HomeMy WebLinkAboutMiscellaneous - 77 BRUIN HILL ROAD 4/30/2018 (2)��1
MAP # LOT # ....... .... ... ..... .... ....
_
PARCEL # STREET
CONGTRUCTION_APPROVAL
HAS PLAN REVIEW FEE BEEN PAID? YES
^�
Y� PLAN APPROVAL-: DATE APP. BY_
DESIGNER: PLAN DA[E
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---- ----
WATER SUPPLY:
WELL PERMIT__
WELL TESTS:
COMMENTS:
TO
WELL
DRILLER_
CHEMICAL
B:T'ERIA II
DAlE APPHUVED
DA|E (U14RUVED
DA7E APP|<UVEU
FORM U APPROVAL: APPROVAL TO ISSUE
DATE ISSUED Y - -.
CONDITIONS
. z�
FINAL APPROVAL:
ALL PERMITS PAID YES UO
WELL CONSTRUCTION APPROVAL YES NU
SEPTIC SYSTEM CONSTRUCTION APPROVAL YES HO
OTHER YES NU
ANY VARIANCE NEEDED YES NU
FINAL BOARD OF HEALTH APPROVAL: DAlE: DY:
�
\
\
EPTIC_ S
f.IS THE INSTALLER LICENSED?
r 7 �1 {T• r rear � ;;.•
TYPE OF CONSTRUCTION:
NEW CONSTRUCTION:
:ISSUANCE OF DWC PERMIT
DWC PERMIT NO.
F 1 ;y t• t 9 _—
;�„r�'t 4' "BEGIN INSPECTION
ff i
.EXCAVATION.INSPECTION:
PASSED
CONSTRUCTION INSPECTIONS
F11 ,t n
r .t
1�
AS BUILT PLAN SATISFACTORYe
Y S ZE.Mx_N sT 84..L.A_Z
CERTIFIED PLOT
CONDITIONS OF
(FROM FORM U)
YES NO:
PLAN REVIEW
APPROVAL
NEEDED:
Im
NEEDED:
INEWNO
REPAIR
YLS NO
YES NO
YES NU
INSTALLER:7.'•._./ ✓//I% --
\
YESs----
1
APPROVAL TO BACKFILL: DATE:
FINAL . GRADING APPROVAL: DATE
FINAL CONSTRUCTION APPROVAL
�'., I,,i,Ir it -1 -•'` _
DATE:
—5
Of MO eT � 1h
Town of North Andover
s+� HEALTH DEPARTMENT
,SSACM05�4
CHECK #: L
LOCATION:
H/O NAME
CONTRACT
7119
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
$—q)X
❑
Other: (Indicate)
$
le)
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
77 BRUIN HILL RO
Property Address
SHERRI REDDICK
Owner Owner's Name
information is NORTH ANDOVER
required for every
page. City/Town
Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
10I�I
�1rn,
MA 01845 6/10/15
State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may no) 4 altered in any
way. Please see completeness checklist at the end of the form. ,
A. General Information
Inspector:
JAMES H CURRIER II
Name of Inspector
J'S SEPTIC & DRAIN
Company Name
131 FOREST ST
Company Address
MIDDLETON
Cityrrown
978-774-6685
Telephone Number
B. Certification
MA
State
S12327
License Number
01949
Zip Code
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
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.
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17
R
'W.
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
77 BRUIN HILL ROAD
rroperry Haaress
SHERRI REDDICK
owners Name
NORTH ANDOVER MA 01845 6/10/15
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
SYSTEM WORKING PROPERLY
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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
77 BRUIN HILL ROAD
t-roperty Address
SHERRI REDDICK
Owner Owner's Name
tion isrequiredfor every NORTH ANDOVER
MA 01845
page. Cityrrown State Zip Code
B. Certification (cont.)
6/10/15
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 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
❑ 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 is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
77 BRUIN HILL ROAD
Property Address
SHERRI REDDICK
Owner's Name
NORTH ANDOVER MA 01845 6/10/15
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well"*.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ Liquid depth in cesspool is less than 6" below .nvert or a% ;table volume is less
than 'h day flow
t5ins • 3/13 Title 5 Official Inspection Form: SU ?i `ace Sewage i sposal System - Page 4 of 17
OM
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M •y
77 BRUIN HILL ROAD
Property Address
SHERRI REDDICK
Owner Owner's Name
information is
required for every NORTH ANDOVER MA 01845 6/10/15
page. Citylrown 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
E] DN � 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, 000g pd.
❑ ® 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 et of a surface drinking water supply
❑ ❑ the system is within 200 f e a tributary to a surface drinking water supply
❑ ❑ the system is located in ,nitrogen sensitive area (Interim Wellhead Protection
Area — IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 5 of 17
,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
, 77 BRUIN HILL ROAD
Property Address
SHERRI REDDICK
Owner Owner's Name
information is NORTH ANDOVER
required for every
page. Cityrrown
C. Checklist
MA nIQAA
—V vvuc
6/10/15
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): 4 Number of bedrocros (actuai;: 4
DESIGN flow based on 310 CMR 15.203 (for example: A-gpd x # of bedrooms): 660 GPD
Ii -4
t5ins - 3113 Title 5 Official Inspection Forth: Subsurface Sewage Disposal System - °age 6 of 17
RjI
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
77 BRUIN HILL ROAD
Property Address
SHERRI REDDICK
Owner Owner's Name
information is
required for every NORTH ANDOVER MA 01845
page. Cityrrown State Zip Code
D. System Information
Description:
Number of current residents:
6/10/15
Date of Inspection
Does residence have a garbage grinder?
Is laundry on a separate sewage system? (Include laundry system inspection
information in this report.)
Laundry system inspected?
Seasonal use?
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump?
Last date of occupancy:
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203):
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present?
Industrial waste holding tank present?
Non -sanitary waste discharged to the Title 5 system?
Water meter readings, if available:
1
❑
Yes
®
No
❑
Yes
®
No
❑
Yes
❑
No
❑
Yes
®
No
236.40 GPD
❑ Yes ® No
CURRENT
Date
Gallons per day (gpd)
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
t5ins - 3113 Title 5 Official Inspection Fo•m: Sursurface Sews > Disposal System • Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
77 BRUIN HILL ROAD
Property Address
SHERRI REDDICK
Owner Owner's Name
information is NORTH ANDOVER
required for every
page. City/Town
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
MA 01845 6/10/15
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?
Reason for pumping:
Date
9/25/12 B.O.H. FILE
❑ Yes ® No
gallons
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection cecords, 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 West
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other (describe):
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17
Commonwealth of Massachusetts
N W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
77 BRUIN HILL ROAD
rroperty Aaaress
SHERRI REDDICK
Owner Owner's Name
information is NORTH ANDOVER
required for every
page. City/Town
D. System Information (cont.)
MA 01845 6/10/15
State Zip Code Date of Inspection
Approximate age of all components, date installed (if known) and source of information:
AS BUILT DATED 7/13/93
Were sewage odors detected when arriving at the site?
Building Sewer (locate on site plan):
Depth below grade:
Material of construction:
❑ cast iron ® 40 PVC ❑ other (explain):
18"
feet
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
A
feet
❑ Yes ® No
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 10'6" x 68" - 1500 GALLONS
9..
Sludge depth:
t5ins - 3/13 Title 5 Official Inspection Form: ° Lo,.,,_. --oe Disposal System - Page 9 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
77 BRUIN HILL ROAD
Property Address
SHERRI REDDICK
Owner Owner's Name
information is NORTH ANDOVER
required for every
page. CitylTown
t5ins • 3/13
D. System Information (cont.)
State
01845
Zip Code
6/10/15
Date of Inspection
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
26"
Scum thickness 0 - 1/2"
Distance from top of scum to top of outlet tee or baffle 6
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? SLUDGE JUDGE
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
TANK DOES NOT NEED PUMPING AT THIS TIME. INLET AND OUTLET BAFFLES IN PLACE.
LIQUID LEVEL CORRECT, NO EVIDENCE OF LEAKAGE.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ ether (explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
77 BRUIN HILL ROAD
Property Address
SHERRI REDDICK
Owner Owner's Name
information is NORTH ANDOVER
required for every
page. City/Town
MA 01845
State Zip Code
6/10/15
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, evidenceff 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? ❑ �Ies ❑ No
t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal Sysl�m - 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
77 BRUIN HILL ROAD
rroper[y /aaaress
SHERRI REDDICK
owners name
NORTH ANDOVER MA 01845 6/10/15
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.):
BOX IS LEVEL AND WORKING PROPERLY. NO EVIDENCE OF SOLIDS CARRYOVER, LIQUID
LEVEL CORRECT. BOX IS 16" BELOW GRADE.
Pump Chamber (locate on site plan):
Pumps in working order: ❑ Yes ❑ ,Vo"
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, co/dition 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 - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17
Commonwealth of Massachusetts
w W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°w 77 BRUIN HILL ROAD
D. System Information (cont.)
Type:
rroperiy Haaress
❑
SHERRI REDDICK
Owner
Owner's Name
information is
leaching galleries
required for every
NORTH ANDOVER
page.
City/Town
D. System Information (cont.)
Type:
❑
leaching pits
❑
leaching chambers
❑
leaching galleries
®
leaching trenches
❑
leaching fields
❑
overflow cesspool
❑
innovative/alternative system
MA 01845
State Zip Code
6/10/15
Date of Inspection
number:
number:
number:
number, length:
number, dimensions:
number:
12) 40'
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
SOILS DRY, NO SIGN OF HYDRAULIC FAILURE, VEGETATION NORMAL.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth — top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow
t5ins • 3/13
❑ Yes ❑ No
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17
owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
77 BRUIN HILL ROAD
Property Address
SHERRI REDDICK
Owner's Name
NORTH ANDOVER MA 01845 6/10/15
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
d.,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
77 BRUIN HILL ROAD
Property Address
SHERRI REDDICK
Owner Owner's Name
information is NORTH ANDOVER
required for every
page. City/Town
MA 01845
State Zip Code
6/10/15
Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand -sketch in the area below
® drawing attached separately
t5ins • 3/13 Tifle 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
77 BRUIN HILL ROAD
rroperty Address
SHERRI REDDICK
Owner Owner's Name
information isequired or every NORTH ANDOVER
MA 01845
page. Cityrrown State Zip Code
D. System Information (cont.)
Site Exam:
❑
Check Slope
❑
Surface water
❑
Check cellar
❑
Shallow wells
Estimated depth to high ground water:
6'
feet
6/10/15
Date of Inspection
Please indicate all methods used to determine the high ground water elevation:
1/
0
Obtained from system design plans on record
If checked, date of design plan reviewed
12/30/92
Date
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health - explain:
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
TEST PIT DATA ON FILE WITH B.O.H. BOTTOM OF TRENCH 41 ELEVATION 150.7, T -H 92-3
SHOWS WATER TABLE AT 146.7 WHICH MAKES A SEPERATION BETWEEN BOTTOM OF
SYSTEM AND GROUND WATER.
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
77 BRUIN HILL ROAD
rrroperty Address
SHERRI REDDICK
Owner Owner's Name
information is every
NORTH ANDOVER
required for eve MA 01845 6/10/15
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information — Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17
?3-- (a 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: '7� j&eV14 ,� �C �d� fJiv At 010 �l.q
Owner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within, inn, /�
'PTH TO GROUNDWATER
pth to groundwater: feet
thod of determination or approximation: C '5 ie b
viaed 8/15/95) 9
ki
LV, LV,w
41AD
Surm*vy Rawro Card p mratw an 8128l2a1S 1128:18 PM by Karen hankm
•J
Town of North Andover
a ACtual
Tax Map # 210-104,0-0101-0000.0
73
Parcel Id 18328
MISCFEEADMIN FEE
77 BRUIN HILL ROAD
06354
REDDICK, PAUL & 8HERRI
27
77 BRUIN HILL ROAD
UB et®r Maintenance
N. ANDOVER, MA
aActual
01845
Chis 101 SIMIs rarrily
Property Type
ZoningZ 1 Re5wentiai
Zoning3
Size Total 4.06Acree
Location
FY 2019
n New Meter
US Mallind Index
Dote
Name/Addrm
Type Loan Number Active/arm
REDOICK, PAUL & SHERRI
Payor
77 BRUIN HIU:ROAD
t 2116/201 4
N. ANDOVER, MA
a Actual
01845
447
US Account Maint.
6/12/2014
Account No Cycle
Occupant Name
Bldg Id. 16158.0 - 77 BRUIN HILL ROAD
Last SIRIng Date 4116,2015
3180186 03 Cycle 03
12116/2013
US Serviges Maint.
41AD
incaua�
Account No. 3180486
175
a ACtual
Service Coda
73
Rate
MISCFEEADMIN FEE
88
06354
WTRWATER
27
01 ALL METER 812E
UB et®r Maintenance
21
aActual
611312011
Account No. 3180188
a Actua•
3145/2011
Scrlai No status
aAotuat
Location
40861262 a Active
n New Meter
00 ERT HH
Dote
Reading
Code
3119/2015
486
a Actual
t 2116/201 4
478
a Actual
911812014
447
a Actual
6/12/2014
380
a Actual
3113/2014
371
a ActudI
12116/2013
338
a Actual
911312013
327
aActuat
0114/2013
256
a Achill]
U113/Lul z
41AD
incaua�
9/191x012
175
a ACtual
611812012
73
a Actual
312012012
88
a ACtual
121/9/2011
27
a Actual
9/18/2011
21
aActual
611312011
9
a Actua•
3145/2011
2
aAotuat
12128/2010
0
n New Meter
12P2812010
1554
r Replacement
W16/2010
11136
m Manual estimate
MEG
7
7120/2011
8111/2010
11120
m Manual estimate
MSG
16
1112/2011
3/1712010
1498
sAotual
12/1412009
1489
aActual
816/Z009
1478
aActual
6110/2009
1480
a Actual
3/1512009
1437
aActual
!x!15/2008
1422
aActual
Cl+a4;a Multiplle
782 1!
28.80 �^
Brand
TVpq
b Bed -W
w Water
Consumption
Posted Gate
7
4W20t6
31
1115120118
- 57
'0/15/2014
9
7/1612014
3
411112014
41
1117/2014
62
10115/2013
26
7/Z412413
34/2212013
- �-
----
--
103
103
or
10/15/2012
6
7/16/2012
41
411412012
0
1/1712012
12
10113/ZDil
7
7120/2011
2
4113/2011
0
1112/2011
16
1112/2011
19
10/16/2010
22
7116/2010
9
4/1412010
11
1x12/2310
'19
10/15/20%
22
7/20/2009
15
4129/2008
13
1/20/2009
ivy, J;.,7 11 i
731
2 v
C - Cis
Size YTD Coro
0.83 0.63 500 1
Variance
.g$% I
64694 I
187%
-92% �
-36%
125% i
$78%
-J070
1894%
-88%
598%
-49%
----�,, 62%
100% -100%
-10046
-280/0
•2396
L
Q9b
-22%
-36%
-26%
62%
13%
-340%
�- 0 �� �z C, -,� -
XFII MTY Connect %) I
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https://web.mail.c,omeast.net/h/viewimages?id=54280
6/12/2015 3:14 PM
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IMG_0249.jpcg
https://web.mO.comcast.net/h/viewimages?ld=54280
3of3
6/12/2015 3:14 PM
Commonwealth of Massachusetts _
F
City/Town of North Andover FSEP
e!!i
a System Pumping Recor5
Form 4
DEP has provided this form for use by local Boards of Health. Other forms mayak5'sb`fi btu;t�theOENT
R
information must be substantially the same as that provided here. Before using this form, c-fieck=with+our
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 within 14 days from the pumping date in
accordance with 310 CMR 15.351.
2. System Ownep:. -
Name
Address (if different from location)
City/Town
State
Telephone Number
Zip Code
Zip Code
B. Pumping Record
1. Date of PumpingAw Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradfoi
7,gnai�
re of Hauler
of Receiving acility
t5form4.doc• 03/06
Vehicle License Number
Ma 01835
Date
Date
System Pumping Record • Page 1 of 1
A. Facility Information
Important: When
filling out forms
1. System Location:
on the computer,
11
77:1 Til)inho
use only the tab1
key to move your
Address
cursor - do not
North Andover Ma
use the return
City/Town State
key.
2. System Ownep:. -
Name
Address (if different from location)
City/Town
State
Telephone Number
Zip Code
Zip Code
B. Pumping Record
1. Date of PumpingAw Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradfoi
7,gnai�
re of Hauler
of Receiving acility
t5form4.doc• 03/06
Vehicle License Number
Ma 01835
Date
Date
System Pumping Record • Page 1 of 1
M
1-/N V NUK HSND, , _ 1,��� — S
U It /��.�� JY9'1'�1�•1 PUMPINU R.P_c�Ok1,.
h
------.__---�
SYSTE
17b CZ -L
Aho
DATE of pN�;,�1.�1
� .. QUANTITY PUMP - -- -
�'tssPOOL; Np Y
Wn rVk� UN sexvic
Kv rim„
Uto4dAy
aaoD CON01'r rVU, 11.,
K pp'r'3
BXCU$ry8 SoLlp8 �,�.. PLUODBD
4L CD CA KA YQ YZR 0Tt{E R EXPLAIN
,�...
vN ItN ,j r11 h1N tx&
4<7
p, � !y� x�<�Y 1,�,'� f t<r� psi, �k� �,y'. � � �a 2 �+ " �f P F,d _ ;. ��a •
Y` ��'t�,•-,t�,�yk�`� �s� � 4>diir k � r x b y � �
w�w1ip,i' Q f�-tr,I!J�lt tfia >TOWrsNt Or_.. F E NORTH
ORTH
r.
i.
ANDOVER t
SYSTEM PUMPING RECORD �
a �
3�%r',����.3}.rt {Y,� 4� �5� �i+���� N f �r t C k+ . >' t x S' "✓� rr a i ti � 1 4 _ , ;
ti � t�t�j� �� ��T�/• TN t r, �! s � ' �y f - .- '�.i {.
��0s,�����H ��}}� 43.' � hr� , �'•r f g, it ,
tVik�}�s�SYSTEM OWNER & ADDRESS SYSTEM CATION'
H>rt fM t�
(exam ple left runt of house
��
,�, �}Pt Y W tl fid^
{ * f 5k«SiF r t b, �, � t r i ; 1 Lac ) " J c—
VI
. •�'t.+�' x �•
V,Fa �p7 }
C .
�� i�4� 'Y 43fi?.}p? iY h�. _ YZ•1 i f I ;
rr,pb z'" u� a� �'si �tr��'YZ�11x E�n��,.K�� {Nx I �tii�+ ray -k;# �'t iso p 3 7 y; l iyy..s9a�F ^" rx _ w• . r h }' ;
'+u+3 t'"�rTP^tf.? p q ,rfa cfax,,,.. '. y p
a Cyt 3'x;j' 'tr i �77
�DATE
x k Oi QUANNGTITY PUMPED �_
GALLONS
p
1 f
141
3 �i.'���y�� yi,yiiF 2 zffi`9 , 4zp r v -, , t : t 2: t ;,ef ,� I `•c
CE$SPOOL:'�:No' � � C TANK: NO YES
i , v YES SEPTI .rx
OF SERVICE: P, TINE
ROU
EMERGENCY
TIONSQ Ct'
3'C04D CONDITION ` t `` `t` FULL TO COVER
(r�. a �E •f _ + ..
t E HEAVY GREASE t BAFFLES IN PLACE
( s,
ROOTS LEACHFIELD R
EXCESSIVE SOLIDS RUNBACK SOLIDS
CARRYOVER^ , (.OTHER (EXPLAIN _
.•' z '�E k. V k c'v�r f3�},rz ,a y
F�
'�
Il +ti-itk Si p Yrd tr f.4 F. 1'S: fr fi`{! 2+'• � .�E f
$T PUMPED BY:
V i'Q
°ki"
ri 43 ut ( +'`+Sr+''f rors�rF.hxs A CS ;It
�� a a , � iy�a�' ♦ 2 � � .rik1 i z ,c� t«. 'k t k;'� t.lf i '.¢1 r` x 7 k. _t f .. l
�
K
fipt C�i1�vRV ENTS' t r . ,a �•N13
� Sr <�+'�� �'�Y�-�'`ci n�. ft 'i�zr -y zt Y y• •� GR��.: *�� e�;\��%i
,Aw �t �7 aka M ��{ .� .,� f 1. • ..._ _ +
t, +- &op
�4_. Z�y 1,4 tk ? }j { �t�• i f h' Y x - - el lop
�0' i
`, � Fielt'r�#;S'"tF k 1F`3#�¢'�,��Wt� xt • c s > ' �'� ' � I
j q-
iJµ�Flu�fe S-'k��r�� ��'�• a %Q ., ,Y Q::.
+�� ,r �S TRANSFE
D TO
id e� tR4g f'x s=Wxf t 1 ,'�
z ,[ +
'L t$
{E�1'a+ �.1
t i h J,#y Pt `"y' , r 7�r�St itis
bt�({'�x=�.. s�e t��,b
y.T 'ET:•""�it�.+.'3'. r�»':�.Rp.'�k fxx� -fr r: �. :Y? �, r•_C f., .. ,r. '1
William F. Weld
Gawrrwr
Trudy t;oxe
S�ent.ry, EDEA
Davldd B_�Strt hs
Commonwealth of Massachusetts
Executive Office of Environmental Affairs.
Department of
Environmental Protection
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
p CERTIFICATION
N,Aiy000eoe.
Property Address: �% CC t i' F r Address of Owner:
Dt fl ld/5155
9s'- Io'7
Lt i
+
a e o nspectton: k (If different)
Name of Inspector: Z tFNJA.►'ti A C• 04&-001b �'-'♦)r-,4(a- Sait()t��S �a'�C-
Company Name, Address and Telephone Number: �liC >N G- �t � ""I- t' #KF} ,
3� W4L)iCIFV- 2d, N. �� dou�e2,
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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails D /
Inspector's Signature: Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owrer shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check�B, C, or D:
AJ SYSTEM PASSES:
y I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
BJ SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not)
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or eAltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
(revised 8/15/95) 1
One Winter Street • Boston, Massachusetts 02108 a FAX (617) 338-1049 • Telephone (617) 292-55W
0 Printed on Recycled Paper
9'S-67
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
�CERTIFICATION (continued)
Property Address: 07'7 8 ICO Ivb Au
Owner: ,� `1 N. m D e r C h e le Iv
Date of Inspection: I _ 1 S J
o �
B) SYSTEM CONDITIONALLY PASSES (continued)
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):
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if (with approval of the Board of Health): .
broken pipe(s) are replaced
obstruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH. DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a seotic tank ana soli absorption system and is within 100 feel lu a �wface walci supp;y ur lrib. zar, li, a
surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system hay a septic tank and soil absorption system and is less than 100 feet but So feet or more from a private water
supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is
free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm.
D) SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
(revised 8/15/95) 2
7-3 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
pp
Property Address: 77 ��Ui•n A`� `.� Fj A) • , da
Owner: S r "w%. c --
Date of Inspection: /o /
D) SYSTEM FAILS (continued):
_• Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
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 Soi! Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E) LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The design flow of system is 10,000 gpd or greater (Large System) and the system is.a significant threat to public health and safety
and the environment because one or more of the following conditions exist:
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 8/15/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 7 7 4%,eU
Owner: So.,,r-
Date of Inspection: /'D /r/yS�
Check if the following have been done:
±�Pumping information was requested of the owner, occupant, and Board of Health.
_None of the system components have beenpumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
As built plans have been obtained and examined. Note if they are not available with WA.
vThe facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non -sanitary or industrial waste flow
The site was inspected for signs of breakout.
ZAII system components, excluding the Soil Absorption System, have been located on the site.
_vThe 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.
b-11Thesize and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non -intrusive methods.
V.
The facility ov.ncr ,a: -.d occi:pants, if differe. from o-wne,) were provided with information on the proper maintenance of Sub -
Surface Disposal System.
(revised 6/1S/9S) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: Ai 11 Ad, Jb, gj d D(/(fic
Owner: Si9•M L
Date of Inspection:
v � g
FLOW CONDITIONS
RESIDENTIAL:
Design flow: gallons
Number of bedrooms:
Number of current residents:
Garbage grinder (yes or
Laundry connected to system (yes or no)::
Seasonal use (yes or (P. & 12
Water meter readings, if available: AA 9PAI X Aw
Last date of occupancy: G�UP.rfd�
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: ¢allons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non -sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available.
Last date of occupancy:
OTHER: (Describe) _
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information: //
&V f P!lMfAro s•ilG� �S7W094'��1 a ye440s Ou.K are
System pumped as part of inspection: @ or no) -%y/
If yes, volume pumped /5'W rtallons
Reason for pumping: Z^ 5 etc f Y�H'n /G � 2- 45
TYPE OE SYSTEM
P9 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)
Other (explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no) !w
(revised 8/15/95)
%r-6 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 17 ,deal ., //,',6l C4, lbio ,&korft *4
Owner: So..*% r.
Date of Inspection:
poli/5s .
SEPTIC TANK:_
(locate on site plan)
Depth below grade: (D
Material of construction: concrete _metal _FRP —other(explain)
(Soo GH (, Qocfw�6oLu�
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: 3� "
Scum thickness: /'
Distance from top of scum to top of outlet tee or baffle: G ��
Distance from bottom of scum to bottom of outlet tee or baffle: lye
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) CO40,)4i0'1 e1' 2,V4k �,)'Cc 6101, o< -
GREASE TRAP:_ - r '•'"
(locate on site plan)
Depth below grade:
Nlaterial of construction: _concrete _metal _FRP —other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to too of outlet tee or baffle:
Qistance from bottorr, ^' c(-1,— r^ h -torr of o7!le! tee or baffle'
Comments.
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
inte.ariry, evidence of leakage, eic.i
(revised 8/15/95) 6
Fl:r •G-7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 7] BeoA 11,4 t! e4, /V • g 4OL161 , W X
Owner: Sn,4.- V —
Date of Inspection: ID i 5-/94b-
TIGHT
/5ti
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _,FRP —other(explain)
Dimensions:
Capacity: gallons
Design flow: ¢allons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert: O
Comments:
(note if level ..d d:snibu!:r^ eGuz'. e-Odence of solids carrvove,, evidence of leakage into or out of box, etc.)
i-; oil. /Z.xGa 66 Au 4- /.G eApe v oble/L
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 8/15/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 7;7 eoeQ1,II /,�,GG GQ , �/v h4 JoP/Fe, MSO,
Owner: 15'tA',r G
Date of Inspection: AD /-/5 5
SOIL ABSORPTION SYSTEM (SAS):_ -
(locate on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:_
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length: i yd
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (note condition of soil, signs of hyy0raulic failure, level ofonding, cpndition of vegetation,etc.)
ao !92r,r oc llyg.P,#c,jCi c. F.4y&,eE - fl so 1-4wom .Zr Gh; foeca
CESSPOOLS: _
(locate on site plan)
is
Number and configuration:
Depth -top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
materials of construction:
indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY: _
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 8/15/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 77 B,PUi
Owner: S*" .
Date of Inspection:
i n /s/qs
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permai
locate all wells within 100'
references landmarks or benchmarks
9.s-(,7
DEPTH TO GROUNDWATER
Depth to groundwater: feet
method of determination or approximation: Feo WN D Cr i" ej-A..' B1i t C ohe p
(revised 8/15/95) 9
r
�F"P
E3R U 10 HILL
r
5LOP6 2�Qvi2��ENr
OE6/6N EL E/,4T/ON AT.... , ....(TOP OF STONE) -
EX/5T/NCF - cc-"LEWT/ON QT ... , ..... 2EQU/2E0 F/LL .............................
,!F1lF aT/ON.5
OE51(�N 4-5 31,1W -
INV PIPE OUT OF 1/OU5E
\ -S, p
S �
/NV P/PE INTO T4NI<
541-1
INV P/PE OUT OF TANK
.4
/NV PIPE INTO O. BOX
53,
1 9
INV. PIPE OUT OF D. BOX
, o
3 ,
INV ENO OF P/PE
S3, o
3.03
�2,d
ask
Al�d TE2 EL EV,4 T/ON
.4 VE2,466c 5 TONE
DEPTH ,4T PICOBE
NOTE.• T///5 PL 4N /S NOT ,4 141,41(?1e41VTY
OF TILE SYSTEM 3U7-,,4 VE�2IF/C.1T/0/V
OF THE LO"T/ON OF THE EXIST/NCS
S7,eUC7U2E5.
RD.
V
s/5 BU/LT
SUB-SU.2FOCE D/,
SYSTEIl�I
/N
No. 4 A,.�7;>d ✓Z� ✓L
FOR
40 #
Cgs /5TIQN15EEN
1600 SUMMER 57'15EET
oQ rE. -21131,Y3
SER GI , INC.
HAVERAULL , MASS.
93d66aoZ
' 1 ; r
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: 77 Rrn i n Hi 1 1 Rd _
Anc3nvPr, MA 01845
Owner's Name: pa„ 1 R Rharri Rt-drl i ck
Owner'sAddress:
1 0/25 01
Date of Inspection:
Name of Inspector: (please print) John J. Soucy
Company Name: Soucy' s Sewer Services
Mailing Address: 830 Livingston St.
TPwkshuryf MA 01876
Telephone Number: 7,9 � 8 51 — , 3 3
Tolwj! OF FOH ANDO?%=RE:ARDOHEALTH
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:
XX Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: / o I z51 pl
The system inspector shall sub it a dy of this inspection report to the Approving Authority (Board of Health or
DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
A , f
Page 2 of I 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: .7.7.,BrtiB__13 RB`
N. Andover..JAA;01845
Owner: Paul & Sherri Reddick
Date of Inspection: 1 0
Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D
A. System Passes:
x_ 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 (Y,N,ND) in the for the following statements. If "not determined" please
explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of 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 times a year due to broken or obstructed pipe(s). The system will
pass inspection if (with approval of the Board of Health):
ND explain:
broken pipe(s) are replaced
Obstruction is removed
2
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 77 Bruin Hill Rd.
NLAndover, MA 01845
Owner: Panl R Sherri Reddick
Date of Inspection: 10/25/01
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 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: 77 Bruin Hill Rd.
N.Andover, MA 01845
Owner: Paul & Sherri Reddick
Date of Inspection: -IU/2b/U
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or "no" to each of the following for all inspections:
Yes No
XX
XX
XX
XX
X
XX
XX
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool .
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow
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 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.
4
Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 77 Bruin Hill Rd.
N.Andover, MA UIU4b
Owner: Paul & Sherri Red is
Date of Inspection: 1-0 7 2 57 01
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
-XX _ Pumping information was provided by the owner, occupant, or Board of Health
-XX Were any of the system components pumped out in the previous two weeks ?
XX _ 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 ?
–.2LX _ Were as built plans of the system obtained and examined? (If they were not available note as N/A)
--2LX — Was the facility or dwelling inspected for signs of sewage back up ?
XX _ Was the site inspected for signs of break out ?
XX _ Were all system components, excluding the SAS, located on site ?
Xx _ 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 ?
XX_ 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
XX _ Existing information. For example, a plan at the Board of Health.
XX _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 I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 77 Bruin Hill Rd.
N.Andover, MA 01845
Owner:Pau 1 & Sherri Reddick
Date of Inspection: 101-2 5.101
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms):4 4 0
Number of current residents: 4
Does residence have a garbage grinder (yes or no): NO
Is laundry on a separate sewage system (yes or no)T_j&J [if yes separate inspection required]
Laundry system inspected (yes or no): NlA
Seasonal use: (yes or no):NJD_
Water meter readings, if available (last 2 years usage (gpd)): SPP
Sump pump (yes or no):I.
Last date of occupancy: . U r- r- e 14L
COMMERCIAL/INDUSTRIAL N / A
Type of establishment:
Design flow (based on 310 CMR 15.203): Qpd
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 7 / 0 0
Was system pumped as part of the inspection (yes or no): YES
If yes, volume pumped: 15 0 0 gallons - How was quantity pumped determined? gage on truck
Reason for pumping:_MaintPnan & insl2ect interior of tank.
TYPE OF SYSTEM
_XgSeptic 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:
8 YEARS
Were sewage odors detected when arriving at the site (yes or no): _Up
6
Page 7 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 77 $ruin Mill Rd.
N .-mer-, P4A 01845
Owner: Reddi ck
Date of Inspec ion:
BUILDING SEWER (locate on site plan)
Depth below grade: 1 S '
Materials of construction: _cast ironXX 40 PVC _other (explain): _
Distance from private water supply well or suction line: N /A
Comments (on condition of joints, venting, evidence of leakage, etc.):
SEPTIC TANK:XX (locate on site plan)
Depth below grade: 3"
Material of construction�yconcrete _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: 6 ' x 13 '
Sludge depth: 3 "
Distance from top of sludge to bottom of outlet tee or baffle: 3 5 "
Scum thickness: 2 ,,
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: 1
How were dimensions determined: T,, m — a p ds I I I ae tr-r� l
Comments (on pumping recommendations, mlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
No garbage disposal allowed.
GREASE TRAP: N Lfiocate 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: 77 Bruin Hill_ Rd.
nT AnNnvcr MA 01845
Owner:—��1� dick
Date of Inspection: fO/25/01
TIGHT or HOLDING TANK: N /A (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 BOX: XX (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.):
Float checked O.K., No leakage.
PUMP CHAMBER: _N. A(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 l l
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 77 Bruin Hill Rd.
N. Andover, MA 01845
Owner: _Paul & Sherri Reddick
Date of Inspection: 10/25/01
SOIL ABSORPTION SYSTEM (SAS): XX (locate on site plan, excavation not required)
If SAS not located explain why:
Type
leaching pits, number: _
leaching chambers, number:
leaching galleries, number:. 2-401
-Xx— 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.):
No signs of hydraulic failure.
CESSPOOLS: -N_4A(cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth — top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow (yes or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRIVYgUA- (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
OFFICLAI, INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 77 Br1l i n Hill Road
North Andm=,.MA 01845
Owner: ��L,i R Chcrri Redick
Date of Inspection: 10/25/01
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.
\
\ \ LOT 6
\
\
FN
\ NIP
10
Page 11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 77 Bruin Hill Rd.
N.Anclover, MA 845
Owner: Paul & Sherri xTeUdIcK
Date of Inspection: 1 0 9r; n 1
SITE EXAM
Slope
Surface water
Check cellar XX
Shallow wells
Estimated depth to ground water 6 ' feet
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:
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:
Qhtai n d d si an from plan: also dug test hole with auger
in low area, no water incountered at 4', 3' elevation
differanrp from test hole to SAS area
11
REDDICK, PAUL & SHERRI
77 BRUIN HILL ROAD
N. ANDOVER MA 01845
TOWN OF NORTH ANDOVER 30033
2001 WATER/SEWER BILL CYCLE #43 ERM NAWE67/26/2001
Account: 3180186
Meter: 3180186
Service: 77 BRUIN HILL RD
Retain this voucher for your records IIIIIIIIIIIIIIIIIIIIIIillllllllllllllllllllllllllllllllllllllllllllllliilllllllllllllllllllllllllllllllll
DETACH Please detach here and return the bottom voucher with your payment DETACH
REDDICK, PAUL & SHERRI
77 BRUIN HILL ROAD
N. ANDOVER MA 01845
TOWN 22
2001 WATER/OSEWERTBILLDOVECCYCLE #33 ffL+ b ER4/20/200011
Account: 3180186
Meter: 3180186
Service: 77 BRUIN HILL RD
Retain this voucher for vour records IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII1111 IIII1I1MIIIIII!IIIIIIgIIN
TOWN OF NORTH ANDOVER 13883
2001 WATER/SEWER BILL CYCLE #23 JILL WME01/17/2001
Account: 3180186
Meter: 3180186
Service: 77 BRUIN HILL RD
Retain this voucher for your records IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIUIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIOUIIIIII11111IIIIIIII1II
DETACH Please detach here and return the bottom voucher with .your oa.yment DETACH
REDDICK, PAUL & SHERRI
77 BRUIN HILL ROAD
N. ANDOVER MA 01845
TOWN OF NORTH ANDOVER 7173
2001 WATER/SEWER BILL CYCLE #13 BEILL 0AME00/17/2000
Retain this voucher for your records
Account: 3180186
Meter: 3180186
Service: 77 BRUIN HILL RD
DETACH Please detach here and return the bottom voucher with your payment DETACH
REDDICK, PAUL & SHERRI
77 BRUIN HILL ROAD
N. ANDOVER MA 01845
TOWN 2949
2000 WATERO/SEWER BILL CCYCLE #43F NORTH ANDOVE�� �� E�7/19/20008
Account: 3180186
Meter: 3180186
Service: 77 BRUIN HILL RD
'•:::::::::T ...........i}iii:StiJiiiiiiiiii: i::ti•iii:•: iii}i:4}iiiiiiii:6iiiiiiiiiiiii: ii:i :i: i; .:
;�i.i.::.
DO
DE
XXX
Retain this voucher for your records IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
DETACH Please detach here and return the bottom voucher with your payment DETACH
REDDICK, PAUL & SHERRI
77 BRUIN HILL ROAD
N. ANDOVER MA 01845
TOWN ANDOVE
2000 WATERO/SEWERTBILL CYCLE #33 PH WWE94/26/20006
Retain this voucher for your records
Account: 3180186
Meter: 3180186
Service: 77 BRUIN HILL RD
Edi! ::xx
DETACH Please detach here and return the bottom voucher with your payment DETACH
REDDICK, PAUL & SHERRI
77 BRUIN HILL ROAD
N. ANDOVER MA 01845
TOWN OF ANDOVE
2000 WATER/SEWERTBILL CYCLE #23 PH UTP.92111120007
Retain this voucher for your records
Account: 3180186
Meter: 3180186
Service: 77 BRUIN HILL RD
MAKE PAYMENTS TO
TOWN OF NORTH ANDOVER
P.O. BOX 124
NO. ANDOVER MA 01845
KEVIN F. MAHONEY
COLLECTOR
REDDICK, PAUL & SHERRI
77 BRUIN HILL ROAD
N. ANDOVER MA 01845
TOWN OF NORTH AN
2000 WATER/SEWER BILLDOVECYCLE #13 RWWREN 1/02/19999
Account: 3180186
Meter: 3180186
Service: 77 BRUIN HILL RD
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Line 4
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TO:
BOARD OF HEALTH
120 MAIN STREET
NORTH ANDOVER, MASS. 01845
3 Pondview Place
Tyngsboro, MA 01879
FROM: Sandra Starr
RE: 6 Bruin Hill Road
Dear Mr. Erickson:
TEL. 682-6483
Ext. 32
DATE: Aug, 2g, lag
This is to inform you that the proposed septic design plans
for the above site dated April 18, 1992 have been
APPROVED.
If you have any questions about the next step in the
process, please call the Board of Health office.
APPROVED WITH THE FOLLOWING CONDITIONS:
DISAPPROVED FOR THE FOLLOWING REASONS:
1. Leaching facility not 35' from dwelling
2. Need foundation drain with elevation (must be above the
leaching facility.)
3. Insufficient distance to water table.
4. Septic tank not 25' from dwelling.
5— Soil tests no longer current. —0K
Also, our records show that the design review has not been paid.
Please call me to discuss these items.
Thanks.
TO:
BOARD OF HEALTH
: 120 MAIN STREET
NORTH ANDOVER, MASS. 01845
3 Pondview Place
Tynasboro, MA 01879
FROM: Sandra Starr
RE• 6 Bruin Hill Road
Dear Mr. Erickson:
TEL. 682-6483
Ext. 32
This is to inform you that the proposed septic design plans
for the above site dated April 18. 1992 have been
APPROVED.
If you have any questions about the next step in the
process, please call the Board of Health office.
APPROVED WITH THE FOLLOWING CONDITIONS:
DISAPPROVED FOR THE FOLLOWING REASONS:
1. Leaching facility not 35' from dwelling
2. Need foundation drain with elevation (must be above the
leaching facility.)
3. Insufficient distance to water table.
4. Septic tank not 25' from dwelling.
5.. Soil tests no longer current.
Also, our records show that the design review has not been paid.
Please call me to discuss these items.
Thanks.
FORM U - LOT RELEASE FORM
r
INSTRUCTIONS: This form -is used to verify that all necessary
a rovals
pp /permits from Boards and Departments having jurisdicti
have been obtained. This does not relieve the applicant and/or
i
landowner from compliance with any applicable local or state law
regulations or requirements.
i
****************Applicant fills out this section*****************
//.. -m00%%
APPLICANT: W 1� J `- 1/S�' ^eA, cC1 n J� j Phone % 03 O
LOCATION: Assessor Is Map Number Parcel
---------------
Subdivision �JwJ/A Lot(s)
Street Owl"1 ��- St. Number /
t ************************Official Use Only************************
RECO DATIONS OF TOWN AGENTS:
Date Approved r�
Conservation Administrator Date Rejected
Comments
Town Plai
Comments
- 21-- J�9AA_,
Health Agent
Comments
Date Approved
Date Rejected
Date Approved
Date Rejected
Public Works - eewerfwater connection &WKc S
- driveway permit tl�; ca�ar�oQe.
Fire
Received by Building Inspector Date
T 6 InT
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
epartment of
• Environmental Protech®n
William F. Weld
Govemor
Trudy Coxe
seoree.ry, Solea
David B. Struhs
Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
LL gIV000e'e,VVk
Property Address; 7? t NJ r Address of Owner:
Date of Inspection: /0 I l � S (If different) vt vO (is ,T
(vJ13rna
cc`Ntrn C•( CN0 j�
Name of Inspector: li-Al p (` VvG,t��rNG-
C cioUe r
Company Name, Address and Telephone Number; iUC err, �d
CERTIFICATION STATEMENT
ce rtify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection The inspection was performed based on my training and experience in the proper function and
inaintenance.of on-site sewage disposal systems The system:
�passes
Conditionally Passes
Needs Further Evaluation By the Local Approving .Authorih
_ Fails
D i /
Inspector's Signature: Date; l � �' !fl �1�5
',lie System
Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
,n,oe�ion If the s, -stem is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
tl-,; report to the appropriate regional office of the Department of Environmental Proterion.
l , ontalnal should be sen' tri the sysiem owner and oopie> >er,t to the buyer, if applic:Uble and thu appro, ng
I,^^.;SPECTION SUMMARY:
Checl,OB. C. or D.
A? SYSTEM PASSES;
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
Bl SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair;
passes inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not)
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
T imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
revised 8/15/95)
One Winter Street • Boston, Massachusetts 02108 Y FAX (617) S56-1049 • Telephone (617) 292.5.500
J Primed on Recycled Paper
SUBSURFACE SELVAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
L� �� t �0 �n mUi;4
r� .i 1 `..1.J � rti � ' .
Property Address:
Owner: _ ,J �.i .. E e t (t�1 i K" tl�
Date of Inspection: J j
B) SYSTEM CONDtT1Ctir:',1,[" PASSES ;continued)
or breakout or high static water level observed in the distribution box is due to broken or °ovtat otructf h e
p il.el, ;,r due to a broken, settled or uneven distribution box. The system will ass inspection if (with app
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
\a llh appro'v'al ofthe Board of Healthy.
broken pipe's) are replaced
obstruction is removed
C) FURTHER EYA'...::"\7(t'%� !S REQUIRED By THE BOARD OF HEALTH:
.. .r`', require further evaluatior. by the Board ()I Health jr. order to determine if the wst(m is failing to protect the
Conditlor. '
public he—'. • ...... and thr> environment.
1) SYSTEM %VILL !' :`S L.!NLESS BOARD OF HEALTH DETERNIINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH \A'!! -L PP,(".) ECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
pr„, r5 with.n 50 feet of a surface Fater
pr,,,,' ,s \Within 50 feet of a bordering vegetaied wetland or a salt mars
r) SYSTEM ',',`;i,;, Fgli UNLESS THE BOARD OF HEALTH (AND PUBLIC
ATTR SHEALIE AND SAIF FETY AND NERN11NE5 THAT
THE SYSTt.`', !> Ft-i�;CJIONING IN A N1ANNER THAT PROTECT
THE..., d je;,tiC :ol: anC) 50!1 a:?501pU0n 5`:5'Pr'i: dr10 U \4ii!li! iUG leti lu a p,I�t_t: '•vhle:i pt,,l,/In� u! irlbuigl} i�
iter supo'' i, within Tone i of a public vrater suppl\' well.
tar�h ano SOIi ab�orp>Ion 4'..,iEl'"1 and p
septic tank and soil absorption sy5tr>m and is within 50 feet of a private water supply \yell. atPr
h, :, c SePUc t<i lk and SOiI absorption sy5:er'• and is less thin 100 feet but 50 feet or more from a private
unless a well water analysis for coliform bacteria and volatile organic compour,' Indicates that the well is
r,; ,; ;lollutlon from that 'facility and the presence of ammonia nitrogen and nitrate nitrogen is eq
wal to or less than 5
DI SYSTEM FAIL`'; or
lure
a as
n 310
3. The basis
I have de:err„ined ihatithe system
identified bellow` The Board rof Heae of lthpshould gbeicontactedrtto determinewhatHCI^be neon Sart to correct
one
for this ci+ae; rn�n<,,�,. r
the failur+::
of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
t
t:eviseq
9P� r
t
''
n r,,,. � - SUBSURFACE' SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
7 7 �',�v,'� �,1, � C �� � • fill civ vee r �ti9 �
Owner: ,
Date of Inspection:
DI SYSTEM FAILS (continued):
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion or the Soil Abscrption Systern, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or prey' is within 100 feet of a surface water supply or tributary to a surface water suppiy.
Am, por'io:-, of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any porion of a cesspool or pri;v is less than 100 feet but greater than 50 feet from a private water supply well with no
. If the well has been analyzed to be acceptable, attach copy of well water analysis for
acceptable water quality analysis
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
EJ LARGE SYSTEM FAILS:
The following cr ter a appl;r to large systems in addition to the criteria above'
t r > 10,00Ci �t `; or reatcr t arge System! and rile s}sic,n i5 a slenificant threat to public health and safety
The �ie"gn flo•.�: of ;;� e'' b.• gr.
and the env��or rnent because one or n; re of the following conditions ex,st:
the syster^ is Within 400 feet of a surface drinking water suppl}
T the system is within 200 feet of a tributary to a surface drinking water supply
_ th(> sysiem is located in a nitrogen sen5rtive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone L' of a
T pubs, +a!er supply well)
The owner or'operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR c,.00 and 6.00. Please consult the local regional office of the Department for further information.
3
(re: ise: e
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Prcperty Address:
Owner:
Date of Inspection:
Check if the foliov:ing have been do.^.e:
&" Purnp,ng information :,;:,s requested of the owner, occupant, and Board of Health
en
None o` the system components have been PuR'p'oeen lintroduced intoweekseast two '�
the�sys emthe srecentltem y orreceiving
or as part ofthis normal inspection. rates
during that penod Lar`; volumes of water have nodt
k/�s built plans have beer: obtained and examined. Note if they are not available with N/A.
./The facility or dwelling was inspected for signs of sewage back-up
The systen-i does not recerve non sanitary or industrial waste flow
The s to was inspected for signs of breakout.
/Al; ��'s;em components, excluding the Soil A.bsorpt on System, have been located on the site.
The septic tank manholes were uncovered, opened: and the interior of the septic tank was inspected for condition of baffles or
tees, material of construc_iion, limens a -s, depth of liquid, depth of sludge, depth of scurn.
The s.ze and locatnon of the Soil Absorption System on the site has been determined based on existing information or
appriir.r sated b,, non-ir,;rusive method's.
wr,e proyid,d rrrth mformalion on the proper maintenance of Sub•
ere
Surface Disposal 5V -t(...
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
,��,iv 99/�,GG fid, 1v, r� �o���, �'� •
Property Address:
Owner. S
Date of Inspection: /
FLOW CONDITIONS
RESID_ ESI,
Design flow.__._____gallons
Number of bedrooms -
Number of current res dents:
Garbage grinder (yes or q;'
Laundry connected to system (yes or no):
Seasonal use (yes or
Water meter readings: if available:
Last date of occu,)ar)cti': 2Uee'#w-
COMMERCIALiINDUSTRIAL
Type of establishrnent:
Design floe, _ ___ _gallons/day
Grease trap present. (yes or na'___
Industrial Waste Holding Tank present: (yes or no!,
Non -sanitary waste discharged to the Title S system: iyes or noi,`.
\water meter readings, if avadat?!e.
L,:�t dat,> of accupanc,,;
OTHER: (Describe` --
Cast date of occupanc, .--
GENERAL. INFORMATION
PUMPING RECORDS and source of information.
System pumped as pan of inspection: (& or no) -
ons
If yes. vo�umt _��r /G G�
Reason for pumping_ d 5 Pew
TYPEo SYSTENA
to 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)
Other (explain)
96-r,L) _✓�
APPROXIMATE AGE of a!! components,' "date installed (if known) and source of information: e5
sewage �s detected v,hen arriving at the site: (yes or no)
5
(revised
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address; LqeO 1'h 6, D vee
Owner: 5 (P—.- ---
Date of Inspection: ( 5- J-7
TIGHT' OR HOLDING TANK;—
(locate on site plan)
Depth below grade:
Material of construction: —concrete _metal —FRP _other(expfain)
Dimemion5�
Capacity: gallons
Design
,6,larrn level.
('OM,ment5:
(condition of inlet tee, cond;Oon of alarm and float switches, etc)
DISTRIBUTION BOX:
(locateon Site plan
Depth of liquid level Pbo,ve outlet Invert:
Comments:
:rn!c C. -C! an2 rjvn%-pr, evident? of lcat.agp into or out of box, etc
mon 4� eL /ZX
PUMP CHAMBER:—
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition.of pump chamber, condition of pumps and appurtenances, etc,)
(revised 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
/SYSTEM INFORMATION (continued)
Property Address: 77 �iPui`r1 ��, GG Gd , ��/� iT►� ioill ,
Owner: siP v
Date of Inspection: ID h•/5 5~
SOIL ABSORPTION SYSTEM (SAS):_
(locate on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods?
If not determined to be present, explain:
leaching pits. number:_
Ir?aching chambers, number:_
leaching galleries, number: ,
leaching trenches, number,length: i Vol
leaching fields, number, dimensions:
overflow cesspool, number:
Comments. (note condition of soil/,/signs of
hydraulic failure, level of1�ponding, c%ndition of vegetation,etc.)
i%l,� SiGH OR �t i�D �lE(It'�OO'/SUN �S UH�I�OCLH-
CESSPOOLS:
(locate -on site pian)
Nun-,ber'and configuration:
Depth -top of liquid to inlet rove^.
Depth of solids layer
Depth of scum layer:
Dimensions of cesspool
ti!arerials of construrion
!nd,catson of ground,�ate
inflow (cess000i must be pumped as pan of inspection)
Comments: (nate cond:uon. ofsod, signs of hvdrauhc failure, level of ponding, condition of vegetation, etc.)
PRIVY: T
(locate on site plan)
Dimensions:
Materials of construction:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
t:evised 8/:5/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: %V 9,&Oi'J �d� v Ad/0(�/�f1�
-owner: S C
Date 'of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties
locate all w
9,S''-(07
DEPTH TO GROUNDWATER
Depth to groundwater: feet
method of determination or approximation:
2o wt D a i C,•t. P A f31'' e o� b
(revised 6/:5/95) 9
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTBiilJ vEh/
TITLE 5_
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CFRTTFIrATrnN
Property Address:
N AnrinvorF MA 01845
Owner's Name: Ua„ 1 R Sharri RPr1r1 i rk
Owner's Address. -
10/25t,01
Date of Inspection:
Name of Inspector: (please print) John J. Soucy
Company Name: '_Sou6y �s , Sewer Services
Mailin Address:
1; 830 Livingston St.
Tew_ k_ shury, MA 01876
Telephone Number: 4_U 7 R) 8 S 1–—
T0v�,IyOF NVo iR
� OF : 3 AVER/
IVUV
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
Fails
Inspector's Signature: Date: ,_I/
The system inspector shall subiWt 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 hpw the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
C -D 0
� -() U " A. r, j
aTalllfl.t lo GRAOB-
Page 2 of I 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A >
CERTIFICATION (continued)
Property Address: 77LiBrUig lffiil R>?
N: Andover; :�.IKA 01 845
Owner: Paul & Sherri Reddick
Date of Inspection:
Inspection Summary: Check A,B,CM or E / ALWAYS complete all of Section D
A. System Passes:
XX 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 (Y,N,ND) in the for the following statements. If "not determined" please
explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of 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 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: _77 Bruin Hill Rd.
N_ Andcwpr„ MA 01 845
Owner: Ua„i R Rharri Rpddick
Date of Inspection: 10 / 2 5 / 01
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 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 I 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:
3
Page 4 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
PropertyAddress: 77 Bruin Hill Rd.
N.Andover, MA 01845
Owner: Paul & 5hrZ:i. Reddick
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate "yes" or "no" to each of the following for all inspections:
Yes No
xx Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_, xx Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool .
XX Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
xx Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped
xx Any portion of the SAS, cesspool or privy is below high ground water elevation.
xx Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_XX Any portion of a cesspool or privy is within a Zone 1 of a public well.
_XX Any portion of a cesspool or privy is within 50 feet of a private water supply well.
xx 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:
N
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.
4
Page 5 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 77 Bruin Hill Rd.
N.Andover, MA 01645
Owner: Paul & Sherri Red is c
Date of Inspection: 1-0-7-2-7701
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
-XX _ Pumping information was provided by the owner, occupant, or Board of Health
_ -XX Were any of the system components pumped out in the previous two weeks ?
XX _ Has the system received normal flows in the previous two week period ?
_ _XX Have large volumes of water been introduced to the system recently or as part of this inspection ?
_.XX _ Were as built plans of the system obtained and examined? (If they were not available note as N/A)
-XX _ Was the facility or dwelling inspected for signs of sewage back up ?
XX _ Was the site inspected for signs of break out ?
XX _ Were all system components, excluding the SAS, located on site ?
XX. _ 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 ?
XX _ 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
XX — Existing information. For example, a plan at the Board of Health. '
XX _ 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 5 of I 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 77 Bruin Hill Rd.
N. Andover MA 45
Owner: Paul & Sherri Red is t
Date of Inspection: 1-07-2-5701
Check if the following have been done You must indicate `yyes" or "no" as to each of the following
Yes No
..XX _ Pumping information was provided by the owner, occupant, or Board of Health
ALX Were any of the system components pumped out in the previous two weeks ?
XX _ Has the system received normal flows in the previous two week period ?
_ M Have large volumes of water been introduced to the system recently or as part of this inspection ?
._.XX _ Were as built plans of the system obtained and examined? (If they were not available note as N/A)
.IXX — Was the facility or dwelling inspected for signs of sewage back up ?
*XX _ Was the site inspected for signs of break out ?
XX — Were all system components, excluding the SAS, located on site ?
.)M. _ 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 ?
XX _ 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
XX _ Existing information. For example, a plan at the Board of Health.
XX _ 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)]
5
Page 6 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 77 Bruin Hill Rd.*
N.Andover. MA 01845
Owner:pau 7 &EPerrri Reddick
Date of Inspection: ,��,/ 25,/..01_
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms):4 4 0
Number of current residents: 4
Does residence have a garbage grinder (yes or no): NO
Is laundry on a separate sewage system (yes or no)T10 [if yes separate inspection required]
Laundry system inspected (yes or no): Kies,
Seasonal use: (yes or no): Na
Water meter readings, if available (last 2 years usage (gpd)): SPP
Sump pump (yes or no): DILL
Last date of occupancy:`
COMMERCIAUINDUSTRIAL N / A
Type of establishment:
Design flow (based on 310 CMR 15.203): >;ad
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 7 / 0 0
Was system pumped as part of the inspection (yes or no): YES
If yes, volume pumped: 1 50 0 gallons — How was quantity pumped determined? gage on truck
Reason for pumping: Ma i ntPnan & ' n pest interior of tank.
TYPE OF SYSTEM
—XXSep4c 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:
8 YEARS
Were sewage odors detected when arriving at the site (yes or no): •Up
6.
Page 7 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 77 Srtitin Hi11 Rd.
N • AedeveETA=�^ 1845
Owner•
Date of Inspec ion•
Reddick
BUILDING SEWER (locate on site plan)
Depth below grade: 1 A '
Materials of construction: _cast ironX2L40 PVC _other (explain): _
Distance from private water supply well or suction line: N / A
Comments (on condition of joints, venting, evidence of leakage, etc.):
SEPTIC TANK:XX (locate on site plan)
Depth below grade: 3"
Material of constructions 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: 6 ' xi 3 '
Sludge depth: 3 "
Distance from top of sludge to bottom of outlet tee or baffle: 3 5 "
Scum thickness: 2 1,
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: 1 "
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.):
No garbage disposal allowed.
GREASE TRAP: N Lflocate 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.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 77 Bruin Hill Rd.
-N--And.�o�vpx, MA n 1 8 4 5
Owner: -T> -ay,1-.8 d i c k
Date of Inspection: T 0 2
TIGHT or HOLDING TANK: N / A (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: _ ¢allons
Design Flow: aallons/day
Alarm present (yes or no):
Alarm level: Alarm in working order (yes or no):
Date of last pumping:
Comments (condition of alarm and float switches, etc.):
DISTRIBUTION BOX: XX (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.):
Float checked O.K., No leakage.
PUMP CHAMBER: _U.[A(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.):
8
Page 9 of l 1 .
OFFICIAL INSPECTION TORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 77 Bruin Hill Rd.
N. Andover, MA 01845
Owner: Paul & Sherri Reddick
Date of Inspection: 10/25/01
SOIL ABSORPTION SYSTEM (SAS): XX (locate on site plan, excavation not required)
If SAS not located explain why:
.Type
leaching pits, number: _
leaching chambers, number:
leaching galleries, number:
-XX-leaching trenches, number, length:2 — 40'
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,
etcNo signs of hydraulic failure.
CESSPOOLS:-N,4A(cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth — top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow (yes or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRIWgZ p_ (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 77 Bnj; n Hill Road
Nnrt-h Andoy i-� _01845
Owner: P,„i P. eHimrIr; Redrlick
Date of Inspection: 10/ 25/01
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.
\
LOT 6
IN\
FN
�!W \ F S
BRUIN
10
HILL RL
Page 11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 77 Bruin Hill Rd.
N.Anctover, MA 0 845
Owner: Paul & Sherri Recictick
Date of Inspection: 1 n f 9 C; n_^
SITE EXAM
Slope
Surface water
Check cellar XX
Shallow wells
Estimated depth to ground water 6 ' feet
Please indicate (check) all methods used to determine the high ground water elevation:
,XZ.- Obtained from system design plans on record - If checked, date of design plan reviewed:
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health -explain:
Checked with local excavators, installers- (attach documentation)
Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Ohta;nPd design from plan- also dug test hole with auger
in low area, no water encountered at 4'. 3' elevation
diffAranne from test hole to SAS area
11
REDDICK, PAUL & SHERRI
77 BRUIN HILL ROAD
N. ANDOVER MA 01845
TOWN OF NORTH ANDOVER 30033
2001 WATER/SEWER BILL CYCLE #43 BqLLLL UAWE@7/26/2001
Account: 3180186
Meter: 3180186
Service: 77 BRUIN HILL RD
Retain this voucher for your records IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIilllllllllllllllllllllllllllllllllllilllllllllllllllllllilllllllllllll
ULIACH Please detach here and return the bottom voucher with your payment DETACH
REDDICK, PAUL & SHERRI
77 BRUIN HILL ROAD
N. ANDOVER MA 01845
TOWN O
2001 ANDOVE22444 #33 bER4/20/2001
Ilan
� S�u
Account: 3180186
Meter: 3180186
Service: 77 BRUIN HILL RD
Retain this voucher for m it rPrnrric IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII11111111111IIIN111111111111111111111111111111111111111111111111
REDDICK, PAUL & SHERRI
77 BRUIN HILL ROAD
N. ANDOVER MA 01845
TOWN OF NORTH ANDOVER 13883
2001 WATER/SEWER BILL CYCLE #23 JILL WME61/17/2001
Account: 3180186
Meter: 3180186
Service: 77 BRUIN HILL RD
Retain this voucher for your records IIIIIIIIIIIIIIIIillllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllill
DETACH Please detach here and return the bottom voucher with .vour Davment DETACH
REDDICK, PAUL & SHERRI
77 BRUIN HILL ROAD
N. ANDOVER MA 01845
TOWN OF NORTH ANDOVER 7173
2001 WATER/SEWER BILL CYCLE #13 BILL 01WE60/17/2000
Retain this voucher for your records
Account: 3180186
Meter: 3180186
Service: 77 BRUIN HILL RD
DETACH Please detach here and return the bottom voucher with your payment DETACH
REDDICK, PAUL & SHERRI
77 BRUIN HILL ROAD
N. ANDOVER MA 01845
85
TOWN 2000 WATERO/SEWERTBILL CYCLE #43 WEE �� E�7/19/20008
Account: 3180186
Meter: 3180186
Service: 77 BRUIN HILL RD
......
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DETACH Please detach here and return the bottom voucher with your payment DETACH
REDDICK PAUL
, &SHERRI
77 BRUIN HILL ROAD
N. ANDOVER MA 01845
85
TOWN
2000 WATERO/SEWOERTBILLDOVECCYCLE #33 PH 'RTE54/26/20006
Retain this voucher for your records
Account: 3180186
Meter: 3180186
Service: 77 BRUIN HILL RD
3ME::>::>::::»:::<:::>::>::::::::::«:::>::»::>;:::::<::::;<:>::>:<�:�:�:�:::::
DETACH Please detach here and return the bottom voucher with your payment DETACH
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REDDICK, PAUL & SHERRI
77 BRUIN HILL ROAD
N. ANDOVER MA 01845
TOWN OF
2000 WATER/SEWERTBILLDOVECCYCLE #23 PH WTP.92/11/20007
Retain this voucher for your records
eliv
Account: 3180186
Meter: 3180186
Service: 77 BRUIN HILL RD
� r
MAKE PAYMENTS TO
TOWN OF NORTH ANDOVER
P.O. BOX 124
NO. ANDOVER MA 01845
KEVIN F. MAHONEY
COLLECTOR
REDDICK, PAUL & SHERRI
77 BRUIN HILL ROAD
N. ANDOVER MA 01845
TOWN NORTH ANDOVE
2000 WATERO/SEWER BILL CYCLE #13 RWWME 1/02/19999
Account: 3180186
Meter: 3180186
Service: 77 BRUIN HILL RD
Retain this voucher for your records
DETACH Please detach here and return the bottom voucher with your payment DETACH
4. Effluent Tee Filter present? ❑ Yes 1( No If yes, was It cleaned? ❑ Yes ❑ No
5. Condition of System:
6. ystem Pumped By:
ru lie 9. 00 M4.
I'Ame. Vehicle License Number
' —d &Wer'
Company
7. Location where contents were disposed:
Signature of Hauler
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MASS
C
System Pumping Record
Form 4
NOV 14 2007
DEP has provided this form for use by local Boards of Health.
n��~�111 o r d must
be submitted to the local Board of Health or other approving a
A. Facility Information
Important:
When filling out
1. System Location:
forms the
computer, use
99�1JJ i , II.V�
only the tab key
move your
Address
Nto (} r hiA
06LI 5
cursor - do not
use the return
City/Town State
Zip Code
key.
rt
2. Sstem Owner:
` � ryr1 - oc
Name
Address (if different from location)
City/Town sttatep
q/1 �
G / (� �iip�Code
�OW' I�oIS'
Telephone Number
B. Pumping Record
ii
(Soo
1. Date of Pumping 2. Quantity Pumped:
Date
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank
❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes 1( No If yes, was It cleaned? ❑ Yes ❑ No
5. Condition of System:
6. ystem Pumped By:
ru lie 9. 00 M4.
I'Ame. Vehicle License Number
' —d &Wer'
Company
7. Location where contents were disposed:
Signature of Hauler
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
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