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Home My WebLink AboutMiscellaneous - 83 CAMPBELL ROAD 4/30/2018 (2)1 1�, o ypeLO NN ONIdd3 Sll3SnHOVSSVW'H3AO(3NV avowiSv Set Q�102i "1139dWV'J ig Syy3Sf1HOVSSVW'ti3A0ONV 'N ONLL ,iOI3A pVO-d 11394 ES 1N31NdOl3A3p ONV'� A3Nti N`dld 311S NO-11tld Aom �/(jT \��\�Il NOI1tlNIW1i3134 Nem t�Jl`�� H0.11S3nmb III�III� I'a ®e:i�ao I I I I I I I I I 4� N Illllllil �� Ibt`�8§ gOp�?� gygggg�� gg38F€�8ggg3�yyMPP� $tl5HUMS i5� �324iIlT61�� 1111 N Big Ildh a e a 4 las---_�-- J ' � EXIS77NO WaL N 18"OAK EXIS AfG PATIO LAWN (PAVERS) / P EXIS �� 5 .'FRET ININGSCWALL PAVED pRIVEWAY I EKI$71MG \ 11 r f l L GARAGE 1 � -------------- .200 --.200----_-"- r 61 ilk LAWN $O L 1, 0 90 Ex%slot A. )IJ MNG PA770 cS\ LA VPW OF A2 ✓ Al, JIL 'IL W AAL '� to PLUM , 11L t I� AL t`ti y� WF A5 L A6} LOT 3B AMmI.18 AC`. I � I 3' HIGI PE 9 WALL "\O- PA O_ PA If200. I , .I + II I I I I 1/2' i\ , , 1 , , , 1 ! � 1 N EXISTING RIGH N STONE RETAIIJ'JNG a t%�V'ALL 10 ` rler 1(1 I t4 vi / � n i I F: v + © ! IW 87 © Lo 't1` `o i ,. , 91it 1 IL rbflr. WF 89 of 7014 Town of North Andover HEALTH DEPARTMENT SAC CHEC 4:1X41 DAT LOC TION- M -AM Odi 44 H/O NAME: CONTRACTOR NAME: Type of Permit or License: (Check box) • Animal $ • Body Art Establishment $ • Body Art Practitioner $ 0 Dumpster $ • Food Service - Type. $_ • Funeral Directors $ • Massage Establishment $ 0 Massage Practice $ • Offal (Septic) Hauler $ • Recreational Camp $ 0 Sun tanning $ • Swimming Pool $ • Tobacco $ • Trash?Solid Waste Hauler $ • Well Construction $ SEP77C Systems • Septic - Soil Testing $ • Septic - Design Approval $ 0 Septic Disposal Works Construction (DWQ $ 0 Septic Disposal Works Installers (DM) $ 0 Title 5 Inspector $ Title 5 Report 0 Other (Indicate) $ Lb Health Agent Initials p White -Applicant Yellow -Health Pink -Treasurer MM Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 CAMPBE Property Addre KIM ARN Owner's Name ,,A L V NORTH ANDOVER MA 01845 9/19/14 Cityrrown State Zip Code Date of inspection Inspection results must be submitted on this form. Inspection forms may not be altered In any way. Please see completeness checklist at the end of the form. Important: When A. General Information RECEIVED filling out forms on the computer. use only the tab key to move your 1 Inspector, SEP 2b 2014 [HE'ALTH cursor - do not JAMES H CURRIER 11 use the return Name of Inspector TOWN OF NORTH ANDOVER key. J'S SEPTIC & DRAIN DEPARTMENT Company Name 131 FOREST ST Company Address MIDDLETON MA 01949 City/Town State Zip Code 978-774-6685 S12327 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 CMIR 15.000). The system: F Passes El Conditionally Passes El Fails F� Needs Further Evaluation by the Local Approving Authority 9119/14 I)Aectors Signature Date The system inspector Shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins - 3113 Title 5 Offidat lnspectio� Form S,bs.rface $.age Disp.1 Syste. - Page 1 of W S Al Ulm UN. Owner Information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ROAD Property Address Owner's Name NORTH ANDOVER MA 01845 9/19/14 City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: F� 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: Z 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. El Y El N E] ND (Explain below): t5ins - 3113 TrIe 5 OffilciOl Inspedion Form: SubsurfaLl Sewage 01s,osel System - Page 2 of 17 n�, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 CAMPBELL ROAD Property Address KIM ARN Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 9/19/14 page. 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.): E] 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): F1 broken pipe(s) are replaced F1 obstruction is removed 7 distribution box is leveled or replaced [-] Y F] N El ND (Explain below): [] Y E] IN El ND (Explain below): E] Y F] N 0 IND (Explain below): D -BOX AND OUTLET BAFFLE NEED TO BE REPLACED. 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): 0 broken pipe(s) are replaced E] Y El N El ND (Explain below): F-1 obstruction is removed 0 Y [I N 0 IND (Explain below): C) Further Evaluation is Required b Y the Board of Health; El 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(l)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: • Cesspool or peivy 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 - 3/13 Title 5 Official inspection Form; Subilvf8ca Sissrage Disposal System - Page 3 of 17 f�,N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 CAMPBELL ROAD Property Address KIM ARN Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 9/19/14 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) X 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: Ej 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. El The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. D 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 6 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 El z clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters 11 z 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 E3 IT7 than 1/2day flow t5ins - 3M3 Title 5 Official Inspection Form: Subsurface sewage Djs�ssl System - Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Insp Subsurface Sewage Disposal System Fo 83 CAMPBELL ROAD Property Address KIM ARN Owner Owners Name nformation is required for every NORTH ANDOVER page. Cityrrown B. Certification (cont.) Yes No 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 wt 'in 400 f et of a surface drinking water supply the system is wI:In 20 at of a tributary to a surface drinking water supply the system is located i a nitro an sensitive area (interim Wellhead Protection 0 El Area–IWPA)oram ped 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: Supsu6ace Sewage, Disposal System - Page 5 of 17 Required pumping more than 4 times in the last year NOT due to clogged or ection Form rm - Not for Voluntary Assessments Any portion of cesspool or privy is within 100 feet mf a surface water supply or tributary to a surface water supply. El El� Any portion of a cesspool or privy is within a Zone 1 of a public well. El El�� Any portion of a cesspool or privy is within 50 feet of a private water supply well. El 0 V\�e Any poton 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 plesence of ammonia nitrogen and nitrate nitrogen is equal to or less than 6 ppm, MA 01845 9/19/14 and chain of custody must be attached to this form.] State Zip Code Date of Inspection 10,000gpd. El Z The system fails. I have determined that one or more of the above 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 wt 'in 400 f et of a surface drinking water supply the system is wI:In 20 at of a tributary to a surface drinking water supply the system is located i a nitro an sensitive area (interim Wellhead Protection 0 El Area–IWPA)oram ped 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: Supsu6ace Sewage, Disposal System - Page 5 of 17 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 mf a surface water supply or tributary to a surface water supply. El El� Any portion of a cesspool or privy is within a Zone 1 of a public well. El El�� Any portion of a cesspool or privy is within 50 feet of a private water supply well. El 0 V\�e Any poton 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 plesence of ammonia nitrogen and nitrate nitrogen is equal to or less than 6 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. El Z The system fails. I have determined that one or more of the above failure criteria exist �'sdescrjbed 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 wt 'in 400 f et of a surface drinking water supply the system is wI:In 20 at of a tributary to a surface drinking water supply the system is located i a nitro an sensitive area (interim Wellhead Protection 0 El Area–IWPA)oram ped 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: Supsu6ace Sewage, Disposal System - Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 CAMPBELL ROAD Property Address KIM ARN Owner Owners Name nformation is required for every NORTH ANDOVER MA 01845 9/19/14 page. Cityrrown 'gitate Yip 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 • El 19 0 Pumping information was provided by the owner, occupant, or Board of Health E3 19 Were any of the system components pumped out in the previous two weeks? Z 11 Has the system received normal flows in the previous two week period? E] Z Have large volumes of water been introduced to the system recently or as part of The size and location of the Soil Absorption System (SAS) on the site has this inspection? E] []S�Z Were as built plans of the system obtained and examined? (If they were not Determined in the field (if any of the failure criteria related to Part C is at issue i Z E] Was the facility or dwelling inspected for signs of sewage back up? Yes No • El 19 0 Pumping information was provided by the owner, occupant, or Board of Health E3 19 Were any of the system components pumped out in the previous two weeks? Z 11 Has the system received normal flows in the previous two week period? E] Z Have large volumes of water been introduced to the system recently or as part of The size and location of the Soil Absorption System (SAS) on the site has this inspection? E] []S�Z Were as built plans of the system obtained and examined? (If they were not Determined in the field (if any of the failure criteria related to Part C is at issue available note as N/A) Z E] Was the facility or dwelling inspected for signs of sewage back up? Z 1:1 Was the site inspected for signs of break out? • El Were all system components. excluding the SAS, located on site? • El 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? • El 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: • El Existing information. For example, a plan at the Board of Health. Z 0 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): NA Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedroorns): NA t5[n, - 3113 rife 5 Official Inspection Fom: subsurface Sawago 0tsWsa4 System - Page 6 of 17 S_N Commonwealth of Massachusetts uTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,p 83 CAMPBELL ROAD Property Address Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? El YeL [D No Last date of occupancy: CURRENT Da,,; Commercial/industrial Flow Conditions: Type of Establishment: rl� r Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) E3 Yes [__1 No El Yes Ej No El Yes [__1 No Sins - 3113 Title 5 Official ll F�� Subsurface Sewage Dil System - Page 7 W 17 KIM ARN Owner Owners Name information is required for every NORTH ANDOVER MA 01845 9/19/14 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? Z Yes [I No Is laundry on a separate sewage system? (Include laundry system inspection El Yes 0 No information in this report.) Laundry system inspected? Yes [] No Seasonaluse? El Yes 9 No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? El YeL [D No Last date of occupancy: CURRENT Da,,; Commercial/industrial Flow Conditions: Type of Establishment: rl� r Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/sq.ft., Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) E3 Yes [__1 No El Yes Ej No El Yes [__1 No Sins - 3113 Title 5 Official ll F�� Subsurface Sewage Dil System - Page 7 W 17 <C_\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 CAMPBELL ROAD Property Address KIM ARN Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 9/19/14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date 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: Type of System: LPD 6/2/14 - SOURCE - COPY OF INVOICE gallons E Septic tank, distribution box, soil absorption system El Single cesspool n Overflow cesspool F Privy El Shared system (yes or no) (if yes, attach previous inspecJon recoAs, if any) El Innovative/Alternative technology. Attach a copy of the current operajon 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. El Other (describe): t5als - 3113 Title 5 Official lns�cticn Fow Subsurface S�ago Disposal Systern - Page 8 0 17 Commonwealth of Massachusetts Title 5 Official Insp Subsurface Sewage Disposal System Fo 83 CAMPBELL ROAD D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: HOUSE BUILT IN 1967 Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below SwAe: 51') t: Material of construction: 0 cast iron El 40 PVC El other (explain): Distance from private water supply well or suction line: 41 " feet 24' feet El Yes E No Comments (on condition of joints, venting, evidence of leakage, etc.): NO EVIDENCE OF LEAKAGE Septic Tank (locate on site plan): Depth below grade: Material of construction: 0 concrete El metal If tank is metal, list age: 6"-8" feet D fiberglass El polyethylene 0 other (explain) years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes [I No Dimensions: 6'XB'- 1000 GALLON Sludge depth: 1 V-112" t5inS - 3113 Title 5 Offidal Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 ection Form rm - Not for Voluntary Assessments Property Address KIM ARN Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 9/19/14 page. City/Town s—tate lip �Code Date of inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: HOUSE BUILT IN 1967 Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below SwAe: 51') t: Material of construction: 0 cast iron El 40 PVC El other (explain): Distance from private water supply well or suction line: 41 " feet 24' feet El Yes E No Comments (on condition of joints, venting, evidence of leakage, etc.): NO EVIDENCE OF LEAKAGE Septic Tank (locate on site plan): Depth below grade: Material of construction: 0 concrete El metal If tank is metal, list age: 6"-8" feet D fiberglass El polyethylene 0 other (explain) years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes [I No Dimensions: 6'XB'- 1000 GALLON Sludge depth: 1 V-112" t5inS - 3113 Title 5 Offidal Inspection Form: Subsurface Sewage Disposal System - Page 9 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 83 CAMPBELL ROAD Property Address KIM ARN Owner's Name NORTH ANDOVER Cityrrown D. System Information (cont.) MA 01845 9/19/14 State Zip Code Date of Inspection Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? IN SLUDGE JUDG Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): INLET AND OUTLET BAFFLE IN PLACE. OUTLET SHOULD BE REPLACED AT TIME OF D BOX REPAIR. LIQUID LEVEL CORRECT, TANK DOES NOT NEED PUMPING AT THIS TIME. OWNER HAD TANK PUMPED ON A REGULAR BASIS. Grease Trap (locate on site plan): Depth below grade: Material of construction: 0 concrete El metal Dimensions: feet [I fiberglass El polyethylene [I other (explain): Scum thickness Distance from top of scum to top of u:1et t le �ce 0 r ba Distance from bottom of scum to bottom ; f outlet tee or baffle Date of last pumping: t51ns - 3113 Title 5 Official insnection Form: Subsudece Sewa� DiSPOW1 SYStOm - P890 10 of 17 Commonwealth of Massachusetts Title 5 Official Insp Subsurface Sewage Disposal System Fo 83 CAMPBELL ROAD D. System Information l 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: El concrete D metal E) fiberglass El polyethylene El )ther (explain): Dimensions: Capacity: Design Flow: Alarm present: Alarm level: gallons gallons per day El Yes El No Alarm in working order: 0 Yes El No Date of last pumping: -Ea-t-e Comments (condition of alarm and float switches, etc,): * Attach copy of current pumping contract (required). Is copy attached? El Yes E] No t5ins - 3113 Title 5 Offidal Inspedion Form Suasurfaoe, Sewage Disposal System - Pass I I of 17 ection Form rm - Not for Voluntary Assessments Property Address KIM ARN Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 9/19/14 page. City[Town State Zip Code Date of Inspection D. System Information l 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: El concrete D metal E) fiberglass El polyethylene El )ther (explain): Dimensions: Capacity: Design Flow: Alarm present: Alarm level: gallons gallons per day El Yes El No Alarm in working order: 0 Yes El No Date of last pumping: -Ea-t-e Comments (condition of alarm and float switches, etc,): * Attach copy of current pumping contract (required). Is copy attached? El Yes E] No t5ins - 3113 Title 5 Offidal Inspedion Form Suasurfaoe, Sewage Disposal System - Pass I I of 17 <L N Commonwealth of Massachusetts uTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,p 83 CAMPBELL ROAD Property Address KIM ARN Owner Owner's Name information is MA 01845 9/19/14 required for eve., NORTH ANDOVER page. City/Town 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 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 ): BOX NEEDS TO BE REPLACED. SOME SOLIDS CARRYOVER, LIQUID LEVEL CORRECT. BOX IS 8" BELOW GRADE. Pump Chamber (locate on site plan): Pumps in working order: Yes Ej No* Alarms in working order: Yes No* note condition of pump cha ition o Comments ( 7tt r, cond 7 f 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 pl n, excavation not required): If SAS not located, explain why: t5ms - 3113 Title 5 Ofloal Insp.dion Foms: Subsul.os S"age DisPosal System - Page 12 of 17 Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding. damp soil, condition of vegetation, etc.): SOILS DRY, NO SIGN OF HYDRAULIC FAILURE, VEGETATION NORMAL. USED CAMERA TO LOCATE SIDES AND END OF FIELDS. 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 El Yes El No Sins - 3113 Title 5 Offloal inspection Fon: Subsuftce Sewage Disposal System - Page 13 W 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 CAMPBELL ROAD Property Address KIM ARN Owner Owners Name information is required for every NORTH ANDOVER MA 01845 9/19/14 page. Cityrrown s—tate zjp �Code Date of inspection D. System Information (cont.) Type: E] leaching pits number: E] leaching chambers number: El leaching galleries number: El leaching trenches number, iangL'h: z leaching fields number, dimens'ons: JjL2t�X30' 11 overflow cesspool number: El innovative/afternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding. damp soil, condition of vegetation, etc.): SOILS DRY, NO SIGN OF HYDRAULIC FAILURE, VEGETATION NORMAL. USED CAMERA TO LOCATE SIDES AND END OF FIELDS. 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 El Yes El No Sins - 3113 Title 5 Offloal inspection Fon: Subsuftce Sewage Disposal System - Page 13 W 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 CAMPBELL ROAD Property Address KIM ARN Owner Owners Name information is required for every NORTH ANDOVER MA 01845 9/19/14 page. 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 hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins - W1 3 Title 5 Official inspection Foart: Subsurfacat tilowag. Di�,.a� Syatarn - Pago 14 of 17 �LN Commonwealth of Massachusetts uTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,p 83 CAMPBELL ROAD Property Address KIM ARN Owner Owner's Name information is C!4 A required for every NORTH ANDOVER MA 01845 page. Cityfrown State Zip Code Date of Ins.9ection 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 10 feet. Locate wher public water supply enters the building. Check one of the boxes below: hand -sketch in the area below El drawing attached separately ar 3 fe. 3 t5ins - 3113 Title 5 Official Inspedion Fomm: Subsui1ace Se�age Discosal 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 83 CAMPBELL ROAD Property Address KIM ARN Owner's Name MA 01845 9/19/14 State Zip Code Date of Inspection D. System Information (cont.) Site Exam: [I Check Slope El Surface water El Check cellar El Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water Pl-vntion: Obtained from system design plans on record If checked, date of design plan reviewed: Date El Observed site (abutting property/observation hole within 150 feet -)f SAS) F-1 Checked with local Board of Health - explain: 11 Checked with local excavators, installers - (attach documentation) 11 Accessed USGS database - explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t51m; - 3113 Title 5 Official Inspection FOM: Sulostunace S�ga Diii,,osel System - Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 CAMPBELL ROAD Property Address KIM ARN Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 9/19/14 — Da—te of Inspection page. City[Town State Yip Code E. Report Completeness Checklist • inspection Summary: A, B, C, D, or E checked • inspection Summary D (System Failure Criteria Applicable to All Systems) completed [0 system information – Estimated depth to high groundwater Z Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5,ns - W13 Title 5 official Inspection Fom Sitostiface Sewage Disposal System - Page 17 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 83 CAF Property KIM AF Owners 115 L �' -/ . q,L-A V NORTH ANDOVER MA 01845 9/19/14 — Ip Code Date of Inspection CityfTown '�tate Inspection results must be submitted on this form. Inspection forms may not be altered In any way. Please see completeness checklist at the end of the form. Important: When A. General Information filling out forms on the computer, use only the tab I Inspector: key to move your cursor - do not JAMES H CURRIER 11 use the return Name of Inspector TOV key. HI SS SEPTIC & DRAIN L Company Name 131 FOREST ST Company Address MIDDLETON— MA 01949 Cityrrown State Zip Code 978-774-6685 S12327 Telephone Number License Number B. Certification RECEIVED SEP 2b ?014 OF NORI H ANDOVER 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: F Passes Z Conditionally Passes El Fails F� Needs Further Evaluation by the Local Approving Authority 4�)Vll 9/19/14 In ,.4ectors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DER 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. Sire - 3113 Title 5 Official inspection Forrin. Subsurface $mass DISPOsal SYStOm - P090 i of 17 <L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 CAMPBELL ROAD Property Address Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 9/19/14 page. 6�_rrown 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: 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. 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. El Y [I IN [] NO (Explain below): Tille 5 Official Inspectibn Fo,: Subs,afa�l S�age Ois. -owl System - Page 2 of 17 t5ins - 3j1 3 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 CAMPBELL ROAD Property Address KIM ARN Owners Name NORTH ANDOVER MA 01845 9/19/14 Zip Code Date of Inspection City/Town State B. Certification (cont.) E] 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): E] broken pipe(s) are replaced [I obstruction is removed distribution box is leveled or replaced E] Y El N [I ND (Explain below): [-I Y El NEI NO (Explain below): [:1 Y [:1 N El ND (Explain below): D -BOX AND OUTLET BAFFLE NEED TO BE REPLACED. E] 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): El broken pipe(s) are replaced Ej Y [I NEI ND (Explain below): 0 obstruction is removed [:1 Y [I N 0 ND (Explain below): C) Further Evaluation is Required by the Board of Health: El 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(l)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: El Cesspool or peivy is within 50 feet of a surface water E] Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 15ins - 3413 Ttfle 5 Offidal Inspection Form Subsurface Se�age Dls�sal SWOm - Page 3 V 17 i Mot i, .'s, Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 CAMPBELL ROAD Property Address Owner's Name NORTH ANDOVER MA 01845 9/19/14 Cityrrown Vt—ate -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. El The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. El 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 El Z clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters 0 z 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 \,Z&,/ Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins - W13 Title 5 Official Inspection Fom Stilasufface Sawage Disioceal System - Page 4 of 17 J,\ Commonwealth of Massachusetts uTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,p 83 CAMPBELL ROAD Property Address KIM ARN Owner Owners Name information is required for every NORTH ANDOVER MA 01845 9/19/14 page. CftyrFown 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. E] F�sfrk Any portion of cesspool or privy is within 100 feet nf a surface water supply or tributary to a surface water supply. El El� Any portion of a cesspool or privy is within a Zone 1 of a public well. El Any portion of a cesspool or privy is within 50 feet of a private vlater supply well. El El V\3�( 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 plesence of ammonia nitrogen and nitrate nitrogen is equal to or less than 6 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- El N 10,000gpd. The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system falls. 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 El 0 the system is wi in 400 f et of a surface drinking water supply t' El E] the system is within 20 et of a tributary to a surface drinking water supply the system is located I a nitro en sensitive area (Interim Wellhead Protection El El Area—IWPA)oram ped 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, isms 3/13 Tille 5 Official Inspection Form: Subsurfiece Sewage Disposal System - Page 5 of 17 < L' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments k1pi 83 CAMPBELL ROAD Property Address Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 9/19/14 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 Z El Pumping information was provided by the owner, occupant, or Board of Health E] 0 Were any of the system components pumped out in the previous two weeks? Z 11 Has the system received normal flows in the previous two week period? El Z 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) Z F-1 Was the facility or dwelling inspected for signs of sewage back up? Z 0 Was the site inspected for signs of break out? N El 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? Z E] 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: Z E] Existing information. For example, a plan at the Board of Health. Z 1:1 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): INA Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): INA t5m. - W13 Title 5 Official Inspection Fom: Subsurface Se,vage Disposat System - Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Insp Subsurface Sewage Disposal System Fo 83 CAMPBELL ROAD Property Address KIM ARN Owner Owners Name nformation is required for every NORTH ANDOVER page. City/Town D. System Information Description: Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) Laundry system inspected? Seasonaluse? Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Last date of occupancy: Commercial/industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): I , etc Basis of design flow (seats/persons/sq.ft., etc. . Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: perday(gpd) 2 N Yes ection Form 0 rm - Not for Voluntary Assessments 0 No Z Yes [] No El Yes [K No MA 01845 9/19/14 State Zip Code Date of Inspection Does residence have a garbage grinder? Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) Laundry system inspected? Seasonaluse? Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Last date of occupancy: Commercial/industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): I , etc Basis of design flow (seats/persons/sq.ft., etc. . Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: perday(gpd) 2 N Yes 0 No 0 Yes 0 No Z Yes [] No El Yes [K No EJ Ye!� Z No CURRENT Da,,� El Yes Ej No El Yes El No El Yes [:] No t5ins - 3113 Tile 5 Official Inspection Form: Subsurface Se�age 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 83 CAMPBELL ROAD Property Address KIM ARN Owner's Name NORTH ANDOVER MA 01845 9/19/14 CityrFown 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: Type of System: LPD 6/2/14 - SOURCE - COPY OF INVOICE gallons 9 Septic tank, distribution box, soil absorption system El Single cesspool F-1 Overflow cesspool F-1 Privy El Shared system (yes or no) (if yes, attach previous inspecJon reco,-ds, if any) Innovative/Alternative technology. Attach a copy of the current operaJon 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 El Tight tank. Attach a copy of the DEP approval. D Other (describe): Sms - W13 Title 5 Official Inspection Fwm: Subsulace Se�ege Disposal System - Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Insp Subsurface Sewage Disposal System Fo 83 CAMPBELL ROAD D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: HOUSE BUILT IN 1967 Were sewage odors detected when arriving at the site? D Yes N No Building Sewer (locate on site plan): I Depth below awl �3i 11: Material of construction: Z cast iron [--] 40 PVC El other (explain): Distance from private water supply well or suction line: 24' feet Comments (on condition of joints, venting. evidence of leakage, etc.): NO EVIDENCE OF LEAKAGE Septic Tank (locate on site plan): Depth below grade: 6"-8" feet Material of construction: 0 concrete El metal El fiberglass El polyethylene F-1 other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes [-] No Dimensions: 5'X8'- 1000 GALLON — Sludge depth: 11"-12" Sire - 3/13 Tit� 5 Official Inspedion Form: Subsu�aoe Sewage Disposal System - Page 9 of 17 ection Form mn - Not for Voluntary Assessments Property Address KIM ARN Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 9/19/14 page. Cityrrown st—ate zip �code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: HOUSE BUILT IN 1967 Were sewage odors detected when arriving at the site? D Yes N No Building Sewer (locate on site plan): I Depth below awl �3i 11: Material of construction: Z cast iron [--] 40 PVC El other (explain): Distance from private water supply well or suction line: 24' feet Comments (on condition of joints, venting. evidence of leakage, etc.): NO EVIDENCE OF LEAKAGE Septic Tank (locate on site plan): Depth below grade: 6"-8" feet Material of construction: 0 concrete El metal El fiberglass El polyethylene F-1 other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes [-] No Dimensions: 5'X8'- 1000 GALLON — Sludge depth: 11"-12" Sire - 3/13 Tit� 5 Official Inspedion Form: Subsu�aoe Sewage Disposal System - Page 9 of 17 <C—N Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 CAMPBELL ROAD Property Address KIM ARN Owner Owners Name information is required for every NORTH ANDOVER MA 01845 9/19/14 page. CityfTown 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 Scum thickness Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 20" How were dimensions determined? SLUDGE JUDGE Comments (on pumping recommendations. inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): INLET AND OUTLET BAFFLE IN PLACE. OUTLET SHOULD BE REPLACED AT TIME OF D BOX REPAIR. LIQUID LEVEL CORRECT. TANK DOES NOT NEED PUMPING AT THIS TIME. OWNER HAD TANK PUMPED ON A REGULAR BASIS. Grease Trap (locate on site plan): Depth below grade: Te—et Material of construction: El concrete El metal El fiberglass polyethylene El other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet Yte or ba e ,jom f 0 Distance from bottom of scum to bottom f outlet tee or baffle Date of last pumping: Date i5ins - 3113 Title 5 Offidal Inspectim Fixm: Subsurface Sewage Dismsal System - Page 10 of 17 <L,,, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 83 CAMPBELL ROAD Property Address KIM ARN Owner Owner's Name information is MA 01845 9/19/14 required for every NORTH ANDOVER page. CityfTown 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: El concrete El metal El fiberglass El polyethylene El -)ther (explain): Dimensions: Capacity: Design Flow: Alarm present: Alarm level: Date of last pumping: gallons gallons per day E] Yes El No Alarm in working order: El Yes 0 No Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). is copy attached? El Yes F� No t5i,s - 3113 Tifte 5 official Jnspsdic� Form Subsurface S�age Disposal SYstem - Pass 11 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 CAMPBELL ROAD Property Address KIM ARN Owner's Name NORTH ANDOVER MA 01845 9/19/14 CityfTown 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 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.): BOX NEEDS TO BE REPLACED. SOME SOLIDS CARRYOVER, LIQUID LEVEL CORRECT. BOX IS 8" BELOW GRADE. Pump Chamber (locate on site plan): Pumps in working order: EI Yes El No* Alarms in working order: 0 Yes El No* Comments (note condition of pump cha r, 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 pI n, excavation not required): If SAS not located, explain why: Sms - 3113 Title 5 Official Inslowation Form: Subsurfew Se�aga Disposal System - Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Insp Subsurface Sewage Disposal System Fo 83 CAMPBELL ROAD D. System Information (cont.) Type: ection Form leaching pits number: rm - Not for Voluntary Assessments leaching chambers number: El leaching galleries number: Property Address leaching trenches number, iangL'h: z KIM ARN number, dimens'ons: El Owner Owner's Name El innovative/alternative system information is required for every NORTH ANDOVER MA 01845 9/19/14 page. Cityrrown St—ate Tip Code Date of Inspection D. System Information (cont.) Type: 11 leaching pits number: E] leaching chambers number: El leaching galleries number: El leaching trenches number, iangL'h: z leaching fields number, dimens'ons: El overflow cesspool number: El innovative/alternative system Type/name of technology: J!LZ(�X30' Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp so;l, condition of vegetation, etc.): SOILS DRY, NO SIGN OF HYDRAULIC FAILURE, VEGETATION NORMAL. USED CAMERA TO LOCATE SIDES AND END OF FIELDS. 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 El Yes El No t5ms - SM3 Title 5 Offidal Inspection Form: SubsQrface Se.999 Disposal System - Page 13 of 17 :LN Commonwealth of Massachusetts uTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,p 83 CAMPBELL ROAD Property Address KIM ARN Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 9/19/14 page. CityfTown 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.): f t5lns - 3113 Title 5 Offidal Inspection Form Subsurface Sewage Djs;Fosal System - Page 14 of 17 _C\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 CAMPBELL ROAD Property Address KIM ARN Owner Owners Name information is :'14 A required for every NORTH ANDOVER MA 01845 page. City/Town State Zip Code Date of Ins.-tection 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 10 feet. Locate wherg.public water supply enters the building, Check one of the boxes below: T(hand-sketch in the area below El drawing attached separately 3 �,oeote-- L 1 isms - 3113 Title 5 Official inspection Fom, Substirface, Sewage Dispsal System - Page 15 of 17 MAL Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 CAMPBELL ROAD Property Address KIM ARN Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 9/19/14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: El Check Slope El Surface water El Check cellar El Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water its'-vation: a F� Obtained from system design plans on record If checked, date of design plan reviewed: -6a—te Observed site (abutting property/observation hole within 150 feet .1 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 filing this Inspection Report, please see Report Completeness Checklist on next page. aline - 3113 Title 5 Official linspectim Famr: Subsurface Sewage DIsPasal System - Page is 0 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 CAMPBELL ROAD Property Address KIM ARN Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 9/19/14 page. Cityrrown State zip �code -6-a-t-e 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 Title 5 Official napeetion Fom S�bauffaci, Sewage Qisposal Symtem - Page 17 el 17 t5ins - 3113 North Andover Health Department fommunity Development Division December 15, 2014 Dear Ms. Smedile, This letter is in response to a question raised regarding the status of the septic system at 83 Campbell Road, North Andover. On October 27, 2014, the NA Health Department received an official Title 5 Inspection form from James Currier, a MA licensed Septic Inspector, identifying that this system "Passes" the criteria set forth by the MA DEP. If a property, such as 83 Campbell, has an onsite septic system that passes a Title 5 inspection, as well has access to municipal sewer, the Health Department does not currently require the abandonment of that system and subsequent connection to the sewer. Note that MA DEP Title 5 inspections only describe conditions at the time of the inspection and are not a guarantee of future function of the system. Tha ou, S san Sa r, S/RS Public Health Director Page 1 of 1 North Andover Health Department, 1600 Osgood Street, Suite 2035, North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 Sawyer, Susan From: Sawyer, Susan Sent: Monday, December 08, 2014 11:55 AM To: Smedile, Rosemary Subject: 83 Campbell Dear Ms. Smedile, This email is in response to a question raised regarding the status of the septic system at 83 Campbell Road, North Andover. On October 27, 2014, the NA Health Department received an official Title 5 Inspection form from James Currier, a MA licensed Septic Inspector, identifying that this system "Passes" the criteria set forth by the MA DEP. If a property, such as 83 Campbell, has an onsite septic system that passes a Title 5 inspection, as well has access to municipal sewer, the Health Department does not currently require the abandonment of that system and subsequent connection to the sewer. Note that MA DEP Title 5 inspections only describe conditions at the time of the inspection and are not a guarantee of future function of the system. Thank you, Susan Susan Sawyer Public Health Director Town of North Andover 1600 Osgood Street Suite 2035 North Andover, MA 01845 Phone 978.688.9540 Fax 978.688.8476 Email mailto:ssawver@townofnorthandover.com Web www.TownofNorthAndover.com 4 etO4iht 1� a om O y ts=�Cetu`��ti Commonwealth of Massachusetts 3w&l Title 5 Official Inspection FormHEcl- p��- a Subsurface Sewage Disposal System Form - Not for Voluntary AssessmeFts C u, i 201/1 83 CAMPBELL ROAD TOWN uF Iyn&Tti n ,vFR Property Address TME HEALTH DEPARN KIM ARN —.: s =� J Owner Owner's Name information is required for every NORTH ANDOVER MA 01845 10/8/14 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor - do not JAMES H CURRIER II use the return key. Name of Inspector SEPTIC &DRAIN Co � Company Name 131 FOREST ST Company Address MIDDLETON MA 01949 City/Town State Zip Code 978-774-6685 S12327 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 ❑ Needs Further Evaluation by the Local Approving Authority 10/10/14 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 -tel_ Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 CAMPBELL ROAD Property Address KIM ARN Owner's Name NORTH ANDOVER MA 01845 10/8/14 Cltylrown 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: ® 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: SYSTEM WORKING PROPERLY 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 83 CAMPBELL ROAD Property Address KIM ARN Owner's Name NORTH ANDOVER City/Town B. Certification (cont.) MA 01845 10/8/14 State Zip Code Date of Inspection ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below).- elow):❑ E] 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 th)34ard of Health: El Conditions exist which require further a aluation 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 • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. t5ins - 3/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 CAMPBELL Property Address KIM ARN V YYIIGI J 110IIIC _---- NORTH ANDOVER MA 01845 10/8/14 City/Town State Zip Code Date of Insnectinn ts. uertitication (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 1/2 day flow Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments cM Svey'et 83 CAMPBELL ROAD Property Address KIM ARN Owner Owner's Name tiis equine for NORTH ANDOVER quired for every MA 01845 10/8/14 age. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No 1:1® Required pumping more than 4 times in the last year NOTdue 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. El * Any portion of a cesspool or privy is within a Zone 1 of a public well. 11 1*Any portion of a cesspool or privy is within 50 feet of a private water supply well. El 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. El® 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. i r p 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 t in 400 feet of a surface drinking water supply ❑ ❑ the system is with feet of a tributary to a surface drinking water supply ❑ ❑ the system is locat d in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a pped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. T`.,, Uw,,-, :,- operator of any large system considered a significant threat under Section E or failed unc:er -Section; r shall upgrade the system in accordance with 310 CMR 15.304. The system owner shou`d conract tl.e appropriate regional office of the Department. t5ins • 3113 Title 5 Official Inspection Form: Subsurface ewage Dispo, al System - Page 5 of 17 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 t in 400 feet of a surface drinking water supply ❑ ❑ the system is with feet of a tributary to a surface drinking water supply ❑ ❑ the system is locat d in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a pped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. T`.,, Uw,,-, :,- operator of any large system considered a significant threat under Section E or failed unc:er -Section; r shall upgrade the system in accordance with 310 CMR 15.304. The system owner shou`d conract tl.e appropriate regional office of the Department. t5ins • 3113 Title 5 Official Inspection Form: Subsurface ewage Dispo, al System - Page 5 of 17 Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 CAMPBELL ROAD Property Address KIM ARN Owner Owner's Name information is NORTH ANDOVER required for every page. Ci crown G. Checklist nno 01845 10/8/14 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): NA Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): NA t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 CAMPBELL ROAD Property Address KIM ARN Owner Owner's Name information is NORTH ANDOVER required for every page. City/Town D. System Information Description: Number of current residents: MA 01845 State Zip Code 10/8/14 Date of Inspection Does residence have a garbage grinder? Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/per s/s . _etc.): Grease trap present? Industrial waste holding tank presen ? Non -sanitary waste discharged to the itle 5 system? Water meter readings, if available: Gallons per day (gpd) ® Yes ❑ No ❑ Yes ® No ® Yes ❑ No ❑ Yes ® No WELL ❑ Yes ® No CURRENT Date L7 Yes ❑ No ❑ Yes ❑ No EJ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 CAMPBELL ROAD D. System Information (cont.) Last date of occupancy/use: Other (describe below): MA 01845 State Zip Code Date 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: 10/8/14 Date of Inspection LPD 6/2/14 - SOURCE - COPY OF INVOICE gallons Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Yes ® No ❑ 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 • 3113 Title 5 Official Inspection form: Subsurface Sewage Disposal System • Page 8 of 17 KIM ARN Owner Owner's Name information is required for every NORTH ANDOVER page. Cityrrown D. System Information (cont.) Last date of occupancy/use: Other (describe below): MA 01845 State Zip Code Date 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: 10/8/14 Date of Inspection LPD 6/2/14 - SOURCE - COPY OF INVOICE gallons Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Yes ® No ❑ 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 • 3113 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 83 CAMPBELL ROAD Property Address KIM ARN Owner Owner's Name required for is every NORTH ANDOVER required for eve MA 01845 10/8/14 page. 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: HOUSE BUILT IN 1967 Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): " Depth below grade: 41feet Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: 24 feet Comments (on condition of joints, venting, evidence of leakage, etc.): NO EVIDENCE OF LEAKAGE Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 6"-S„ fee: ❑ Yes ® No ❑ fiberglass ❑ polyethylene D other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of cerilficate) ❑ Yes ❑ No Dimensions: 5'X8' - 1000 GALLON Sludge depth: 11 "-12" t5ins - 3/13 Title 5 official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 CAMPBELL ROAD r'rOperiy /1a0ress KIM ARN Owner Owner's Name information is NORTH ANDOVER required for every page. City/Town D. System Information (cont.) Septic Tank (cont.) MA 01845 10/8/14 State Zip Code Date of Inspection Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 16" 1" 5" 20" How were dimensions determined? SLUDGE JUDGE Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): INLET AND OUTLET BAFFLE IN PLACE. LIQUID LEVEL CORRECT, TANK DOES NOT NEED PUMPING AT THIS TIME. OWNER HAD TANK PUMPED ON A REGULAR BASIS. D BOX AND OUTLET BAFFLE REPLACED 10/8/14. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal [b fiberglass Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: t5ins - 3/13 feet ❑ polyethylene ❑ other (explain): Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 CAMPBELL ROAD —1-1 , ..,... — KIM ARN Owner Owner's Name information is NORTH ANDOVER required for every MA 01845 10/8/14 page. Clty/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 be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass Dimensions: Capacity: Design Flow: Alarm present: Alarm level: gallons ❑ polyethylene ❑ other (explain): gallons per day ❑ Yes ❑ No 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 83 CAMPBELL ROAD Property Address KIM ARN Owner Owner's Name information is NORTH ANDOVER required for every MA 01845 10/8/14 page. Clty/Town 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.): LIQUID LEVEL CORRECT, NO EVIDENCE OF SOLIDS CARRYOVER. BOX IS 8" BELOW GRADE. D -BOX WAS REPLACED ON 10/8/14. 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.): N - * 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 - 3l13 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 83 CAMPBELL ROAD D. System Information (cont.) Type: -IVFaILY 1UUIUZ)b ❑ KIM ARN Owner Owner's Name information is leaching galleries required for every NORTH ANDOVER page. Clty/Town D. System Information (cont.) Type: ❑ leaching pits ❑ leaching chambers ❑ leaching galleries ❑ leaching trenches ® leaching fields ❑ overflow cesspool ❑ innovative/alternative system Type/name of technology: MA 01845 State Zip Code 10/8/14 Date of Inspection number: number: number: number, length: number, dimensions: 1 20'X30' number: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SOILS DRY, NO SIGN OF HYDRAULIC FAILURE, VEGETATION NORMAL. USED CAMERA TO LOCATE SIDES AND END OF FIELDS. 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 c Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow t5ins - 3/13 ❑ Yes ❑ No Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 CAMPBELL ROAD Property Address KIM ARN Owner's Name NORTH ANDOVER City/Town u. ,ysiem intormation (cont.) MA 01845 State Zip Code 10/8/14 Date of Insnertinn Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of v6getation, 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 Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 CAMPBELL ROAD Property Address KIM ARN Owner Owner's Name information atiis every NORTH ANDOVER MA 01845 required for eve 10/8/14 page. 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 a i it's- -2- lf s— _Z q, t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1s 01 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 CAMPBELL ROAD Property Address - _— KIM ARN Owner Owner's Name information is NORTH ANDOVER required for every MA 01845 10/8/14 page. Clty/Town 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: 6 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: Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: COMPARED BOTTOM OF BASEMENT ELEVATION TO SAS AND FOUND TO BE ABOVE. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 a Commonwealth of Massachusetts 'w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 83 CAMPBELL ROAD riVNCny rAaaress KIM ARN Owner Owner's Name information is NORTH ANDOVER required for every MA 01845 page. City/Town State Zip Code E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked 10/8/14 Date of Inspection ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 10/9/2014 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: G" Complete Repair of D -box and baffle By: John Currier At: 83 Campbell Road Map 106.B Lot 0039 l0rth Andover, MA 01845 of this �erti icaje shall no� be construed as a guarantee that the system will function satisfactorily. Mic'fiele Grant ' Public Health Agent 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com e North Andover Health Department Community Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 83 Campbell Rd. MAP INSTALLER: John Currier DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS D -box and baffle: 10/9/14 DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS Comments: LOT: Contractor reports any changes to design plan H ----E- sting septic tank properly abandoned ❑ Intern umbing all to one building sewer ❑ Topography appreciably altered SEPTIC TANK ❑ Building sewer in continuous grade, on compacted Ti m base �i ❑ Cleanouts pe Ian ❑ Bottom of tank ole has 6" stone base ❑ Weep hole plugg d ❑ 1500 gallon tank h s been installed H-10 loading ❑ Monolithic tank constru tion ❑ Water tightness of tank h been achieved by visual testing Inlet tee installed, centered un er access port Comments: PUMP CHAMBER Comments: CONTROL PANEL Comments: DISTRIBUTION -BOX Comments: ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet ❑ Bottom of tank hole has 6" stone base ❑ p hole plugged ❑ 150 gallon Pump Chamber installed ❑ H-10 ading ❑ Monoli is tank construction ❑ Inlet tee ' stalled, centered under access port ❑ Pump(s) i stalled on stable base ❑ Alarm float orking ❑ Pump On/O oats working ❑ Separate on/o loats ❑ Drain hole in pre ure line ❑ cover at fina rade installed over pump access port ❑ Water tightness of tank as been achieved by testing ❑ Hydraulic cement around in t & outlet E]Alarm & P are on separate circuits El Alarm sounds n float is tripped F-1Location of control anel: basement ❑ Alarm signal located inside: basement Installed on stable stone base H-20 D -Box Inlet tee (if pumped or >0.08'/foot) Hydraulic cement around inlet & outlets Observed even distribution Speed levelers provided (not required) Schedule 40 PVC Pipe Commonwealth of Massachusetts BOARD OF HEALTH North Andover Map -Block -Lot 106.BO039 ----------------------- Permit No BHP -2014-0812 ----------------------- FEE DISPOSAL WORKS CONSTRUCTION PERMIT $125.00 ---------- Permission is hereby granted CurrierSeptic A -Drain- Servi-ce -------------------------------------------------------------- to (Repair) an Individual Sewage Disposal S stem. at No 83 CAMPBELL ROAD ----- ----- -------- -- ------------------------------------------------------ as shown on the application for Disposal Works Construction Permit No. BBP-2014-081 Dated October 09, 2014 ----------------------- ------------------------------ Issued On: Oct -09-2014 ...................... " .............. **'"*"*"*'* ...... * ........ ....... 83 CAMPBELL ROAD Reference No: BHJ-2014-000071 ................................... Permit No: BHP -2014-0812 Department: ................................... North Andover BOARD OF HEALTH ......................................................................................... Account No: 1001001.1.5.0510.00 FeeType: .................................... DWC-Component Repair PERMIT Receipt No: REC-2015-000435 ......................................................................................... .................................... Paid By: Paid in Full On: Thu Oct 09,2014 Currier Septic & Drain Service ................................... ......................................................................................... Check No: 3365 Received By: .................................... Lisa Blackburn ......................................................................................... DEPARTMENT'S COPY Amount: $125.00 L......................................................................................................................................... ..... ............ Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. os� / C�� - 40-69-ftz�sj 4 n4)�- Application for Septic Disposal System (Construction Permit —TOWN OF M• Application is hereby made for a permit to: ❑ Construct a new on-site sewage disposal system* TODAY'S DATE $ 250.00 — Full Repair $125.00 - Component ❑ Repair or replace an existing on-site sewage disposal system* ❑ Repair or replace an existing system component — What? 11Y C " A. Facility Information or Cot # d ^ 106, City/Town 2.- *TYPE OF&EPTIC SYSTEM*: ❑ Pump Z Gravity (choose one) ** If pump system, attach copy of electrical permit to application*** Conventional System (pipe and stone system) ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D -Box Present) S.A.S. 2. Owner I Name ' R-3 l Address (if different from above) City/Town State Zip Code Telephone Number 3. Installer Information Name7 Name of Company 13/ yes S 7-- Address ,Address 14,14 - City/ I own State Zip ode Telephone Number (Cell Phone # if possible please) 4. Designer Information C/�e/ '97f Z07 Name Name of Company Address City/Town State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 N°wT„ Application for Septic Disposal System a Construction Permit -TOWN OF TODAY'S DATE �,$ 250.00 - Full Repair ORTH ANDOVER, MA 01845 A[HUSQ�4y $125.00 -Component PAGE 2 OF 2 A. Facility Information continued.... 5. Type of Building: esidential Dwelling or ❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore -described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of North Andover, and not to place the system in operation until a Certificate of Compliance has been iqued by this Boats of Health. Date � I� Applicat' Ap roved By: (Board of Health Representative) c7Xro i a g l ZPPII/ication Date Di Approved for the following reasons: For Office Use Only: 1. Fee Attached. Yes No 2. Project Manager Obligation Form Attached.? Yes No 3. Pump S sY tem? If so, Attach copy ofElectrical Permit Yes No 4. Foundation As -Built? (new construction ronly): (Same scale as approved plan) Yes No 5. Floor Plans? (new construction only): Yes No Application for Disposal System Construction Permit • Page 2 of 2 Commonwealth of Massachusetts City/Town of North Andover 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 within 14 days from the pumping date in accordance with 310 CMR 15.351. RECEIVED JUL 07 2014 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT A. Facility Information Important: When filling out forms 1. System Locatio on the computer, / S l use only the tab key to move your Address cursor - do not North Andover use the return City/Town key. VQ 2. System Owner: Name 21f0A Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ Other (describe) Ma State State Telephone Number 610 2 Q t't 01886 Zip Code Zip Code Date Uan I y u pe . Gallons ❑ Cesspool(s) �, Septic Tank -❑ Tight Tank ❑ Grease Trap 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: If.yes, was it cleaned? ❑ Yes ❑ No Name Vehi a License Number Stewart's Septic Service Company 7. Location where contentsrvfie a disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Hauler Signature of Receiving Facility Date Date t5form4.doc- 03/06 System Pumping Record - Page 1 of 1 Commonwealth of Massachusetts W City/Town of North Andover RECEIVED System Pumping Record 2012 Form 4 QCT �{ 8 Mg TOvyNOF NOR OVER DEP has provided this form for use by local Boards of Health. Other forms ayiL�i LV14.q* H Ah�D@NT information must be substantially the same as that provided here. Before using Inis TorM, CMUCK with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out forms 1. System Location: on the computer, use only the tab key to move your Address cursor - do not North Andover Ma use the return key. City/Town State Zip Code 2. System Owner: rehan Name Address (if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping p g Date 2. QuantityPumped: p Gallons 3. Type of system: ❑ Cesspool(s) (Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: wart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Si ure of Hauler Date Signature of Receiving Facility Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD D� I•E:'�1 OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) 4 i E OF PUM?INC: /0-`b`oZ. QUANTITY PUMPED lcvd 1'00L: NO YES SEPTICTANK: N'0 YES ✓ 0 URE OF SERVICE: ROUTINE OU E EMERGENCY ! FRV.\TIONS: COOD CONDITION HEAVY CREASC ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER ,) )ILN1 PUMPED BY U, I N•1 FNTS: U-- I I:'N 1'5 TIZANSFCIZIZED TO: _ BULL TO COVER 13AFFLES IN PI_.AC! LEACHFIELD 1ZLNDACK _ FLOODED O,�HER (EXPL.AIN) �y1 � ,77/ TOWN OF NORTH v. DOVES DA 1 1, SYSTEM PUMPIN "I RECORD iYSTEM OWNER ADDRESS DATE OF PUMPING: YSTEM LOCkl-19—qWj H _-QUANTITY PUMPED: SOPOC Tank: NO NA PUKE OF SERVICE: KOUTINE...J,% jEN(-)! FE cl Z, i v NOV — 3 200 4 c 7�20 ObSERVA' .FULLJYJ COVER 6DcoYEO R E. A"S r, BAFFLES IN PLACE ROOT13 LEACKRELD RUNBACK EXCESSIVE SOLIDS.".-- FLOODED SOLID CARRYOVER,....OTKFR EXPLAIN System Pumped by - 6... M.K.Z/ . (–C)7L,,. 19-7a COMMENTS. CUN VENTS rKANSYt;RKED I -L) z lil Mwn tY State zip ode 2, System weer, n N99 Address (If different from location) 1.. Clty/rown State Zlp Code Telephone Number B. Pumping Record 1. Date of Pumping Date t 2. Quantity Pumped: Gallons 3. 1 Type of system:.. ❑ Cesspool(s) Septic Tank ❑Tight Tank Other (describe): j 4, Effluent Tee Filter present? ❑ Yes ❑ No If yes, was 1t cleaned? ❑ Yes No 5. Condition of System: ErmnPu ped �{ �Vehicle License Number al�!b C Company 7, Locatlo where contents were disposed: s n ure f Hauler at , h ; s. disposed- -/7s • `s• " ^•. System Pumping Record Pape 1 of t ti l!s�C� (rC ht�{i4e F (I��1 ( ! KUI 1 SE ?w` C�1� Y �! �Jlt�t'�Il ,'t ��. � ri 9 '\i + � � � - r��, V•1�'. - _ 1 4 mmonwealth �of Massachusetts .�:. ANDOVER M _y�.1`6Wn'of,NORTH ', System Pim In Record • p 9.. .. , Form 4' c7 , DEP has provided this form for use by loyal Boards of Health. The System Pumping Record mu: be submitted to the local Board of Health or other approving authority. _A.• Facility Information . _ r . 1, Sy am�atfon�L-� .,, ,. „►— _ /i/i �� lil Mwn tY State zip ode 2, System weer, n N99 Address (If different from location) 1.. Clty/rown State Zlp Code Telephone Number B. Pumping Record 1. Date of Pumping Date t 2. Quantity Pumped: Gallons 3. 1 Type of system:.. ❑ Cesspool(s) Septic Tank ❑Tight Tank Other (describe): j 4, Effluent Tee Filter present? ❑ Yes ❑ No If yes, was 1t cleaned? ❑ Yes No 5. Condition of System: ErmnPu ped �{ �Vehicle License Number al�!b C Company 7, Locatlo where contents were disposed: s n ure f Hauler at , h ; s. disposed- -/7s • `s• " ^•. System Pumping Record Pape 1 of t TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: SYSTEM WNER & ADDRESS D &4� SYSTEM LOCATION (example: left front of house) DATE OF PUMPING: o , a QUANTITY PUMPED - /000 - GALLONS E V C SSPOOL: NO �/ YES, SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE `" EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS !� SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: .,gnOoVe — SegQ4--1 C, COMMENTS: _CONTENTS TRANSFERRED TO:I }'� r �/(�