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HomeMy WebLinkAboutMiscellaneous - 781 WINTER STREET 4/30/20181 1 1 L_ O T 5 T ,. �} 5 %.o .n � ' F. r- u tIs • J ;r �j ;v r- 0NS _ 15 _7 1;r 1 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. 101 mnm Commonwealth of Massachusetts Title 5 Official Inspection Fo Subsurface Sewage Disposal System Form - Not for Voluntary) 1 W I V1tf r 5- ;essments e Address YE7VvN t�tA Nlifsvi ��ffttyyt n Fij "I n W.; A - A " State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: r1� ____ C Name of Inspector /I A L -3-ew-e Company Name -�- 1 -3 -Pa� 4�y n '- �] J * __7__ Company Address LkJk City/Town Telephone Number f' B. Certification Stale License Number 01874, 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 experiencelin 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 Insp c,tarrs signature Date 11--7-1/ The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies -sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the.time of Inspection and under the conditions of use at that time. This inspection does not-addresi how the system will perform in the future under the same or different conditions: of use. t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 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 Property Address Owner's Name Cityrrown state .Zi Code P Date of Inspection B. Certification. (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: [►f 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, " pleas e explain. The septic tank is metal and over 20 Years old* or the septic k (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfi tion or tank failure is imminent. System will pass inspection if the existing tank is replaced with complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it i ructurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less n 20 years old is available. ❑ Y ❑ N ❑ ND ( plain below): 15ins • 09/08 TIBe 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Owner information is required for every page. tsps • osroa Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Notfor Voluntary Assessments Property Address Owner's Name Gity/rown 15. Uenitication (cont.) B) System Conditionally Passes (cont.).: State Zip Code Date of Inspection ❑ Observation of sewage backup or break out'br high static water level in the distribution box due to broken or obstructed pipe(s) or due toa broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of.Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND plain below): ❑ distribution box is leveled or replaced El ❑ N D (Explain below): ❑ The system required pumping more an'4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (wi approval of the Board of Health): ❑ broken pipe(s) are r aced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction i emoved ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation Is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the B of Health in order to determine if the system is failing to protect public health, safety a environment. I. System will pass unless Board of He determines in accordance with 310 CMR 15.303(1)(b) that the system is not ctiQning in a manner which will protect public health, safety and the environment: ❑ Cesspool or p . is within 50 feet of a surface water ❑ Ce s of or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Pape 3 of 17 Owner information is required for every page. t5ins • 09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System .Form - Not for Voluntary Assessments -� % I W )A 4 (- st Property Address Owner's Name City/Town State Zip Code B. Certification (cont.) Date of Inspection 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 Z e 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is wit ' 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less an 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 analys' , performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presenc f ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other ilure 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 ❑ E],' Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ g, Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool d Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool D / Liquid depth in cesspool is less than 6" below invert or available volume is less �t1 than Y2. day flow Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Owner information is required for every page. t5ins • 09/09 Commonwealth of Massachusetts Title 5 Official Insnectlon Form Subsurface Sewage iS 1 WIC Property Address Owner's Name Disposal System Form - Not. for Voluntary Assessments City/Town B. Certification (cont.) State Zip Code Date of Inspection Yes No ❑ 2- Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s): Number of times pumped: ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion of'a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ d 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 th following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet surface drinking water supply ❑ ❑ the system is within , feet of a tributary to a surface drinking water supply ❑ the system is to ed in a nitrogen sensitive area (Interim Wellhead Protection Area — IWP or a mapped Zone II of a public water supply well If you have answered "yes" t ny question in Section E the system is considered a significant threat, or answered "yes" in Sect' D above the large system has. failed. The owner or operator of any large system considered a s' ificant threat under Section E or failed under Section D shall upgrade the system in accordant with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Me 5 official inspection Form: Subsurface sewage Disposal System ' Page 5 of 17 _5 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I Property Owner's Name City/Town Stafe. C. Checklist Zi Code P Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: YesNo U ❑ ❑ Pumping information was provided by the owner, occupant, or Board of Health L� ❑ Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two weekp eriod? ❑ 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 NJA) ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? ❑ Were all systern 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? d ❑ 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)1 D. System Information Residential Flow Conditions: Number of bedrooms (design): ' — Z/" Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 3c3n t5,Dq t5ins • 09/09 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Owner Information is required for every page. Comlrnonwealth :ot I�assacNus��s title, 5 Officia-I Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner's Name Cityfrown D. System Information Description: 6 State Zip Code Date of Inspection Number of current residents: Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes B rNo Laundry system inspected? I W ❑ Yes ❑ No Seasonal use? ❑ Yes 2No Water meter readings, if available (last 2 years usage (gpd)): Proffliirtzks Detail: '1 Sump pump? ❑ Yes No 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 Water meter readings, if available: per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t51ns • 09/08 / Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 7 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewa a Disposal System form - Notfor Voluntary Assessments Property Address Owner's Name City/Town D. System Information (cont..) Last date of occupancy/use: Other (describe below): Pumping Records: State Zip code Date of Inspection General Information Date Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: How was quantity pumped determined? Reason for pumping: 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 records, if any) ❑ Innovative/Alternative technology Attach a co f th py o e current operation and . maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system try system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. El Other (describe): t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Owner information is required for every page. (Sins • 09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewagq Disposal System Form - Not for Voluntary Assessments _�T.fL'o1�,T�C5-� Property Address vwners Name Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: Material of construction: ❑lcast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well -or suction line: ❑ Yes ❑ No feet MIA feet Comments (on condition of joints, venting, evidence of leakage, etc.): Vl'? 126LAC-e- n6S�e�-Ve,� Septic Tank (locate on site plan): .Depth below grade: C) feet Material of construction: 1311concrete ❑ metal ❑ fiberglass ❑ polyethylene y El other (explain) If tank is metal, list age: /J 1A years Is age confirmed by a Certificate of:Cortrpliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Owner Information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspect'! 1.1 Form Subsurface Sewage Disposal System Form-.Not,for Voluntary Assessments 15? Li ,'1+'e r- 5+ Address Owners Name City(rown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of.outlet tee or baffle How were dimensions determined? a-� • `J /> a Comments (on pumping recommendations, inlet.and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence Of leakage, etc.): C +A ri 16 LLA (Y If P 10 rq�ll [e V4 V P g -AL n I ei vi v(c rA �'O.P4 Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete [j metal Dimensions: / Scum thickness feet [],06eiglass ❑ polyethylene Distance from top of scu/Sm of outlet tee or baffle Distance from bottom of bottom of outlet tee or baffle Date of last pumping: ❑ other (explain): t5ins • 09/08 Date TtUe 5 Oftel inspection Form: Subsurface Sewage Disposal System • page 10 of 17 FA Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System --Form - Not for Voluntary Assessments Property Address Owner's Name cityrrown State Zip Code Date of Inspection D. System Information (cont:.) Comments (on pumping recommendations,.inlet and outlet tee or baffle liquid levels as related to outlet invert, evidence of leakage, etc.): / , structural integrity, 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: g ns 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 d float switches; etc.): Attach, copy of current pumping contract (required). Is copy attached? El Yes ❑No t5ins • 09M Title 5 official Inspm*M Forth: Sub -ft - Sewage Disposal System .page 11 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System -Form - Not:for Voluntary Assessments Property Address Owner's Name Cityrrown State Zip Code Date of Inspection D. System Information (colt.) Distribution Box (if present must be opened).(ldcate on site plan): Depth of liquid level above outlet invert 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.): i�x l � � �v ? j 43--�J �v 1 � � S 2v�P vl-���1�1,�J'� yVl 1 �I 11'✓� � o�a5-e rV--fd Pump Chamber (locate on site plan): Pumps in working order. Alarms in working order. Comments (note condition of pump chamber; ❑ Yes ❑ No ❑ Yes ❑ No of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plbn, excavation not required): If SAS not located, explain why: t5ins • 09/08 Title 5 Offidai 1 nq_c6- F— Sub-rrp- Sewage Disposal System • Page 12 or 17 Owner information is required for every page. t5ins • 09/08 Commonwealth of Massachusetts Title.5 Official Inspection Form Subsurface Sewa a Disposal System Form .. Not for Voluntary Assessments Property Address Owner's Name Cityrrown state Zip Code Date of Inspection D. System Information (cont.) Type: (] leaching pits ❑ leaching chambers ❑ leaching galleries ❑ leaching trenches leaching fields ❑ overflow Cesspool number: number. number: number, length: number, dimensions: number: ❑ innovative/altemative 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 groundwate cJulJC�i'� ❑ Yes ❑ No Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page is of V Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Foran - Not -for Voluntary Assessments Property Address Owner Owner's Name information is required for every page. City/Town State Zip Code. Date of Inspection D. System Information (cant.) 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 s/si* hydraulic failure, level of ponding, condition of vegetation, etc.): t5fns - Ong TWO 5 offidal inspection Foran: Subsurfece Seyoege DISposel System • Page 14 of 17 a Owner Information is required for every page. (1151ns - 09/08 Commonwealth of Massachusetts Title 5.Official Inspection Form. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Owner's Name City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: hand -sketch in the area below ❑ drawing attached separately �O Title 5 Official Inspection Form Subsurface Sewage Disposal System - Page 15 of 17 a Owner Information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Address Owner's Name Cityfrown D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: State Zip Code Date of Inspection feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design plan reviewed: 1 7d DOE— El e❑ 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: -- _ e r,� P l G `(. lc> / leo-tiawx, 1�, ejo C err 0 Before filling this Inspection Report, please see Report Completeness Checklist on next page. (t5ins • 09/08 Title 5 Oficial Inspection Forth Subsurface Sewage Disposal System •Page 16 of 17 r �\ 4 a Owner Information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary. Assessments I �c- St Property Address Owner's Name City/Town State Zip Code Date of Inspection E. Report Completeness Checklist 92( Inspection Summary: A, B, C, D, or E checked Q� Inspection Summary D (System Failure Criteria Applicable to All Systems) completed Q,System Information - Estimated depth to high groundwater U?/Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file T5ins - 09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAI �EIVED DEPARTMENT OF ENVIRONMENT' PR TER JUN 2 3 2005 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT TITLE 5 SSESS OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY FORM MENTS SUBSURFACE SEWAGE DISPOSAL SYST PART A CERTIFICATION Property Address: ` Owner's Name: Owner's Address: Date of Inspection: Name of Inspector: please print) S Company Name: Mailing Address: Telephone Number: gg CERTIFICATION STATEMENT performed based on my have personally inspected the sewage disposal system at this addresos and the information reported I certify that I h P 1pe as of the time of the inspection. The tnsp stems. I a e a DEP below is true, accurate and comp The system: training and experience in the proper nitto functionZi and n 5.340 of Title 5 (310 CMR 15 000) a h approved system inspector pursuaes _ Conditionally Passes the Local Approving Authority _ Needs Further Evaluation by F ils Date: Inspector's Signature: Board of Health or inspector shall sub,000 mit a copy of this insp ection report to the Approv�g Authority The system ittsp this �pection. If the system is a shared system or has a delignaflofwfioe of the DEP) within 30 days of completing rovtn owner and copies sent to the buyer, if applicable, and the app g gP d or greater, the inspector and the system own shall submit the report to the appropriate reg DEP. The original should be sent to the system authority. Notes and Comments perform in the future under the same or different rt only describes conditions at the time of inspection and under the conditions of use at that This repo Y 1 time. This inspection does not address how the system P conditions of use. Title 5 Inspection Form 6/15/2000 page l Page 2 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOM N INSARY CTIN FORM SSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTE PART A CERTIFICATION (continued) Property Address: O 1 Owner: ��l�I -� '7�E' ✓ Date of Inspection: Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: yl* 3" I have not found any information which indicates that any of the failure criteria described in 310 C MR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: 1_ / f 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 ves, 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 leakine 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 pipes) 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 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: I'-1 U N Owner: /<-_,// 19�P✓ Date of Inspection: C. Further Evaluation is Required by the Board of Health: /I///, - 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 supple 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 1 I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSME'N'TS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 7 j �//tl%��✓ Owner: Date of Inspection: to 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 faciliry or system component due to overloaded or clogged SAS or cesspool _ /Discharge or ponding of effluent to the surface of the g7ound or surface waters due to an overloaeea 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 voltune is less than '/� day floµ _Required pwnping more than 4 times in the last ,year NOT due to clogged or obstructed pipe(s) Numoer 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 mbutar% to a �u, . -c water supply. _ _fAny 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 pr gate dater supply well with no acceptable water quality analysis (This system passes if the well water analyse, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compowiads 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 forma (Yes/No) The system fails. I have determined that one or more of the above failure criteria exist ds described in 310 C..MR I S 30. therefore the *•stem fads The s,siem o��ner shm;',: r.ta:' :`!e R, ::•_ 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 addiuon to the criteria above) yes no the system is within 400 feet of a surface drinking water supple the system is within 200 feet of a tributary to a surface drinking water supply the system is located to a nitrogen sensitive arca (Interim Wellhead Protection Arca I WPA ) or e mappcd 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 ansµerea ..yes" in Section D above the large system has failed. The owner or operator of any laree system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance wish 3 10 t Mk 15.304. The system owner should contact the appropriate regional office of the Department Page 5 of 1 l OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: ,?/ All) Owner: 6=�o 2,�"t✓ 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 ---w--ere any of the system components pumped out in the previous two weeks Has the system received normal flows in the previous two week period ? ave 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 I/-"— Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems I The size and location of the Soil Absorption Svstem (SAS) on the site has been determined based on. Yes no Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)J 5 Page 6 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: T Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL l Number of bedrooms (design): `► Number of bedrooms (actual): DESIGN flow based on 310 CM11Y.203 (for example: 110 gpd x # of bedrooms): Number of current residents: Does residence have a garbage grinder (yes or no): A-10 Is laundry on a separate sewage system (yes or no): I`id(if yes separate inspection required) Laundry system inspected (yes pr no): _ Seasonal use: (yes or no): u Water meter readings, if avpi)able (last 2 years usage (gpd)): Sump pump (yes or no): _ Last date of occupancy:Q�1 r COMMERCIALANDUSTRIAL Type of establishment: H /pf- Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sgft, etc.): Grease trap present (yes or no): _ Industrial waste holding tank present (yes or no): Non -sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records C Source of information: J ^ ec" Was system pumped as part of the inspection (yes or no): _ If yes, volume pumped: _gallons -- How was quantity pumped determined? Reason for pumping: TYPE.PF SYSTEM _ eptic tank, distribution box, soil absorption sysrcm _ 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 iniormatton. Were sewage odors detected when arriving at the site (yes or no): v[o PLI�v 7 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 7tf/.[1/;4/ 3 i' Owner:7�� Date of Inspection: —! 70 J— BUILDING SEWER (locate on site plan) Depth below grade: ?' n Materials of construction: _cast iron _40 PVC _other (explain). Distance from private water supply well or suction line: Comments (on condition ofjoints, venting, evidence of leakage, etc.): p 0-,(j &a4 ?na 14 SEPTIC TANK: Y—Olocate on site plan) Depth below grade: <� Material of construction: oncrete _other(explain) If tank is metal list age. _ is age confirmed by a Certificate of Compliance (yes or no). _ (attach a copy of metal _fiberglass_polyethylene certificate), Dimensions: Sludge depth tt OY Distance from top of sludge to bottom of outlet tee or baffle:R Scum thickness: Q k u Distance from top of scum to top of outlet tee or baffler Distance from bonom of scum to bonom of outlet tee or baffle. How were dimensions determined: Q/i 5lTF Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity as elated to outlet invert, evidng nice of leaka e, etc.): e Cdllt J4 t kt/ /P / d !K /� }� 2r A/ liquid levels &f fFLE S -f- ��4A1/1 CoOt,/J C'0/�l Q/ //o•� LJ9�! GREASE TRAP: _(loca e on site plan) Depth below grade _ Material of construction _concrete _metal _fiberglass polyethylene _other (explain): vi6—L1 T Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bonom of scum to bonom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integriry, liquid levels as related to outlet invert, evidence of leakage, etc.): ' Page 8 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 7(f/ /,y/,y'%rf- 3 f Owner: Date of Inspection: 6-17 TIGHT or HOLDING TANK: It—ik must be um ed at time of inspection)(locate on site plan) pumped 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: �Sof present must be opened)(locate on site plan) Depth of liquid level above outlet invert: &'/5LO-Z / 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.): AC a 7 �1 PUMP CHAMBER: /(ro'te 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 I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: P 5 f— v' Owner: a!� Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: _ leaching chambers, number: leaching galleries, number: leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number: innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Ile' 9 P TA 7-70 --� /--/o n AI / G%2 -z- 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 or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: (locaM a bn 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 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE D SPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ,e 4/ 4F2 5'✓ Owner: ell 4�C> � Date of Inspection: 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. Titci� U D-3 d, 10 13-c , 3 a. 6 Face -o vv Page I 1 of"I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: S/ M rev ; j— / h a /,p ►-' __11161. 19"'Pc ��ty Owner: LLL 2je)-- Date of Inspection: SITE EXAM Slope — Q -- Surface water 7 4 o r Check cellar Shallow wells %S t feet Estimated depth to ground water Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record - If checked, date of design plan reviewed: S �` 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 F// 0 © 7 '/,,v A._.- 0 Y 0 71, tomo M /7— A14 Y H144'4f '1re/2.Svt A4,4 -4y '2 T-/ TL.t' _, C'ejM /�4- 1 ,9_, Gee 1IVU rf %O.4 •l -71-, Y I? I 29 RAGGS, INC., P. 0. Box 1027, CONCORD, MA 01742--"------J (978) 1742' "---- (978) 369-1100 OFFICIAL CERTIFICATION SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION IN ACCORDANCE WITH TITLE 5 (310 CMR 15.000) CERTIFICATION PREPARED FOR ADDRESS OF PROPERTY: DATE OF INSPECTION: RESULTS: Thomas and Mary Enright 781 Winter Street North Andover, MA 01845 December 8, 1997 This property has PASSED the criteria set X forth in 310 CMR 15.000. This property has CONDITIONALLY PASSED the criteria set forth in 310 CMR 15.000. This property has NEEDS FURTHER EVALUATION BY THE BOARD OF HEALTH according to the criteria set forth in 310 CMR 15.000. This property has FAILED the criteria set forth in 310 CMR 15.000. C C C I Q C RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (978)369-1100 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ADDRESS OF PROPERTY: 781 Winter Street North Andover, MA 01845 OWNER'S NAME: Thomas and Mary Enright DATE OF INSPECTION: December 8, 1997 PART A CERTIFICATION Name of Inspector: Richard S. Larsen - Certified Title 5 System Inspector Company Name: Raggs, Inc. Company Address: P. 0. Box 1027, Concord, MA 01742 Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported 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: X PASSES CONDITIONALLY PASSES NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY FAILS Inspector's Signature Richard S. Larsen - Certified Title 5 System Inspector 2 - is- 9 Date Raggs, Inc. certifies that all work performed on the aforementioned property was done in accordance with the guidelines set forth in Title 5 (310 CMR 15.303). Fred T. Fish, President Date Raggs Septic Service, Inc. d/b/a E. A. Comeau File No.: 97-16220/ENRIGHTTHO Copies to: Payer of inspection Local Board of Health or its agent E RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (978369-1100 a97-16220/ENRIGHTTHO SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM aINSPECTION SUMMARY 11 c 1 C 1 d C A. System passes: I have not found any information which indicates that the system violates any of the X failure criteria as defined in 310CMR 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, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. Septic tank is: Metal : Cracked: Structurally unsound: Substantial infiltration: Substantial exfiltration: Tank failure imminent: Tee(s) missing: The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to a broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with the approval of the Board of Health): Broken pipe(s) are replaced: Obstruction is removed: Distribution box is leveled or replaced: 2 C e I A D D D G RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (9781369-1100 97-16220/ENRIGHTTHO SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM INSPECTION SUMMARY continued 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 public health, safety, and the environment. 1. System will pass unless the Board of Health determines 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: C RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (978)369-1100 97-16220/ENRIGHTTHO SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM INSPECTION SUMMARY continued C 2. System will fail unless the Board of Health (and Public Water Supplier, if C appropriate) determines that the system is functioning in a manner that will protect public health, safety, and the environment. c w C D C' o 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 a soil absorption system and is within a Zone 1 of a public water supply well.: The system has a septic tank and a 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 that the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.: Method used to determine distance: 3. Other: (approximation not valid). RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (9781369-1100 97-16220/ENRIGHTTHO SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM INSPECTION SUMMARY continued aD. System Fails: You must indicate either "Yes" or "No" as to each of the following: have determined that the system violates one or more of the following failure criteria a as defined in 310CMR 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. D Backupof sewage into facility or stem component due to an overloaded or 9 Y Y p clogged SAS or cesspool.: Discharge or ponding of effluent to the surface of the ground or surface waters D 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 cesspool.: Liquid depth in cesspool is less than 6" below invert or available volume is less Cthan 1/2 day flow.: Required pumping more than four times in the last year NOT due to clogged or a 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.: a Any portion of a cesspool or privy is within 50 feet of a private water supply well.: a 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 a analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.: 0 5 C RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (978)369-1100 C97-16220/ENRIGHTTHO SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM INSPECTION SUMMARY continued C PE. Large System Fails: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria listed above: (� The design flow of the system is 10,000 gpd or greater (Large System) and the Li system is a significant threat to public health, 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: aThe 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 of Environmental Protection for I a additional information. C 1 D 8 C D RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (9781369-1100 97-16220/ENRIGHTTHO SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST The following have been done - You must indicate "Yes" or "No" as to each of the following: 1. Pumping information was requested of the owner, occupant, and Board of Health: yes 2. None 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: yes 3. As -built plans have been obtained and examined (Note if they were not available with n/a.): n/a 4. The facility or dwelling was inspected for signs of sewage back-up: yes 5. The site was inspected for signs of breakout: yes 6. All system components, excluding the SAS, have been located on the site: yes 7. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum: yes 8. The size and location of the SAS on the site has been determined based on: yes The facility owner (and occupants, if different from owner) were provided with information the proper maintenance of Sub -Surface Disposal System: yes Existing information (example Plan at Board of Health): yes Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.305(3)(b)] yes 7 RAGGS. INC.. P.O. BOX 1027. CONCORD. MA 01742 19781369-1100 97-16220/ENRIGHTTHO SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS Residential: design flow: No design plan available number of bedrooms: 3 number of current residents: 2 garbage grinder: no laundry connected to system: yes seasonal use: no Water meter readings, if available (last two (2) year usage: 1995- 95 c.f.; 1996- 69 c.f. 1997-219 c.f. private well: sump pump: no Last date of occupancy: current Commercial / Industrial: Type of Establishment: n/a design flow: gallons/day grease trap: industrial waste holding tank present: non -sanitary waste discharged to the Title 5 system: Water meter readings: Other: Last date of occupancy: Last date of occupancy: GENERAL INFORMATION Pumping records and source of information: homeowner System pumped as part of inspection: yes Volume pumped: 1000 Reason for pumping: inspection Tvpe of system - Septic tank/distribution box/soil absorption system: Yes Single cesspool: Overflow cesspool: Privy: Shared system: I/A Technology etc. (Copy of up to date contract?): Other: n C RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (9781369-1100 a97-16220/EN R I GHTTH O SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM a PART C SYSTEM INFORMATION continued Approximate age of all components: 19 years Date installed: not known Source of information: homeowner Sewage odors detected when arriving at the site: no BUILDING SEWER (locate on site plan) L -i Depth below grade: 6" Material of construction: Cast Iron: 40 PVC: X Other: Distance from private water supply well or suction line Diameter: 4" Comments.- Condition omments:Condition of joints: ok Venting: roof n Evidence of leakage: no CSEPTIC TANK (locate on site plan) -- yes Depth below grade: 6" Material of construction - E, If tank is metal list age: 40' approximately Concrete: X Metal: Fiberglass: Polyethylene: Other (explain): Is age confirmed by Certificate of Compliance: Dimensions: 5'X 5'X 8' CSludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle: 28" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 5" Distance from bottom of scum to bottom of outlet tee or baffle: 25" How dimensions were determined: tape measure Recommendation for pumping: annually Condition of inlet and outlet tees or baffles: in place . Depth of liquid level in relation to outlet invert: zero Structural integrity: o.k. Evidence of leakage: no C, Recommendation for repairs: none C 9 C 1 C I� C u 1 i III I RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (978)369-1100 97-16220/E N R I.G HTTHO SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION continued GREASE TRAP (locate on site plan) -- no Depth below grade: Material of construction - Concrete: Metal: Polyethylene: Other: 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: Recommendation for pumping: Fiberglass: Condition of inlet and outlet tees or baffles: Depth of liquid level in relation to outlet invert: Structural integrity: Evidence of leakage: Recommendation for repairs: TIGHT OR HOLDING TANK (locate on site plan) -- no Must be pumped prior to or at time of inspection Depth below grade: Material of construction - Dimensions: Concrete: Metal: Polyethylene: Other: Capacity: gallons Alarm level: Date of previous pumping: Condition of inlet tee: Condition of alarm and float switches: Recommendations: Fiberglass: Design flow: gallons/day Alarm in working order (Y/N): DISTRIBUTION BOX (locate on site plan) -- yes Depth of liquid level above outlet invert: zero Level and distribution are equal: yes Evidence of leakage into or out or box: no Recommendation for repairs: none Evidence of solids carryover: no 10 RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (978)369-1100 97-16220/ENRIGHTTHO SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION continued PUMP CHAMBER (locate on site plan) -- no F Pumps in working order: Alarms in working order: Condition of pump chamber: Condition of pumps and appurtenances: Recommendation for maintenance or repairs: SOIL ABSORPTION SYSTEM (SAS) -- yes (locate on site plan, if possible; excavation not required, but may be approximated by non - intrusive methods). n If not determined to be present, explain: U Type: Leaching pits and number: Leaching chambers and number: C Leaching galleries and number: Leaching trenches, number, length: Leaching fields, number, dimensions Overflow cesspool, number: Alternative system : Name of Technology: Condition of soil: rock/sand y y Level of ponding: no Recommendations for maintenance or repairs 5 trenches - approximately 30' long it D i Signs of hydraulic failures: no Condition of vegetation: normal, grass none El 11 .E. RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (978)369-1100 P97-16220/ENRIGHTTHO SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION continued CESSPOOLS (locate on site plan) -- no 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) Condition of soil: Signs of hydraulic failure: Level of ponding: Condition of vegetation: Recommendations for maintenance or repairs: a PRIVY(locate on site plan) -- no Materials of construction: �? Dimensions: L Depth of solids: Condition of soil: Signs of hydraulic failure: C Level of ponding: Condition of vegetation: Recommendations for maintenance or repairs: 12 RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (978)369-1100 97-16220/ENRIGHTTHO SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM * Include ties to at least two permanent references, landmarks or benchmarks * Locate all wells within 100 ft. Locate wnere pumic water supply comes into house 781 Winter St. DEPTH TO GROUNDWATER: 7+ feet A B Tank 21' 6" 20' D -Box 31' 6" 25' 0 13 RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (9781369-1100 97-16220/E N R IG HTTHO SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION continued Please indicate all the methods used to determine High Groundwater Elevations: Obtained from design plans on record: Observation of Site (Abutting property, observation hole, basement sump etc.): Determine it from local conditions: yes Check with local Board of Health: Check FEMA Maps: Check pumping records: yes Check local excavators, Installers: Use USGS Data: Describe in your own words how you established the High Groundwater Elevation. (Must be completed): Located distribution box 18" below grade. Drove probing bar down into ground approx. 7. Probing bar came up dry. House is located on top of a hill. 14 El RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (978)369-1100 97-16220/ENRIGHTTHO Ell APPENDIX A: HISTORICAL PUMPING RECORDS, REPAIR RECORDS 15 RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742(9781369-1100 E97-16220/ENRIGHTTHO D C C 0 c APPENDIX B: SITE PLAN / AS BUILT PLAN No as -built plan available 16 RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (978)369-1100 97-16220/EN R I G HTTHO APPENDIX C: LISTING SHEET No listing sheet available 17 RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (9781369-1100 97-16220/E N R I G HTTHO Appendix D: Water Usage Documentation 1995- 95 c.f.; 1996-69 c.f; 1997-219 c.f. Mandatory Records Found (Y/N Applications, plans, and specifications N Approved system capacity N Soil Evaluation Data N Disposal construction permits N Certified As -Built Plan N Construction Inspection reports N Certificate of Compliance N System Pumping Records Y Letters of Non -Compliance N Enforcement orders N Other Public Information Considered (Y/N FEMA Flood Maps N Soil Maps N Assessors Map Map Block Lot N USGS Topographical Map N Local Conservation Map N Builders Sketch Y RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (978)369-1100 97-16220/E N R IGHTTH O Appendix E: Recommendations: Pump annually 19. E"- - C w IN vjng fo �� Sime�C)� GG,1 General Maintenance Recommendations Proper maintenance of your septic system can help prevent premature failure of your soil absorption system. RAGGS, INC. recommends the following: DO make sure you know where your LEACHING FIELD is LOCATED. DO look for GREEN STRIPES over leaching field. DO check to determine if you can smell any ODORS from field location. DO bring your COVERS WITHIN 6" OF GRADE. DO USE LIQUID DETERGENT. DO USE NON-ABRASIVE HOUSEHOLD CLEANING PRODUCTS. DO USE ENVIRONMENTALLY SAFE PRODUCTS. DO INSTALL WATER SAVING DEVICES, where appropriate. DO USE SMALL AMOUNTS OF BLEACH when cleaning toilets, etc. DO AVOID having roof gutters and downspouts DRAIN ONTO the LEACHING FIELD. U RAGGS SEPTIC SERVICE, INC. n d.b.a. E.A. COMEAU SEPTIC LP.O. Box 1027 Concord, Massachusetts 01742 (508) 369-1100 (800) 287-5541 FAX (508) 897-3848 website: http://www.raggsinc.com e-mail: info@raggsinc.com DO PUMP your system ANNUALLY. DO OPEN your D -Box every THREE TO FOUR YEARS. DO ensure that your VENT PIPES are installed properly. DO make sure you know where your TANK is LOCATED. DO make sure you know where your LEACHING FIELD is LOCATED. DO look for GREEN STRIPES over leaching field. DO check to determine if you can smell any ODORS from field location. DO bring your COVERS WITHIN 6" OF GRADE. DO USE LIQUID DETERGENT. DO USE NON-ABRASIVE HOUSEHOLD CLEANING PRODUCTS. DO USE ENVIRONMENTALLY SAFE PRODUCTS. DO INSTALL WATER SAVING DEVICES, where appropriate. DO USE SMALL AMOUNTS OF BLEACH when cleaning toilets, etc. DO AVOID having roof gutters and downspouts DRAIN ONTO the LEACHING FIELD. U RAGGS SEPTIC SERVICE, INC. n d.b.a. E.A. COMEAU SEPTIC LP.O. Box 1027 Concord, Massachusetts 01742 (508) 369-1100 (800) 287-5541 FAX (508) 897-3848 website: http://www.raggsinc.com e-mail: info@raggsinc.com C i 11 0 C c C El C *46 �ouSimy��• GS,1 General Maintenance Recommendations (con'd) DON'T DISPOSE anything NON -BIODEGRADABLE IN TOILETS. (i.e.: cigarettes, sanitary napkins, diapers) DON'T wash paint brushes used in latex or oil PAINT. DON'T allow any PAINT, THINNERS, OR ANY OTHER TOXIC OR CAUSTIC LIQUIDS to go down sink or toilets. DON'T allow ANY GREASE or FAT to enter system. DON'T DISPOSE BONES, EGG SHELLS, COFFEE GROUNDS,OR FIBROUS MATERIAL, etc. when using a garbage disposal DON'T use powdered detergents with phosphates. DON'T use any DRAIN CLEANERS. DON'T use any ENZYMES. DON'T use any GREASE DISSOLVERS. DO NOT ADD ANY ADDITIVES TO YOUR SYSTEM FOR ANY REASON. In the event of a clog or other plumbing problem, contact your local plumber, rooter or pumper. DON'T PLANT any trees or shrubs WITHIN 10 FT. OF THE LEACHING FIELD. DON'T ALLOW SPRINKLER SYSTEMS or other WATERING DEVICES OVER THE LEACHING FIELD. DON'T DRIVE any VEHICLES or place any HEAVY OBJECTS ON TOP OF THE LEACHING FIELD. DON'T INSTALL a swimming pool, a patio, or a driveway over the tank or leaching field. DON'T CONNECT a basement sump pump to a household drain. RAGGS SEPTIC SERVICE, INC. d.b.a. E.A. COMEAU SEPTIC P.O. Box 1027 Concord, Massachusetts 01742 (508) 369-1100 (800) 287-5541 FAX (508) 897-3848 website: http://www.raggsinc.com e-mail: info@raggsinc.com NORTH ANDOVER BOARD OF HEALTH INSTALLATION CHECK LIST APPROVU DATE DISAPPROVED DATE tXCAVATION OK l SONS • AIL I OK 1. Di nee To: 77 Wetlands �510�l� Drains Well 2. Water Line Location 3. VC Pipe 4. S ;:is Tank Tees - Length & To Clean Out C Cement Pipe to Ta - On Bo' i o Tan 5. Distribution Box �-& Box - No Cracks to -if _ �. Lines o a�.ng qua unts --r�oB ckFlow 6. Leach Field or ench Dimensi St ons 2pth Ca.Updd Ends can Double Washed Stone 7. beach Pits Dimensions Stone Depth Splash Pads Tees Cement Pipe to Pit - Both Sides Clean Double Washed Stone .. No Gar'. -age Disposal 9. Final Grading Inspection 10�,B arracading Covered System Dimensions of System Location with Regard to Pere Test Elevations Water Table d SUiLrAC-E USPO�,At_.-T M 4F LOT X40, � W i NIi'ER S --r R E F - T t�ar-c �&,wrxnvF=P, , m A PR EPh.NZ -D F Oi- """"' VI O M A S Et --4 R N G HT 21 WELLS AVE E ORGFE "'CovtW ) m4 I G N GFt..mr+►� L G�L�rv+o.s Aivr� Assoc,<s.Z'��,. �r.,C,�rrc�Rs Arra (�Ftc�lrE.c_-rs Nc�a_-r►a A.rvt3c�v�R.C�Fc.i�� Pb�t..x.. NORTH A.rvObv�R SMA C}\$q�j r:. NIA /W -4 .Q i� CP 31 Tyyr p � � a � A � i— .► r a � v 10. r C� -4 .Q i� CP 31 Tyyr p i� iii i— .► �' C� Dvcj In z A 01 tl In z A 01 SIGN DATA 4 CAL0jLXTtOKs A Ao-"A I I 4 . A-ts SATURATION -MNS. D Ro-p DROP _T I! SSOIL PROlFtLE-Dv_ P PIT NO. 1 1 2- 34- TTIiT, Top- ELEVATION -TOFISOIL SUDSOIL PAPE NT Sail.' TO WATER -TABLE '-TILL WA-TETz WAXERIAsa ELEVATION ((.c, 4 150TTONA ELEVAMION 4 IK --CAL. JUNIT G040 rPD FLOW 606 _GPD Ftow x 1570%- I 900 _GPD USE GA L. S E PT %C_ -TANIK, LEAkc.v4iNev AREA _C) . 600 GrPO FLOW A ro-AL.= t 2(n SF IBEZ U 45 E 'S F _P Type My P.) I DF-vq AREA. D SF GPD Bo NN ARZA GALS./SF GPD T Lp TA PIT LEAc_"iNrqr rApAcjTy TAL P GPD PPIT GPD 1: Low _____GpD/PlT plis RF-Qo USE PITS _T'RF_WCHF_s. SIDEWALL A GALS I S r z JUA FT. IBOTTO AREA LF GALS / S IF -TO 71:(F -MCH LEACHING- CAPACITYT No -T E S U S 13 EZ)t 2S-' Y- 4 2 10 bm -,Sf= At, Copy to Public Works _ SUBSURFACE DISPOSAL SYSTEM CHECK LIST LaT"s NORTH ANDOVER BOARD OF HEALTH APPROVED DATE PROVIDED DISAPPROVED DATE TIME REASON - e Title 5 Reg. 2.5 Reg. 6 FailJOKI The submitted plan must show as a minumum: '(a) the lot to be served (area,dimensions,l,ot //,abutters) (Planning Board files) --(b) location and log of deep observation holes -distance to ties (16) location and results of percolation tests -distance to ties ­wc`C design calculations & calculations showing required leaching area {e)- location and dimensions of system (including reserve area) t(`f existing and proposed contours location of any wet areas within 100' of the sewage disposal system of disclaimer (check wetlands mapping) 101 --- surface and subsurface drains within 100' of sewage disposal system of disclaimer -} location of any drainage easements within 100' of sewage disposal system or disclaimer (planning board files) �--{ j -)--known sources of water supply within 200' of sewage disposal system or disclaimer - _(-k)-location of any proposed well to serve the lot (100' from leaching facility) -(1 'location of water lines on property (10' from leaching facilities) (m) location of benchmark )—driveways ­('6) P garbage disposers no PVC is to be used in construction -(q) a profile of the system (elevations of basement, plumberE pipe septic tank, distribution box inlets and outlets, distribution field piping and any other elevations) r) maximum ground water elevation in area of sewage disposal system —Fs-) plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such l plans, i Septic Tanks (a)"Capacities - 150% of flow, water table, tees, depth of tees, access, pumping„ (b) Cleanout (c) 10' from cellar wall or inground swimming pool (d) 25' from subsurface drains North Andover Subsurface disposal system check list - Page 2 . 0 Reg. 10.2 Reg-, 10.4 Reg.11.2 Reg.11.4 Reg -el 1 .1 C Reg.11 .11 Reg.15.1 Reg.15.1 Reg. 15.4 Reg. 15.8 Reg. 3.7 Reg.14.1 Reg. 14.3 Reg.14.4 14.5 _Reg.14.6 Reg.14.7 Reg.14.1C Reg. 9.1 Reg. 9.6 it OK Distribution Boxes (a Slope greater than 0.08 (b� Sump d- 601 , Q Leaching Pits Leaching pits are preferred where the installation is possible (a) Calculations of leaching area (minimum 500 S.F.) (b) Spacing (c) Surface drainage 2% (d) Cover material Leaching Fields (a)A2Greater than 20 minutes/inch �(b) Area (minimum 900 S.F.) (c) Construction of field (d) Surface drainage 2% (e) 20' from -cellar wall or inground swimming pool Leaching Trenches (a) Calculations of leaching area (min. 500 S.F.) MSpacing (4 ft. min. 6 ft. with reserve between) Dimensions (d) Construction (e) Stone (f) Surface drainage 2% Downhill Slope a) Slope y/x = (to be shown) b) y/x X 150 = (to be shown) Pum p (a) Approval (b) Stand-by power Town of North Andover. MA _ Watershed Septic System Servicing Report IAN 2 7 Date: 12-/g7 Homeowner: Thomas and Mary Enriaht Street :781 Winter Street Phone Nature of Service: Routine x� Emergency Pumper :RAGGS SEPTIC SERVICE INC Address: P.O. Box 1027 Phone : AZ8 3rgl 3C)9 Observations: Good Condition Full to Cover Baffles in Place Leachfield Runback Excessive Solids Heavy Grease Roots Other (Explain) Description of Work: Comments: Em Town of North Andover.2�A ;,4,,r, OFF,!ORTH Watershed Septic System �� ��-'` Servicing Report i 7 Date: 12/1/97 Homeowner: Robert Lubin Street : 141 Stonecleave Road Phone Nature of Service: Observations: Description of Work: Comments: Routine x Emergency __ Pumper : RAGGS SEPTIC SERVICE IC Address: p P.O. Box 1027 Phone :978-369-1100 Good Condition Full to Cover Baffles in Place Leachfield Runback Excessive Solids Heavy Grease Roots Other (Explain)