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Home My WebLink AboutMiscellaneous - 81 PADDOCK LANE 4/30/2018Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 Paddock Lane Property Address Richard & Doreen Swadel Owners Name North Andover Cityrrown MA 01845 State Zip Code 10/16/2015 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information RECEIVED 1. Inspector: OCT 2 6 2015410 Neil J. Bateson TOWN OF NORTH ANDOVER Name of Inspector HEALTH DEPARTMENT Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover MA 01810 City/Town State 978-475-4786 S115 Telephone Number B. Certification License Number 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: E Passes ❑ Conditionally Passes ❑ Fails ❑ Needs urther Evaluation by the Local Approving Authority 10/16/2015 Inspectors ignature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 Paddock Lane Property Address Richard & Doreen Swadel Owner's Name North Andover MA 01845 10/16/2015 Citylrown 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 Paddock Lane Property Address Richard & Doreen Swadel Owner's Name North Andover MA 01845 10/16/2015 City/Town 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins • 3113 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 81 Paddock Lane Property Address Richard & Doreen Swadel Owner's Name North Andover MA 01845 10/16/2015 Citylrown 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 % day flow t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. 1 have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone 11 of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �c 81 Paddock Lane Property Address Richard & Doreen Swadel Owner Owner's Name information is required for North Andover MA . 01845 10/16/2015 every page. C4rrown 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. 1 have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone 11 of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 Paddock Lane Property Address Richard & Doreen Swadel Owner's Name North Andover Cityrrown C. Checklist MA 01845 10/16/2015 State Zip Code 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): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): Cnn t5ins • 3113 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 81 Paddock Lane Property Address Richard & Doreen Swadel Owner Owner's Name information is required for North Andover MA 01845 10/16/2015 every page. CityrFown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): On well water 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? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins • 3113 Title 5 Official Inspection Fomc Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts ,p Title 5.Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 Paddock Lane Property Address Richard & Doreen Swadel Owner Owner's Name information is required for North Andover MA 01845 10/16/2015 every page. Cityrrown 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 - 3/13 1 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 Paddock Lane Property Address Richard & Doreen Swadel Owner owner's Name information is required for North Andover MA 01845 10/16/2015 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Tank & Trenches installed 11/11/1984, as built plan. D -box & outlet tee was replaced 4/16/2004, info at B.O.H. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 1.6 feet Material of construction: ❑ cast iron ❑ 40 PVC ❑ other (explain):. Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Finished cellar unable to see Dioina Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal S. 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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts 02 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 Paddock Lane Property Address Richard & Doreen Swadel Owner Owner's Name information is required for North Andover MA 01845 10/16/2015 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 31" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 14" 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.): Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. Inlet cover unable to di , under deck. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: t5ins • 3/13 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 81 Paddock Lane Property Address Richard & Doreen Swadel Owner information is required for every page. Owner's Name North Andover MA 01845 10/16/2015 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 Paddock Lane Property Address Richard & Doreen Swadel Owner Owner's Name information is required for North Andover MA 01845 10/16/2015 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 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, has flow levelers. No evidence of leakage. No evidence of Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 Paddock Lane Property Address Richard & Doreen Swadel Owner information is required for every page. t5ins - 3/13 Owner's Name North Andover City/Town State D. System Information (cont.) Type: 01845 Zip Code 10/16/2015 Date of Inspection ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2 trenches 64' 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 Tide 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title. 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 Paddock Lane Property Address Richard & Doreen Swadel Owner's Name North Andover MA 01845 10/16/2015 Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins - 3/13 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 81 Paddock Lane Property Address Richard & Doreen Swadel Owner's Name North Andover MA 01845 10/16/2015 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: �j hand -sketch in the area below ❑ drawing attached separately t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 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 81 Paddock Lane Property Address Richard & Doreen Swadel Owner's Name North Andover MA 01845 10/16/2015 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 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: 5/3/1980 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: Test pit data on design plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 3113 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 81 Paddock Lane Property Address Richard & Doreen Swadel Owner information is required for every page. Owner's Name North Andover MA 01845 10/16/2015 Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 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: Left /Right front of Nous , Right ear of house Left/ right side of house, Left/ Right side of building, Left / Right front of fiakring, Left / Rlg rear of building, Under deck Address UUC/f C'ityrrown State Zip Code Z. System Owner. Name Address (if different from location) Citylrown B. Pumping 1. Date of Pumping 3. Type of system: 4. a State � 6/rde Telephone Number f r Date 2. Quantity Pumped: Gallons ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other (describe): Effluent Tee Filter present? ❑ Yes to 5. Condition of System: 6: System Pumped By: Neil. Bateson Name Bateson Enterprises Inc Company 7. Location here contents -were disposed: Lowell Waste Water If yes, was it cleaned? ❑ Yes ❑ No F5821 Vehicle License Number 60- (b ---15- 41 Date t5form4.doo• 06/03 System Pumping Record • Page 1 of 1 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: /IF/ /��c70C/c� zj�/ Owner's Name: UlE 5T Owner's Address: Date of Inspection: 4- !S- o L/ Name of Inspector: (please print) Company Name: 3. -,-$v '42-r C -aft Mailing Address: Telephone Number: 37 2- 7,/x'i► / CERTIFICATION STATEMENT 1 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 Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature:4:�2eDate: f/ /.3'' G Cyt The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page l Page I of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: F1 /,) C -i< L /-/ f-1 14 1-112o v t v Owner: 7 - Date Date of Inspection: Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: /�,5 I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired: The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipes) are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed ND explain: m Page 3 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 'F/ Oc%f Owner: Date of Inspection: y- i 5- G 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(i)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 fi A, P'hge 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:/ /2� ars or i1 G Owner: Date of Inspection: 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 ''/s 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 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 coliform bacteria and volatile organic compomads 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.] _ (Yes/No) 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: j To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either "yes" or "no" to each of the following: (The following criteria apply to large systems in addition to the criteria above) 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 Il 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. 4 G Page 5 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B y' / CHECKLIST Property Address: (J / / ,d d0,% rf" L -1i Owner: 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 tf 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 ? _ /4 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: Yes no Existing information. For example, a plan at the Board of Health. _Ix 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(3)(b)] 5 �y E Page 6 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 'F/ /% lJ/70 niC L/✓ Owner: Date of Inspection: /- i Sy ✓ FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMS 15.203 (for example: 110 gpd x # of bedrooms): Number of current residents: _t Does residence have a garbage grinder (yes or no): S 12 P r C o wf Ki r t, TU /Z 10 M au -'f- Is cIs laundry on a separate sewage system (yes or no):/ -/u [if yes separate inspection required] Laundry system inspected (yes or no): _ Seasonal use: (yes or no): / / d Water meter readings, if available (last 2 years usage (gpd)): W c (t Sump pump (yes or no): h� 0 Last date of occupancy: cC e �,0/ P d COMMERCIALANDUSTRIAL Type of establishment: /-j #4 Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sgft,etc.): Grease trap present (yes or no): _ Industrial waste holding tank present (yes or no): _ Non -sanitary" waste discharged to the Title 5 system (yes or no): _ Water meter readings, if available: Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: / O - Z - U Was system pumped as part of the inspection (yes or no): y 5 If yes, volume pumped/ 5 o gallons -- How was quantity pumped determined? Reason for pumping: C 4 e < << 'S -;-/z "'_ T(-, 2 -f - 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) — Tight tank _ Attach a copy of the DEP approval — Other (describe): Approximate age of all components, date installed (if known) and source of information: �y `► ✓ Were sewage odors detected when arriving at the site (yes or no): � / u 6 Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: / / d dc> < ri = 6,A- I Owner: Date of Inspection: BUILDING SEWER (locate on site plan) Depth below grade: -3-4 Materials of construction: _cast iron �0 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 on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _ (attach a copy of certificate) . , Dimensions: //J G A Sludge depth: 4 Distance from top of sludge to bottom of outlet tee or baffle: �L Scum thickness: /' /41 Distance from top of scum to top of outlet tee or baffle: L ' v Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: O ,4 S i %•=` Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 6oUO C'6 Ho/i/*.tii GREASE TRAP: _(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.): J� Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: U TIGHT or HOLDING TAN'�'/ A (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:Vf S (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: ��yG 1 / 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.): AT�Arte/ 7- �3v�f,I ��,o,r F1 A 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 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: /) U O Gr (e L Owner: Date of Inspection: /.S— SOIL ABSORPTION SYSTEM (SAS): �l 4(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:,;? Gi d p 4 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: k' (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth — top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow (yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): r/. 4 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.): 9 Page 10 of 11 ' OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEMINFORMATION (continued) Property Address: / 1,6J aj o r i,- L / Owner: Date of Inspection: IV- / S' o 4/ 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. /1 10 7) U �- .i j �F►�G h/S �0 3 , .i j �F►�G h/S Page I l of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) , Property Address:{4 00 or �c Z_ i-/ Owner: Date of Inspection: 4/ — /S__ o SITE EXAM Slope /:/-,a 7 - Surface Surface water 20 k n n T s/ Check cellar y Shallow wells Estimated depth to ground water i feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record - If checked, date of design plan reviewed: �- Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Checked.with local excavators, installers- (attach documentation) Accessed USGS database -explain: You must describe how you established the high ground water elevation: 0 L G J i4r o- 13u a 5' 1-3 U S Town of North Andover Office of the Health Department Community Development and Services Division 27 Charles Street North Andover, Massachusetts 01845 Susan Y. Sawyer, RENS/RS 978.688.9540 - Phone Public Health Director 978.688.9542 - Fax TOWN OF. NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE DATE OF COMPLIANCE April 16, 2004 This is to certify that The Distribution Box repaired (X) by John DiVincenzo at 81 Paddock Lane North Andover, MA 01845 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. The Issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorilyi Susan Y. Sawyer, R S/RS Public Health Director BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE:CURRENT INSTALLER'S LICENSE#_ LOCATION: R I tipckd('f o G t< k Cc iut T YO NTCU" TXTC'TAT T VD. _ 1 M ) 1\` \r �n n _O Y1 T1 I - 1E# Commonwealth of Massachusetts Map -Block -Lot 107.D- 0102 - ------------------------ Board ------ --------- ----- Board Of Health Permit No North Andover BHP -20040345 P.1. FEE F.I. $250.00 ------------ Disposal Works Construction Permit Permission is hereby granted John DiVincenzo -------------------- --------- -------- ....-------------------------- ------- to (Repair) an Individual Sewage Disposal System. at No 81 PADDOCK LANE (� -- ---.......... -----------------------------------------------------------------------------------..- --- ---- . ... - .-..----- as shown on the application for Disposal Works Construction Permit No. BHP -2004-034 >W April 06,_ 2004 -------- -- ----------- Issued On: Apr -06-2004 ----------------- -------------------------- -----_..... --- - -- --- - .... ............ ............................... .................................................... ................................................ 6........................ 0.. Commonwealth of Massachusetts Map -Block -L 107. 02 - Board Of Health ------------ ------- North Andover Certificate of Com e THIS IS TO CERTIFY,That the Individ ewage Disposal System (Repair) by... John DiVincenzo ---- ---- ------ - - - - - - -_.._ ..__ Installer at No 81 PADDOCK hasbeen installe ' accordance with the provisions of TITLE 5 of the State Environmental Code as described in the applicati r Disposal Works Construction Permit No. ..BHP -2-004---034 -_ Dated ... Apri106,_2004------- ------------- I ---------------------- ---------------------- rinted On: Apr -06-2004 Board Of Health ------------------------------------------------- ........................................................................................ �1 O d e o A b ti C) 9 ebo A b 0 w a ti b w. r `A N 3 N �• A Z O O w o C7 N r bd G� b rA 0-4 N m r ° 3 A G1 O O O o O --4 Ln K m z h d e b b d ro N wi <D F CD ° b gay = c = P'! o N O !r • n N w w 0 000 O �1 u0• cn s C O• /A m B "A C"D C .•. O °wwy CD O a X a ZT' WJ eO,ti`L bA M bIn. 00 d N o a o x x o 0 C) v a x CD O O00 o N OO Board of Health ' North FAn OK SEPTIC SISTEK INSTALLATICK CHECK LIST __XCAVATIICN Ob FAIL 1. Distance Tot a. Wetlands b. Drains c Well 2, Water Line Location 3. No PPC Pipe 4. Septic Tank - a. _Tess -_Length & To Clean Out Covers. b. Cement Pipe to Tank on Doth Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Lines Flowing Equal Amounts c. No Back Flow 6. Leach Field or Trench a. Dimensions b. Stone Depth c: Capped Inds d. Clean Double -Washed Stone' 7. Leach Pits a. Dimensions b. Stone Depth c. Splash Pads d. Tees e. Cunt Pipe to Pit - Both Sides f. Clean Double Washed Stone 8. No Garbage Disposal 9. -Final Graffi Inspection 10. Barricading Covered System 11. As Built Submitted ` a. Lot Location b. Dimensions of System c. Location with Regard -to Pere Test d. Elevations e: Water Table :ard of Health )r MaBs Lndovc r i APPROM DATE Provided: `/3/ Title V FAIL CK . Reg 2.5 SUBSOFACE DISPOSAL DESIGN CHECK LIST -LOT 7 P4 PP Zf �n. DISAPPROVED Reasons: �3 DATE .he submitted plan must show as a MiniMUM: the lot to be served -area, dimensions lot #J abutters location and log deep observation hoes -distance to ties location and results percolation tests -distance to ties design calculations & calculations showing require area _ g area j) location and dimensions of sgs g P) existing and proposed contours location any vet areas -Athin 1001 of sewage disposal system or disclaimer -check wetlands mapping lsurface and subsurface drains within 3.001 of sewage disposal system or discizimer L) location any drainage easements within 100' of swage disposal. / system or disclaimer -Planning Board files kno= sources of -cater supply within 2001 of sewage disposal e system or disclaim' fir)' -Location --of -arT }).roposed wel _ veto serlot-1001 leaching fac, Lylocation of water lines on property -101 from leaching facili�— tion of benchmark driveu,-ays garbage disposals _ p) no PVC to be, used in construction tic tan 4) profile of -system-elevations of basement, plunb, pipe., a ep distribution box -inlets and -outlets, distribution field piping an 0tLer elevations 0"mayS =m ground water elevation in area sez7age disposal system s) plan wast be prepared by a Professional Ehgineer or other professional authorized by lair to prepare such plans ,,- Septic Tani s a) capacities -150%" of flog, inter. table, tees, depth of tees, access, pu.'ping b) cleanout .c) 10' from cellar wall or i.n groun d �--ng Pool d) 25+ from subsurface drains Reg 10.2 I Distribution Duxes �) slope greater than 0.08 Reg 10.4 ( b) mimp -LAwENo. �r vT' D.-/ lw7 - 8 1' ulci1*7 8ub6urfece Design Check List Page 2 - — -FAIL :_-----.--- j Reg 11.2 11.4 11.10 11,.11 f Reg 15.1 15.4 15.8 t 3•7 r Reg 1.4.1 14.3 14.6 j 14.4je) I 14•7 14.10 r + !K Leaching Pits Leaching pits are preferred where the installation is possible a) calculations of leas g area -id nimrin 540 sq ft b) spacing c) aurfa a 2% d) cover ma al e I'x2 ' splash pad fI to t elbow g) bends in pipe from d -box to pipe Leaching_Fields a) no greater than 20 utes/inch b) area -minimum aq ft c construc of field d) surf drainage 2 % e) 2 from cellar va7.1 or inground swimming pool Leaching Trenches - calculatIons of leaching area -man 500 sq ft spacing -4 ft min 6 ft with reserve between dimensions construction stone surface drainage 2% Downhill S122e slope y x = to be shown) b) y/x x 150 = (to be shown) _ Pins ..Reg 9.1 j 9.6 Power ,< ,o T'rPE Com ozl IT.SS. September 12 l0 84 RC ARD OF 0 M: DE—SIGN, =NC—IN—ER Re: Soil IDSOrption Se-wace Disposal Sl7stem This is to certify that I have reviewed the co-..str;�ction ; ,aterials of said disposal system at Lot 7.A,Paddock Lane Site Location North zndover, ?Mess. The Grades and construction ;,.ateria��cifiea in my plans and '; specifications dated May 29 ��84wi`�,n�', , p� �A _ s'. wilt September 11 1984 � civic "4!' No.. 31012 ,� Reg. Prof `'Xi; TV,,� g . Sani tarian Q atz F isuTL,&.Klt-2 9 k! Olt Lo -r -7 A IlAvO _Ai n0& �JEdi.lU� 13.14.. �X'�t-►►.IG w�u..-p a �' Imy PIVIE---- To t 7y 34 174,.2 E 0 UTCOFT 17� i 7 N o m 1?2. q9 172 • 9,-2 d 1-72 • So 172.7 WAXES EL AvE IZ A 4 E pFr-rH C-0-P'2AE+�C� DCStGN I Liv Dtflst! ouT mr- As Imy PIVIE---- To t 7y 34 174,.2 E 0 UTCOFT 17� i 7 N o m 1?2. q9 172 • 9,-2 d 1-72 • So 172.7 WAXES EL AvE IZ A 4 E pFr-rH C-0-P'2AE+�C� ;Z.) %J I L. S VES- S U GL-y-^,C,E D t S P'05At_.. 5Y5T eM . ttJ 00- AQ VOV5V K44, SAM V�A_ GATA 40' D,o�r E ;P'C 11 y t��1r• 2tc►-+o�.v .F tC..�./..t i N S�.t b►.iv pSSOGta�cE�=►.ic. Et.►Glt�lt_E�.S� di''C►-ttTE�TS, LL�.t�iT7 PLdt.ItJE;2.S�QND 51,�2..ti/E.YOIi✓-S NdeTN dlJvov�.rz dot=tcE PQtizt�. NOfz.TN_t3.ND0�/Ef��1V1Q. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. VQ ISI Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 RECEIV DEC 0 3 2007 AN 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, Address 9 r 2. System Owner. Name Address (if different from location) City/Town State Tip Code Stir Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes [-No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition o�m: 6. System P�,4lmpeday: / /� F Name nen VehiGe License Number Company 7. Location " %..— — '-.1 - Date t5form4.doc- 06/03 System Pumping Record - Page 1 or 1 Commonwealth of Massachusetts City/Town of -- -- System Pumping Record Form 4 1 nF.r; 2010 DEP has provided this form for use by local Boards of Health. %f®p%Wp)pq@p but the information must be substantially the same as that provided h re#�AtWLA iMENb check with your local Board of Health to determine the form they use. The Sys m umping ecord must be submitted to the local Board of Health or other approving authority. A. Facility Information �-�� 1. Syst : Left front of house, right front of house, left side of house, right side of housc,Zeft�?.� ar of house, r' t rear of house, left side of building, right rear of building, under deck. CityTrown State Zip Code 2. System Owner: Name Address (if different from location) City/Town Stat ed ode Telephone Number B. Pumping Record 1. 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? ❑ Yes L;3 - If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System:A_j�� WA-) �- 6. System Pumped By: Neil J. Bateson Name Bateson Enterprises Inc. Company 7. Locere contents were disposed: L.S. F5821 Vehicle License Number Date . t5form4.doc• 06/03 System Pumping Record • Page 1 of 1