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HomeMy WebLinkAboutMiscellaneous - 80 SUTTON HILL ROAD 4/30/2018 (2)TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: —1 —d TEM OWNER & ADDR �rD SYSTEM LOCATION (example: left front of house) DATE OF PUMPING:( QUANTITY PUMPED I Wo GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES ✓ NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: COMMENTS: FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) E! C A'. D OFF �LTH JUI 3 O 2001 CONTENTS TRANSFERRED TO: -� Commonwealth of Massachusetts City/Town of System Pumping Record to14 Form 4 TOWN ur NUKIH ANDOVER HEALTH DEPARTMENT 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. A. Facility Information 1. System Location: Left / Right front of Nous ft // ig ear of house Left / right side of house, Left / Right side of building, Left / Right front of bolding, Left Ig rear of building, Under deck Address c� 1 4) , n _ City/Town SCJ state (� Zip Code 2. System Owner. Name l Address (if different from location) Cityfrown t IC=Y Zip'"I e Telephone Number B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): /0`6 --Cl( — 2. Quantity Pumped eptic Tank Date Cesspool(s) 4. Effluent Tee Filter present? ❑ Yes LSO 5. Condition stem: ofK� 6. System Pumped By. Neil. Bateson Name Bateson Enterprises Ina Company 7. 1-050tion�%" contents were disposed: Waste Water Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ Na V..j-�.- 45��� F5821 Vehicle License Number Date t5form4.doa 06/03 System Pumping Record • Page 1 of 1 Dr. Pernokas 0 Sutton Hill Rd. APPLICATION FOR SEWAGE DISPOSAL INSTALLATION HEALTH DEPARM--NORTH ANDOVER, MASS. I hereby make application for a permit for a sewage disposal, installation at - � ��� .� _,�((Jf� • I will install this system in accordance with all the lavis of the Commonwealth of Massachusetts and regulations of the Board of Health of the Town of North Andover. Furthers, I will construct the house sewer of bell and spigot pipe't the minimum diameter being 4 inches.. and will maintain a minimum grade of 1% until 10 feet preceding the septic tanks, where the grade shall not exceed 2%. 1 will install a concrete septic tank of ..250 gal. _ in size. A manhole (s) permitting easy cleaning will be.provided with removable cover (s) of iron or concrete within 12 inches of the ground surface. I will provide subsurface disposal field with open jointed bell and spigot Ackron pipe at least 4 inches in diameter and laid in a series of trenches, the bottom of which will provide a minimum of 200 lineal )6MqVMj feet of effective absorption area. The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging in size from 3A to 1-•1/2 inches (dia.) and the pipes will be surrounded by similar material to a height of 2 inches above the crown of the pipe. The joints of these pipes will be protected from clogging and before filling the trench, 2 inches of gravel or stone 1/8" to 1/4" (dia.) will be placed over the course gravel or stone. The disposal field will be Installed at a grade of 4 to 6 inches/100 feet. No single tile line will exceed 100 feet in length and in any case.. two lines of tile will be installed. A minimum of 6 feet will be maintained between the center lines of the disposal field trenches and the average depth of trench shall not exceed 36 inches. No part of the in— stallation will be less than 1.00 feet from any private water supply., 25 feet from any streams, 20 feet from any dwelling or 10 feet from any property line. I further o (icer.. as provided belowt and to incorporate any additional, requirements that may be attached to the permit. Plot Flans must be submitted with application. DATE A tle is' C howl "SignqWe Applicant I hereby issue the above permit for the Board of Health of the Town of North Andover„ Massachusetts. DATE .. Siinature of Health Agent I have inspected the uncovered system indicated above and find everything done as described. DATE/� , ' % 1 ') Signature of nspecting Officer Percolation Test ,Bandy.: Clay Garbage Grinders S s BOARD OF HEALTH TOWN OF NORTH ANDOVER, MASS. 1 ZS 3t % S_v7ro w 41 L L Fes. _____---+ Fk-'CA-L / AKS5 , m 1. NAME 0,, ,` 1i1 F- , /� i� ; /-,�; E ;� c. (:� ? . . . . . . DATE. 2. ADDRESS * .d P v� .LOT N0. .TEL. . 3, N0, OF BEDROOMS . `.. . . . DEN YES NO. . 4. GARBAGE GRINDER YES N0. . . . 5. SHOW DIMENSIONS OF HOUSE b. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES J 7, SHOW DIlvENSIOIZ OF LOT $. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL 9, NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM 10. SHOW LOCATION OF BROOKS, STREAKS, DITCHES, LEDGE OUTCROP, ETC. 11, SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE NOTE: : LOCAL REGULAT IOINS SHOULD BE READ CAREFULLY. �Zo h ILA NO - .--� _ � "� • � 1 � ` r ' e y � � , � I „ � �.. 1 �. . .. l y December 13, 1958 Miss Mary Sheridan R. N. Health Agent Board of Health North Andover, Mass. Dear Miss Sheridan: An examination was made as requested in order to determine the suitability of the soil for the subsurface disposal of sewage on the proposed Sutton Hill Road building site of Dr. & Mrs. Arthur Pernokas. The subsoil in the area was of a sandy clay content. The land in general is high. A hole was dug, but there was some frost in the ground which made it difficult to obtain a true percolation test. A percolation test was made at this location last June by Charles Cyr, Civil Engineer, and his report is enclosed. The results obtained are in conformance with the type of soil at this location. It is recommended that a 750 gallon concrete septic tank be installed together with 200 lineal feet of drain pipe. ir;JD:hd Very truly yours, W William J. D iscoll TELEPHONE MURDOCK � 5-4824 8-5100 ._P 477 ESSEX STREET Brainerd & MacClaren Reservation Road. North Andover, Mass, Dear Sirs REG. PROF. ENGINEER REG. LAND SURVEYOR MEM. B. S. C. E. MEM. AM. CONC. INST. CHARLES E. CYR CIVIL ENGINEER AND SURVEYOR LAWRENCE, MASSACHUSETTS December 10, 1958 - Architects ATT s Mr. Archibald D. MacClaren As per your request, I conducted a percolation test at i,oio Sutton Hill Road, North Andover,, Mass, The results of this test indicate that 33 feet of 44 Bell and Spigot pipe sill be required in the disposal field for common use for each occupant, with a minimum total of 200 lineal feet. I recommend a 750 -gallon septic tank* If above by � garbage disposal unit is installed, increase the The distribution trench should have a minimum width Min 18 , a minimum of lo% of crushed stogie under the pipe and a minimum of 44 above the pipe, maximum pitch shall not be over 8"` per 100 lineal feet. The pitch of pipe should be reversdd in the last .fen feet in each trench. I recommend that this leaching bed be placed as high as is practicable in relation to finish grading so as to promote all possible aerobic activity, and also that the pipe be placed sa that it will be parallel to the contours of the finished grade. I further recommend that the laundry waste crater be disposed of through a separate system. Yours very truly, CHARLES E. CYR J HM tD BY: M X"M WATERSHED RESIDENTS QUESTIONNAIRE 1. Name !q er l)'zjt -r 2. Street Address �� /✓ ► �f C� 3. How many members are in your household? 4. What type of sewage disposal system do you have? ❑ cesspool R septic tank and leaching area ❑ connection to municipal sewer ❑ other (describe) ❑ do not know 5. Are the plans (drawings) for your sewage disposal system on file with the Board of Health? ❑ yes ❑ no X do not know'- •-<: _;4f 6. How old is your sewage disposal system? ❑ 0-5 years ❑ 6-10 years ❑ 11-20 years``_' over 20 years ❑ do not know 7. Has your sewage disposal system been rebuilt or repaired? ❑ yes X no ❑ do not know If yes, approximately how long ago? years. What was done? 8. How frequently is your sewage disposal system pumped out? ❑ annually ❑ every 2-4 years ❑ every 5-10 years over 10 years ❑ never 9. Have you had any problems with your sewage disposal system? ❑ yes ® no _ If yes, what problems? ❑ repeated pump -outs needed ❑ -system clogs, backs up, or drains slowly ❑ odors ❑ sewage surfaces through ground 10. How many of each appliance are connected to your sewage disposal system? washing machine '&/ dishwasher V, garbage disposal dehumidifier drain sump pump toilet V", roof/pavement drains shower/bathtub t! 11. Please state the brand and type (liquid or powder) of detergent you use for: dishwasher Sunt L 47- clotheswasher 11+ 5K --kQijj,h% DC– 12. Does your property have a lawn? 0 yes ❑ no If yes, approximately what size? ❑ less than 1/4 acre ❑ 1/4 acre ® 1/2 acre ❑ 3/4 acre ❑ 1 acre ❑ more than 1 acre (Specify) acres 13. How often do you fertilize your lawn? - No. of applications per year -3— * Season(s) 3— Season(s) of the year 6RQ%NS – 14. Please state the brand and type (liquid or granular) of lawn fertilizer you use: ❑ Check here if your lawn is maintained by a professional landscape contractor. ADDRESS ou DATE INSPECTED SEPTIC SYSTEM INSPECTION FORM stl f+6 vi i %`OJT PROPERLY FUNCTIONING? (�Y) N WEATHER CONDITIONS COMMENTS: WA', F -P, at; ALI Ty TES I C -v-) t,E,—,0 5 ? DYE TEST PERFORMED? Y N DATE? SKETCH: COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION OCT 2 5 2001 TITLE 5 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 80 Sutton Hill Road North Andover Owners -Name: Arthur Pernokas Owners Address: 80 Sutton $ill Road North Andover Date of Inspection: 8/14/01 Name of Inspector: Richard A. Briscoe Company Name: R. A. Briscoe. Inc. Mailing Address: 61 Garrison St. Groveland, MA 01834 Telephone Number: [9781372-2200 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. I am a DEP approved systems inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority ils , Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and, the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and conditions of use at that time. This inspection does not address how the systmi will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 Page 1 Page 2 of 12 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 80 Sutton Hill Road North Andover Owner: Arthur Pernokas Date of Inspection: 8/14/01 INSPECTION SUMMARY: Check A, B, C, D, or E / ALWAYS complete all of section D: A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One.or more system components as described in the "Conditional Pass" section needs to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no, or not determined (Y, N, or ND) in the for the following statements. If "not determined", please explain _The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and is a Certificate of Compliance indicating that the tank is less than 20 years old is avaliable. ND Explain: _Observation of sewage backup or breakout 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 the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ND Explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed ND Explain: Page 3 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: 80 Sutton Hill Road North Andover Arthur Pernokas 8/14/01 C. Further Evaluation is Required by the Board of Health:/j# _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1. System will pass unless the 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 protect the public health and safety and the environment: _ The system has a septic tank and.soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. _The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. _The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well", Method used to determine distance "This system passes if the well water analysis, performed at a DEP certified laboratory, for coloform 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 was triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: 80 Sutton Hill Road North Andover Arthur Pernokas 8/14/01 D. System failure criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: Yes No �C Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. �C Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. �c 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 the high groundwater elevation. -�C Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. �G Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water T` supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coloform 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.] Py (Yes/No) The system fails. I have determined that one or more of the above failure criteria exists as described in 310 CMR 15.303, there fore 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: 464 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 "yes" or "no" as to each of the following: (The following criteria apply to large systems in addition to the criteria above) ,The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public water supply well. If you have answered "yes",. to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Page 5 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Date of Inspection: 80 Sutton Hill Road North Andover Arthur Pernokas 8/14/01 Check if the following have been done: You must indicate either "yes" or "no" as to each of the following: Yes No K _ Pumping information was requested of the owner, occupant, and Board of Health. __�C Were any of the system components pumped out in the previous two weeks ? _ Has the system received normal flow in the previous two week period ? �C Have large volumes of water been introduced to the system recently or as part of this inspection ? x Were as built plans of the system obtained and examined? (If they were not available note a N/A Was the facility or dwelling inspected for signs of sewage back up ? Was the site inspected for signs of break out x_ Were all system components, excluding SAS, located on site ? _ Were the septic tank manholes were uncovered, opened, and the interior of the inspected for condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum ? x _ Was the facility owner (and occupants if different from the owner) provided with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes no 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) [15.302(3)(b)] 5 Page 6 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: Date of Inspection: 80 Sutton Hill Road North Andover Arthur Pernokas 8/14/01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): k14 Number of bedrooms (actual) DESIGN flow eased on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): Number of current residents: Z - Does residence have a garbage grinder (yes or no): 4-0 Is laundry on a separate sewage system) (yes or no):44 ; [If yes, separate inspection required] Laundry system inspected (yes or no):AV Seasonal use (yes or no): AO Water meter readings, if available (last 2 year's usage (gpd)): S'Cboo !t/l(, P -- fir Sump pump (yes or no): X1 2 2 n Last date of occupancy: OCC- v iced COMM ERCIAL/INDUSTRIAL: Type of establishment: Design flow based on 15.203): gpd Basis of design flow (seats/persons/sqft, etc.): Grease trap present: (yes or no) Industrial Waste Holding Tank present: (yes or no) Non -sanitary waste discharged to the Title 5 system: (yes or no) Water meter readings, if available: Last date of occupancy/use: OTHER: (Describe) GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of inspection: (yes or no): _Q If yes, volume pumped gallons - How was the quantity pump 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 copy of the current operation and maintenance contract (to be obtained from the system owner) Tight Tank Attach a copy of DEP Approval Other (describe): Approximate age of all components, date installed (if known) and source of Were sewage odors detected when arriving at the site: (yes or no) -Q0 6 Page 7 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: 80 Sutton Hill Road North Andover Arthur Pernokas 8/14/01 BUILDING SEWER: (Locate on site plan) Depth below grade: 3 - S— Material of construction: cast iron_ 40 PVC _ other (explain): Distance from private water supply well or suction line Comments (on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: , (locate onsite plan) Depth below grade: 3 Material of construction: Xconcrete _ metal _Fiberglass _ polyethylene _ other (explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance (yes/no): (attach a copy of certificate) Dimensions: 1606 ciu UO Sludge depth: ..3 Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: i Y 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 dimensions were determined: 121,2 52—' -"C Comments:(on pumping recommendations, fiet and outlet tee or baffle condition, structural integrity, evidence of leakage, etc.): bAtt�'W/ 4 GREASE TRAP: A10 (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _ Polyethylene _other (explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments:(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet ihvert, evidence of leakage, etc.): Page 8 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: 80 Sutton Hill Road North Andover Arthur Pernokas 8/14/01 TIGHT OR HOLDING TANK: U (Tank must be pumped at time of inspection)(locate on site plan) Depth below grade: .Material of construction: _concrete _metal _Fiberglass _ Polyethylene _other (explain): Dimensions: Capacity: gallons Design flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX:Y6 (if present, must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 Comments: (note if box is level and distribution to outlets is equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): PUMP CHAMBER: & (locate on site plan) Pumps in working order: (yes or no)._ Alarms in working order: (yes or no) _ Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Page 9 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: 80 Sutton Hill Road North Andover Arthur Pernokas 8/14/01 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: i leaching trenches, number, length: /—So leaching fields, number, dimensions: overflow cesspool, number: innovative/alternative system Type/name of technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) CESSPOOLS: VO (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 (yes or no): Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: /iQ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Page 10 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 80 Sutton Hill Road North Andover Owner: Arthur Pernokas Date of Inspection: 8/14/01 SKETCH OF SEWAGE DISPOSAL SYSTEM: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. V -L&-- 10 7,2 2• S— ir "1✓ — Q . f) , 73•S� Page 11 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells 80 Sutton Hill Road North Andover Arthur Pernokas 8/14/01 Estimated depth to groundwater ' � Feet Please indicate all the methods used to determine high groundwater elevation: Obtained from system design plans on record - If checked, date of design plan reviewed: Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Checked local excavators, installers- (attach documentation) Accessed USGS database -explain: You must describe how youa tablished the high ground water elevation: o /,e zSflt_-_ X 11 Page 12 of 12 R. A. BRISCOE, INC. 61 GARRISON ST. GROVELAND, MA 01834 TEL. (978) 372-2200 FAX (978) 372-2450 SEPTIC SYSTEMS: DESIGNED, BUILT, REPAIRED AND PUMPED Title V Inspections Title V Inspection Report Property Address: 80 Sutton Hill Road North Andover Owner: Arthur Pernokas Date of Inspection: 8/14/01 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. Q� R. A. Briscoe 12 . t COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 80 Sutton Hill Road North Andover, MA Owners Name: Arthur Pernokas Owners Address: P.O. Box 960 Atkinson, NH Date of Inspection: 04/09/04 Name of Inspector: Richard A. Briscoe Company Name: R. A. Briscoe, Inc. Mailing Address: 61 Garrison St. Groveland, MA 01834 Telephone Number: [9781372-2200 TC'V 4 OF NORTIA ANDC'.1—R/ BOA09D OF HE;1TH MAY 1 2 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. I am a DEP approved systems inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: Passes Conditionally Passes NiFurds ther Evaluation By the Local Approving Authority Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and, the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 Page 1 Page 2 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 80 Sutton Hill Road North Andover, MA Owner: Arthur Pernokas Date of Inspection: 04/09/04 INSPECTION SUMMARY: Check A, B, C, D, or E / ALWAYS complete all of section D: A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: /�14 One or more system components as described in the "Conditional Pass" section needs to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no, or not determined (Y, N, or ND) in the for the following statements. If "not determined", please explain The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and is a Certificate of Compliance indicating that the tank is less than 20 years old is avaliable. ND Explain: _Observation of sewage backup or breakout 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 the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ND Explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed ND Explain: 2 ` 'Page3of12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: 80 Sutton Hill Road North Andover, MA Arthur Pernokas 04/09/04 C. Further Evaluation is Required by the Board of Health: W _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1. System will pass unless the 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 protect the public health and safety and the environment: _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. _The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. _The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well", Method used to determine distance "This system passes if the well water analysis, performed at a DEP certified laboratory, for coloform 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 was triggered. A copy of the analysis must be attached to this form. 3. Other: Page .4 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: 80 Sutton Hill Road North Andover, MA Arthur Pernokas 04/09/04 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 an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. )i Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the SAS, 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. �C Any portion of a cesspool or privy is within 50 feet of a private water supply well. �C 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 coloform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] _NO (Yes/No) The system fails. I have determined that one or more of the above failure criteria exists as described in 310 CMR 15.303, there fore 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: V/9 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 "yes" or "no" as to each of the following: (The following criteria apply to large systems in addition to the criteria above) The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public water supply well. If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. ' Page.5 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Date of Inspection: 80 Sutton Hill Road North Andover, MA Arthur Pernokas 04/09/04 Check if the following have been done: You must indicate either "yes" or "no" as to each of the following: Yes No X _ Pumping information was requested of the owner, occupant, and Board of Health. Were any of the system components pumped out in the previous two weeks ? %K Has the system received normal flow in the previous two week period ? X 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 X _ Were all system components, excluding SAS, located on site ? _ Were the septic tank manholes were uncovered, opened, and the interior of the inspected for condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum ? --)L _ Was the facility owner (and occupants if different from the owner) provided with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes no X 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 6-tance is unacceptable) [15.302(3)(b)] 5 Page6 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: Date of Inspection: 80 Sutton Hill Road North Andover, MA Arthur Pernokas 04/09/04 FLOW CONDITIONS RESIDENTIAL ,c�ry Number of bedrooms (design):." Number of bedrooms (actual) � /I - e -e DESIGN flow based on 310 CM15.203 (for example: 110 gpd x # of bedrooms):41A Number of current residents: Does residence have a garbage grinder (yes or no): Is laundry on a separate sewage system) (yes or no): iVp[If yes, separate inspection required] Laundry system inspected (yes or no): MV Seasonal use (yes or no): IVO Water meter readings, if available (last 2 year's usage (gpd)): Z zo Oi'4v Sump pump (yes or no): A/O Last date of occupancy: `y (0 '-ro COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow based on 15.203): and Basis of design flow (seats/persons/sqft, etc.): Grease trap present: (yes or no) Industrial Waste Holding Tank present: (yes or no) Non -sanitary waste discharged to the Title 5 system: (yes or no) Water meter readings, if available: Last date of occupancy/use: OTHER: (Describe) GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of inspection: (yes or no): A/D If yes, volume pumped gallons - How was the quantity pump determined? Reason for pumping: TYPE OF SYSTEM X 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 copy of the current operation and maintenance contract (to be obtained from the system owner) Tight Tank Attach a copy of DEP Approval Other (describe): Approximate age of all components, date installed (if known) and source of information: S&A >67*eS Were sewage odors detected when arriving at the site: (yes or no) 6 Page.7 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: 80 Sutton Hill Road North Andover, MA Arthur Pernokas 04/09/04 BUILDING SEWER: (Locate on site plan) Depth below grade: 3 • S Material of construction: )c cast iron_ 40 PVC _ other (explain): Distance from private water supply well or suction line Comments (on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK:-S(locate on site plan) Depth below grade: 3 Material of construction: _Cconcrete _ metal _Fiberglass _ polyethylene _ other (explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance (yes/no): (attach a copy of certificate) Dimensions: Sludge depth: . y Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: -3 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 dimensions were determined: Comments:(on pumping recommendatiorig, inlet and outlet tee or baffle condition, structural integrity, evidence of leakage, etc.): , GREASE TRAP: AD(locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _ Polyethylene _other (explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments:(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): ' Page.8 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: 80 Sutton Hill Road North Andover, MA Arthur Pernokas 04/09/04 TIGHT OR HOLDING TANK: .40 (Tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _ Polyethylene _other (explain): Dimensions: Capacity: gallons Design flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: y6(if present, must be opened)(locate on site plan) Depth of liquid level above outlet invert: 4 Comments: (note if box is level and distribution to outlets is equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): / d 7`" �tG� PUMP CHAMBER: A0 (locate on site plan) Pumps in working order: (yes or no) _ Alarms in working order: (yes or no) _ Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): 8 Page 9 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: 80 Sutton Hill Road North Andover, MA Arthur Pernokas 04/09/04 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: 2 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.) IF 7 CESSPOOLS: A0 (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 (yes or no): Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: W (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Page,10 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: 80 Sutton Hill Road North Andover, MA Arthur Pernokas 04/09/04 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. 7`- 10 Page l I�of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells 80 Sutton Hill Road North Andover, MA Arthur Pernokas 04/09/04 Estimated depth to groundwater Y4 Feet Please indicate all the methods used to determine high groundwater elevation: Obtained from system design plans on record - If checked, date of design plan reviewed: Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Checked local excavators, installers- (attach documentation) Accessed USGS database -explain: You must describe how you established the high ground water elevation: it Page„12 of 12 R. A. BRISCOE, INC. 61 GARRISON ST. GROVELAND, MA 01834 TEL. (978) 372-2200 FAX (978) 372-2450 SEPTIC SYSTEMS: DESIGNED, BUILT, REPAIRED AND PUMPED Title V Inspections Title V Inspection Report Property Address: 80 Sutton Hill Road North Andover, MA Owner: Arthur Pernokas Date of Inspection: 04/09/04 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. e R. A. Briscoe 12 ,ge 10 of 12 ' OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 80 Sutton Hill Road North Andover Owner: Arthur Pernokas Date of Inspection: 8/14/01 SKETCH OF SEWAGE DISPOSAL SYSTEM: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 10 AC:. 272 9_(f r1,o �4�rJ= 72•S' COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 80 Sutton Hill Road North Andover, MA Owners Name: Arthur Pernokas Owners Address: P.O. Box 960 Atkinson, NH Date of Inspection: 04/09/04 Name of Inspector: Richard A. Briscoe Company Name: R. A. Briscoe, Inc. Mailing Address: 61 Garrison St. Groveland, MA 01834 Telephone Number: [978] 372-2200 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. I am a DEP approved systems inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: Passes Conditionally Passes N ds Further Evaluation By the Local Approving Authority Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and, the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 Page 1 Page 2 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 80 Sutton Hill Road North Andover, MA Owner: Arthur Pernokas Date of Inspection: 04/09/04 INSPECTION SUMMARY: Check A, B, C, D, or E / ALWAYS complete all of section D: A. System Passes: �I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: /�� One or more system components as described in the "Conditional Pass" section needs to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no, or not determined (Y, N, or ND) in the for the following statements. If "not determined", please explain The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and is a Certificate of Compliance indicating that the tank is less than 20 years old is avaliable. ND Explain: _Observation of sewage backup or breakout 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 the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ND Explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed ND Explain: Page 3 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: 80 Sutton Hill Road North Andover, MA Arthur Pernokas 04/09/04 C. Further Evaluation is Required by the Board of Health: /l/f% Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1. System will pass unless the 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 protect the public health and safety and the environment: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. _The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. _The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well", Method used to determine distance `*This system passes if the well water analysis, performed at a DEP certified laboratory, for coloform 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 was triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION (continued) Property Address Owner: Date of Inspection: 80 Sutton Hill Road North Andover, MA Arthur Pernokas 04/09/04 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 an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. i( Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the SAS, 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. x Any portion of a cesspool or privy is within a Zone I of a public well. �( Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for coloform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] NO (Yes/No) The system fails. I have determined that one or more of the above failure criteria exists as described in 310 CMR 15.303, there fore 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: /c//i 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 "yes" or "no" as to each of the following: (The following criteria apply to large systems in addition to the criteria above) The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public water supply well. If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Page 5 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B Property Address: Owner: Date of Inspection: 80 Sutton Hill Road North Andover, MA Arthur Pernokas 04/09/04 CHECKLIST Check if the following have been done: You must indicate either "yes" or "no" as to each of the following: Yes No X _ Pumping information was requested of the owner, occupant, and Board of Health. Were any of the system components pumped out in the previous two weeks ? Has the system received normal flow in the previous two week period ? LC Have large volumes of water been introduced to the system recently or as part of this inspection ? -X_ 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 ? �S Was the site inspected for signs of break out X _ Were all system components, excluding SAS, located on site ? _ Were the septic tank manholes were uncovered, opened, and the interior of the inspected for condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum ? - _ Was the facility owner (and occupants if different from the owner) provided with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes no X 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) [15.302(3)(b)] 5 Page 6 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: Date of Inspection: 80 Sutton Hill Road North Andover, MA Arthur Pernokas 04/09/04 FLOW CONDITIONS RESIDENTIAL �c�ry Number of bedrooms (design): �/Q Number of bedrooms (actual) �' /1e if DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms):4/h Number of current residents: Does residence have a garbage grinder (yes or no): '"O Is laundry on a separate sewage system) (yes or no): Np[If yes, separate inspection required] Laundry system inspected (yes or no): /Pv Seasonal use (yes or no): IVO Water meter readings, if available (last 2 year's usage (gpd)): 2 z o 01-,;•-0✓ Sump pump (yes or no): 440 Last date of occupancy: `y G Azo COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow based on 15.203): and Basis of design flow (seats/persons/sqft, etc.): Grease trap present: (yes or no) Industrial Waste Holding Tank present: (yes or no) Non -sanitary waste discharged to the Title 5 system: (yes or no) Water meter readings, if available: Last date of occupancy/use: OTHER: (Describe) GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of inspection: (yes or no): A10 If yes, volume pumped gallons - How was the quantity pump determined? Reason for pumping: TYPE OF SYSTEM X 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 copy of the current operation and maintenance contract (to be obtained from the system owner) Tight Tank Attach a copy of DEP Approval Other (describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site: (yes or no) SX4 IVcy*eS Page 7 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: 80 Sutton Hill Road North Andover, MA Arthur Pernokas 04/09/04 BUILDING SEWER: (Locate on site plan) Depth below grade: 3 * S Material of construction: )c cast iron_ 40 PVC _ other (explain): Distance from private water supply well or suction line Comments (on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK:-yC-,S(locate on site plan) Depth below grade: 3 Material of construction: _Cconcrete _ metal _Fiberglass _ polyethylene _ other (explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance (yes/no): (attach a copy of certificate) Dimensions: Sludge depth: Y Distance from top of sludge to bottom of outlet tee or baffle: �• y Scum thickness: -3 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 dimensions were determined:1-7 -,/- Comments:(on pumping recommendationf, inlet and outlet tee or baffle condition, structural integrity, evidence of leakage, etc.): / , GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _ Polyethylene _other (explain) Dimensions: Scum thickness.- Distance hickness:Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments:(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page 8 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: 80 Sutton Hill Road North Andover, MA Arthur Pernokas 04/09/04 TIGHT OR HOLDING TANK: 4.0 (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: imensions: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: y�(if present, must be opened)(locate on site plan) Depth of liquid level above outlet invert: 4 Comments: (note if box is level and distribution to outlets is equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): � Am S.cyS d 7"�" Goe PUMP CHAMBER: " (locate on site plan) Pumps in working order: (yes or no) _ Alarms in working order: (yes or no) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Page 9 of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: 80 Sutton Hill Road North Andover, MA Arthur Pernokas 04/09/04 SOIL ABSORPTION SYSTEM (SAS): %'S (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.) r ___ me 00A/V0_ CESSPOOLS: /W (cesspool must be pumped as part of ins pection)(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 (yes or no): _ Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: /14 _ (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Page 10 of 12 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: 80 Sutton Hill Road North Andover, MA Arthur Pernokas 04/09/04 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. SEF 4174 Ski +s.•c 7` mi Page I I of 12 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells 80 Sutton Hill Road North Andover, MA Arthur Pernokas 04/09/04 Estimated depth to groundwater y'f Feet Please indicate all the methods used to determine high groundwater elevation: Obtained from system design plans on record - If checked, date of design plan reviewed: Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Checked local excavators, installers- (attach documentation) Accessed USGS database -explain: You must describe how you established the high ground water elevation: " Page 12 of 12 R. A. BRISCOE, INC. 61 GARRISON ST. GROVELAND, MA 01834 TEL. (978) 372-2200 FAX (978) 372-2450 SEPTIC SYSTEMS: DESIGNED, BUILT, REPAIRED AND PUMPED Title V Inspections Title V Inspection Report Property Address: 80 Sutton Hill Road North Andover, MA Owner: Arthur Pernokas Date of Inspection: 04/09/04 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. R. A. Briscoe 12 .ge 10 of 12 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: 80 Sutton Hill Road North Andover Arthur Pernokas 8/14/01 SKETCH OF SEWAGE DISPOSAL SYSTEM: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 10 Commonwealth of Massachusetts City/Town of System Pumping Record MAY 20 6 Form 4 TOWN OF NORTH AV -OVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health.. The System umpinn RecoT be submitted to the local Board _of -Health or other approving authority. . A. Facility Information .Important: When filling out 1. System Locatio ' forms on the computer, use only the tab key Address to move your cD cursor - do not use the;retum Gityfrown State Zip Code key. 2. System Owner: must name `"1fA Address (if different from location) Cityrrown State /l W --Code Telephone Number B. Pumping Record J. Date of Pumping Date 2- Quantity' Pumped. Gallons .3. Type of system: ❑ Cesspool(s) eptic Tank_ ❑ Tight Tank ❑ Other (describe): 4: Effluent Tee Filter present? F1 Yeso If yes, was it cleaned?❑ N Yes ❑ o 5. Conditi n of System: 6. Syste P mla@d B :" F5�3—(. Name Vehicle License Number Company -- 7. Location here contents w disposed: Signatur of H ul r Date http://www.mass.gov/dep/water a rovals/t5formshtm#inspect t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of NO �4) k J(A) e V' System Pumping Record Facility Information: System Location: Address L 1 Keel City/Town State Zip Code System Owner: Name: Adress (if different from location of pump) City/Town State Zip Code q-79- &�b-5)qV Telephone Number Pumping Record Date of Pumping 2—�/ 7�6 Quantity Pumped__1401)_gallons Type of System--Y—Septic Tank Grease Trap Other (what) System Pumped by: M ff�) 6 Company: ROOTER -MAN 12 East Dracut Rd., Methuen, MA 01844 Location where contents were disposed: Signature of Hauler Datej-�"- 7