HomeMy WebLinkAboutMiscellaneous - 82 LIBERTY STREET 4/30/2018 (2).,BOARD OF HEALTH
No.Andover, Nass.
SUBSURFACE DISPOSAL DESIGN CHECK LIST
LOT
(J( -U, GGrA i JO,A/(;o/:My PtAoJ — —
APPROPED - DATE/�., �(��
provided:
DISAPPROVED DATE
Reasons:
IzfVlS ropi
Title V
FAIL
CK
-
Reg 2.5
1
I
The submitted plan must show as a minimum: _
a) the lot to be served-area,dimensions lot #,abutters
b location and log deep observationtion teststiers
c location and results perco
d design calculations & calculations showing required leaching area
(e) location and dimensions of system -including reserve area
f) existing and proposed contours
(g) location any wet areas within 100' of sewage disposal system or.-_--
disclaimer-check wetlands mapping
(h) surface and subsurface drains within 100' of sewage disposal
system or disclaimer
(i) location any drainage easements within 1001 of sewage disposal
system or disclaimer -Planning Board files
known sources of water supply within 2001 of sewage disposal d _
1(j)
system or disclaimer
(k) location of any proposed well to serve lot -1001 from leaching facility
(1) location of water lines on property -101 from leaching facility
(m) location of benchmark
(n) driveways
(o) garbage disposals
(p) no PVC to be used in construction
(q) profile of system -elevations of basement, plumb, pipe, septic tank,
distribution box inlets and outlets, distribution field piping and
Other elevations
(r) maximum groundwater elevation in area sewage disposal system
(s) plan must be prepared by a Professional Ragineer or other
professional authorized by law to prepare such plans
Reg 6
Septic Tanks
(a) capacities -150,% of flow, water table, tees, depth of tees,
access, pumping
(b) cleanout
(c) lot from cellar wall or inground swimming pool
(d) 25+ from subsurface drains -
Reg 10.2Distribution Boxes
(a) slope greater 0.08
Reg 10.4 b) sump
Leaching ftmches
Reg 3.4.1 a) c ons of leaching area -min 500 sq ft
14.3 b) spacing -4 ft min 6 -Vith reserve between
14.4 c) dimensions
14.6 d) construc
14.7 1 e) ston
14.10 f) ace drainage 2%
Downhill S10 e
slope y x �to be shown)
y/x X 150 - (to be shoran)
Pu res
Reg 9.1 a) approval.
9.6 jb) stand-by power
Reg 11.2
31.4
11.10
11.11
Reg 15.1
15.4
15.8
3.7
Leaching Pits • '
Leaching pits are preferred where the installation is possible
a) calculations of leaching area -minimum 500 eq ft
b) spacing -
c surface drainage 2;6
d� cover m4teAal
e) Z1x2' a splash pad
f) at elbow "
no bends in pipe from d -box to pipe
Leachin Fields
a_ no greater than 20 minutes/inch
area-mi.ni.mmm 900 sq ft
) construction of field
) surface drainage 2
e) 20' from cellar va11 or inground swimming pool
Leaching ftmches
Reg 3.4.1 a) c ons of leaching area -min 500 sq ft
14.3 b) spacing -4 ft min 6 -Vith reserve between
14.4 c) dimensions
14.6 d) construc
14.7 1 e) ston
14.10 f) ace drainage 2%
Downhill S10 e
slope y x �to be shown)
y/x X 150 - (to be shoran)
Pu res
Reg 9.1 a) approval.
9.6 jb) stand-by power
f
TOWN OF NORTH ANDOVER, MASSACHUSETTS
OFFICE OF
CONSERVATION COMMISSION
f NORTH 1
3?0 ttao it.a�QOL
t
M E M O R A N D U M
April 7, 1987
TO: Board of Health
FROM: Nancy J. Sullivan
Conservaiton Administrator
Lot 3 - Liberty Street - DEQE #242-343
Gentlemen:
TELEPHONE 683-7105
This letter is written regarding a recent request by the owner
of the above referenced property for consideration by the Conservation
Commission. The owner of the property has submitted a modification
to the approved site plan, revised plan titled'8ubsurface Sewage
Disposal System prepared by Engineering Design Consultants"
Lot 3 Liberty Street, previously approved plan titled "Site Plan of
Land" prepared for Republic Development Corp., dated: November 6,
1985 revised January 28, 1986. During the review process, the issue
of the location of the driveway over the septic system was raised.
Although the Conservation Commission is concerned about this matter
it apparently is not within our jurisdiction. The Commission would
like this letter to serve as a notification of this situation.
If you have any further questions please call me.
C: Planning
NJS/mlb
No►�TN Au�.����, MA, .
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0161-C,3 APPRWIA)6
LOT 6A
LOT 4A
454.12,
Well 42.2'
�"�1p
54,403 S.F.
229.3 EXISTING FNDN.
TF= 219.68 45.2'
381.60'
LOT 2
GRADES
ELEVATIONTO TOP OF PIPE
DWELLING: --
TANK IN: 211.75
TANK OUT: 211.50
D—BOX IN: 207.52
D—BOX OUT: A 207.38
B 207.38
C 207.35
D 207.37
END OF DISTRIBUTION
LINE: A 207.08
B 207.04
C 207.04
D 206.92
Well
•
THIS IS TO CERTIFY THAT I HAVE INSPECTED
THE CONSTRUCTION OF THE SAID DISPOSAL
SYSTEM LOCATED AT LOT 3, LIBERTY ST.,
NORTH ANDOVER, MA. THE GRADES ARE AS
SPECIFIED IN THE PLANS AND SPECIFICATIONS
DATED 7/2q„A. : l.. ICH L J, OSATI."
r„
MICHAEL J. RMATI DATE
AS - BUILT SEWAGE DISPOSAL
SYSTEM PLAN
IN NORTH ANDOVER, MA.
AS PREPARED FOR NORTH MIDDLESEX CONSTRUCTION CO.
SCALE 1"=80' DATE APRIL 1989
MARCHIONDA & ASSOC., INC.
ENGINEERING AND PLANNING CONSULTANTS
80 MAPLE STREET R. F. D. 16
STONEHAM, MASS. 02180 MANCHESTER, NH 03103
(617) 438-6121 (603) 434-8725
W
W
0
126.8%
6
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'tq
Well
•
THIS IS TO CERTIFY THAT I HAVE INSPECTED
THE CONSTRUCTION OF THE SAID DISPOSAL
SYSTEM LOCATED AT LOT 3, LIBERTY ST.,
NORTH ANDOVER, MA. THE GRADES ARE AS
SPECIFIED IN THE PLANS AND SPECIFICATIONS
DATED 7/2q„A. : l.. ICH L J, OSATI."
r„
MICHAEL J. RMATI DATE
AS - BUILT SEWAGE DISPOSAL
SYSTEM PLAN
IN NORTH ANDOVER, MA.
AS PREPARED FOR NORTH MIDDLESEX CONSTRUCTION CO.
SCALE 1"=80' DATE APRIL 1989
MARCHIONDA & ASSOC., INC.
ENGINEERING AND PLANNING CONSULTANTS
80 MAPLE STREET R. F. D. 16
STONEHAM, MASS. 02180 MANCHESTER, NH 03103
(617) 438-6121 (603) 434-8725
PATRICK J. DONOVAN ASSOCIATES, INC.
elaim and Foss ✓`` d ustments
P. O. BOX 110
WAKEFIELD, MA 01880
(617) 245-5540 — FAX (617) 245-7016
June 26, 2000
Building Commissioner
City or Town Hall
North Andover, MA 01845
Insured
Property Address
Insurer
Policy Number
Type of Loss
Date of Loss
Our File #
: Robert Colby
:82 Liberty St, N Andover, MA
: Merrimack Mutual
: HP0793742
: Water Damage
: 6/22/00
: WAP31065
Claim has been made involving loss, damage or destruction of the above -captioned
property, which may either exceed $1,000 or cause Mass. Gen. Laws, Chapter 143,
Section 6, to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section
3B is appropriate, please direct it to the attention of the writer and include a reference to
the captioned Insured, location, policy number, date of loss and file number.
On this date, I caused copies of this notice to be sent to the persons named above at
the addresses indicated above by first class mail.
eA- ✓
John Spano, djuster
JS/so
OF INDEPENDENT INSURANCE ADJUSTERS
of Massachusetts
T ..
JUL 5 -
i
z
I certify that the building shown on this
plan is located as shown and that, at the
time of construction, complied with the
zoning laws of the Town of Nom Anvo\jEF
The structure is not in a HUD Flood Zon
of GEORGE sG or GEORGE
a EDWARD V EDWARD
v SMITH, JR. �' „ SMITH, JR '"
f 1SIS3
NO. 15106 W
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PLOT P L Afv
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LAND
LOT 3
LIBERTY STREET
NORTH ANDOVER, MASS.
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FORM U - LOT RELEASE 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: R G 13 EXel'- C -ti L 8 `/ Phone e� o
LOCATION: Assessor's Map Number 90 Parcel --4
Subdivision Lot(s) 3
Street /. / 66'rL^1 St. Number
************************Official Use Only************************
RECOMMENDATIONS OF TOWN AGENTS:
e►� e� Date Approved I! q'11
Conservation Administrator Date Rejected
Comments
�-))OU Date Approved 1r q
Town Planner Date Rejected
Comments
Date Approved /l
Health Agent Date Rejected
Comments 1-16r TU6 TD 1&- 7/,!�-7 D /NTD UT/G/Ty 5I NK
F,ok -DR191NA6Z-
Public Worcs - sewer/water connections
- driveway permit
Fire Department
Received by Building Inspector Date
f 5 v I AV?Z
�L Rar5L-W--r NSG I
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-rtl ed
1307Y 7
i' SLa...>t, `f Zr2v,%.; D
-3) ✓�:� mac; Gl'La t-y'v !L /O�-i"� r� U��
Biomarine
Research Corporation
P. 0. BOX 1153,16 E. MAIN ST., GLOUCESTER, MASS. 019309TELEPHONE: (617)283-7705
To: Mr. Daniel Dineen Report No.: 15255
182 Washington Street Date: 5/21/87
Gloucester, MA 01930
OQ•5D7
Attn:
Re: Well Water Analysis
Sample No.: 16552
Sample Description: Sample of water taken from anew artesian well, 330
feet deep, located on the property at Lot #3 Liberty Street, North Andover,
Mass.
Sampled By: Delivered by customer. Date: May 13, 1987
Findings:
pHValue ............................. 8.10
Hardness (as CaCO, mg/L)............ 80
Iron Content (mg/L�.................. 1.36
Manganese Content ( /L) ............. 0.06
Sodium Content (mg/L)................ 11.9
Nitrate Nitrogen Content (mg/L)...... 0.07
Specific Conductance (umhos/cm)...... 240
Remarks: Iron and manganese levels found in this water exceed the EPA recommended
levels set to prevent nuisance staining. However, with continued usage and flushing
of the well, these problems may abate.
Inspection of pH, hardness and specific conductance does not indicate a potential
corrosive problem.
JM/bf
By:
J Marletta
Laboratory Director
Rimmnrina RPgParch Corn.
OFFICES OF:
APPEALS
BUILDING
CONSERVATION
HEALTH
PLANNING
To:
From:
Sub j
OF NORT/{,
Town of
NORTH ANDOVER
Hu DIVISION DIVISION OF
PLANNING & COMMUNITY DEVELOPMENT
KAREN H.P. NELSON, DIRECTOR
May 20, 1987
Michael Graf
Nancy J. Sullivan, Cons. Admin.
120 Main Street
North Andover,
Massachusetts 01845
(617) 685.4775
Lot 3 - Liberty Street - DEQE #242-343 istova S-5 r 7
Dear Michael:
At our meeting held May 13, 1987, the NACC
approved the enclosed plan as a modification to
the original plan which was approved. Would you
kindly comment on this proposal as it relates to
public health issues.
Sincerely
NORTH ANDOVER CONSERVATION COMMISSION
Nancy J. Sul van
Conservation Administrator
NJS/mlb < _
Enclosure S �OTey SC' �-�j G, ,
l
OFFICES OF: Town of
A,>,>EAI._s NORTI3 ANDOVER
BUILDING_
CONSERVATION " 5DIVISION OF
HEALTH le
PLANNING PLANNING & COMMUNITY DEVELOPMENT
KAREN H.P. NELSON, DIRECTOR
Nancy Sullivan
Conservation Administrator
April 8 1987
re- Lot 3 Liberty St.
120 Main Street
North Andover,
Massachusetts O 1845
(G 17) 685.4775
The Septic System for this Lot is designed in accordance with
H-20 standards to accept vehicle loads and specifies heavy duty piping and
proper bedding for them. I am attaching the relevant portions of the
plan.
Sincerely
Engineer Board of alth
mgIgc
NdI� I N �tipoUEl�, MAt
• ��P�i Citi I ��N��
�PLl �] f6w�l - Et.c_ AP oyCD 11�T'C
70
s
PLAN) 9L95A � I
t'L,�,v R476� 7-zc)
Dl 5A�'PP.� vCp
RQsoms
1ATE
CojpIT(,D�JS
IQP6:�1-100 Pi PC- FROM HOO'56
1005 (Ip A0,/
DI APt71o0\j6) D,a i C
Rc,/J�so NS
RUM APPIJ6' VAL
- -'►��S S [] F'41L-
1-0 Tor L1 Nr 5 1---3 h=/0)L-
API�l�OvJivG AUTHoj�i Ty
r N,5 mw,&(� -Ti)) -
APPRW Co ---A,
The Water Works Laboratories
/f K�SSACAUSMS INC.
P�lBox 887 * Leominster, Massachusetts 01453 * (5O8)5341444 ~ 800LA8-0094
on Mass)
Name : Skilling & Sons Inc Sample Location : Mark Conserver
Address : 269 Proctor Hill Road Lot 3 Liberty Street N. Andover Ma
City : Hollis Sampled By : Skillings & Sons W -54
State : Nh Zip Code : 03049 Invoice Number : 12123
Date : Sep 15, 1988
{ P } Primary Standard
{ S } Secondary Standard
Coliform Bacteria { P }
Fecal Bacteria { P }
Standard Plate Count
Arsenic { P }
Sodium { S }
Copper { S }
Iron { S 3 -
Lead
Lead { P }
Manganese { S }
Magnesium
Calcium
Alkalinity { S 3 -
Chlorine Chlorine
Chloride { S }
Hardness
Nitrate { P }
Corrosiveness { S 3 -
Sulfate
Sulfate { S 3 -
Total
Total Solids { S }
pH{S}
Conductivity
Color { S }
Dissolved Oxygen
Odor { S }
Turbidity { P }
WATER QUALITY TEST RESULTS
RESULTS LIMITS
0/100 4/100 ml
NT 0/100 ml
NT 200/100 ml
NT
0-0.05 mg/l
4.40
0-250 mg/l
ND
0-1 mg/l
0.05
0-0.3 mg/l
NT
0-0.05 mg/l
ND
0-0.05 mg/1
4.30
0-200 mg/l
29.30
0-200 mg/l
51.00
NO LIMIT
ND
0-0.05 mg/l
0.20
0-250 mg/l
84.00
0-160 mg/l
ND
0-10 mg/l
CORR
NO LIMIT
ND
0-250 mg/l
88.50
0-500 mg/l
7.10
6.5-8.5
177.00
0-550
1.00 0-15 cu
7.10 0-15 mg/l
ND 0-3 TON
1.00 0-5 NTU
Comments :
NT - Not tested
ND - Below level of detection for this parameter
For those items tested, this sample meets the following EPA criteria for
drinking water. { X } Primary { X } Secondary { } >Neither
Date : Sep 19, 1988 Reported By : Eric J. Koslowski
Department of Environmental Management/Division of Water Resources
/ WATER WELL COMPLETION REPORT -
f WELL LOCATIQN V
Address
��
UNCONSOLIDATED WELL
City/Town' ,
G.S. Quadrangfx- Map
Grid Location_
STATIC WATER LEVEL
i/ y�
Owner '3 ' =s n- C
S,1
Sand: fine ❑ medium ❑ coarse ❑
.
Address `.. ' f r r
WELL USE
Domestic 0 Public ❑ Industrial ❑
Other
Method Drilled '
Date Drilled :/ : /
CASING
Length Diameter � r
CONSOLIDATED WELL s�
Type of Water -bearing RockLt:
Water -bearing Zo es
1) From r To � alp
2) From-To-
3)
romTo3) From Tc
4) From jTo
Depth to Bedrock ; )of
DRILLER h
Firm
Address �'roctcz, 111 0
City
Registration No. f
7
Operator's Signature
BOARD OF HEALTH COPY r 25M•10.85.807101
r
Type
UNCONSOLIDATED WELL
STATIC WATER LEVEL
Water -bearing Materials
Feet below land surface ` t
Sand: fine ❑ medium ❑ coarse ❑
Date measured
Gravel: fine ❑ medium ❑ coarse❑
Screen:
GRAVEL PACK WELL
Slot# length
romto_Yes
YesU No
-from-to-
Split Screen (or 2nd screen)
WATER QUALITY TESTS MADE
Slot# length from to
Chemical ❑ Biological ❑
Depth To Bedrock
PUMP TEST
Drawdown feet after pumping
days hours at ---t--^--GPM.
How measured.. f n r n yn .
RecOVery feet after hours.
LOG of FORMATIONS
COMMENTS: (On well or water)
Materials From To
DRILLER h
Firm
Address �'roctcz, 111 0
City
Registration No. f
7
Operator's Signature
BOARD OF HEALTH COPY r 25M•10.85.807101
r
BOARD Ur HLAL H
1 ,
Town of North Andover,Mass.. t
Permit +# Date 19 W
APPLICATION FOR WELL & PUMP PERMI,,T/
Application is hereby y made for permit to drill a well (`7. Application is
1 _L' a um s stem.
made to instal ( pump y
Location: Address A Lot #
Owne0444
Cy 1 A resel /3 3
Well ContractorAdds el���52s6
Pump Contractor Address Tel.
WELL CONTRACTOR be completed
at time of pump test)
r(To
f
Type of Well `1�-
Well used for
Diameter of Well 6 �(
Size of,Casing
into Bed Rock Q0
Depth of Bed Rock
Depth casing
'7 '-7 a
Was Seal Tested? Yes (1--r No ( )
Date. of Testing _
Depth 40-.
Well Ended in What. Materiai,�,�k�L��4
Depth to Water r
Delivers_Gals.Per Min. for 4 hours
Drawdown_feet after pumping_,�___hours- at -GPM
t
Date of Completion
S` nature Wel Contr for
.bJ J.:: _'' :: :': :: ''" :: ''' :: '.'::C i•' ::' is ''"'' iii%ji !.. .. .. i. n .. n i. .. .. .: '': i; :: i; :: :. .. .. i. .. n n .. i. i. n n n .. .. n .. n n n - .. n .0 .-� n �. JiC �. .��
��
PUMP INSTALLER (To be•£•ilicd in- before installation)
Size & Name Pump SYS
--- ------ --- ---Pump Type Used
Water Pump Delivers ��"'N GPM
Size of Tank --
Pipe Material Used in Well: Cast Iron. (`) Onlvnnized (_) Plastic
r.
Well Pit (_) or Pitless •Adapter
Was sleeve used to protect pipe? Yes (k NO(_) hype or Name Well Sealc (U' e
1 g
Date �%�%^
2
rS� Qilc�t�:lG.,.j�?,I�CTndP'k5k�k�ItsM1k
*�'rpt*�M��F�4��M�4��F�Y�r�M����r�4�MtiM�r�4�ttk�4�r�r►4�4�4�4�4�Y►4�4�'r►4ti4►Y'�r�'��rus`r,::;; •.c,'c,csc c,.,.,c..,..c.,,c,..c, , , ,
Date Water analysis report 'submitted to Board of }ieal'th
Date release given tD.owner,of record & Bldg. Insp
Health Inspector
PATRICK J. DONOVAN ASSOCIATES, INC.
Claim and Loss Adjustments
PO BOX 110
WAKEFIELD, MA 01880
TEL. (781) 245-5540 - FAX (781) 245-7016
April 30, 2003
Building Commissioner
City or Town Hall
N Andover, MA 01845
Insured
Property Address
Insurer
Policy Number
Type of Loss
Date of Loss
Our File #
IVA r,; -
MAY 2 1 M
FMAY20M
Robert Colby
82 Liberty St., N andover
Merrimack Mutual Fire Insurance company
HP0793742
Water Damage
2/11/03
WAP34792
Claim has been made involving loss, damage or destruction of the above -captioned
property, which may either exceed $1,000 or cause Mass. Gen. Laws, Chapter 143,
Section 6, to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section
313 is appropriate, please direct it to the attention of the writer and include a reference to
the captioned Insured, location, policy number, date of loss and file number.
On this date, I caused copies of this notice to be sent to the persons named above at
the addresses indicated above by first class mail.
Vern Laws, Adjuster
VL/mn
AORTN ... 5526
Of
o w
Town of North Andover
HEALTH DEPARTMENT
,SS�CNU5t1
CHECK f -DATE: (v /
LOCATION: �i�
H/O NAME:
CONTRACTOR NAME:
Type of Permit or License: (Check box)
❑ Animal
$
❑ Body Art Establishment
$
❑ Body Art Practitioner
$
❑ Dumpster
$
❑ Food Service - Type:
$
❑ Funeral Directors
$
❑ Massage Establishment
$
❑ Massage Practice
$
❑ Offal (Septic) Hauler
$
❑ Recreational Camp
$
❑ Sun tanning
$
❑ Swimming Pool
$
❑ Tobacco
$
❑ Trash/Solid Waste Hauler
$
❑ Well Construction
$
SEPTIC Sustems:
❑ Septic - Soil Testing $
❑ Septic - Design Approval $
❑ Septic Disposal Works Construction (DWC) $
❑ Septic Disposal Works Installers (DWI) $
❑�Titlenspector $
lcJeport $
❑ Other: (Indicate) $
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer
Owner
information is
required for
every page.
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
VQ
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Gamrronwealth of Massachusetts
Title 5 Official Inspection Form �
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
5
Py4perty dress
�\ U
wner's m ell
0-V P'r 0/05 5
itv/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms
way. Please see completeness checklist at the end of the form.
A. General Information
1. Inspector:
C�.n r if
r
Name of Inspector
�ka.r 1 es J' �l 6 k -
Company Name ,--.
TOWN OF NORTH ANDOVER
HEALTH DEPA tTLwN7
Company Address
� 7� 0/ R 7 �,
Cityrl own StateZip Code
-7-6"-1D-5q2455 91
Telephone Number License Number
B. Certification
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
:Insp
Needs Further Evaluation the Local Approving Authority .
l -
c s ature 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 - 09/08 Title 5 Official Inspection f ce age Ois ai System • Page 1 of 17
Owner
Information is
required for
every page.
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface S
� L11
Property Address
Owner's Name
City/Town
Disposal System Form - Not for Voluntary Assessments
B. Certification (cont.)
State Zip Code Date of Inspection
Inspection Summary: Check A,B,C,D or E / always complete all of Section D
A) System Passes:
I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
Low►VA\t Y1 de j C5 �enQCw t 0141 r0�Y1L`9-
❑ 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 statyements. If "not
determined, " please explain.
The septic tank is metal and over 20 years old* or th septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltratio r exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replace with a complying septic tank as approved by the
Board of Health.
* A metal septic tank will pass inspectioo it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the7D(Explain
s ssthan 20 years old is available.
ElY ElN ❑ below):
15ins - 09/08
Title 5 Official Inspection Form Subsurface Sewage Disposal System •Page 2 of 17
1.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewag Disposal System Form - Not for Voluntary Assessments
} � 5
wN Property Address
Owner
Information is Owner's Name
required for
every page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
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❑ D (Explain below):
❑ obstruction is removed El ElN ND (Explain below):
t5ins • 09/08
❑ distribution box is leveled or replaced ❑ Y 0 N ❑ ND (Explain below):
❑ The System re/pumpinre than 4 times a year due to broken or obstructed pipe(s). Thesystem will paapproval of the Board of Health):
❑ brokened ❑ Y ❑ N ❑ ND (Explain below):
❑ obstru❑ 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, safe=ermines
environment.
1. System will pass unless Board of Health in accordance with 310 CMR
15.303(1)(b) that the system is not fund ing in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is ' in 50 feet of a surface water
El Cesspool or pr' is within 50 feet of a bordering vegetated wetland or a salt march
Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 3 of 17
e
Owner
Information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Address
Owner's Name
Cityfrown State Zip Code
B. Certification (cont.)
Date of Inspection
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
deterimes 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 th SAS is within
100 feet of a surface water supply or tributary to a surface water sup y.
❑ The system has a septic tank and SAS and the SAS is /ae 1 of a public water
supply.
The system has a septic tank and SAS and the SAS is of a private water
supply well.
❑ The system has a septic tank and SAS and the
more from a private water supply well"
Method used to determine distance:
less than 100 feet but 50 feet or
" This system passes if the well water analysi , performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence'V ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other f ' re 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
❑ LJ
Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ T�
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 m day flow
t5ins • 09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System - Page 4 of 17
Commonwealth of Massachusefts
Title 5 Official Inspection Form
i;
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
Owner Owner's Name
Information is
required for
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
YesN_o(
E3E Required pumping more than 4 times in the last year NOT due to clogged or
_/ obstructed pipe(s). Number of times pumped:
I
❑ Any portion of the SAS, Cesspool or privy is below high ground water elevation.
❑ E� Any portion of cesspool or privy is within 100 feet of a surface water supply or
,,�( tributary to a surface water supply.
El LI Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ E, Any portion of a cesspool or privy is within 50 feet of a private water supply well.
El IJ 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.]
❑ LJ This system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ E� 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 o surface drinkiing water supply
❑ ❑ the system is within feet of a tributary to a surface drinking water supply
❑ ❑ the syste orated in a nitrogen sensitive area (Interim Wellhead Protection
Area - PA or a mapped Zone II of a public water supply well
If you have answe "yes" to any question in Section E the system is condidered a significant threat,
or answered " s" in Section D above the large system has failed. The owner or operator of any large
system sidered 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 • 09/08
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
o
r
Property Address
Owner Owner's Name
Information is
required for
every page. Cityrrown State Zip Code Date of Inspection
C Checklist
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
❑ 0 Were any of the system components pumped out in the previous two weeks?
d❑ Has the system received normal flows in the previous two week period?
❑ IJ 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)
I� ❑ Was the facility or dwelling inspected for signs of sewage back up?
d❑ Was the site inspected for signs of break out?
l�J ❑ 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?
k>� ❑ Was the facility owner (and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
This size and location of the Soil Absorption System (SAS) on the site has
�/ been determined based on:
IIZJ ❑ Existing information. For example, a plan at the Board of Health.
E ❑ 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): Number of bedrooms (actual): 37
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): �46PTI,
t5ins • 09108 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 6 of 17
Owner
Information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface_Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
Owner's Name
City/Town State Zip Code Date of Inspection
D. System Information
Description:
,6(
Number of current residents:
Does residence have a garbage grinder?
r
N1m
❑ Yes 5"No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes LJ No
Laundry system inspected? P,/A ❑ Yes ❑ No
Seasonal use? ❑ Yes L/ No
Water meter readings, if available (last 2 years usage (gpd)):
Detail: A) A
Sump pump?
Last date of occupancy:
Commercial/Industrial Flow Conditions:
Type of Establishmen/resent?
Design flow (based o3
Basis of design flow (.ft.,etc.):
Grease trap present?
Industrial waste holdiNon-sanitary waste dTitle 5 system?
Water meter readings, if available:
Gallons per day (gpd)
I/ Yes ❑ No
Date
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
t5ins - 09/08
Title 5 official Inspection Form Subsurface Sewage Disposal System • Page 7 of 17
Owner
Information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official. Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
F a- LII S
Property Address
Owner's Name
City/Town State
D. System Information (cont.)
Last date of occupancy/use:
Other (describe below):
Zip Code Date of Inspection
Date
General Information
Pumping Records:
Source of information: Qv f (i x o Ili —
Was system pumped as part of the inspection? 9 Yes ❑ No
If yes, volume pumped:
How was quantity pumped determined?
Reason for pumping:
gallons
6�2 6U
Typee of System:
LJ 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 • 09/08 Title 5 Official Inspection Farm Subsurface Sewage Disposal System • Page 8 of 17
Owner
Information is
required for
every page.
t5ins • 09/08
Commonwealth of Massachusetts
Title 5.0fficial Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Address
Owner's Name
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
z ?, — rk, 4
Were sewage odors detected when arriving at the site? ❑ Yes 0"No
Building Sewer (locate on site plan):
Depth below grade:
feet
Material of construction:
❑ cast iron ❑ 40 PVC ❑ other (explain)
Distance from private water supply well or suction line: A
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade:
Material of construction:
6 concrete ❑ metal
If tank is metal, list age:
VLt
feet
❑ fiberglass ❑ polyethylene ❑ other (explain)
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) 1❑ Yes ❑ No
Dimensions:
Sludge depth
10 -X/'5
Title 5 Official Inspection Forth Subsurface Sewage Disposal System • Page 9 of 17
a
Owner
Information is
required for
every page.
t5ins • 09/08
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
- � �- L I L11-9
Property Address
Owner's Name
Cityfrown
D. System Information (cont.)
Septic Tank (cont.)
State Zip Code Date of Inspection
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
44
Distance from top of scum to top of outlet tee or baffle 1�
Distance from bottom of scum to bottom of outlet tee or baffle !' 0
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
%� ICGt G e �l t� � 14 V15 �"))(, � � �4-e '13a Arie Ae5
Grease Trap (locate on site plan):
Depth below grade:
feet
Material of construction:
❑ concrete ❑ metal ❑iberglass ❑ polyethylene ❑ other (explain)
Dimensions:
Scum thickness
Distance from top of scum to p of outlet tee or baffle
Distance from bottom of s m to bottom of outlet tee or baffle
Date of last pumping:
Date
Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 10 of 17
. ? a
. Owner
Information is
required for
every page.
Commonwealthof Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
—2 0--L�,Q Az
Property Address
Owner's Name
City/Town
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
Depth below grade:
Material of construction:
❑ concrete ❑ metal
Dimensions:
Capacity:
Design Flow:
Alarm present:
Alarm level:
pumped at time of inspection) (locate on site plan):
❑ fiberglass ❑
gallons per day
❑ Yes ❑ No
❑ other (explain)
Alarm in working order: ❑ Yes ❑ No
Date of last pumping:
Date
Comments (condition of alar/afloat switches, etc.):
* Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins . 09/08
Title 5 Official Inspection Form Subsurface Sewage Disposal System - Page 11 of 17
i;
Owner
Information is
required for
every page.
(t5ins • 09/08
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
2 a L, tA;�,I 5t
Property Address
Owner's Name
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
..r
Depth of liquid level above outlet invert 0.r -
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.):
,-11:)-N,,\), l --, IQ-u.P I j -p rzVj�,e5 Q.,4-►-Pl6w--114)1)jMg1
-SwA5 b�- (C
Pump Chamber (locate on site plan):
Pumps in working order:
Alarms in working order:
Comments (note condition of pump chamber,
❑ Yes ❑ No
❑ Yes ❑ No
ition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
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
ti Property Address
owner Owner's Name
Information is
required for
every page. Cityfrown State Zip Code Date of Inspection
(t5ins - 09/08
D. System Information (cont.)
Type:
0 leaching pits
number:
❑ leaching chambers
number:
❑ leaching galleries
number:
❑ leaching trenches
number, length:
❑ leaching fields
number, dimensions:
❑ overflow cesspool
number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
5D)iI 1', Sa,v�� I t< rUV2 1 M 1 )l -- n16 -P611d )yl1 . A /,.,
Cesspools (cesspool must be pumped as part of in
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 nflow ❑ Yes ❑ No
Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 13 of 17
(locate on site plan):
Owner
Information is
required for
every page.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
Owner's Name
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (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 ydraulic failure, level of ponding, condition of vegetation,
etc.):
(t5ins • 09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System - Page 14 of 17
Owner
Information is
required for
every page.
(t5ins • 09/0e
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewagefi
sposal System Form - Not for Voluntary Assessments
1 _ _C) -
Property Address
Owner's Name
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
hand -sketch in the area below
drawing attached separately
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 Slewage Disposal System Form - Not for Voluntary Assessments
9 a h -1J
Property Address
Owner's Name
Cityrrown
D. System Information (cont.)
Site Exam:
❑
Check Slope
❑
Surface water/
v
ElCheck
cellar
F1
Shallow wells
Estimated depth to high ground water:
State Zip Code Date of Inspection
feet
Please indicate all methods used to determine the high ground water elevation:
91
0
a
FE]
Obtained from system design plans on record
If checked, date of design plan reviewed: (59-5
Ua e
Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health - explain:
Checked with local excavators, installers - (attach documentation)
Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
Before filling this Inspection Report, please see Report Completeness Checklist on next page.
(t51ns - 09/08 Title 5 official Inspection form Subsurface Sewage Disposal System - Page 16 of 17
Owner
Information is
required for
every page.
TSins - 09108
Com'. ohwealth Of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Q L I� r V
Property Address
Owner's Name
City[Town
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
dSystem Information - Estimated depth to high groundwater
ell Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
Title 5 Official Inspection Forth Subsurface Sewage Disposal System • Page 17 of 17
SCW91DOLE OF ELEVATI635
IN Vr: AT AT T3U I L"D I N,6
fhN.P,RT twro SEPTIC'
TA KLI"
rr our or 5EPTIC TAH9
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tqTo w6Tfzt;Bvri6r4 t6k li,44-
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INVERT AT SSC- 40MYE Pir ip4 1142
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:777 71 ��'Wi
CSTIMAIM SSvA(cE FLOW
TOTAL LZACRIH6r ASA
11
jib F-
43
tom, �q ' z •
certify that the building sho��n on th
'�NV JtNt7 plan is located as shown .arid that, at t
-� time of construction, complied with .the
.....�
zoning. laws of the Town of NbR Ik Am -DOVE
The structure is not in a HUD Flood Zo
Ila
GEORGE sc o�� GEORGE yN
i EDWARD . EDWARD,
SMITH,JR. SMITH, JR. H
`N E t� Leiusa o Na 1s1o6 w
Sif AL
00
ICAVA
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PLOT PLAN
1 00
OF
LA ND
6T4 -AND L 0 T 3
kz�► i �� M E
ERTY. ST R EET
\\4) �ti iia
NORTH ANDOVER MA SS./
is T S7R ,I
1 or vltkl y f.i
C9-'ommonwealthf
Massachusetts
City/T. own. of NORTH ANDOVER
MASSACHUSETTS='
System Pumping Record
`
s:
Form 4
OCT 12 2006
ANDOVER
DEP has provided this form for use by local Boards of Health. The System Pumpin§?f�6cor-d mu:
be submitted to the local Board of Health or other approving
authority. -------
A. Facility Information
-
Important:
When filling out
1. System Location:
forms on the
computer, use
only the tab key
Address
to move your
2
cursor • do not
use the return
Clt /Town
y
Zip Code
key.
2. System Owner:
Name
•
Address different
— "-- --
(if from location)
— ---- -- - --
CI ty/y/Town - ----------
�Zip CodeTNumber
Saephone
B. Pumping Record
1. Date of Pumping
3. _)Type of system: ❑
❑ other (describe):
9
Date U Quantity Pumped
Cesspools) �,Septic
Tank
Gallons
❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. Sy em Pumped By:
ti
ame ---
Z4 Vehicle License Number
Company
7. Location where contents were disposed:
Si ature of Hau Date ---"— ---- ---- —
hnp://www.mask,gov/dep/water/ provals/t5forms.htm#inspect
t5form4.doc- 06/03
System Pumping Record - Page t of 1.
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