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HomeMy WebLinkAboutMiscellaneous - 764 JOHNSON STREET 4/30/2018 (2)roy>o t-4 tri n rozxy ''.. H trJ C=7 C� F3 > w C -4o 1-3 S .. p z °z Cf)m 0 t3 H j I� _/ /� `... • v 107 FOREST STREET MIDDLETON, MA 01949 (978) 774-2772 FILE # 41999A SEPTIC &DRAIN SERVICE SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PROPERTY OWNER'S NAME: CASCIO PROPERTY ADDRESS: 764 JOHNSON STREET, NORTH ANDOVER ADDRESS OF OWNER: SAME (IF DIFFERENT) DATE OF INSPECTION: APRIL 19, 1999 NAME OF INSPECTOR: THOMAS J. CHIGAS THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY WNF30ARD OF HE-ALI 11 - MAY 61999 107 FOREST STREET MIDDLETON, MA 01949 (978) 774-2772 FILE # 41999A !RAM SEPTIC & DRAIN SERVICE SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION PROPERTY ADDRESS:764 JOHNSON STREET NAME OF OWNER: CASCIO NORTH ANDOVER ADDRESS OF OWNER: SAME DATE OF INSPECTION: APRIL 19, 1999 NAME OF INSPECTOR: (PLEASE PRINT) THOMAS J. CHIGAS I AM A DEP APPROVED INSPECTOR PURSUANT TO SECTION 15.340 OF TITLE 5 (3 10 CMR 15.000) COMPANY NAME: CURRIER SEPTIC & DRAIN MAILING ADDRESS: 107 FOREST STREET; MIDDLETON MA 01949 TELEPHONE NUMBER: 978 774-2772 CERTIFICATION STATEMENT I CERTIFY THAT I HAVE INSPECTED THE SEWAGE DISPOSAL SYSTEM AT THIS ADDRESS AND THAT THE INFORMATION REPORTED BELOW IS TRUE, ACCURATE AND COMPLETE AS OF THE TIME OF INSPECTION. THE INSPECTION WAS PREFORMED BASED ON MY TRAINING AND EXPERIENCE IN THE PROPER FUNCTION AND MAINTENANCE OF ON-SITE SEWAGE DISPOSAL SYSTEM. THE SYSTEM: YES PASSES CONDITIONALLY PASSES NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY FAILS INSPECTOR'S SIGNATURE:G��c DATE: APRIL 19. 1999 - 4w'7 THE SYSTEM INSPECTOR SHALL SUBMIT A COPY OF THIS INSPECTION REPORT TO THE APPROVING AUTHORITY (BOARD OF HEALTH OR DEP) WITHIN THIRTY (30) DAYS OF COMPLETING THIS INSPECTION. IF THE SYSTEM IS A SHARED SYSTEM OR HAS A DESIGN FLOW OF 10,000 GALLON GPD OR GREATER, THE INSPECTOR AND THE SYSTEM OWNER SHALL SUBMIT THE REPORT TO THE APPROPRIATE REGIONAL OFFICE OF THE DEPARTMENT OF ENVIRONMENTAL PROTECTION. THE ORIGINAL SHOULD BE SENT TO THE SYSTEM OWNER AND COPIES SENT TO THE BUYER, IF APPLICABLE, AND THE APPROVING. NOTES AND COMMENTS: N/A REVISED 9/2/98 PAGE 1 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (CONTINUED) PROPERTY ADDRESS: 764 JOHNSON ST, N. ANDOVER OWNER: CASCIO DATE OF INSPECTION: APRIL 19, 1999 INSPECTION SUMMARY: CHECK© B, C, OR D: A. SYSTEM PASSES: YES I HAVE NOT FOUND ANY INFORMATION, WHICH INDICATES THAT ANY OF THE FAILURE CONDITIONS DESCRIBED IN 310 CMR 15.303 EXIST. ANY FAILURE CRITERIA NOT EVALUATED ARE INDICATED BELOW. COMMENTS: B. SYSTEM CONIDTIONALLY PASSES: N ONE OR MORE SYSTEM COMPONENTS AS DESCRIBED IN THE "CONDITIONAL PASS" SECTION NEED TO BE REPLACED OR REPAIRED. THE SYSTEM, UPON COMPLETION OF THE REPLACEMENT OR REPAIR, AS APPROVED BY THE BOARD OF HEALTH, WILL PASS. INDICATE YES, NO, OR NOT DETERMINED (Y, N, OR ND). DESCRIBE BASIS OF DETERMINATION IN ALL INSTANCES. IF "NOT DETERMINED", EXPLAIN WHY NOT. N THE SEPTIC TANK IS METAL, UNLESS THE OWNER OR OPERATOR HAS PROVIDED THE SYSTEM INSPECTOR WITH A COPY OF A CERTIFICATE OF COMPLIANCE (ATTACHED) INDICATING THAT THE TANK WAS INSTALLED WITHIN TWENTY (20) YEARS PRIOR TO THE DATE OF THE INSPECTION; OR THE SEPTIC TANK, WHETHER OR NOT METAL, IS CRACKED, STRUCTURALLY UNSOUND, SHOWS SUBSTANTIAL INFILTRATION OR EXFILTRATION, OR TANK FAILURE IS IMMINENT. THE SYSTEM WILL PASS INSPECTION IF THE EXISTING SEPTIC TANK IS REPLACED WITH A COMPLYING SEPTIC TANK AS APPROVED BY THE BOARD OF HEALTH. N SEWAGE BACKUP OR BREAKOUT OR HIGH STATIC WATER LEVEL OBSERVED IN THE DISTRIBUTION BOX IS DUE TO BROKEN OR OBSTRUCTED PIPE(S) OR DUE TO A BROKEN, SETTLED OR UNEVEN DISTRIBUTION BOX. THE SYSTEM WILL PASS INSPECTION IF (WITH APPROVAL OF THE BOARD OF HEALTH). N BROKEN PIPE(S) ARE REPLACED N OBSTRUCTION IS REMOVED N DISTRIBUTION BOX IS LEVELLED OR REPLACED N THE SYSTEM REQUIRED PUMPING MORE THAN FOUR TIMES A YEAR DUE TO BROKEN OR OBSTRUCTED PIPE(S). THE SYSTEM WILL PASS INSPECTION IF (WITH APPROVAL OF THE BOARD OF HEALTH): N BROKEN PIPE(S) ARE REPLACED N OBSDTRUCTION IS REMOVED REVISED 9/2/98 PAGE 2 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (CONTINUED) PROPERTY ADDRESS: 764 JOHNSON ST, N. ANDOVER OWNER: CASCIO DATE OF INSPECTION: APRIL 19. 1999 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N CONDITIONS EXIST WHICH REQUIRE FURTHER EVALUATION BY THE BOARD OF HEALTH IN ORDER TO DETERMINE IF THE SYSTEM IS FAILING TO PROTECT THE PUBLIC HEALTH, SAFETY AND THE ENVIRONMENT. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 (1)(B) THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRNONMENT: N/A CESSPOOL OR PRIVY IS WITHIN 50 FEET OF SURFACE WATER N/A 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 AND SAFETY AND THE ENVIRONMENT: N THE SYTEM 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. N THE SYTEM HAS A SEPTIC TANK AND SOIL ABSORPTION SYSTEM AND THE SAS IS WITHIN A ZONE I OF PUBLIC WATER SUPPLY WELL. N THE SYSTEM HAS A SEPTIC TANK AND SOIL ABSORPTION SYSYTEM AND THE SAS IS WITHIN 50 FEET OF A PRIVATE WATER SUPPLY WELL. N THE SYSTEM HAS A SEPTIC TANK AND SOIL ABSORPTION SYSYTEM AND THE SAS IS LESS THAN 100 FEET BUT 50 FEET MORE FROM A PRIVATE WATER SUPPLY WELL, UNLESS A WELL WATER ANALYSIS FOR COLIFORM BACTERIA AND VOLATILE ORGANIC COMPOUNDS NDICATES THAT THE WELL IS FREE FROM POLLUTION FROM THAT FACILITY AND THE PRESENCE OF AMMONIA NITROGEN AND NITRATE NITROGEN IS EQUAL TO OR LESS THAN 5 PPM. METHOD USED TO DETERMINED DISTANCE (APPROXIMATION NOT VALID). 3) OTHER: N/A REVISED 9/2/98 PAGE 3 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (CONTINUED) PROPERTY ADDRESS: 764 JOHNSON ST, N. ANDOVER OWNER: CASCIO DATE OF INSEPCTION: APRIL 19, 1999 D. SYSTEM FAILS: YOU MUST INDICATE EITHER "YES" OR "NO" TO EACH OF THE FOLLOWING: N I HAVE DETERMINED THAT ONE OR MORE OF THE FOLLOWING FAILURE CONDITIONS EXIST AS DESCRIBED IN 310 CMR 15.303. THE BASIS FOR THIS DETERMINATION IS IDENTIFIED BELOW. THE BOARD OF HEALTH SHOULD BE CONTRACTED TO DERTERMINE WHAT WILL BE NECESSARY TO CORRECT THE FAILURE. YES NO N BACKUP OF SEWAGE INTO FACILITY OR SYSTEM COMPONENT DUE TO AN OVERLOADED OR CLOGGED SAS OR CESSPOOL. N DISCHARGE OR PONDING OF EFFLUENT TO THE SURFACE OF THE GROUND OR SURFACE WATERS DUE TO AN OVERLOADED OR CLOGGED SAS OR CESSPOOL. N STATIC LIQUID LEVEL IN THE DISTRIBUTION BOX ABOVE OUTLET INVERT DUE TO AN OVERLOADED OR CLOGGED SAS OR CESSPOOL. N/A LIQUID DEPTH IN CESSPOOL IS LESS THAN 6' BELOW INVERT OR AVAILABLE VOLUME IS LESS THAN 'h DAY FLOW. N REQUIRED PUMPING MORE THAN 4 TIMES IN THE LAST YEAR NOT DUE TO CLOGGED OR OBSTRUCTED PIPE(S). NUMBER OF TIMES PUMPED N ANY PORTION OF THE SOIL ABSORPTION SYSTEM, CESSPOOL OR PRIVY IS BELOW THE HIGH GROUNDWATER ELEVATION. N/A ANY PORTION OF A CESSPOOL OR PRIVY IS WITHIN 100 FEET OF A SURFACE WATER SUPPLY OR TRIBUTARY TO A SURFACE WATER SUPPLY. N/A ANY PORTION OF A CESSPOOL OR PRIVY IS WITHIN A ZONE I OF A PUBLIC WELL. N/A ANY PORTION OF A CESSPOOL OR PRIVY IS WITHIN 50 FEET OF A PRIVATE WATER SUPPLY WELL. N/A ANY PORTION OF A CESSPOOL OR PRIVY IS LESS THAN 100 FEET BUT GREATER THAN 50 FEET FROM A PRIVATE WATER SUPPLLY WELL WITH NO ACCEPTABLE WATER QUALITY ANALYSIS. IF THE WELL HAS BEEN ANALYZED TO BE ACCEPTABLE, ATTACH COPY OF WELL WATER ANALYSIS FOR COLIFORM BACTERIA, VOLATILE ORGANIC COMPOUNDS, AMMONIA NITROGEN AND NITRATE NITROGEN. LARGE SYSTEM FAILS: YOU MUST CATES EITHER "YES" OR "NO" TO EACH OF THE FOLLOWING: THE FOLLOWING CRITRTIA APPLY TO LARGE SYSTEMS IN ADDI TO THE CRTERIA ABOVE: N THE SYSTEM SERVE FACILITY WITH A DESIGN FL F 10,000 GPD OR GREATER (LARGE SYSTEM) AND THE SYSTEM IS A SIGNIFICA THREAT TO PUBLI ALTH AND SAFETY AND THE ENVIRONMENT BECAUSE ONE OR MORE OF THE FOLLOWJNG CONDITIONS EXIST: ` YES NO THE SYSTEM IS WJTTrfN 400 FEET OF A­S-�ACE DRINKING WATER SUPPLY THESYST WITHIN 200 FEET OF A TRIBU Y TO A SURFACE DRINKING WATER SUPPLY THE MIS LOCATED IN A NITROGEN SENSITIVE-A4A (INTERIM WELLHEAD PROTECTION AREA -1 ) OR A MAPPED ZONE II OF A PUBLIC WATER SUPPL, LL TH ER OR OPERATOR OF ANY SUCH SYSTEM SHALL UPGRADE THE SYSTEM CCORDANCE WITH 310 C�gR 15.304(2). PLEASE CONSULT THE LOCAL REGIONAL OFFICE OF THE DEPARTMENT FURTHER INFORMATION. REVISED 9/2/98 PAGE 4 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INPSECTION FORM PART B CHECKLIST PROPERTY ADDRESS: 764 JOHNSON ST, N. ANDOVER OWNER: CASCIO DATE OF INSPECTION: APRIL 19, 1999 CHECK IF THE FOLLOWING HAVE BEEN DONE: YOU MUST INDICATE EITHER "YES" OR "NO" AS TO EACH OF THE FOLLOWING: YES. NO Y PUMPING INFORMATION WAS PROVIDED BY THE OWNER, OCCUPANT, OR BOARD OF HEALTH. Y NONE ON THE SYSTEM COMPONENTS HAVE BEEN PUMPED FOR AT LEAST TWO WEEKS AND THE SYSTEM HAS BEEN RECEIVING NORMAL FLOW RATES DURING THAT PERIOD. LARGE VOLUMES OF WATER HAVE NOT BEEN INTRODUCED INTO THE SYTEM RECENTLY OR AS PART OF THIS INSPECTION. Y AS BUILT PLANS HAVE BEEN OBTAINED AND EXAMINED. NOTE IF THEY ARE NOT AVAILABLE WITH N/A. Y THE FACILITY OR DWELLING WAS INSPECTED FOR SIGNS OF SEWAGE BACK-UP. Y THE SYSTEM DOES NOT RECEIVE NON -SANITARY OR INDUSTRIAL WASTE FLOW. Y THE SITE WAS INSPECTED FOR SIGNS OF BREAKOUT. Y ALL SYSTEM COMPONENTS, EXCLUDING THE SOIL ABSORPTION SYSTEM HAVE BEEN LOCATED ON THE SITE. Y THE SEPTIC TANK MANHOLES WERE UNCOVERED, OPENED, AND THE INTERIOR OF THE SEPTIC TANK WAS INSPECTED FOR CONDITION OF BAFFLES OR TEES, MATERIAL OF CONSTRUCTION, DIMENSIONS, DEPTH OF LIQUID, DEPTH OF SLUDGE, DEPTH OF SCUM. THE SIZE AND LOCATION OF THE SOIL ABSORPTION SYSTEM ON THE SITE HAS BEEN DETERMINED BASED ON: Y EXISTING INFORMATION. FOR EXAMPLE, PLAN AT B.O.H. Y DETERMINED IN THE FIELD (IF ANY OF THE FAILURE CRITERIA RELATED TO PART C. IS AT ISSUE, APPROXIMATION OF DISTANCE IS UNACCEPTABLE) [15.302(3)(b)] Y THE FACILITY OWNER (AND OCCUPANTS, IF DIFFERENT FROM OWNER) WERE PROVIDED WITH INFORMATION ON THE PROPER MAINTENANCE OF SUBSURFACE DISPOSAL SYSTEMS. REVISED 9/2/98 PAGE 5 OF 11 SUBURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION PROPERTY ADDRESS: 764 JOHNSON ST N. ANDOVER OWNER: CASCIO DATE OF INSPECTION: APRIL 19. 1999 FLOW CONDITIONS RESIDENTIAL: DESIGN FLOW: 440 G.P.D./BEDROOM. NUMBER OF BEDROOMS (DESIGN): 4 NUMBER OF BEDROOMS (ACTUAL): 4 TOTAL DESIGN FLOW: 440 NUMBER OF CURRENT RESIDENTS: 3 GARBAGE GRINDER (YES OR NO): YES LAUNDRY (SEPARATE SYSTEM) (YES OR NO): NO; IF YES, SEPARATE INSPECTION REQUIRED LAUNDRY SYSTEM INPECTED (YES OR NO): NO SEASONAL USE (YES OR NO): NO WATER METER READINGS, IF AVAILABLE (LAST TWO YEAR'S USAGE (GPD): WELL ON SIGHT. SUMP PUMP (YES OR NO): NO LAST DATE OF OCCUPANCY: CURRENT TYPE OF EST ENT: DESIGN FLOW: GPD D ON 15.203) BASIS OF DESIGN FLOW: GREASE TRAP PRESENT (YES OR NO): INDUSTRAIL WASTE HOLDING TAN NT (YES OR NO): NON -SANITARY WASTE RGED TO THE TITLE 5 SYSTEM (YES OR WATER ME AINGS, IF AVAILABLE: TE OF OCCUPANCY: OTHER (DESCRIBE): LAST DATE OF OCCUPANCY: GENERAL INFORMATION PUMPING RECORDS AND SOURCE OF INFORMATION: SYSTEM PUMPED AS PART OF INSPECTION (YES OR NO): NO IF YES, VOLUME PUMPED: GALLONS REASON FOR PUMPING: TANK WAS PUMPED DEC 1998 TYPE OF SYSTEM YES SEPTIC TANK/DISTRIBUTION BOX/SOIL ABSORPTION SYSTEM N SINGLE CESSPOOL N OVERFLOW CESSPOOL N PRIVY N SHARED SYSTEM (YES OR NO) (IF YES, ATTACH PREVIOUS INSPECTION RECORDS, IF ANY) N I/A TECHNOLOGY ETC. ATTACH COPY OF UP TO DATE OPERATION AND MAINTENANVE CONTRACT TIGHT TANK COPY OF DEP APPROVAL OTHER: N/A APPROXIMATE AGE OF ALL COMPONENTS, DATE INSTALLED (IF KNOWN) AND SOURCE OF INFORMATION: INSTALLED 6-20=89 ASBUILTS SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE (YES OR NO): NO REVISED 9/2/98 PAGE 6 OF 11 SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C SYSTEM INFORMATION (CONTINUED) PROPERTY ADDRESS: 764 JOHNSON ST N. ANDOVER OWNER: CASCIO DATE OF INSPECTION: APRIL 19, 1999 BUILDING SEWER: (LOCATE ON THE SITE PLAN) DEPTH BELOW GRADE: 19" MATERIAL OF CONSTRUCTION: YES CAST IRON 40 PVC OTHER (EXPLAIN) DISTANCE FROM PRIVATE WATER SUPPLY WELL OR SUCTION LINE: 104' DIAMETER: 4" COMMENTS: (CONDITION OF JOINTS, VENTING, EVIDENCE OF LEAKAGE, ETC.) NO SIGNS OF LEAKAGE IN OR OUT SOILS ARE CLEAN AN DRY. SEPTIC TANK: YES (LOCATE ON SITE PLAN) DEPTH BELOW GARDE: 12" MATERIAL OF CONSTRUCTION:YESCONCRETEYESMETEL FIBERGLASS POLYETHYLENE OTHER (EXPLAIN): IF TANK IS METAL, LIST AGE N/A IS AGE CONFIRMED BY CERTIFICATE OF COMPLIANCE (YES/NO) DIMENSIONS: 101 X 5'W X 5'H OUTLET INVERT na 4'1" = 1500 GAL TANK SLUDGE DEPH: <2 DISTANCE FROM TOP OF SLUDGE TO BOTTOM OF OUTLET TEE OR BAFFLE: 35" SCUM THICKNESS: <2" — DISTANCE FROM TOP OF SCUM TO TOP OF OUTLET TEE OR BAFFLE: 7" DISTANCE FROM BOTTOM OF SCUM TO BOTTON OF OUTLET TEE OR BAFFLE: 14" HOW DIMENSIONS WERE DETERMINED: SLUDGE JUDGE ROD RULER COMMENTS: (RECOMMENDATION FOR PUMPING, CONDITION OF INLET AND OUTLET TEES OR BAFFLES, DEPTH OF LIQUID LEVEL IN REALTION TO OUTLET INVERT, STRUCTURAL INTEGRITY, EVIDENCE OF LEAKAGE, ETC.) THE INLET AND OUTLET TEE BAFFLES ARE IN GOOD CONDITION.LI UID LEVELS ARE @ NORMAL HIGHT NO SIGNS OF LEAKAGE IN OR OUT. THE INTEGRITY IS IN GOOD SHAPE.THERE'S A LIGHT SCH MANHOLE COVER OVER MIDDLE COVER. REASE TRAP: N_ 0&4,TE ON SITE PLAN) DEPTH BELOW,,('RADE: MATERIAL OF CO RUCTION: CONCRETE METAL FIBERGLASS POLYETHLENE OTHER (EXPLAIN) DIMENSIONS: SCUM THICKNESS: DISTANCE FROM TOP OF SCUM TO T UTLET TEE OR BAFFLE: DISTANCE FROM BOTTOM OF TO BOTT OF OUTLET TEE OR BAFFLE: DATE OF LAST PUMPING- AMENDATION FOR PUMPING, CONDITION OF INLET AND OU TEES OR BAFFLES, DEPTH OF LIQUID IN REALTION TO OUTLET INVERT, STRUCTURAL INTEGRITY, EVID E OF LEAKAGE, ETC.) REVISED 9/2/98 PAGE 7 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (CONTINUED) PROPERTY ADDRESS: 764 JOHNSON ST, N. ANDOVER OWNER: CASCIO DATE OF INSPECTION: APRIL 19, 1999 GHT OR HOLDING TANK: N(TANK MUST BE PUMPED PRIOR TO, OR AT TIME OF PECTION) (LO E ON SITE PLAN) DEPTH BELO DE: MATERIAL OF CONS CGLA TION: CONCRETE METAL BERSS POLYETHYLENE OTHER (EXPLAIN) DIMENSIONS: CAPACITY: GALLONS DESIGN FLOW: GALLONS ALARM PRESENT: ALARM LEVEL: ARM IN WORKING ORDER: Y NO DATE OF PREVI PUMPING: OF INLET TEE, CONDITION OF ALRM AND FLOAT SWIT DISTRIBUTION BOX: YES (LOCATE ON SITE PLAN) DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT: 0" DEPTH BELOW GRADE: 15" COMMENTS: (NOTE IF LEVEL AND DISTRIBUTION IS EQUAL, EVIDENCE OF SOLIDS CARRYOVER, EVIDENCE OF LEAKAGE INTO OR OUT OF BOX, ETC.) THERE'S NO SIGNS OF LEAKAGE IN OR OUT SOILS ARE CLEAN AND DRY.NO SIGNS OF HYDRAULIC FAILURE,NO SIGNS OF CARRYOVER.THERE'S AN SCH 20 P V C TEE IN D -BOX CHAMBER: NO TE-QN SITE PLAN) PUMPS IN WORKING (YES O ALARMS IN WORKING ORD OR NO): COMMENTS: (NOTE CON SOF PUMP CHAMBER, C( REVISED 9/2/98 PAGE 8 OF 11 F PUMPS AND APPURTENANCES, ETC.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (CONTINUED) PROPERTY ADDRESS: 764 JOHNSON ST, N. ANDOVER OWNER: CASCIO DATE OF INSPECTION: APRIL 19. 1999 SOIL ABSORPTION SYSYEM (SAS): YES (LOCATE ON SITE PLAN, IF POSSIBLE; EXCAVATION NOT REQUIRED, LOCATION MAY BE APPROXIMATED BY NON -INTRUSIVE METHODS) IF NOT LOCATED, EXPLAIN: ASBUILTS TYPE: LEACHING PITS, NUMBER: LEACHING CHAMBERS, NUMBER: LEACHING GALLERIES, NUMBER: LEACHING TRENCHES, NUMBER, LENGTH: TWO TRENCHES 24"W X 491 LEACHING FIELDS, NUMBER, DIMENSIONS: OVERFLOW CESSPOOL, NUMBER: ALTERNATIVE SYSTEM: NAME OF TECHNOLOGY: COMMENTS: (NOTE CONDITION OF SOIL, SIGNS OF HYDRAULIC FAILURE, LEVEL OF PONDING, DAMP SOIL, CONDITION OF VEGETATION, ETC.) NO SIGNS OF HYDRAULIC FAILURE,OR SOILD CARRYOVER. THE LINES ARE SCH 20 P.V.C. AN IN GOOD CONDITION. THERE'S NO SIGNS OF WETLAND VEG. 'OOL: NO TE ON SITE PLAN) NUMBER A CONFIGURATION: DEPTH -TOP OF L ID TO INLET INVERT: DEPTH OF SOILD LA DEPTH OF SCUM LAYER: DIMENSIONS OF CESSPOOL: MATERIALS OF CONSTRUCTION: INDICATION OF GROUNDWATER: INFLOW (CESSPOOL BE PUP PART OF INSPECTION) (NOT)�DITION OF SOIL, SIGNS OF HYDRAULIC FAILURE, LEVEL OF PON -DING, CONDITION OF VEGETATION, ETC.) Y: N_ (LOC N SITE PLAN) MATERIALS OF CONST ON- DIMENSIONS: DEPTH SOLIDS: COMMENTS: (NOTE COND OF SOIL, SIGNS OF HYDRAULIC FAIL REVISED 9/2/98 PAGE 9 OF 11 OF PONDING, CONDITION OF VEGETATION, ETC.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (CONTINUED) PROPERTY ADDRESS: 764 JOHNSON ST. N. ANDOVER OWNER: CASCIO DATE OF INSPECTION: APRIL 19,199 SKETCH OF SEWAGE DISPOSAL SYSTEM: INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCE LANDMARKS OR BENCHMARKS LOCATE ALL WELLS WITHIN 100' (LOCATE WHERE PUBLIC WATER SUPPLY COMES INTO HOUSE) 1 � -10, v, D &A ODD) a('fIG Tank CT!) I�GtCk YGtrd REVISED 9/2/98 PAGE 10 OF 11 - -.._...-.-_ - A �6 -30 13 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (CONTINUED) PROPERTY ADDRESS: 764 JOHNSON ST, N. ANDOVER OWNER: CASCIO DATE OF INSPECTION: APRIL 19,199 NRCS REPORT NAMEN/A SOIL TYPE N/A TYPICAL DEPTH TO GROUNDWATER N/A USGS DATE WEBSITE VISITED OBSERVATION WELLS CHECKED GROUNDWATER DEPTH: SHALLOW N/A MODERATE DEEP SITE EXAM SLOPE SURFACE WATER CHECK CELLAR SHALLOW WELLS ESTIMATED DEPTH TO GROUNDWATER 8' FEET PLEASE INDICATE ALL THE METHODS USED TO DETERMINE HIGH GROUNDWATER ELEVATION: Y OBTAINED FROM DESIGN PLANS ON RECORD Y OBSERVED SITE (ABUTTING PROPERTY, OBSERVATION HOLE, BASEMENT SUMP, ETC.) Y DETERMINED FROM LOCAL CONDITIONS N CHECKED WITH LOCAL BOARD OF HEALTH N CHECKED FEMA MAPS Y CHECKED PUMPING RECORDS N CHECKED LOCAL EXCAVATORS, INSTALLERS Y USED USGS DATA DESCIBE HOW YOU ESTABLISHED THE HIGH GROUNDWATER ELEVATION. (MUST BE COMPLETED) THE HOUSE DIDN'T HAVE A SUMP PUMP IN BASEMENT AN BASEMENT IS DRY. THE HOUSE HAS 10' FOUNDATION WITH NO SIGNS OF WATER TABLE IN IT.WHILE ON SIGHT I DIDN'T SEE OR FIND ANY SIGNS OF WATER TABLE. NO SIGNS OF ABUTTING PROPERTY'S WELLS WITHIN 150' FROM SYSTEM. REVISED 9/2/98 PAGE 11 OF 11 aDepartment of, Environmental Management/Division of Water Resources 1�tgJ ,u ,WATER WELL COMPLETION P } WELL LOCATION EftkApb t ObsdRaiwh •G'of FORMATIO • aTCOPY S (.� W or (feet) (circle) City/To n %y Well owner /road), Address /? Q NS� (E-) W- of (nil, in ten(hs)- (circle) intersect w/ (road) .' Board of Health permit: yes no E] WELL USE WELL.DATA Domestic, Public ❑ Industrial ❑ Total well depth 02� ft. Monitoring ❑ Other q4 Depth to bedrocks ft. Water -bearing rock/unconso i aced material: Method dr.ille .. 9 Date chilled Description Water -bearing zones: / t 1) From —/ �­ To CASING Type 2) From To Length3w—ft. Dia(I.D.)�in. Length into bedrock ft. 3) From To Gravel pack well: dia. Protective we I seal: Screen: dia. Grout.❑ Other Slot 0' length from_ to STATIC WATER LEVEL f 2S_ g 9 Static water level below land surface fI. Date WELL TEST ! Drawdown�after pumping p rft. o hr. min. at' gpm liow.m asured4 ,rr Recovory3:- ft. after_hr._min. •G'of FORMATIO • aTCOPY BOARD OF 111'.ALTH Town of North Andovcr,Mass.. �W Date 1.9, Permit r# APPLICATION FOR WELL & PUMP PERMIT Application is hereby made for permit to drill. a well ( ) App1i.cat1°on Ls made to install (' ') a pump system'. Location: Address -%,'Z ,TD%�� S 'Pe%�' Lot,:#• Owner o e CQA.Cttr1Address T,el. well Contracto AddrC s� Pump Contractor Address Tel' i WELL CONTRACTOR (To be completed at: tinier of pu►np ,test ) Type of Well— c'sj�i�/ Well .:used for Ly Y W e' 11 !� Size Diameter of of Casing=pry ' a lati as k 2y w m 1 �a /xr Depth of Bed Rock / Djv ep,Ch� `casa.n� LnCoBed 1R`otc�le# p 14. Was t ' 9• Y r y*'�A- � '� «�' g. t iw. ice..., '�� �.�"�' � �i `�S.`*4' 1` �y '' . Seal Tested? Yes No ( )-: �+�_ Dalt,e, of ,Testing x, .t� , � l 4'''t_.;i .'p k���. ���S�..k ���*'h�'»'�,'yi�wqY" �t � c�����y.�+� ��}xa�,-p2s*a��r x,�,� �, 4i•°ae•"xp w*.k Depth of—�Je�1 — We411• ,REn`dyefdf �n :What: M'a`Ce=ri.'al ` 1 Depth to Water �u�r ( Deliv;e.rs� Gals£ Per. 'M>in� fo,r4sµhour,s Drawdown ��j feet after pum�iin'P hotfir,sCPMt �> . kia.t.-a,x ^��' t "y-a.N� R x, rvr <, ,� 4e�'.,, t -r 2• Date of Completion • � 5� �r�c� �zt ; � . � o n�Cr�a�c�t'o�r��,� .. ': C :t".'f :�::C :�::.:.........:: '::....:v :. S,C.'.i..: �::.......................... f .C,. i � t � �.t.' • :: t �' :� A � �' k��� � ;'g* PUMP INSTALLER (To be' f-i.lIcd in before instal],at `on) �1,7c & Name Pump �� =-_� --- ----- ---r.� Pump Type Used j �ater Pump DeliversGPM Size of Tank Pipe Material Used in Well: Cast Iron (_) Gnl.vnni.zed ( ) Plastic (. Well Pit (_) or Pitless ,Adapter v).as sleeve used to protect pipe?. Yes (—) N— type or Name We 11 Sea I? Date v. ,4 ,'c ,F >+r ,M i4 i4 �� �4 ►�r �'t �� �� �Y �F ter �M ►�C Ye ye lM ti4 �4 �r �r 14 14 �4 iN 1't �Y ti4 �Y +41�f �'r �4 5V ,4 �4 1't,': tS ,"r Q n � ise t't t C !7 T:'D l41M Ye. � iF ;�`:, , {+,�F �'tk dr 1M,�► �4,1,t til. Date Water analysi's r'epor--t 'submitted to Board of ,ITeal•f:h Date, release given tD owner of record & .Bldg.- Ins.p Health Inspector 6s -f y y t � I I �� I � (, Y`~ rf k NUM It THE COMMONWEALTH OF MASSACHUSETTS } d TOWNNORTH ANDOVER ofr' k; This is to Certify that ........ Skillln.95 .... ` Sons .Inca ................: ....... ..... NAME Artesian• - - .W.e.11 Drillin... -- ..g, 269 .... Proctor -.._.... Hi11 Road, H011ks , N H.: ..... •••••...•............-----.•••-..._.......•--•..••......_..:_..........._..•....... ADDRESS } IS HEREBY GRANTED A LICENSE ti For...............Dri..........................11 Well.....764 Johnson Street .......---..................._...............----•-....•----•----....._......-.............. .r , .i ................ -••-------•............................................._..........................------........-------•------•-•---............................... ....................... ..................................................................................................................................... ......... Th;s HCe[ltle k grantod in conformity with the Statutt s and ordinances rclatin;,-thereto, Ind, expires...Decemher.... 31 ...... 19.9.2 .......... ...... onless soonc�A;Vlc 11 or revoked.. ' S v. .............t; J :: ....R ..E.ebruar-. 2.5. 1.9-92 W y� 4 V FORM 433 HOBBS a WARREN, INC. �..ir � 0 8,-,,96 99.60 IIVV P/PE /HTO T4NK 86.36 99,80 INV,01,0C OUT OF TANK 66-11 it F f � { r iiI, 111 l 86,0i INV END OF 10/PE �A SS -69 I 1 � 78.20 78.20 AVEE246E STONE DEPTf/ 4T P,eOBE qi 2 �I'I �jN I I 0 �J 1�4 PROPOSED FEn(C6 Ta 055T oF2 EkcGED TOWN =oD§F- JOHNSON ST2" 5LOPF 260U11?EUEN7- ' (/50) X 150 . _ ............................ DES/GN ELEV4T/0N 4r.........(TOP OF STONE) ....t36 nom ............... EX/5T/Wei ELEI1GT/ON 4T......,,, � I i i. OEs/QN 4s aU/cT �!5 BL//L T I, t� kl7 INV PIPE OUT 01'1-101,16E 8,-,,96 99.60 IIVV P/PE /HTO T4NK 86.36 99,80 INV,01,0C OUT OF TANK 66-11 89, 72 /NV 10/PE INTO D. BOX r iiI, INV. P/PE OUT OF D. BOX 65.75- 86,0i INV END OF 10/PE 85-,-5-0 SS -69 �J 1�4 PROPOSED FEn(C6 Ta 055T oF2 EkcGED TOWN =oD§F- JOHNSON ST2" 5LOPF 260U11?EUEN7- ' (/50) X 150 . _ ............................ DES/GN ELEV4T/0N 4r.........(TOP OF STONE) ....t36 nom ............... EX/5T/Wei ELEI1GT/ON 4T......,,, � I i i. OEs/QN 4s aU/cT �!5 BL//L T I, t� kl7 INV PIPE OUT 01'1-101,16E 8,-,,96 99.60 IIVV P/PE /HTO T4NK 86.36 99,80 INV,01,0C OUT OF TANK 66-11 89, 72 /NV 10/PE INTO D. BOX 85, q/ 86.10 INV. P/PE OUT OF D. BOX 65.75- 86,0i INV END OF 10/PE 85-,-5-0 SS -69 W.4TEl2 ELEV4TION 78.20 78.20 AVEE246E STONE DEPTf/ 4T P,eOBE 2' 2 IVOTF: T///5 PL 4N 16 NOT ,4 W ,E e41VTY OF TALE 5Y57E11? BUT 4 IiE,Q/F/C,4T/ON Of THE LOC4TION OF Tf/E EX/5T/NC, 7/ICTU,PE5. ,5610 SYSTEM /N NORTH ANDOVER FO.e ROSARIO CASCIO 5"LE:'/'= qp' D4TE: 6-20-84 MKG ASSOCIATES RFD'l I30X 2E,n C l? A"; U.'' ;!,; 03047 JO H N SDN STS EE -r- SLOPF ?iFOZIME tAclVT DES16N EL EV/dT/ON 4T..... , , , .(TIoP OF 57ONE) EX/5T/N6 ELCWT/ON 47 ......... 2EQU/,eED F11 . ............................. aFZ014TT/OW,5 DE54N .4.5 BU/LT IN1 P/PE 007'0F1 -101-15L' 8G.86 94.60 IN! P/PE INTO T4NK 86-36 89,80 INV P/f'E OUT OF 74- NK 86.11 89, ZZ IN!/. PIPE INTO D. BOX 65,91 86-10- 6.,0-INV INVPIPE OUT OF D. BOX gs , 7S` 86,0, INV ENO OF PIPE 8s:so 85.69 iV.BTE� E1E 4TION 78.Z0 78.z0 .4VEP,46E STONE DEPT,y ,4T' PROBE N.OTE'.° 7'11/5 P1 -,4N /S N07,4 Ai4,eR,,4NTY OF. 7//cSYSTEM BUT .4 G'E,e/F/C.4TlON Of ` T#E I-OC.4RON OF 711"r FY1STIN6 Kms_ col, 30 Jc sov'. ST - 6 woo SUB-SU�F,4CE D/SPOSAL SYSTEM /N NORTH AN[70VER FOS ROSARlO CASClO 3L.ALE:-/"=¢0' DATE: 6 -2o -g4 MKS ASSOCIATES RFD�I 130X 26H C FREMONT� NH 03044 0 of NUMxzF.R 't ITHE COMMONWEALTH OF MASSACHUC�ETTS FEE TOWN . NORTH ANDOVER -25.00_ -....---... of .._.•.... ...................•--•----•-----------....... ......... This is to Certify that ....... Skjj x• g.S Sons, Inc. NAME Artesian Well Drilling, 269 Proctor Hill Road, Hollis, N.H. ................ ..... .... ADDRESS IS HEREBY GRANTED A LICENSE For ..............Drill Well - 764 Johnson Street ......-•----••........................ ----------........................................................ --•••----•------•--•-------•........... .......•--...-•------.. This license is granted in conformity with the Statutes, and ordinances relatin-, thereto, and expires ... Dec.emhe-r... 31 ...... 19.9.2................sinless soone� or revoked. ..E.ebrnary..2.5.,---------------------7.9...42 \....... ... ................ l yY , w FORM 433 HOBBS a WARREN. INC. :.�.� r O moD mx� mm Ln r ti W ti r m Ln m .a o �a r� Om va •z x* Om r r. r z _F wr Z A L7 10 0 W co i0 N O O LIS 1_1 O BOARD 0I" HE.ALTM Town of North Andovcr,Mass. Permit u Dace 1.9 APPLICATION FOR Wi;LL & PUMP PERMIT r Application is hereby made for permit to drill. a well (�). Application is made to install (,�) a pump system'. Location: Address 7/•S/ ToA, - sT�Pe%' - -Lot • Owner o AddressUi✓/ i' Tel . Well Contractor Address Tel. Pump Contractor Address WELL CONTRACTOR (To be completed at time of pump test) Tel. - "Type of Well �� Well used for t'-2&1 TAT Diameter of Well l' Size of. Casing _ �G Depth of Bed Rock - r -Depth cas;-.-xnto Led Rock Q_ Was Seal Tested? Yes ( No���s*�}'� ( ) Date of De th • ofd- _ _ P y, Well ,Ended a:n ` W.haa. Maaeral Depth to Water_ Delivers Gals.Per Min `for 4.hour.s Drawdown feet after pumping hours GPM S Date of Completion Az rc:W' onCrac:tor... PUIMP INSTALLER (To be-- fi_llcd i.n- before installation) r i.ze & Name Pump _ :Pump Type Used '.�ter Pump Delivers GPM Size of Tank Pipe Material Used in Well: Cast Iron (_) 0n1.v,1ni.zed (_) Plastic (_I ,-Jell Pit (_) or Pitless Adapter (_) Jar sleeve used to protect pipe?. Yes (_) NO(_) Type or Name Well Seal ill C c fi 4�4iryM�'��rilr��r�4�lri4�E��r�'r�E�4�N���'r�Irti4�4�4�M�4�'t�Ir�r�4iMti4�1rt4�Nti4►'t�'ri4�4�4�'r14�'r1'tti4i:1ST;Q�11G1Gti't1t5:n•L-.�•7n�tiF;� , iF�lklkikt41Mtk1M Da Cb Water analysi's report submiCCed to Board of jmal'th Date. release given to owner, of record & nog. I 00,00E In Y I 00,00E -to -T�c Aeogs, I -s, _q 0,1tr, 76 SLOPE 2IFQU/A ('150) X /50 DESIGN RElIWZON EX15T/N6 ELEWT/ON z ziFY..QT/4 - - - DESICjN 41 A34Y/LT INVP/PE OUT OFA MSE 56,96 94:60 INV P/PE INTO TgNK 86-36 89-80 INV PIPE OUT OF MAIX 86-11 89, 7z INV PIPE INTO D. BOX 65,9186..ro INV PIPE OUT OF D. BOX 85,75- 86.0/ INV END OF PIPE 8s s0 gs 6 9 &W76 -le R EY,4 TION AVE2,46EE STONE .DEPTH ,47- PROBE /VOTE.-. TN/S PLAN 15 N07-,4 X1.4,e�.4N,7"Y OF 71VE SYSTEM BUT .4 IlERIFIC,4T/ON Of T#F LOC.4TION OF T,/E FY1.57/N6 w,, ST�UCTU2E5. s SIJ UU/L/ .SUB—5URF4CE D/SPOS�lL SYSTEM //v NORTH ANDOVER FOR ROSARIO CASClO SLALE: y'= ¢p' DATE: 6-2-89 MKG ASSOCIATES HFot"i 130x 26h c FREMONT� ld.H 03044 b s Nol�iM AAJLDOVEJ� I MA, ❑ WEU AP%'li0UC1� j�J j C �PPl�c�vlr—v , AU1hot�ITy Of lV 5PE�TloO 1 PFRWEP FIFE FRo � �;o(Y--6 FEa T/J0r L1 PASS) `0 .AVP(TIoAJAL- IAj5i-E--c-i o" DISApv-)�UvC.V FML APPi�jvAL 9AiC 14)FIRDVIwG l Ns1:�Du,Gr�, "*-14cv�P�T %(l1b^ C?� 7';r7 APPI?WvJCS G I �- Ilk-