Loading...
HomeMy WebLinkAboutMiscellaneous - 793 SALEM STREET 4/30/2018 (2)r 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. tab MAA Commonwealth of Massachusetts 1 Title 5 Official Inspection Form �gNgf,'D Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 793 Salem St ' 40 Property Address Marty Dutton A' Owners Name North Andover Ma 01845 6/27/2017 City/rown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be al er in any way. Please see completeness checklist at the end of the form. /_ 1Q, A. General Information 1. Inspector: Dean Dvnan Name of Inspector Company Name 2 Suntaug Street Company Address Lynnfield City/Town 508-726-9935 Telephone Number B. Certification Ma State SI 12837 License Number 01940 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 pector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 e Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 793 Salem St Nroperty Address Marty Dutton Owner's Name North Andover Ma 01845 6/27/2017 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: ® 1 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: 3 bedroom single family dwelling with pipe in stone drainfield in working order B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old" or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. " A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 r Owner information is required for every page. t5ins • 3/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 793 Salem St Property Address Marty Dutton Owner's Name North Andover Cityrrown B. Certification (cont.) nna . wis 01845 Zip Code 6/27/2017 Date of Inspection ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ 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 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 793 Salem St Property Address Marty Dutton Owner's Name North Andover Citylrown B. Certification (cont.) Ma 01845 State Zip Code 6/27/2017 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 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 Y2 day flow t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 793 Salem St the system is within 400 feet of a surface drinking water supply Property Address ❑ Marty Dutton ❑ Owner Owner's Name information is the system is located in a nitrogen sensitive area (interim Wellhead Protection required for North Andover Ma 01845 6/27/2017 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or 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. ❑ ® 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 11 of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 3113 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 ;M 793 Salem St Property Address Marty Dutton Owner Owner's Name information is required for North Andover Ma 01845 every page. City/Town State Zip Code C. Checklist 6/27/2017 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): N/A t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 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 793 Salem St Property Address Marty Dutton Owner's Name North Andover Cityrrown D. System Information Description: 3 bedroom single familv dwell 01845 Zip Code 6/27/2017 Date of Inspection t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Number of current residents: 1 1�Does / residence have a garbage grinder? El Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): to() gpd ave Detail: see attached Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins - 3/13 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 Sewage Disposal System Form - Not for Voluntary Assessments 793 Salem St Property Address Marty Dutton Owner's Name North Andover City/Town D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: Ma 01845 6/27/2017 State Zip Code Date of Inspection Date General Information Was system pumped as part of the inspection? Homeowner / Board of Health / pumped last year ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ 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 - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17 Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 793 Salem St �M Property Address Marty Dutton Owner Owner's Name information is required for North Andover Ma 01845 every page. Cityrrown State Zip Code D. System Information (cont.) 6/27/2017 Date of Inspection Approximate age of all components, date installed (if known) and source of information: system installed 1980's when house built Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): 50" feet ❑ Yes ® No Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): building sewer in good condition no evidence of leakage / located under slab of walk out basement Septic Tank (locate on site plan): Depth below grade: Material of construction: 54" feet ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) 1500 concrete tank with center cover within 12" of grade / HD septic tank has concrete riser with cast iron cover If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 11'X5'10"X510" Sludge depth: 25 t5ins • 3/13 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 M 793 Salem St Owner information is required for every page. t5ins • 3/13 Property Address Marty Dutton Owner's Name North Andover City/Town State D. System Information (cont.) Septic Tank (cont.) 01845 Zip Code 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 29" 0" 6" 20" 6/27/2017 Date of Inspection How were dimensions determined? infield with measure stick and tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1500 gallon HD concrete septic tank with concrete inlet and outlet / Tank in working order with separation from inlet to outlet / no evidence of leakeage Liquid at bottom of outlet invert / no evidence of back up or riding high recommend pumping every two to three years depending on usage and number of occupants Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass 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: feet ❑ polyethylene ❑ other (explain): Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 793 Salem St Property Address Marty Dutton Owner Owner's Name information is required for North Andover Ma 01845 6/27/2017 every page. Cityrrown 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 ❑ 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 • 3/13 Title 5 Official Inspection Form: Subsurface 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 793 Salem St Property Address Marty Dutton Owner's Name North Andover Ma 01845 6/27/2017 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" above 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.): 20" x 20" Concrete box level with five outlet pipes / some evidence of solids carryover / no evidence of leakage into or out of box D Box in fair to good shape D Box is 42" below 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.): " If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 793 Salem St Property Address Marty Dutton Owner Owner's Name information is required for North Andover Ma 01845 6/27/2017 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields 1 20'X 45' 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.): drainfield found in green lawn area with slight slope so no to hold rain water / soils in good condition / no signs of hydraulic failure / no ponding/ no damp soild/ grass is uniform in good condition Drain field is a 20'X 45' pvc pipe in stone conventional system in working order 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 - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 793 Salem St Property Address Marty Dutton Owner's Name North Andover Ma 01845 6/27/2017 Citylrown 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.): l5ins • 3113 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 w� 793 Salem St 6/27/2017 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: t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Property Address Marty Dutton Owner Owner's Name information is required for North Andover Ma 01845 every page. Cityrrown State Zip Code 6/27/2017 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: t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 793 Salem St Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water* 01845 Zip Code 60"+ 6/27/2017 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: 1976 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: Plans on file dated 1981 for salem st @ 78" plans on file dated 1976 for lot 4 Summer st @ 69" Info from previous title five inspection showing transit points and calling edge of man made pond which seams plausible The only accurate way to determine high ground water is by performing a deep hole soil test on property with a licensed soil evaluator Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17 Property Address Marty Dutton Owner Owner's Name information is required for North Andover Ma every page. City/Town State D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water* 01845 Zip Code 60"+ 6/27/2017 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: 1976 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: Plans on file dated 1981 for salem st @ 78" plans on file dated 1976 for lot 4 Summer st @ 69" Info from previous title five inspection showing transit points and calling edge of man made pond which seams plausible The only accurate way to determine high ground water is by performing a deep hole soil test on property with a licensed soil evaluator Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 793 Salem St Property Address Marty Dutton Owner Owner's Name information is required for North Andover Ma 01845 every page. Cityrrown State Zip Code E. Report Completeness Checklist 6/27/2017 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 - 3/13 Title 5 Official Inspection Form:'Subsurface Sewage Disposal System - Page 17 of 17 0j'A Summary Record Card generated on 7/712017 10'01:19 AM by Karen Hanlon Page I Town of North Andover Tax Map # 210-065.0-0088-0000.0 Parcel Id 15312 793 SALEM STREET HARRIS, CLARK 793 SALEM STREET N. ANDOVER, MA 01845 Class 101 Single Family Property Type I Residential ZonIng2 1 Residential Zonlng3 I Residential Size Total 1.48 Acres FY 2017 ... ... . ............ ................ . ............... UB Mailing Index Narne[Address Type Loan Number Activelinact. From Until HARRIS, CLARK Payor 793 SALEM STREET N. ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Activellnactive Bldg Id. 16163.0 - 793 SALEM STREET Last Billing Date 416/201.7 3160209 03 Cycle 03 Active UB Services Maint. Account No. 3160209 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 11 WTR WATER 01 ALL METER SIZE 34,20 /1 UB Meter Maintenance .Account No. 3160209 Serial No Status Location Brand Type Size YTD Cons 32707591 a Active 00 b Badger w Water 0.630.63 1011 Date Reading Code Consumption Posted Date Variance 6/6/2017 1253 a Actual 11 13% 3/3/2017 1242 a Actual 9 4/12/2017 .14% 1216/2016 1233 a Actual 11 1/23/2017 -47% 9/6/2016 1222 a Actual 21 10/24/2016 36% 616/2016 1201 a Actual 16 81212016 -23% 3/3/2016 1185 a Actual 19 412212016 -23% 12/7/2015 1166 a Actual 27 1/20/2016 -11'/a 9/3/2015 1139 a Actual 29 10/16/2015 4% 6/4/2015 1110 a Actual 28 7/24/2015 56% 3/5=15 1082 a Actual 18 4/28/2015 -1% 12/4/2014 1064 a Actual 18 1/15/2015 -43% 9/5M14 1046 a Actual 32 10/1512014 12% 6/5/2014 1014 a Actual 28 7116/2014 24% 817/2014 986 a Actual 23 4/11/2014 12% 12/5/2013 963 a Actual 20 1/1712014 -52% 9/6/2013 943 a Actual 41 10/15/2013 79% 6/10/2013 902 0 Actual 25 7/24/2013 7% 3/6/2013 877 a Actual 22 4/22/2013 -31% 12/6/2012 855 a Actual 32 1/9/2013 -616/0 917/2012 823 a Actual 83 10/1512012 19% 6/7/2012 740 a Actual 69 7/16/2012 203% 3/8/2012 671 a Actual 23 4/14/2012 7% 1217/2011 648 a Actual 21 1/17/2012 -39% 9/8/2011 627 a Actual 36 10/13/2011 65% 616/2011 591 a Actual 22 7/2012011 -.5% 3/3/2011 569 a Actual 22 4/13/2011 12%, 1213/2010 547 a Actual 19 1112/2011 -66% 9/71201'0 528 a Actual 61 10/15/2010 73% 6/3/2010 467 a Actual 33 7115/2010 40% 0j'A j,0WT" 7967 • : Town of North Andover '+�'•�,; ; :: HEALTH DEPARTMENT sswCHU CHECK #: DATE: LOCATION: 7 9 H/O NAME: of 7�0 CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ xTitle 5 Report //9{}, SU $ SO-- ❑ Other: (Indicate) $ He t."gent Initials White - Applicant Yellow - Health Pink - Treasurer Commonwealth of Massachusetts�1 City/Town of No.Andover�'ii System Pumping Record TOWN OFNORTHANDOV12A Form 4 HEALTH DRPARTMRINT DEP has provided this form for use by local Boards of Health,.,,,Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. 6. System Pumped By: Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of HaI Signature of Re"ty t5form4.doc• 03/06 Date Date System Pumping Record • Page 1 of 1 A. Facility Information Important: When filling out forms the 1. System Location: computer, use 2 only the tab key Address to move your No.Andoye_ r Ma 018.45 cursor - do not use the return _ City/Town _ State Zip Code key. 2. System Owner: Name ,7 31 le, ff Address (if different from location City own State Zip Code Telephone Number B. Pumping Record ALJ 7 2,611 X D� 1. Date of Pumping Date Z Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes eo If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System Ljz5o (J-7 .--- 6. System Pumped By: Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of HaI Signature of Re"ty t5form4.doc• 03/06 Date Date System Pumping Record • Page 1 of 1 TOWN QF NORTH AN'DOVE, UA ll 8YSTF-M PUMPING} PECOR.0 SYSTSM OWNSR_& ADDRESS SYSTEM LOGS I JUN -C,,4 4/t- 7 2'moo, ������i � DATE OF _—QUANTITY PUMPED: k:t3SPOOL: NO Y.ggsoptic 1,"k: No Y Es.�, 'A rUKb OF 5L)tvIeE: RECEIVED E E ED 2005 ' A N V 0 3 0, H DOVER C OOOD CONDITION JUN U: :l TM T KRAVY ORBAH BAFYL33 IN PLACL, JUN 0 3 KcKm LWKneLD RUNBACK TOWN OF NOE�TH ANDOVER OXC6361VE SOLIDS FLOODED [HEALTH DEPARTMENT -SOLID CARA YOYU,* oll� L VUMIAENTS, .......... �-:uN rtwi's rKANsytmbo ru A 107 Forest St. Middleton, MA 01949 f506) 774-2772 %v25 y,5 �i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION s N ADDRESS OF PROPERTY- -7 93 m S�- e PROPERTY OWNER'S NAME: DATE OF INSPECTION: u 0 THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY + h PART A CHECKLIST Check if the following have..been done:. Pumping information was requested of the owner' occupant, and Board of Health.' ` _Z.None of the system'.'components have'�een' 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.: V As built•plans have been obtain d and examined. Note if they are not available with N/A. -owewe,- //aal 4 The facility or dwelling was inspected for;'signs.of sewage backrup. The site was inspected,.for signs of. breakout. All system comp'onents.,:,.excluding the'SAS, have been located on the site. The septic tank.manholes.were-uncovered, opened, and the interior.of the . septic tank. was inspected for.condition 'of 'baffles or tee*, material .of construction,,dimensions,.depth of liquid, depth of sludge, depth of "scum...., ...' The size and •location of �tYie: SAS on'.the site has been determined based on -existing information or approximated.by.nori-intrusive methods. The facility'owner•.(and occupants ,'if different from owner) were provided with information on the proper maintenance of SSDS. c CURRIER SEPTIC DRAIN, INC. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM' PART B SYSTEM INFORMATION FLOW CONDITIQNS• If residential " number of bedrooms number of current residents NO garbage grinder, yes or 'NLS laundry connected to s t� es r no. -hLo seasonal use, yes Or -2ys If nonresidential, calculated flow: Water meter readings, if available: Last date of Occupancy p cy GENERAL INFORMATION' Pumping records and source of information: /UU System p v Y Pumped as part of ins ectio , yes or ��• if yes, volume pumped Reason for pumping: `K 7-7- L _ . 0 7.26-96-,9 Typ�p, of system Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if<yes, attach previous inspection records, if'any) Other (explain) Approximate age of all components. Date installed, if known. information: Source of Fla P7 S.ewage odors detected when.'arriving at the g site, yes or no CURRIER SEPTIC & DRAIN , INC. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK (locate on site plan) depth below�jt� grade: material of construction: 702 5-y6x W1 ce" C 7s N,lf up t�, /�yf,ora 9raole /' w/ t� aS� Seel r+�,, 14OAe y concrete _,metal FRP other(explain) alar r�'i-c,eci.St�- dimensions: sludge depthle �•, distance from top of scum thickness sludge to -bottom of'outlet tee or baffle Ste'_ distance from distance from top of bottom scum to top of outlet tee or baffle of scum to bottom of outlet tee or baffle 1 Comments: (recommendation for pumping,.condition•of inlet and outlet tees or baffles, depth of liquid level,in relation to outlet invert, structural integrity, evidence of leakage recommendations for repairs, etc.) J. out-/ � �l�s arm �h ve�� �� S�•.�e. DISTRIBUTION BOX: yes Dept Selo w 9 r��/ t (locate on site plan) �e ro depth of liquid level above outlet invert comments: (note if level and distribution is e evidence of leakage into or out of boxalrecommendationevidence of sfordrepairs cars�vetc.) �5ou t- s u- pox IS 8 L7C 136x- l3 - -Vet �►�` ir e G� PUMP CHAMBER: (locate on site plan) umps in working order,.yes or no Comments: (note condition ofl1 chamber, condition ofu recommendations for main ce or re air p nd appurtenances, CURRIER SEPTIC & DRAIN. INC n SUBSIIRFACE'•SEWAQE DISPOSAL SYSTEM INSPECTION FORM PART. 8 SYSTEX-INFORMATION continued SOIL ABSORPTION SYSTEM (SAS): eS (locate on site plan, if possible; excavation,not required, but may be approximated by non--intruslve;methods) If not Peter-emined to be.present, expl in•; 0,n ei j 0 6 f y� �f'�29f�Ut(� lJrQL.�✓10 Type leaching pits and number' leaching chambers and number leaching galleries and number leaching trenche n n aen �thleace s n�ner,.dimens over ow cesspool,er Comments: (note ,condition of soil, .,signs of 'hydraulic�'failure, level of ondiri condition of vegetation,irecommendation,s or maintenance or repairs e, V 1 S Ih 0. n On - recommendation etc.) ne( Sa '�, CESSPOOLS (locate on' site• .plan): /UD number .and configuration dept of liquid to inlet invert depth o.f layer depth of scum .la dimensions of cesspoo Materials of construction indication of groundwater: inflow.(cesspool must be part oinspection) ed as f comments: (note cor condit� 'rtlon of soil. signs of. hydraulic.' failure, level o of vegetation, recommendations for•maintenance or reps PRIVY: UO (loCa a on site plan) materials of consdimensions depth of solids Comments: (note......ition of soil, ition"of vegetation, signs of.hydraulic failu recommendations for main •" level of ponding, 'c or :repairs, etc. ) �oz5 �s�a SUBSURFACE SEWAGE DI POSAL SYSTEM .INSPECTION FORM 'PART B SYSTEM INFO TION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: -- include ties to at least two permanent refes: landmarks or be locate all wells within 1001. - Gj. ,3t0 D= 6J)z 146 � rSlo / 793 Soder S+ ,� N• �9n�ove��l� E �strabcrfioK V -"PVC —• — �-- – fox _____4 -=DEPTH TO GROUNDWATER �CLI' s�7' depth to•groundwater• method of determin do or approxima ion:'. US � � Q �sr . lover- m W Tri CURRIER 'SEPTIC & 'nRATV TWO ZZs9,5'i4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE'CRITERIA Indicate yes, no, or not determined (Y, .N, or ND) Describe basis of determination in all instances. ,If. !'not..determiried!a,' explain why not) :/. Backup of sewage into facility? Discharge or ponding'of effluent to the surface of the round o surface waters? g r Af Static liquid level ,in the. distribution box above outlet invert. I" Liquid depth f low? in cesspool <61''below invert or.'ava-ilable volume< 1%2 day Required pumping 4 times or more number of times pumped in the last year? Septic tank is metel? cracked? structurally unsound? infiltration? substantial•exfiltration?.tank.failure substantial imminent? ^ ' Is any portion of the SAS, cesspool. -or privy:. _L below the high groundwateruelevat4on? c zl - 4 �.�sttn�t txL - D �ZOb within 50 feet of a surface water? wto feet of water a surface water supply.or.tributar terer supply? Y to a surface IL within a Zone -i of a public. well? IQ within'50 feet of a borderingvegetated (cesspools and g ated wetland or salt marsh privies only, not the SAS)? /v within 50 feet of a private water supply well? A/ less than 100 feet but greater than 50 feet from a private supply well with -no acceptable.water quality analyss? If thewellhas been anilyzed'to be acceptable, attach co for coliform bacteria, volatile organic compounds, ammoniaowellter nitranal ogens, and nitrate nitrogen. CURRIER SEPTIC &•DRATN_•TNr I�9.5.4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector Deae) G., "<e"Yco j6_z Company Name Ccsrr'�er 541 C;�;C ' �r'vlG2 Company. Address// lO? /J�,�Q/cv7 Certificatiori,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 and .any recommendations regarding upgrade, maintenance and repair are consistent with my training'and experience in the proper function and manitenance of on-site sewage disposal systems. Che one: have not found an information to adequately y which indicates that the system fails q y protect public health or the environment as defined.in 310 CMR 15.303. Any failure criteria -not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that -the system fails to protect public.health and the environment as defined' in 310 CMR, 1'5.•303. The basis forthis determination'is provided -in the FAILURE CRITERIA section of this form. Inspector's' Signature mac_ Date Original to system owner Copies to: �u,�h co�' A,6r�4 1Iholdojo,- Buyer (if applicable) Approving authority 9 CURRIER SEPTIC & DRAIN_ ITT(: