HomeMy WebLinkAboutMiscellaneous - 80 WINDKIST FARM ROAD 4/30/2018N
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CONDITIONS
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WAFER SUPPLY:
0.
WELL PERMIT
WELL TESTS:'
PLUMBING SIGNOFF
COMMENTS:
4TOW WELL
DRILLER
CHEMICAL DATE APPROVED
A I DATE APPROVED
BACTERIA II�DATE APPROVED
WIRING SIGNOFF
FORM U APPROVAL: APPROVAL TO ISSUE YES NO
r'
DATE ISSUED 71 �71 BY
CONDITIONS:
FINAL APPROVAL:
ALL PERMITS PAID YES NO
WELL CONSTRUCTION APPROVAL YES NO
SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO
OTHER YES NO
ANY VARIANCE NEEDED YES NO
FINAL BOARD OF HEALTH APPROVAL: DATE: BY:
MAP #
/
LOT #
PARCEL #
STREETQI'po
'
CONSTRUCTION APPROVAL
HAS PLAN
REVIEW
FEE BEEN PAID? YES
NO
PLAN APPROVAL:
DATE T ( 7 APP.
BY
DESIGNER:
G�/��l6Ti���E� PLAN
DATE
CONDITIONS
I
WAFER SUPPLY:
0.
WELL PERMIT
WELL TESTS:'
PLUMBING SIGNOFF
COMMENTS:
4TOW WELL
DRILLER
CHEMICAL DATE APPROVED
A I DATE APPROVED
BACTERIA II�DATE APPROVED
WIRING SIGNOFF
FORM U APPROVAL: APPROVAL TO ISSUE YES NO
r'
DATE ISSUED 71 �71 BY
CONDITIONS:
FINAL APPROVAL:
ALL PERMITS PAID YES NO
WELL CONSTRUCTION APPROVAL YES NO
SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO
OTHER YES NO
ANY VARIANCE NEEDED YES NO
FINAL BOARD OF HEALTH APPROVAL: DATE: BY:
• v �
SEPTIC SYSTEM INSTALLATION
Ar ti
IS THE INSTALLER LICENSED? NO
NO
TYPE OF CONSTRUCTION: NEW REPAIR
y
NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW CE % NO.,
CONDITIONS OF APPROVAL YES C ----NO 7
(FROM FORM U)
ISSUANCE OF DWC PERMIT YES NO
DWC PERMIT PAID?/
DWC PERMIT NO.
BEGIN INSPECTION YES., -f10:
EXCAVATION INSPECTION: NEEDED:
PASSED
BY
YES,/ NO
INSTALLER:
CONSTRUCTION INSPECTION: NEEDED:` C %�
AS BUILT PLAN SATISFACTORY: EYES:
r
APPROVAL TO BACKFILL: DATE: / BY
FINAL GRADING APPROVAL: DATE A�2/Z,
FINAL CONSTRUCTION APPROVAL: DATE: BY
/1j
NORTh
O 4L
p
SACHUSf
Town of North Andover, Massachusetts
BOARD OF HEALTH
Form No. 2
DESIGN APPROVAL FOR
SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
ApplicantTest No.
Site Location 1A"A--Qlt
Reference Plans and S
ENGIN
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
69
Fee Lo
CHAIRMAN, BOARD OF HEALTH
Site System Permit No.
TOWN OF NORTH ANDOVER
BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
DATE OF COMPLIANCE:
07/26/99
This is to certify that
the individual subsurface disposal system
constructed (X ) or repaired ( )
by
Christiansen & Sergi
at
Lot 13 Windkist Farm Road
has been installed in accordance with the provisions of Title V of the State Sanitary Code
and with the North Andover Board of Health regulations as described in the Design
Approval Site System Permit # 948 dated 07/07/97.
The Issuance of this certificate shall not be construed as a guarantee that the system will
function satisfactorily.
`
Board of Health Inspector
4T j . Nit, p�,,•,F.1 # 4!r --(9-n P lay-riotil it, ucT
A I.li*��� nITY O f f4 E 'S�+65U��� �lyo*,L.
SYS?EH , tT I s A ¢kora OF T-49 LaArt,0
A NO E 1,EVArnOJ OF Ti.4 & Grp ` T i Nel *YStrf
GaHP0Nkr1 Ty.
AS 0t1I LT PLAN
OF
su-BSU-RFACE DISPOSAL SYSTEM
LOCATED IN
I.In�LT14 4\►-1DovE 1V_ 1-�5
AS PREPARED R y�NOF
FOMAssgcti
G D 1. o ►J At" V I l.l.� E ►�Ev. C o 12 ; oDANIEL
oKORAVOS
DATE: -5— lc2- 99
TM I Oji No CIVIL 2
SCALE:
MERRIMACK ENGINEERING SERVICES, INC.
PROFESSIONAL ENGINEERS 0 LAND SURVEYORS • PLANNERS
60 PARK STREET • ANDOVER. MASSACHUSETTS 01810 or TEL (617) 475-3553. 373-5721
a
+'2-11-19,95 5 : _;aA11 FROM
TOWN OF NOM ANDOVER
SEWAGE DIMAL SYSTEM
INSTALLATION CERWIGA110N
1766 oodwApw hmby cot* that 60 Seww Dicposai System (�consiruciad: ( ) repaired:
by e ✓' Co ,v S a'-v�, f .9��,� Gc,
lomw ar __ I PT W i N Pk T_ F���.•i n n
was ipswitcd M cooYaatuacvc wa t0 North Andvvar Board of Htabh &Wovod pb la. Syaaam
ft.Woval dpip flow of
ism Aa 4y Tho alio aia ttaed w�a in co r cpcc mtk tltosc apeo�SaQ ca $0
pla; tboa sy#Am w L ios lW in acoo 4mca wi* the promwas of 3 l CMR 11,000. Tift S ad
boost rar4wo" ad dw flnat pd%a jroe* cub ttiatty wilt dna approrcd Plan, Ali work is
*414 M* ropros od on the AM� which het boort sabatitted to ias Board dHW&
Steller tic.,
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APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE: ' CURRENT INSTALLER'S LICENSE#_Z�9
LOCATION: Loi'
LICENSED INSTALLER:
SIGNATURE:
CHECK ONE:
I.. I. mo_ •-- �.
IF NEW CONSTU
Ri
$75.00 Fee Attached
Foundation As -Built'
Floor Plans?
Approval
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J11 ANDOVER/
OF 4, EALTH
:''R 2 6 M
FORM U - VERIFICATION FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out /this section*****************
APPLICANT: Lz G Phone I4 Z
LOCATION: Assessor's Map Number 20 5 Parcel
Subdivisionjs
// • Lot (s)
Street G�/Z�G� _5 %� St. Number eo
RECO ATIO S 0 TO AGENTS:
77
4t
Conservation Administrator
Comments
Planne
Comments
Food Inspector -Health
Septic Inspector -Health
Comments
Use Only************************
Date Approved
Data Rejected
Date Approved
Date Rejected
Date Approved
Date Rejected
Date Approved
Date Rejected
7
Public Works - sewer/water connections f FC -3
T-
- driveway permit
F ' re Department ,Le „�.c GIV46
�o
Received by Building Inspector
Date
FORM 11 - SOIL EVALUATOR FORM
Page 1 of 3
E
i
MAY 01997 'Date:
No.
Commonwealth of Mass-a-hQset
Massachusetts
.. ., r, _ ��_�.:�;�, a ccoc.cment or )n-sai�Se�waa�eD�isqsal
{ , i� i7
J
Date:r� � �� " � .
Performed By: //7. �/.��...... `h5i2sCe`(Y� .......... .
\\
Witnessed By: GG.'1'l�C.�........ ,
prrcr�s Name. L�U�G � � G1'I
—77
oatwn �/!l,C lt S a +/%tAaauz, am
Telephorc
-1Lt# s{"7 l'
w Construction Repair I - !7��'j��/. • /.c/ /t�[l(Fi�.�rl.•�hi1,,��:`4v1 n✓
Ql
Office Review Yes
Published Soil Survey Available: No ❑ �—
j : /S �p�0 Soil Map Unit
Year Published -
Publication Scale ...............
f. -
. ..............
......... I ..............................
. .
Drainage Class Well G�;�`�l.li�� Soil I,imltatlOnS
Surficial Geologic Report Available: No
Yes El
Publication Scale
.....................
Year Published
....................................................
Geologic Material (Map Unit)
Landform .............1, Y.L:tYVI .....1.....................
Flood Insurance Rate Map:
No �JYes
Above 500 year flood boundary' ' _
Within 500 year flood boundary No 2 Y es J
Within 100 year flood boundary No lames
Wetland .Area:
......................................
National Wetland Inventory Map (map unit ......................
Map (map unit)
......I ..................
Wetlands Conservancy Program
Current Water Resource Conditions (U
SGS): Month
Range :Above Normal []Normal ❑Bele,•/ Normal ❑
Other References Reviewed:
iiDEP APPROVED FOPUNI • 12/07!95
r 1
FORM 11 - SOIL FVALUATOR I,OKIN�f
Page ' of
Location Address or Lot No. , wt,t2�t
On-site Review
Deep
Hole Number 97..13 Date: Time: jv Weather
Location (identify on site plan) 7—F1.....,.
Land Use Slope M) Surface Stones
Vegetation
Landform
Position on landscape (sketch on the back)
Distances from:
Open Water Body feet _ Drainage way feet
Possible Wet Area feet Property Line feet
Drinking Water Well feet Other
DEP APPROVED FOR -At • 12107195
DEEP OBSERVATION
HOLE
_OG*
Sail Texture
(USDA)
Soil Color I
(Munsell) `(
Soil
Mottling I
Other
(Structure, Stones.G avlellrs, Consistency, °o
Depth from
Surface (Inched
I
Soil Horizon
a -1z
AF
3 -/off
C1
5-/6
•
E L
DepthtoBedrock:
E _
t76/tP� 7�y�
s
Weeping from Pit Face:
• �
Parent Material- (geologic)
Death to Groundwater:
Estimated Seasonal
LH r
Standing
High Ground Water:
:. C ri EVERY
Water in the Hole:
lf02
DEP APPROVED FOR -At • 12107195
FORM 11 - SOIL L` ALI .111 . \ F0101
Page 3 of 3
Location Address or Lot No.
IP /2
etermin-ation for Seasonal �ioh Water Tadle
Method Used:
Depth observed standing in observation hole . inches
Depth weeping from side of observation hole
inches
_Depth to soil mottles 41�2 inches
Ground water adjustment ............... feet
index Well Number Reading Date ................ Index well level
Adjustment factor Adjusted ground water leve!
Deoth of Naturally Occurring Pervious Material
Does at least four feet of naturally
the soil absorptionervious rial exist system? in all areas
observed throughout the area prop —7
If not, what is the depth of naturally occurring pervious material?
�ertiilC�tl'Jn
rmv
uato
examinatio
I certify that on Cdateonmentapprotection annd that the soil lthe above analysis
approved by the Department of �nvi
was aerformed by me consistent with the required training, expertise and experienc
described in 310 CMR 1 5.017.
Signature % Date
DEP APPROVED FORM - 1:!07195
a )
-FORIM 11 - SOIL EVALUATOR FORM
Page 2 of 3
Location Address or Lot No. � �J � �r nc� �� � Fpm &
On-site Review
3
p�
Deep Hole Number q ! -13 -Z Date: Time: 'I
Location (identify on site plan) TP
Land Use .. Slope M) Surface Stones
Vegetation
Landform
Position on landscape (sketch on the back)
Distances from:
Open Water Body feet Drainage way fee:
Possible Wet Area feet Property Line feet
Drinking Water Well feet Other
DEEP OBSERVATION HOLE _OG`
Weather
Other
(Structure, Stones, Boulders, Consistence, 40
Gravel)
• L H C rte CU r C t t H t
DepthtoBedrockc 'Z Z Z�
Parent Material- (geologic)
_ _ —
Depth to Groundwater: Standing Water in the Hole:
• Weeping from Pit Face:
estimated Seasonal High Ground Water:
DEP APPROVED FORM - 12107195
f e
Soil Texture
Soil lor
Munse
Soil
Mottling
Depth from
Surface (lnches)
Soil Horizon
I
SL•
Weather
Other
(Structure, Stones, Boulders, Consistence, 40
Gravel)
• L H C rte CU r C t t H t
DepthtoBedrockc 'Z Z Z�
Parent Material- (geologic)
_ _ —
Depth to Groundwater: Standing Water in the Hole:
• Weeping from Pit Face:
estimated Seasonal High Ground Water:
DEP APPROVED FORM - 12107195
/! _ 1L.
Location Address or Lot No. I3
i �i3 — 2 -
Determination
j' etermination for Se
Method Used:
FORA 11 - SUIi, L .�:.t : 1 vit rUlUvi
Pare ; of
ip,h. Water Fable
Depth observed standing in observation hole
I I Deptn weeping from side of observation hole
depth to soil mottles —1-J
inches
77
_Ground water adjustment .......... 1.1... feet
Index Well.Number ..............
Adjustment factor
Reading Date .................
inches
inches
Index well level
Adjusted around water level . .
De:.th of Naturalfv Occurring Pervious Material
Does at least four feet ofnaturallyrsedcfor the urrinsoil absorption ervious rial system? m all areas
observed throughout the areea pro
p
If not, what is the depth of naturally occurring pervious material?
-eriiil.^.atl'Jn
certify that on. �l/� (date) I have passed the soil evaluator examinatior
I ce t
approved by the Department of with nh e eQuedtraining, expertise and experaen i
was performed by me consistent
described in 310 CMR 13.017.
11/ -�'� Date
Signature
DEP APPROVED FORM - 12107195
Location Address or Lot No
FORM 12 - PERCOLATION TEST
COMMONWEALTH OF MASSACHUSETTS
A),�) nd�� "�� , Massachusetts
Percolation Test*
Date:Time:,L ..
Observation Hole #
Depth of Perc
.�.�
'714 ,
Start Pre-soak
End Pre-soak
a ; S�
Time at 12"
Time at 9"3.
U �-
Time at 6
Time (9"-6")
Rate Min./Inch
* Minimum of 1 oercoiation test must be perfor„iad in both the primary area AND
reserve area.
Site Passed Site Failed ❑
......................................................................................................................................_......._........
Performed By:
Witnessed By:
Comments: .
DEP APPROVED FORM - 12/07/95
o
X Commonwealth of -Massachusetts G��
1
Title 5 Official Inspection Form � `�°� �R
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ,P� P �N�
�0o
& 0�I
80 Windkist Farm Road
Property Address
Meg Rokos
Owner owner's Name
information is
required for every North Andover MA 01845 12/28/2016
page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important: When
filling out forms
on the computer,
use only the tab
key to move your
cursor - do not
use the return
key.
Q
A. General Information
Inspector:
Neil Bateson
Name of Inspector
Bateson Enterprises Inc.
Company Name
111 Arailla Road
Company Address
Andover
City/Town
978-475-4786
MA
State
SI -15
Telephone Number License Number
B. Certification
01810
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
12/28/2016
Inspasigna4ture 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 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.doc • rev. 6/16
( It?
Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17
J
Owner
information is
required for every
page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
80 Windkist Farm Road
Property Address
Meg Rokos
Owner's Name
North Andover MA 01845 12/28/2016
Cityrrown 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:
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.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17
Owner
information is
required for every
page.
t5ins.doc • rev. 6/16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
80 Windkist Farm Road
Property Address
Meg Rokos
Owner's Name
North Andover MA 01845 12/28/2016
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ 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
obstruction is removed
distribution box is leveled or replaced
❑ Y
❑ Y
❑ Y
❑ N
❑ N
❑ N
❑
❑
❑
ND (Explain below):
ND (Explain below):
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
80 Windkist Farm Road
Property Address
Meg Rokos
Owner's Name
North Andover MA 01845 12/28/2016
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or "No" to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y day flow
t5ins.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
80 Windkist Farm Road
Property Address
Meg Rokos
Owner Owner's Name
information is North Andover MA 01845 12/28/2016
required for every
page. Cityrrown 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 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.
t5ins.doc • rev. 6116 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
.•''r 80 Windkist Farm Road
MA 01845
State Zip Code
12/28/2016
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?
® ❑
Property Address
Meg Rokos
Owner
Owner's Name
information is
required for every
North Andover
page.
City/Town
C. Checklist
MA 01845
State Zip Code
12/28/2016
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): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440
t5ins.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
80 Windkist Farm Road
Property Address
Yes
❑
No
Meg Rokos
Yes
❑
No
Owner Owner's Name
Yes
❑
No
information is North Andover MA 01845 12/28/2016
required for every
page. Cityfrown State Zip Code Date of Inspection
D. System Information
Description:
3
Number of current residents:
Does residence have a garbage grinder?
® 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
Yes
Water meter readings, if available last 2 ears usage d
9 ( Y 9 (gP ))�
Detail:
Sump pump?
❑ Yes
®
No
Last date of occupancy:
Current
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?
Industrial waste holding tank present?
Non -sanitary waste discharged to the Title 5 system?
Water meter readings, if available:
❑
Yes
❑
No
❑
Yes
❑
No
❑
Yes
❑
No
t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
80 Windkist Farm Road
Property Address
Meg Rokos
Owner Owner's Name
information is North Andover MA 01845 12/28/2016
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection?
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
Date
Pumped last year, owner
1500
gallons
Measured tank
Inspect tank & tees
® Yes ❑ No
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.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17
Commonwealth of Massachusetts
UWn
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
80 Windkist Farm Road
Property Address
Meg Rokos
Owner Owner's Name
information is North Andover
required for every
page. Cityl-rown
D. System Information (cont.)
MA 01845
State Zip Code
12/28/2016
Date of Inspection
Approximate age of all components, date installed (if known) and source of information:
17 years old, 5/10/1999, as built plan
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):
❑ Yes ® No
2
feet
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
4" PVC through wall to septic tank, 3" PVC in house, no leaks visible.
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
® concrete ❑ metal
1
feet
❑ fiberglass ❑ polyethylene ❑ other (explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate)
Dimensions: 10'x 5'x 4'
Sludge depth:
2"
❑ Yes ❑ No
t5ins.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17
4 Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
r 80 Windkist Farm Road
Property Address
Meg Rokos
Owner Owner's Name
information is North Andover
required for every
page. Citylrown
D. System Information (cont.)
Septic Tank (cont.)
MA 01845
State 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
12/28/2016
Date of Inspection
29"
4"
811
11'1
How were dimensions determined? Tape measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. This is a
two compartment tank.
Grease Trap (locate on site plan):
Depth below grade: feet
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:
t5ins.doc • rev. 6116
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
80 Windkist Farm Road
MA 01845
State Zip Code
12/28/2016
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.doc - rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17
Property Address
Meg Rokos
Owner
Owner's Name
information is
North Andover
required for every
page.
Cityrrown
MA 01845
State Zip Code
12/28/2016
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.doc - rev. 6116 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
80 Windkist Farm Road
Property Address
Meg Rokos
Owner's Name
North Andover
City/Town
D. System Information (cont.)
MA 01845 12/28/2016
State Zip Code Date of Inspection
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D -box level & distribution equal. No evidence of leakage. Evidence of carryover, pumped d -
box to clean .D -box cover broken, replaced it.
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.doc - rev. 6116 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
80 Windkist Farm Road
Property Address
Meg Rokos
Owner Owner's Name
information is
required for every North Andover MA 01845 12/28/2016
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: 2 trenches 62'
long
❑
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.):
Soil ok. Vegetation ok. No sign of ponding to surface.
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.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
80 Windkist Farm Road
MA 01845
State Zip Code
12/28/2016
Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17
Property Address
Meg Rokos
Owner
Owner's Name
information is
required for every
North Andover
page.
Cityrrown
MA 01845
State Zip Code
12/28/2016
Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 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
80 Windkist Farm Road
Property Address
Meg Rokos
Owner's Name
North Andover
Cityrrown
D. System Information (cont.)
MA 01845 12/28/2016
State Zip Code Date of Inspection
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand -sketch in the area below
❑ drawing attached separately
Dor0
U
A
v
k )oau
a �
l�PT�tOtf
=-L10`3 11
.pP_z'( za5t3t�
t5ins.doc • rev. 6/16 Title 5 Official Inspection Forth: 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
80 Windkist Farm Road
v
Property Address
Meg Rokos
Owner
owner's Name
information is
required for every
North Andover
page.
Cityrrown
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
KAA n4OAr
12/28/2016
Date of Inspection
Estimated depth to high ground water: >4
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: 5/12/1997
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health - explain:
Design plan
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
As per design plan test pit data
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc • rev. 6/16 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
80 Windkist Farm Road
Property Address
Meg Rokos
Owner owner's Name
information is
required for every North Andover MA 01845
page. Cityrrown State Zip Code
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
12/28/2016
Date of Inspection
® 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.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17
Summary Record Card generated on 12/20/201612:19:22 PM by lara Huney rand 1
Town of North Andover
Tax Map # 210-109.0-0058-0000.0
Parcel Id 18875
80 WINDKIST FARM ROAD
ROKOS, PAUL E Since Jan 2003
MEG D ROKOS
80 WINDKIST FARM ROAD
NORTH ANDOVER, MA
01845
Class 101 _Single Family Property Type 1 Residential
Zoning2 1 Residential Zoning3 1 Residential
Size Total 1.12 Acres
FY 2017
UB Mailina Index
Name/Address
Type
Loan Number
Active/Inact. From
Until
PAUL ROKOS
Payor
80 WINDKIST FARM RD
NORTH ANDOVER, MA
01845
UB Account Maint.
Account No
Cycle
Occupant Name
Active/Inactive
Bldg Id. 13789.0 - 80 WINDKIST FARM ROAD
Last Billing Date 11/7/2016
1090466
01 Cycle 01
Active
UB Services Maint.
Account No. 1090466
Service Code
Rate
Charge
Multiplier/Users
MISCFEEADMIN FEE
1 1
9.18
1/
WTR WATER
01 ALL METER SIZE 592.15
/1
UB Meter Maintenance
Account No. 1090466
Serial No Status
Location
Brand
Type Size
YTD Cons
33050853 a Active
00
b Badger
w Water 1 1
1929
Date
Reading
Code
Consumption
Posted Date
Variance
10/19/2016
2418
a Actual
113
11/16/2016
23%
7/22/2016
2305
aActual
94
8/16/2016
161%
4/22/2016
2211
a Actual
36
5/25/2016
4%
1/22/2016
2175
aActual
35
2/19/2016
-68%
10/22/2015
2140
a Actual
106
11/20/2015
-1%
7/24/2015
2034
a Actual
105
8/14/2015
246%
4/27/2015
1929
a Actual
30
5/19/2015
-3%
1/30/2015
1899
aActual
35
2/20/2015
-52%
10/24/2014
1864
aActual
68
11/14/2014
-8%
7/25/2014
1796
a Actual
75
8/13/2014
122%
4/24/2014
1721
a Actual
32
5/15/2014
-16%
1/27/2014
1689
aActual
42
2/14/2014
-63%
10/23/2013
1647
aActual
108
11/18/2013
82%
7/23/2013
1539
a Actual
58
8/15/2013
55%
4/24/2013
1481
a Actual
37
5/20/2013
-7%
1/25/2013
1444
aActual
42
2/13/2013
-7%
10/23/2012
1402
aActual
44
11/9/2012
-1%
7/23/2012
1358
a Actual
44
8/14/2012
29%
4/23/2012
1314
a Actual
34
5/9/2012
-13%
1/23/2012
1280
aActual
39
2/13/2012
-73%
10/24/2011
1241
aActual
147
11/14/2011
209%
7/22/2011
1094
a Actual
46
8/15/2011
52%
4/22/2011
1048
a Actual
29
5%16/2011
-18%
1/25/2011
1019
aActual
39
2/11/2011
-62%
10/21/2010
980
aActual
97
11/12/2010
33%
7/22/2010
883
a Actual
73
8/16/2010
103%
4/22/2010
810
a Actual
36
5/12/2010
-25%
1/21/2010
774
aActual
48
2/12/2010
8%
Commonwealth of Massachusetts
City/Town of .
System Pumping- Record
Form 4
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 gh tont ofiRf
, Left/ Right rear of house, Left / right side of house, Left
Right side of builOing.,Left / Rig roilding, Left / Right rear of building, Under deck
Address +. ` EZ
citylrown i� state Zip Code
2. System Owner.
Name'
Address (if different from location)
Citylrown State• Zip Code ;
j Telephone Number;
s
B. Puimping
1. Date of Pumping
3. Type -of system: ❑
❑ Other (describe):
Date
2. Quantity Pumped:
Cesspools)ptic Tank
Gallons
❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes ®- o- , If yes, was it cleaned? ❑ Yes ❑ Na
5. Condition of System-
AkS AACtA- t-euA
6: System Pumped By.-
Nell
y:
Nell Bateson
Name
Bateson Enterprises Inc
Company
7. Locafi�•=where contents were disposed:
Waste Water
F5821
Vehicle License Number
t f 1
Date
t5form4.doc� 06/03 System Pumping Record • Page 1 of 1
NORTI
7764
p� �.�o •�,h0
Town of North Andover
> HEALTH DEPARTMENT
CMUst�
CHECK #: DATE:
LOCATION: 80 azli g&,ST /<V --/7L
H/O NAME: /1,q 60,&)s
CONTRACTOR NAME: &6Q-ss0J
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
$
l7
Sun tanning
$
❑
Swimming Pool
$
❑
Tobacco
$
❑
TrashlSolid Waste Hauler
$
❑
Well Construction
$
SEPTIC Systems:
❑ Septic - Soil Testing $
❑ Septic - Design Approval $
❑ Septic Disposal Works Construction (DWC) $
❑ Septic Disposal Works Installers (DWI) $
XTitle 5 Inspector $ -S0
❑ Title 5 Report $
❑ Other: (Indicate) $
G Healt `agent Initials
White - Applicant Yellow - Health ,Pink - Treasurer