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HomeMy WebLinkAboutMiscellaneous - 78 CROSSBOW LANE 4/30/2018Commonwealth of Massachusetts�- �������� R. City/Town of I System Pumping Record F—HEAL UG 11 2006 Form 4 OF NORTH ANDOVER TH LiEpARTWENT DEP has provided this form for use by local Boards of Health.. The ystem-Pump Record must lie submitted to the.local Board of-Health or other approving authority. . ..A. Facility Information Important: When fining out 1. Syste -Location: forms on the k! computer, use L only the tab key Address to move your cursor - do not'-As use the return Gitylf°wn State Zip Code key. 2.. System Owner: 'Name Address (if different from location) CdyfTown State Code' Telephone Number B. Pumping Record 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 Noif yes, was It cleaned? ed? ❑Yes ❑ No 5: Coriditio of System: 6: SystePu ped-6. Name Vehicle License Number Company 7. Locatio/� ere content ere dis�t/+1� d: Sign re o uler Date �. •/ http://www.mass;gov/deplwa er _ pprovalS/t5forms:hfm#inspect t5form4.doc• 06/03 System Bumping Record -Page 1 of 1 X � r , i (./Y( '7 1 TOWN OF NORTH ANDOVER; SYSTEM PUMPING RECORD OCT 2 4 2005 DATE: ® a c) I TOWN OF NORTH ANDOVER HEALTH DEPARTMENT SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) wl� Cb'�s U3. 3 DATE OF PUMPING: 10-610 ,d QUANTITY PUMPED C j� CESSPOOL: NO YES S PTIC TANK: NO NATURE OF SERVICE: ROUTINE OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: COMMENTS: EMERGENCY GALLONS YES I,// - FULL FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) CONTENTS TRANSFERRED TO: 5TOT y7--1 -71 4Y44NI W.4 7 77Y 11I /VfX'!F- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: % 9 G (0 s5 60 cj! /— d i /o Owner.: Tu t � 13O� 1<G Date of Inspection: •� , —,5-- (, 6 SEPTIC TANK: (locate on site plan) i� Depth below grader Material of construction: _ oncrete _metal _FRP —other(explain) Dimensions: Sludge depth:_11L_ Distance from top of sludge to bottom of outlet tee or baffle: y Scum thickness: Of Distance from top of scum to top of outlet tee or baffle: / Distance from bottom of scum to bottom of outlet tee or baffle: 7 Comments: (recommendation for pumping, condition o i.7t and outl t tees or baffles, depth of liquid level in relation to outlet invert, structural ,/ integrity, gvidence of leakage, etc.) Al QOo--C l`S- 04E %—CiN/� l A _4' 0 �/ GREASE TRAP:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum t- bottom of outlet tee or battle: 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.) i (revised 8/15/95) William F. Weld Governor Trudy loxe Secretary, EOa David B. Struhs Comminioner Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 79 ct-O&S bow L- tj Address of Owner: Date of Inspection: 3 _ '1�_ q 6 (If different) Name of Inspector: �dL, 1) 1 V,, AJ G e Ld Company Name, Address nd Telephone Number: Ski. ctl►t S sept,/c_ Seirvlc,e CERTIFICATION STATEMENT I certify that I have personally inspected mthe sewage disposal system at this address and that the information reported below is t and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper maintenance of on-site sewage disposal systems. The system: , _V Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature:?4j &tJ?' O Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completi 011111111111 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 the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] �SYS�TEM PASSES: V.I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 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 passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank fai imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tan approved by the Board of Health. (revised 8/15/95) One Winter Street a Boston, Massachusetts 02108 a FAX (617) 556-1049 a Telephone (617) 292-1 j%I Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:/g C (-G S S bo w Ajo Avdo vt r Owner: 3'f)j-t e ge Lqa2 Date of Inspection: BI 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 nas a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 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 has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. DI 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 contaded to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or dogged 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) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 21? C('O s r b 0 w 1—^j ✓vd 9.�iWoL,&ei Owners 1v 6e, go l *'e Date of Inspection: 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or.privy is within 50 feet of a private water supply well. _ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: \ R . 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 welt) 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) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: (SSS o U Li Owner: TV Jt P &bic�e, Date of Inspection: Check if the foll wing have been done: Pumping information was requested of the owner, occupant, and Board of Health. done of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ZAs� built plans have been obtained and examined. Note' if they are not available with N/A. i/The facility or dwelling was inspected for signs of sewage back-up. esystem does not receive non -sanitary or industrial waste flow V he site was inspected for signs of breakout. VAII system components, excluding the Soil Absorption System, have been located on the site. he 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. V rhe size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non -intrusive methods. he facility o•aner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub - Surface Disposal System. (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 2 Owner: ITL) LL'�— Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):—�� (locate on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note co9dition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) 005�74 15r CESSPOOLS: (locate on site plan) Number and configuration: Depth -top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of. construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) 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) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: �8 C noss b o w /-,4j Owner: —J– u t i -C. re d Date of Inspection: 3 -'s- 7--6 TIGHT OR HOLDING TANK:_ (locate on site plan) ,/VO AVU 4 iAe l Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Capacity: gallons Design flow: gallons/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: Comments: (note if level and distribut•.on i, equa!, evidence of solids carryover, evidence of leakage into or out of box, etc.) 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) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION/ Property Address: 2 Ur, G io 5S b0 i I - N A AJO vc6 Lir Owner: Date of Inspection: / `i Ib FLOW CONDITIONS RESIDENTIAL: Design flow: gall s Number of bedrooms: Number of current residents: 3 Garbage grinder (yes or no):0 Laundry connected to system (yes or no):216 Seasonal use (yes or no): - Water meter readings, if available: Last date of n occu an VCcop) cel occupancy: COMMERCIAUINDUSTRIAL: Type of establishment: Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non -sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)_ If yes, volume pumped gallons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) 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) _ (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: % G ro 55 Lo (,v ri /Vo- � Owner. r - Tut t -e' fso � & Date of Inspection: SEPTIC TANK: (locate on site plan) i� Depth below grader Material of construction: _k-oncrete _metal _FRP _other(explain) Dimensions. Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: ©, Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle:_ Comments: (recommendation for pumping, condition of.injt and outl t tees or baffles, depth of liquid level in relation to outlet invert, structural integrity evidence of leakage, etc.) ! CoNOaa,_t ff D-dt� '7"Q,j/L GREASE TRAP:. (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Scum thickness. Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum t- bottom of outlet tee or bahle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 8/15/95) Town of North Andover Office of the Health Department Community Development and Services Division 27 Charles Street -= North Andover, Massachusetts 01845 "s$�+caus/ Sandra Starr Health Director December 18, 2001 Mr. and Mrs. Tim Bugbee 78 Crossbow Lane North Andover, MA 01845 Re: Application for an addition and deck proposed at 48 Hawkins Lane, North Andover, MA Dear Mr. and Mrs. Bugbee: Telephone (978) 688-9540 Fax (978) 688-9542 The Health Department has reviewed your application for a proposed addition and deck. The application was denied on October 1, 2001 for the following reason: 1. X Missing information 2. X. Passing Title 5 inspection of septic system may be required 3. 0 Location of structure not acceptable To address the problem(s): If 91 is checked, please supply: a. Floor plan of the existing structure and the proposed addition b. Certified plot plan showing the house, septic system and the proposed addition to scale, including any associated grading and the limit of work. If #2 is checked: a. Have the septic system inspected by a certified Title 5 inspector to determine the size of the system and whether it is operating properly: OR b. Tie-in to municipal sewer If #3 is checked: a. Relocate the project Please feel free to call the Health Office at 978-688-9540 with any questions you may have. Since , B ' J. raGrasse, Health Inspector Cc: Gomaa Construction Co., 37 Prince St., Danvers, MA 01923 Building Department File BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 NURSE 688-9543 PLANNING 688-9535 CO LC rD I 0 -"h F - rt ro 0 -ti -n IV) / Commonwealth of Massachusetts Massachusetts i r System Pumping Record System Owner System Location Date of Pumping c� 5 Cesspool: No (. J Yes L) Quantity Pumped: 52""61 lions Septic Tank: No U Yes UY' System Pumped by: vare4oet License # Contents transferrred to : Greater Lawrence Sanitary District i Date: _ Inspector: �;z/ t William F. Weld Governor Trudy Coxe Secretary, EDEA David S. Struhs Commissioner Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection �F N� OF N Pa \,Jvro SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO PART A CERTIFICATION IF Property Address: Yg c r (%,G S 60 t,,f, j L_ tj Address of Owner: \/ Date of Inspection: 3 « G (If different) Name of Inspector:- 1 Company Name, Add lesss knelrelephoe NumberG { 5-te" 4P4 S scpy-lG �&r, � CERTIFICATION STATEMENT I certify that 1 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 Inspector's Signature: 14+M Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: IV 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. B] 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 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 a Boston, Massachusetts 02108 a FAX (617) 556-1049 a Telephone (617) 292-5500 Q* Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1 8 C r6 S S boW &--j 1,j d fi w do vt r Owner: .7t1 L I C &©L 4!!�t Date of Inspection: 3 -S' - 5,(' 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 septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and 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 has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 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) a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: , 8 Gro s S ti 111a 4,tj oL,,-e i Owner: "3t; L e go L #.e Date of Inspection: 9/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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design floe 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 ..fig C��ssbvL..� �N �a Property Address. Owner: -'V t f E' Date of Inspection: Check if the following have been done: VPumping information was requested of the owner, occupant, and Board of Health. one of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. /As built plans have been obtained and examined. Note if they are not available with N/A. ✓The facility or dwelling was inspected for signs of sewage back-up. he system does not receive non -sanitary or industrial waste flow L/The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. he 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. VIZhe size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non -intrusive methods. he facility o•,%ner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub - Surface Disposal System. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C Com' SYSTEM INFORMATION (continued) Property Address: 2 �✓ ss bo w Owner: ITU I;t Qct Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):-jj✓� (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:__�` leaching fields, number, dimensions: _5 10 iC Y6 overflow cesspool, number: Comments: (note corId ition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) 4rod a 4 4e? 4-,e L y _ jDi c- -S4,?, l It . 51c* -4- S X"'o CESSPOOLS: _ (locate on site plan) Number and configuration: Depth -top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater. inflow (cesspool must be pumped as part of inspection) 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: C. i� jS S b 0 u.) L j IVO A hi C/o w t Owner: 7'V Date of Inspection: 3-5 Ic TIGHT OR HOLDING TANK:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP _other(explain) Dimensions: Capacity: gallons Design flow: gallons/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:-Ay%lL pr Comments: (note if level and distribut!cr is equa!, evidence of so!id� carryover, evidence of leakage into or out of box, etc.) 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) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: / g r , ry sS)3o tj 4t,.1 Ivo 4Naly rye r~ Owner: Date of Inspection: �~ FLOW CONDITIONS RESIDENTIAL: Design flow: Gallons Number of bedrooms:, Number of current residents: Garbage grinder (yes or no):ZW Laundry connected to system (yes or no):PQ Seasonal use (yes or no):-AZP Water meter readings, if available: Last date of occupancy: 0a ('P C d COMMERCIAUIN DUSTRIAL: Type of establishment: Design flow:gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non -sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) _ Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)_ If yes, volume pumped gallons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) 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) _ (revised 8/15/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 26 C ro s5 6,� w 4o Ivo Owner: Tu L t C is U L r, Date of Inspection: SEPTIC TANK:—V" (locate on site plan) Depth below grader Material of construction: — oncrete metal FRP—other(explain) Dimensions: Sludge depth: `' • t!<< Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:Oil ,l Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: l 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.) C!% rd A) 13 c r S tJ 7-C"V Ic /.vg„ 'V_!!5 A GREASE TRAP:_ (locate on site plan) Depth below- grade: Material of construction: —concrete —metal —FRP —other(explain) Dimensions: Scum thickness. Distance from top of scum to top of outlet tee or baffle: Distance from bottom of Brum r- bottom of outlet tee or battle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PAR* C SYSTEM INFORMATION (continued) Property Address: ,/ £� S O U� �' ri Ivo PJB 4 u -e 1 Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' DEPTH TO GROUNDWATER Depth to groundwater:_feet7 method of determination or approximation: ,�v/ t !— (revised 8/15/95) �] 3 10 Z) Board of Health BEFTIC SISTEK North AmLOXI�Irmr,a. INSTALLATICK CHECK LZ3P LOT 17 D Di SAPPR VNU EXCAVATIONOK FAIL / t Distance Tot`— a. Wetlands b. Drains c. Well 2. Water Line Location 3. No PPC Pipe $. Septic Tank a. _Tees -_Length & To Clean Out Covers. b. Cement Pipe to Tank Oa Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Lines Flowing Equal- Amounts c. No Back Flow 6. Leach Field or Trench a. Dimensions b. Stone Depth c. capped 'Ends d. Clean Double'Washed Stone 7. Leach Pits a. DisaBnsions b. Stone Dep c. Splash P d. Tees e. C t Pipe�to Pit - Both Sides f. CDoublashed Stone 8. No Garbage Disposal. 9. Final Grading Inspection 10. Barricading Covered System 11. As Built Submitted a. Lot Location b. Dimensions of System c. Location with Regard-to Pere Test � d. Elevations e: Water Table � I Board of Health Nort*t::andover,Mass APPROM DATE, Provided: SUBSURFACE DISPOSAL DESIGN CHECK LIST LOT # 11 CQ.osSSOtw DISAPPROVED DATE rr�o.�e .� Reasonss 14, 1 , Y N� Title V FAIL OK Reg 2.5minimum• The submitted plan must shave as a a) the lot to be served -areal dimensions lot #,abutters 4Vb location and log deep observation holes -distance to ties location and results percolation tests -distance to ties design calculations & calculations 8hawing required leaching area ) location and dimensions of system -including reserve area existing and proposed contours g) location any wet areas Athin 1001 of sewage disposal system or disclaimer -check wetlands mapping (h) surface and subsurface drains within 100' of sewage disposal system or disclaimer (i) location any drainage easements thin 1001 of sewage disposal system or disclair—er-Planning Board files (j) knoun sources of water sLTply within 200' of sewage disposal a system or disclaimer location of any proposed well to serve lot -1001 from leaching facilit; location of kater lines on property -10' from leaching facility m) location of benchmark (n) drive -ways (o) garbage disposals (p) no PVC to be used in construction s tic tank (q) profile of system -elevations of basement, plumb, pipe , eP a distribution box inlets and outlets, distribution field piping and Other elevations ✓ (r) ma.xianm ground water elevation in area sewage disposal system (s) plan must be prepared by a Professional Ra.gineer or other professional authorized by law to prepare such plans Reg 6 I Septic Tanks ✓ (a) capacities- 50% of flow, water table, tees, depth of tees, access, pupping ✓ (b) cleanout (c) 10' from cellar -.-allor ingrown s�tir�.-Dg pofll d) 251 from subsurface drains Reg 10.2 I Distribution Boxes J(p) slope greater than 0.08 Reg 10.41 b} sump face D-~irn Check.. List FAIL I ar, Reg 15.1 15.4 15.8 3.7 Reg 14.1 14.3 1.4.4 3.4.6 14.7 14.10 Reg 9.1 9.6 Prn3 2 Leaching Pits s Leaching pits are preferred where the installation is possible a) calculations of eaching area.-adnixm 500 eq ft b) spacing C) surface a 21 d) cover terial ,e) 21x2 Am splash pad f) at elbow g) jfo bends in pipe from d -box to pipe Leaching Fields no greater than 20 minutes/inch area -minimum 900 Bq ft construction of field surface drainage 2 % 20t from cellar wall or inground m4mming pool Leaching Trenches Trennc�ches a) calculations of 1,eaelSmg area -min 500 sq ft b) spacing -4 ft 6 ft with reserve betveen c) dimensions d) contra on e) stan f) ace drainage 2% Dowohill Slop e a) slope -vTx ---(ZD be shown) b) y/x X 150 = (to be shown) s a) approval b) s nd-by power r— ROO f 3�5.?Ls+ Tip►�T W oi2.IG SOIL PROFILE & PERCOLATION TES' North Andover, Mass. Street No Loc/Subdiv. Pland Investigator 2%; - Observer SOIL PROFILE DATES 1.Elev 2.Elev 3.Elev n 0 '}' Zo &3 0 1 - 1 T� S 4 5 2 2 3 F3 Soak -Minutes 4 "E3v 5 c.,l �� 5 6 6 Drop of 3" -Time 7 7 3 8 s 9 Mmns.l.st 3" drop 9 10 , 10 Benchmark Location Elevation Datum 4 PERCOLATION TESTS i DATES c71/1 / DATA 0 1 2 3 4 5 6 7 s 9 10 4.Elev Ti,es pl%est Pit Number i 2 3 4 5 Start Saturation Soak -Minutes Start Drop of 3" -Time Drop of 6" -Time Mmns.l.st 3" drop a Mins.2nd " Drop Percolation TO: FROM: NORTH ANDOVER, MASS '5E'1'7— 14- 19 '?-3 BOARD OF HEALTH, DESIGN ENGINEER Re: Soil Absorption Sewage System Inspection This is to certify that I have inspected the construction of the said disposal system at 7 (_�/2 G��%. 6 c���� L�f� /U i" North Andover, Mass. SITE LOCATION The grades and construction are as specified in rte+} plans and specifications dated 14 _'11R 19 i''3-. by Nr VS r 7— /V 9- /4( -61 pl 0 ,1NV,FA.ej* e,4. B. J�N tAr WC_l1 t3ax