License #
Contents transferrred to : Greater Lawrence Sanitary District
Date: __ Inspector:
Yes H'�
�+ SOIL PROFILE & PERCOLATION TEST DATA
I 1
Nor' a„�,... i•...... TTn _ rcon. 4-�j��l//�-Al T.nt- No 2�y
th ,J�n
Loc./Sukbdiv._ Plan Owner
Investigator ✓����GGa Observer, �c�_L ,�rzs,T/
SOIL PROFILES -DATE
1. ?'Elev. 3. 4'Elev.
— Elev. Elev.
0 0 0 - 0
1 1 1 1
Ties to Test Pits
Benchmark
Elevation
2
3
4
5
6
7
8'
9
10
2 3
2
3
4
5
6
7
8
9
10
S
2
3
_ 4
S
6
7
8
9
10
Soak -Mins. iS
Start Test -Time ¢ S
Drop of 3" -Time- : Z
Drop of 6" -Time
art Al
Vjins.lst. 3"Drop 5 Cl�✓
—
Mins.2nd 3"Drop
"
Percolation Rate
�0 0
Location
Datum
Percol2ti2n Tests -Date
Pit Number 1
2 3
4
S
Start Saturation 2%3D
Soak -Mins. iS
Start Test -Time ¢ S
Drop of 3" -Time- : Z
Drop of 6" -Time
art Al
Vjins.lst. 3"Drop 5 Cl�✓
Mins.2nd 3"Drop
"
Percolation Rate
�0 0
Notes & Sketches on B=k
SOIL PROFILE & PERC
OLATION TEST DATA
North Andover, Mass. Street No Lot No 2 io
Lac/Subdiv. Pland Owner
Investigator Cit, z C� �() Observer
Ole/ SOIL PROFILE DATES
1.'Elev 2.Elev 3.Elev 4.Elev
Z
0
1
2
3
4
5
\•6
-AAA
8
9 9
101 � 10
�r
genc�rnark U
Elevation
DATES
2
,13
4
5
6
7
8
9
10
6x g•S Location
0
1
3
4
5
6
7
8
9
10
Ties Ptg9 est
Datum
PERCO;,ATION TESTS
w
Pit Number
i 2
3
4
5
Start Saturation
Soak -Minutes
Start e
Drop of 3" -Time
Drop of 6" -Time
Morns.lst 3" drop
Mins.2nd 311 Drop
Percolation
'
SOIL PROFILE & PERCOLATION TEST DATA
North Andover, Mass. Street No LY' 11Vt,I'e L� Lot No
Loc/Subdiv. Pland Owner
Investigator( Observer U Y6-v�o
SOIL PROFILE DATES
l.'Faev 2.Elev 3.Elev 4.Elev
n
L —
3
Benchmark
Elevation
0 n n
1
2
3
4
5
6
7
8
9
10
DATES
Pit Number
i 2
3
4
Start Saturation
Soak -Minutes
Start, e
Drop of 3" -Time
Drop of 6" -Time
M6ms.lst 3" drop
Mins.2nd " Drop
Percolation
SOIL
PROFILE & PERCOLATION TEST DATA
3
4
North An-----,•_"..
Un . sLS� rrn�- _ �/�7 Y
T.nt No. ,
Loc./Subdiv._
Plan
Owner
Soak. -Mins.
Investigator.
Observer.,
J
SOIL PROFILES-DATE
I
1.
Elev.
2. Elev. 3.
Elev.
Drop of 3" -Time -
"-Time-Dro
Drop of 6" -Time
I �5
Mins. 1 st . 3"Dro �8 3
Mins.2nd 3"Dro ZZ 3
Percolation Rate -7 W -A J
Ties to Test Pits
2
2
2
2
3
3
3
3
-- --
4
4
4
._
4
_
v
_
5
5
5
5
6
6
6
6
_
7
7
7
7
—
S,� k Y
8
CL-AY8 '
l'.l$`
8
9
9
9
9
LO
10
10
10
Benchmark
Elevation
Location
Datum
Percolation Tests -Date
ratio-----
Pit Number 1
2
3
4
S
Start Saturation /U.' Z4
Soak. -Mins.
Start Test -Time
Drop of 3" -Time -
"-Time-Dro
Drop of 6" -Time
Mins. 1 st . 3"Dro �8 3
Mins.2nd 3"Dro ZZ 3
Percolation Rate -7 W -A J
Dotes & Sketches on Back
S-7
31
l�
Ar._i�va~ ?.ass. 5Cilx
IBSTALLATIM CHB', LIL:. LOTAPN
(NFU DATA AVATION OK FAIL .
,s
$eaunsi
- Ci�
FAIL OK
1. Distance Tos,q�Li�,Gl�t�
Wetlands
b. Drains
C . Well
2. Water Line Location
3• No PVC Pipe
$. Septic Tank
L --Tess -_Length & To Clean Ont Covers... --
b. Cement Pipe to Tank Cn Both Sides of Tank
5. Distribution Box
a. Covers & Box - No Cracks
b. All Lines Flowing Equal Amounts
c. No Back Flow
6.. Leach Field
d;ur Trench
a. IIimensions
b. Stone+ Depth
c / wiped Ends
d. Clean Double Washed Stone
7• Leach Pits
a. Dimensions
b. Stone Depth
c. Splash Pads
r d. Tees
e. Cement Pipe to Pit - Both Sides
f. Clean Double Washed Stone
8. No Garbage Disposal
9. Final trading Inspection
10. Barricading Covered System
11. As Built Submitted
a. Lot Location .
b. Dimensions of System
c. Location with Regard -to Perc Test
d. nervations
e: Water Table /
f
F
s \i
SSI)S DoT' '2 1; •13 GRANV(LLE LN.
of r: _ th ,
B lLL IJ �A L L y / M
't'L 4f 4;1 lTT
a SUBS MPACE DIS'DOSAL DESIGN CHECK LIST
LOT # UP 13 Ca P. KI
APPROM DATE - DISAPPROM DATE
Provided: /�
. � _. Reasons:
I?eUtSe� 'H'e�
SEe P Z 29 is2. .
Title V FAIL 09
Reg 2.5 The submitted plan must show as a minimum:
a) the lot to be served-areasdimensions lot i,abntiera
location and log deep observation hoes -distance to ties -
•C location and results percolation tests -distance to ties
d design calculations & calculations showing required leaching area
location and dimensions of system -including reserve area
f) existing and proposed contours
g) location any wet areas vi.thin 100' of sewage disposal system or
disclaimer -check wetlands mapping
h) surface and subsurface drains vi.thin 100' of sewage disposal
system or disclaimer
(i) location any drainage easements within 1001 of sewage disposal
system or disclaimer -Planning Board files
(j) knows sources of water supply within 2001 of sewage disposal e
system or disclaimer
k) location of any proposed well to serve lot -1001 from leaching facility
) location of water lines on property -10' from leaching facility
m) location of benchmark
driveways
gage disposals
v(p) no PVC to be used In construction s tic tank
(q) profile of system -elevations of basea:ent., plumbs pipe., ep
distribution box inlets and outlets, distribution field piping and
other elevations
maximum ground water elevation in area sewage disposal system
s) plan mast be prepared by a Professional Engineer or other
professional authorized by lax to prepare such plans
Reg 6 Sep a Tanks-
(a)
anks(a) capacit s_150�6 of flows water tables tees, depth of tees.,
access, pumping
cleanout
lAt from cellar wall or inground swimming pool
d) 251 from subsurface drains
Reg 10.2 Distribution Boxes
4(pL) slope greater than 0.08
Reg 10.4 b) sumo
�b.'e"frce r:c Cho --k List Paee 2
FAIT, I M
Leaching Pits
Leaching pits are preferred where the installation is possible
Reg 1.1..2
11.4
11.10
11.11
Reg 15.1
15.4
i5.$
3.7
Reg 14.1
14.3
14.4
14.6
14.7
14.10
) calculations of leaching area-ninimm 500 sq ft
) spacing
) surface drainage 2%
d) cover material
e) k+a2ix4ln splash pad
f) tee at elbow
g) no bends in pipe from d -box to pipe
Leaching Fields
a) no greater t 20 minutes/inch
b) area- Bq ft
c construc ho f field `
d) sa:rface e 2 %
e) 201 m cellar v1l or 3nground swimming pool
Leachin M_,ches
a) c cu isoleaching area -min 500 sq ft
b) spacing ft min 6 ft with reserve between
c) dimr ons
d) cans ction
e} s e
f) surface drainage 2%
I)o-,mhill Slope
a) slope y x = to be shown)
b) y/x X 150 = (to be shown)
-PUMP
s
Reg 9.1 9.6 b)d2d-`by power
NrCtt"E� Tb i3E ADDED
'J PBEo �►.>sYEc.-r�oN Zv "�E r-tpp o� o� E� ��
�tJSPEC.�UQ. ' COQ- ro INS?DU.a
Z- Avo a JEE of- C'LV30L4 -To �
1•v °�E'E��4�c 'RT S
76
�iaol�
�WL
F WV PIE# PSE0 7LAW.
cy'Z,
t.
14 L 't
V 171 PE I NTO P. 6CK,
,4 p
Ca
a.vErt � 4 � g'r0�►E
Qfta 6ff
A5. 6 UI LT
�J Ves- S U a- PAGE D S SyOSAL_
SY5T F. M
F' ca rz.
IC.AM1�JStLt 1 �j EL�►.J AS � ASSor,,,�,a.'TE�
N 61rJ EE 2 S Aczr--1-rF_c-TS
4S1 Atit>ovER ST No.A�ipovE2.
TO: NORTH ANDOVER, MASS �� G- d' 19 i 7
BOARD OF HEALTH
FROM: DESIGN ENGINEER Re: Soil Absorption Sewage
System Inspection
This is to certify that I have inspected the construction of the said disposal system at
Z°7- �-c 241yz North Andover, Mass.
SITE LOCATION
The grades and construction are as specified in my plans and specifications dated
19 .
9 'pN �
En neer e itarian
Hd3s0f �o
�bW
J0 Nl�d
CARAIFN 7-6,SCAA/o
5 7- IV14 R_b C
?-A
4
0
/000 G -Az SePTIC, 7/qN,I
Nl�
Tp
7,7
/V
/M
41
00
4
0
/000 G -Az SePTIC, 7/qN,I
Nl�
p 0
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sa
3w ? �i�1
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W �♦ �u
a 3 Iry
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...1„s ,,, t. x ,ie;p fi=.} f °,y...'f . -.�f� 5” rnc�y+ if x it is a�•.,.ee a c.z...>+r xte;+�xr�rr - "'
in
In
• dStSfiN �-\'ivy 1. % /' r ) .S �n�' � . '\ fir'
!I aril ti. _
/r,:
W ' of _
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' •,.. i.y �i� { ', is '], 1 1. '2*• ` .
I
I
0
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