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Home My WebLink AboutMiscellaneous - 78 PENNI LANE 4/30/2018 (2)Commonwealth of Massachusetts North Andover, Massachusetts System Pumpinz Record System Owner & Address: Jessica Lapierre 78 Penni Lane North Andover, MA 01845 Location of system: Rear yard Date of Pumping: January 28, 2013 Type of system: Septic Tank Gallons Pumped: 1500 gallons System pumped by: Service Pumping & Drain Co., Inc. 5 Hallberg Park North Reading, Ma License #: BHP -2013-0098,0100,0765,0096,0097,0099,0101 Contents transferred to: Greater Lawrence Sanitary District RECEIVED 2013 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Date:'January 28, 201;3 ..... - Pumping Technician: JN This is PROPRIETARY.and CONFIDENTIAL information that may be used only by the Board of Health for regulatory purposes 1018 13:30 FAX IM 001/001 r Commonwealth of Massachusetts North Andover, Massachusetts System Pumpin-z Record System Owner & Address: Marie and Carlos Caetano 78 Penni Lane North Andover, MA 01845 Location of system: Rear, Right Side Date of Pumping: June 5, 2012 Type of system: Septic Tank Gallons Pumped: 1500 gallons System pumped by: Service Pumping & Drain Co., Inc. S Hallberg Park North Reading, Ma License #: BHP -2011-0413,0412,0411,0410,0409,0408 Contents transferred to: Greater Lawrence Sanitary District This is PROPRIETARY and CONFIDENTIAL information that may be used only by the Board of Health for regulatory purposes 6139 Town of North Andover LOCA H/O CON I� Ao Type o� ✓✓ ❑ Ani ❑ Bo) a( ❑ Bo! I ❑ Du ❑ Foi` ❑ Fur ❑ Ma ❑ O, ❑ Re ❑ Su � -� a. ��- 4— 6� ❑ Sze ❑ Tc ❑ Tt ❑ 41 SEPTI ❑ Si ❑ Se; O� ❑ Ti ❑ O Whii t Initials 'reasurer i NOR7N Of, � •1y0 �;• r Town of North Andover Mti'•�;;;::°,` HEALTH DEPARTMENT ,SSACNU`+t CHECK #: / LOCATION: H/O NAME CONTRACT 61,39 Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Sustems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑�tit'le Inspector $� Report $ ❑ Other: (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Town of North Andover 't `�'•�,,,,, .:" ' HEALTH DEPARTMENT ,SSACOMW '= CHECK #: / LOCATION: H/O NAME: CONTRACT( 6169 ) Type of Permit or License:, (Check box) ' • Animal i $ r ❑ Body Art Establishment // $ ❑ Body Art Practitioner i $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishmen, $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Sustems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title Inspector $� Title 5 Report $�. ❑ Other: (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Commonwealth of Massachusetts Title 5 Official Inspection Form z4TA,t� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 78 Penni Lane Property Address Carlos H. and Maria C. Caetano Owner's Name North Andover MA 01845 6-5-2012 City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information RECEIVED——" 1. Inspector: JUN ,19 ,ZUQ Michael J. Wood Name of Inspector Service Pumping Company Name 5 Hallberg Park Company Address North Reading City/Town 1-978-276-0217 Telephone Number and Drain Co.. Inc. B. Certification TOWN OF NORTH ANDOVE HEALTH DEPARTMENT MA State 5021 License Number 01864 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 6-12-2012 Inspecto s Sig u 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 - 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Commonwealth of Massachusetts w to Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 78 Penni Lane Property Address Carlos H. and Maria C. Caetano Owner Owner's Name information is required for every North Andover MA 01845 6-5-2012 page. 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: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 78 Penni Lane Property Address Carlos H. and Maria C. Caetano Owner's Name North Andover MA 01845 6-5-2012 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ❑ 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Commonwealth of Massachusetts ro Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 78 Penni Lane Property Address Carlos H. and Maria C. Caetano Owner Owner's Name information is required for every North Andover MA 01845 6-5-2012 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1h day flow t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments G7M 01 1 78 Penni Lane eW Property Address Carlos H. and Maria C. Caetano Owner Owner's Name nformaequined for every tion is equireNorth Andover MA 01845 6-5-2012 age. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No El ® 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. El® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. El® Any portion of a cesspool or privy is within a Zone 1 of a public well. El® Any portion of a cesspool or privy is within 50 feet of a private water supply well. 1:1® 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.] i r p ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. l5ins • 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. l5ins • 11110 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 78 Penni Lane Property Address Carlos H. and Maria C. Caetano Owner Owner's Name information is North Andover required for every page. City/Town C. Checklist nnn 01845 Zip Code 6-5-2012 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: A Number of bedrooms (design): Number of bedrooms (actual): A An DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts u Wo Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM ,ay''p 78 Penni Lane Property Address Carlos H. and Maria C. Caetano Owner Owner's Name information is required for every North Andover MA 01845 6-5-2012 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required] Laundry system inspected? Seasonaluse? 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: Gallons per day (gpd) �1 ® Yes ❑ No ❑ Yes ® No ❑ Yes ® No ❑ Yes ® No N/A ❑ Yes ® No currently occupied ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No l5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts z Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments '�M , •y''L 78 Penni Lane Property Address Carlos H. and Maria C. Caetano Owner Owner's Name information is required for every North Andover MA 01845 6-5-2012 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other (describe below): 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: owner 1500 gallons gauge on the truck maintenance/ inspection Type of System: ® Septic tank, distribution box, soil absorption system ® Yes ❑ No ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 78 Penni Lane Property Address Carlos H. and Maria C. Caetano Owner Owner's Name information is North Andover required for every page. City/Town D. System Information (cont.) MA 01845 State Zip Code 6-5-2012 Date of Inspection Approximate age of all components, date installed (if known) and source of information: This system is approximately 26 years old according to as -built plans dated 7-7-1986. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 16"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): There are no visible siqns of failure or leakaqe. Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 3; feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: approx. 10'x5'x5' Sludge depth: 9.1 t5ins • 11110 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 78 Penni Lane �N yyeJ Property Address Carlos H. and Maria C. Caetano Owner Owner's Name information is North Andover required for every page. Cityrrown D. System Information (cont.) Septic Tank (cont.) AAA AA AAL 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 20" 3-411 7" 12" 6-5-2012 Date of Inspection How were dimensions determined? tape measure/ 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.): This tank should be pumped yearly as part of a maintenance plan. There are no visible signs of failure or leakaoe. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: t5ins • 11110 Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 78 Penni Lane Property Address Carlos H. and Maria C. Caetano Owner Owner's Name required on is North Andover required for every page. City/Town MA 01845 6-5-2012 State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete I❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17 Commonwealth of Massachusetts N W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 78 Penni Lane Property Address Carlos H. and Maria C. Caetano Owner Owner's Name information is North Andover required for every page. Cityrrown D. System Information (cont.) nnA 01845 Zip Code 6-5-2012 Date of Inspection 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.): This distribution box has been replaced. distribution to both lines appears equal and there is no evidence of solids carryover or leakage. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 78 Penni Lane Property Address Carlos H. and Maria C. Caetano Owner Owner's Name information is North Andover required for every page. City/Town State Zip Code 6-5-2012 Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2, 54' ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins - 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 78 Penni Lane Property Address Carlos H. and Maria C. Caetano Owner Owner's Name information is North Andover MA 01845 6-5-2012 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 78 Penni Lane Property Address Carlos H. and Maria C. Caetano Owner Owner's Name information is required for every North Andover MA 01845 page. CitylTown State Zip Code 6-5-2012 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 • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 P.. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 78 Penni Lane Property Address Carlos H. and Maria C. Caetano Owner Owner's Name information is North Andover required for every page. Cityrrown D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: MA State 01845 Zip Code feet 6-5-2012 Date of Inspection Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: 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: According to plans dated 7-7-1986, groundwater was found at 4'. This system is mounded on the left side of the house and there is surface water approximately 125' away and approximately 8' below the level of the system. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 78 Penni Lane Property Address Carlos H. and Maria C. Caetano Owner Owner's Name information is required for every North Andover MA 01845 page. City/Town State Zip Code E. Report Completeness Checklist 6-5-2012 Date of Inspection ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 11/10 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 17 of 17 /'l- X10 / .......... PM SOIL PROFILE & PERCOLATION TEST DATA 4x.h Andover, Mass. Street No �� Lot, No Loc/Subdiv. Pland Owner Investigator 14 CU (a- Observer g 1 Z` e,4SOIL PROFILE DATES l."Elev 2.Elev Elev 4.Elev 0. -- 0 I- n 3 1 1 3- 1 1 Start Saturation - - Tiies ptrots Test .-j 2 2 2 2 ar e - -Drop - of - 311 -Time - �►w 1° NI AGO CLJ�'� - - _ # 5 - 5. 5 6 6 T-+- s 6 6 zi- 9` spy Mins.2nd 311'Dr6 . 014V ' - 7 8- 8 8 _ 8 10 .10 17=7 10 ` Benchmark_,,. Locati6n-_- Elevation-= Datum -. PERCO;4ION TESTS nnmWe Pit- Number--- - 1 - 2 3- 4 Start Saturation - - Soak -Minutes... ar e - -Drop - of - 311 -Time Drop of 6"-Ti.me M(hms.lst 311- drop Mins.2nd 311'Dr6 . Percolation Z 1 A'I if - ' 7 JI 4 Communication Result Report ( May,30, 2012 1:35PM) 2) Date/Time: May,30. 2012 1:34PM File Page No. Mode Destination Pg (S) Result Not Sent ---------------------------------------------------------------------------------------------------- 5426 Memory TX 817819441599 P. 1 OK ---------------------------------------------------------------------------------------------------- Reasonfor error E. 1) Hang up or line fail E.2) Busy E.3) No answer E.4) No facsimile connection E.5) Exceeded max. E—mail size ._.CeVCaab— fit JZZ,4�7 It _I V IAI /oa • /6 Commonwealth of Massachusetts North Andover, Massachusetts System Pumping Record System Owner & address: Marie Caetano 78 Penni Lane North Andover, MA Location of system: Rear, right side Date of Pumping: September 13, 2006 Type of system: Septic tank Gallons Pumped: 1500 Gallons System pumped by: Service Pumping & Drain Co., Inc. License #: BHP -2005-0649 REQ ENED SEP 2 8 2006 TOWN G-� N��RTH ANDOVER FIEALT ! L'EPARTMENT Contents transferred to: Greater Lawrence Sanitary District ,Date 'September 13, 2006 s,. Pumping Technician: PD This is PROPRIETARY and CONFIDENTIAL information that may be used only by the Board of Health for regulatory purposes g Board or Health a North Ano°overzXim a BEPTIC SISTEK • INSTALLATICK CHECK LIST CNID DAT$ DI SAPPROF ED 1 ReaffDast �1 LOT''S-�"�.T�/v��. �\ EXCAVATION OK ML 1. Distance To: a. wetlands b. Drains C.. Well 2. Water Line Location 3• No PPC Pipe 4. SE,.°tic Tank a. . ret s -_Length & To Clean Out Covers. b. '.ement Pipe .to Tank On Both Sides of Tank 5. Diz,tribution Box a. 'overs & Box - No Cracks b. Ul Lines Flowing Equal Amounts c. do Back Flow 6.- Lea,,h Field or Trench a. Dimensions b. Stone Depth c. Capped Ends d.; Clew Double Washed Stone ?• Leach Pits a. Dimensions b. Stone Depth c. Splash ' Pads d.. Tees S. Cerment Pipe to Pit - Both Sides f. `Clean Double Washed Stone S. M� Garbage Disposal 9. -M al Grading Inspection 10. U riCading Covered System 11. As Built Submitted a. Lot Location b. Dimensions of System e. Location vith Regard -to Pere Test d. Elevations e. Water Table Board of Health Wve., Y. :,ndoversMass w SUBSURFACE DISPOSAL DESIGN CHECK LIST LOT # ! '/�1 %�Ei✓ttJl ___ APPRoM DATES?H Provided: DISAPPROVED DATE__.__,,, Reasons: 5S 303 .. Title V FAIL CK Reg 2.5 The submitted plan must show as a minimumt a) the lot to be served-area,dikensions lot #abutters b location and log deep observation hoes -distance to ties c location and results percolation tests -distance to ties d design calculations & calculations showing required leaching area (e) location and dimensions of system -including reserve area f) existing and proposed contours (g) location any wet areas Within 2.001 of sewage disposal system or disclaimer -check wetlands mapping surface and subsurface drains within 1001 of sewage disposal IN - ---- system or-- disclaimer. . . (i) location any drainage easements Within 3.001 of sewage disposal system or disclaimr-planning Board files (j) known sources of water supply within 2001 of sewage disposal e _ system or disclaimer (k) location of amy proposed well to serve lot -1001 from leaching facility (1) location of water lines on property -101 from leaching facility (m) location of benchmark (n) driveways (o garbage disposals (p; no PVC to be used in construction (q) profile of -system -elevations of basement, plumbs pipe, septic tank, distribution box inlets and outletss distribution field piping and . Other elevations (r) maximum ground water elevation in area sewage disposal system (s) plan mast be prepared by a Professional Engineer or other professional authorized by law to prepare such plans -- Reg 6S tic Tanks - - (a) capacities -150;& of flow, water table, tees, depth of teens - access, pumping _ (b) cleanout (c) 101 from cellar mall or inground swimming pool (d) 251 from subsurface drains Reg 10.2 7(a) Distribution Boxes slope gre—a—t—er-1119 0.08 Reg 10.4 b) sump Date ...... 9—.17- 0 l ....... TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING SAcm This certifies that `"" `�'1 J.14................... e .................................. has permission to perform��—,'�..4.-tl ................... ............ wiring in thebuilding of ...................... .. ........... ................ at .... ......... ................. . North Andover, Mass. g Fee;......... .............. L i c. N oqO'v� . ..... ..................... ELECrRkAL INSk&OR Check # �3 694' APPLICATION unnm use urq Permit No. e,� '?V1. cY and Fee Checked i =� Plev, 9l051 (leave blank) �— FOR PERMIT TO PERFORM! ELECTRICAL WORK All work to be performed in acxsot &= with the Massachusm Electrical Curie QaC), 527 CM 12.00 (PLEASE PRINT DV DVKOR nTE.AU WORMATIOi) Date: 0 City or Town of: To the Inspector of Wires: By this application the undetsiped gives notice of his or her intention to perform the electrical work described below. Dation (Street & Number) Owner or Tenant Owner's Address S' W -K Is this permit in conjunction with a building permV. Purpose of Building UtWy Authorization No. . Editing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New _.�._•._ Amps / Volts . Overhead ❑ Uw rd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature ofPrWud Fleebleai warp CanialaribWaftim fallawina table may he wnhwd by tha hmnPmnr af 97roc Na of Rem Luminaires Na of CWL-Su sp. {Paddle) Fans o` W rail Transformers KVA No. of Luminaire Outlets Na of Hot Tabs Generators KVA No. of Lumbmiren Swimming Pool ❑ ❑ °` Ba Units Na of Resale Outlets Na of Oil Burners FIRE ALARMS No. of Zones Na of Switches No. of Gas Burners Belection andTOM NN999 a Devices Na of Ranges No. of Air Cond. Tons Na of Alerting Devices Na of Waste Disposers Hestrump Totals: ons a omtam ed Na. of Dishwashers Space/Area Heating KW Local ❑ Cial on ❑ Olber Na ofDryers ! Appliances KWNa jDev ces orUnivalent No. Heaters KWS of Ne. of Data rhw Nob ofDevices or N0611ydromassage Bathtubs Na of Motors TOWIP onswi Na ofDovices or 9=0 OTSM- Attach additional detail if desired or as rapined by the hapectar of W�- Estimated value of Electrical work: � SQ ,' (When revir-ed by municipal policy.) Work to Start: FA r�� t�1 C M4KXM ns to be requested m accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of come to the permit issuing offim CHECK ONE: INSURANCE C. BOND ❑ OTHER ❑ (SpaW) I certify, wader the pais ind penaNa of pujury, that the information on this Wfica&n is trae and complet& FIRM NAME: M :\1. �t.� r cZec7 r C LIC. NO. :!;�YJ 4 rte: V-ksv�(- N. (&Z—CA, Sigma LIC. NO.: S-2- t k {Ifappticabl� outer -="Pt- in the Baan Lumber Bos. TeL N&Lk2 _Sri 'lfl w �U Address: '� iS T")er(!A (Ld 'W2) y ��% , tU 1r'� O t Adw Tel. N&z-- - y1�S *Security System Cwtrabhr License required for this work, if applicable, enter the license number here: OWNER'S INSURANCE WAIVFdt: I am aware that the Licensee dons not have the liability insurance coverage normally required by law. By my signature below. I hereby waive this requirement. I am the (c tex3c me) ❑ owner ❑ owneess Agent Tie Na PElllKli'FEE: �