HomeMy WebLinkAboutMiscellaneous - 85 CARLTON LANE 4/30/2018 (2)TOWN OI' NORTH ANDOVER
PUBLIC; HEALTH BLPARTMENT
27 CHARLES STREET,
NORTH ANDOVER, MASSACHUSETTS 01845
Sandra Starr
Public Health Director
July 10, 2003
Cliff Speicher
43 Water Street
Beverly, MA
Re: Application for open deck
Dear Mr. Speicher:
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Telephojxe (978) 688-9540
FAX (978) 688-9542 '
Your application for a building permit for an open deck at 85 Carlton Lane, North Andover has been reviewed by
the Health Department. The application was denied on July 10, 2003 for the following reasons:
1. X Missing information
2. ❑ Passing Title 5 inspection of septic system required
3. ❑ Location of structure not acceptable
To address the problem(s):
If #1 is checked, please supply:
a. Floor plan of existing and proposed addition — all rooms
b. Certified plot plan no smaller than 1" = 40' showing house, septic system and proposed
project in scale. Please show the exact location of all 4' concrete footings in relation to the
septic tank,
If #2 is checked:
a. Have the septic system inspected by a certified Title 5 inspector to determine the size of the system
and whether it is operating properly: OR
b. Tie-in to municipal sewer
If #3 is checked:
a. Relocate the project
Please feel free to call the Health Office at 978-688-9540 with any questions you may have.
Sincerely,
Reviewer
Ce: Building Department
Homeowner
File
1Z� (o�X 3U r
FORM U - LOT RELEASE FORM m e c(�
INSTRUCTIONS: This form is used to verify that all necessary approvals/perrnit�s fr
op
Boards and Departments having jurisdiction have been obtained. This does not relieve
the applicant and/or landowner from compliance with any applicable or requirements.
APPLICANT FILLS OUT THIS SECTION******************
APPLICANT �e,� y Ler%T-Dri J�'PHONE��� y 9- ccs'a
LOCATION: Assessor's Map Number 6(oc C PARCEL--M—
SUBDIVISION
ARCELSUBDIVISION LOT (S)
STREET z�� How L N ST. NUMBER.
***►' `"'`*'`**"'` OFFICIAL USE ONLY ********
it
CONSERVATION
COMMENTS
TOWN PLANNER
18Ti7,TJhTJWWM
OF TOWN AGENTS:
FOOD INSPECTOR -HEALTH
SEPTIC INSPECTOR -HEALTH
COMMENTS
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED
DATE APPROVED
DATE REJECTED -
PUBLIC WORKS - SEWERIWATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTO
Revised 9)97 jm
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7/11/03 — Friday
Hi Sandy,
This is regarding 85 Carlton Lane......
Coincidentally you gave me the Form U Denial Letter this morning, and the contractor happened
to come in, and subsequently, the homeowner, Jerry Lemmon. I gave both of them copies of the
letter. The plan is to replace an existing structure (deck) which is currently unsafe, and
contractor was hoping to start it today.
I have attached the sketch out from the contractor, Cliff Speicher of what the plan is. I did go
over your letter with each of them, and reiterated the fact that it is very clear as to what you are
requesting, but h/o is insisting on an appointment to discuss with you.
As access to outlook is down, I cannot check the calendar. Can you let me know what day you
are free next week to meet with him between 9-10 a.m.? Mr. Lemmon would like to meet on
Monday the le if possible. His cell # is: 603-479-2685.
Thanks,
Pam
JUN -16-2003 08:23 PM
`FDECKED OUT DESIGN
978.468.3002 C
www,dec ked(iutdesign.com
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TEL (H) : 7 0 0
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DIMENSIONS `1 ( �30
MATERIAL � e, , �-,t t I p w �' Ih-i
RAIL. 2 k (A M4 u a g n � o�
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DECKING
POST �( y
FOOTING tK to t -c .e
FLOOR HEIGHT
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STEPS
LATTICE
SEPTIC
SET SACKS
44C
SIDING
PERMIT
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7/11/03 —Friday
Hi Sandy,
This is regarding 85 Carlton Lane......
Coincidentally you gave me the Form U Denial Letter this morning, and the contractor happened
to come in, and subsequently, the homeowner, Jerry Lemmon. I gave both of them copies of the
letter. The plan is to replace an existing structure (deck) which is currently unsafe, and
contractor was hoping to start it today.
I have attached the sketch out from the contractor, Cliff Speicher of what the plan is. I did go
over your letter with each of them, and reiterated the fact that it is very clear as to what you are
requesting, but h/o is insisting on an appointment to discuss with you.
As access to outlook is down, I cannot check the calendar. Can you let me know what day you
are free next week to meet with him between 9-10 a.m.? Mr. Lemmon would like to meet on
Monday the 10 if possible. His cell # is: 603-479-2685.
Thanks,
Pam
x 30
FORM U - LOT RELEASE FORM
INSTRUCTIONS: This form is -,used to verify that all necessary approvals/permits�
_o
Boards and Departments havinjurisdiction have been obtained. This does not rele�
the applicant and/or landowner from compliance with any applicable or requirements.
-----"'W ""****APPLICANT FILLS OUT THIS SECTION
APPLICANT , <,n,
LOCATION: Assessor's Map Number t (0 (� C
SUBDIVISION
STREET C) �� L /19
CONSERVATION
COMMENTS ki
USE ONL
N AGENTS:
DATE APPROVED
DATE REJECTED
PHONEG-r03" 441- -A 0-
PARCEL-
LOCATION:
-PARCEL
LOT (S)
ST. NUMBER.
TOWN PLANNER
DATE APPROVED
DATE REJECTED
FOOD INSPECTOR -HEALTH DATE APPROVED
_,d4, / Z ,'li DATE REJECTED
SEPTIC INSPECTOR -HEALTH
COMMENTS
DATE. APPROVED:
DATE REJECTED % t?
PUBLIC WORKS - SEWERAIVATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR
DATE.
Revised 9\97 jm
QOUKONWEALTH OF MASSACHUSETTS
EXEQT 4.OFFICE OF ENVIRONMENTAL AFFAIRS
APAATAWT OF ENVIRONMENTAL PROTECTION
TME 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE. SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address; 85 Carlton: Lane
N-, Andover
OWner'sName:Karcn Pani r `
Owner's Address:
Date of Inspnion:
Name of inspector. (PW" t
Y' p"ltznhn .T SnuCy
Company Name:sn;tcv' Sewer Sere- e T3ic
MailiagAddrm.-
Tekpbone Numbe018 7 6
r. „
-.. ,
CERTIFICATI011I STA,TE� >
I certify that I have pore pay W9600dw a.0wttgt dtspos4l s"
below is true, accwIte aad contplote of0ue time of tttq tits YMm at this address and that the information repotted
training and experitence in the pecgoa The inspection was performed based on my
approved system bss PMP" � and maiAtet>at Of on site sewage disposal systems. i am a DEP
peeto�- rsyant to lon 15.340 otTitle S (310 CMR 1&000 7be system:
Passes
:...._ Coaditioaally passes
Needs Further Evaluation by the Local Approving Authority
FttiJs
Inspector's Stem"'!,
Lot ..,,..,.. Date:
The s -stem , ... .
DEPS within wwv 4;9py of ' iAs cion report to the Approving Authority Board of
C Health or
Bpd or greater, the W�corn greater,"
g Chop. If the sy* is Ashared system or has a design now of 10,040
DEP. The ori • � �e syskm..owner Shell submit ON Mon to the appropriate regional Office of the
su
thorny $ ibouid Sep! to the stem owner and copies sent to the buyer, if applicable, and the approving
Notes and Comments
****This report only describes
time. This lns tetion does. ofeondiaow at the time of utspcction and under the conditions of use at that
conditions of U not anddress 40*0e sYetoat will ".1101`10 in the future under the same or different
Title S h4l)wti6n Form 6/198000
page 1
Page 2 of I 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: as r'arl tnn j,ane
N �nAnvcr' NjA
0184S
Owner: Karen Padir_
Date of lespectton: ;643._...
Inspection Summary: Cheek AAC,D or 1 ALWAYJ complete all of Section D
A, Sy em Paces: '
I bave 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 Conditioaatlly Passes:
One or more system components as described in the "Conditional Pass" section need to be replaced or
repaired The system, upon compledon of. thG,rc. Placement or r P8k, as approved by the Board of Health, will pass.
Answer yes, no or not determined (Y,N,ND) in the
explain. for the following statements. If "not determined" please
-
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 exfiltratiou 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 WSpeetion .jf It is structurally sound, not leaking and if a Certificate of Compliance
indicating that dre tank is less than 20 yoars old is available.
ND explain: .
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health);
broker pipes) are replaced
obstruction is removed
dutributiwt.box is leveled or replaced
ND explain:
The system required Pumping Wors 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 PiPas) are replaced ,
obstr dQu is removed
ND explain;
2 .
Pap 3 of 11
OFFICIAL INSPECTION FORM . NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
PropertYAddress:_$5 Carlton Lane
_ISL And_ a--er ` MA 0184_5
Owner:
Date of Inspection: -
C. Further Evaluation uired by the Board of Health;
Conditions exist which require iltrther evaluation by the Board of Health in order to determine if the system
is failing to protect public be" safety or tho, environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 11303(l)(b) that the
system is not functioning In .& manner which will protect public health, safety and the environment:
_ Cesspool or privy*is within So feat of a surface water
— Cesspool or privy is within SO feet of a bordering vegetated wetland or a salt marsh
Z. System will tail unless the Board of Health (and Public Water Supplier, if any) determines that the
system is functioning in a manner that protests the public health, safety and environment:
_ The system has a septic tank U4 soil abtarpdon system (SAS) and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
— The system has
septic tank and SAS and the SAS is within a Zone I of a public water supply,
The system has a septic tmk and SAS aad 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 feat or more from a
private water supply wet!••. INethod used to determine distance
••This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile prgante compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is.equal to or less than S ppm, provided that no other
failure criteria are triggered. A copy.of the analysis must he attached to this foam.
F
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
ProPertyAddress: 85 Carlton Lane
_K. _An over, U1845
Owner:P i r
Date of Inspection:.
oda
D. System Failure Crheris Applicable to no systems:
You Wig indicate 66yes" or •`Ao" each of the following for ALinspections:
Yes N3iDiWso
o
kup of sewaga into facH'tyorsystemcomponem dug to overloaded or clo ed SASor cesspoole or ponding of eilluent to the
clogged SAS or cesspool surface of the ground or surface waters to an overloaded or
Static liquid level bs the diatrtbuttop box above outlet invert due to an overloaded or clogged SAS or
cesspool
-� uquid depth in cesspool is less than 6" below. invert or available volume is less than % day flow
— --, Required Pumping more than 4 times in the last year MT
of times pumped due to clogged or obstructed pipe(s). Number
/
-..I�
Any Portion of the SAS, cesspool or privy is below high ground water elevation.
_ tf Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
✓ water supply,
y► Any Portion of a cesspaot or privy is within a Zone 1. of a public well.
_. /Any portion of a cesspool or Privy 4 within 50 feet of a private water supply well.
soY portion of a cesspool or pt7jvy; is less than 100 fat but greater than 50 feet from a private water
supply
Y well with no acceptable water quality analysis, )This system passes if the well water analysis,
performed that
a DEP certiQed laboratory, for coliform bacteria and volatile organic compounds
Indicates drat the wen is -free from pollution from tbat facility and the presence of ammonia
nitrogen and nitrate nitrogen Isequalto or less than S ppm, provided that no other failure criteria
triggered. A copy of the analysts must be attached to this form.)
(Yes/No) The system I have determined that one or more of the above failure criteria exist as
desen'bed 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 tho failure.
L Large systems:
To be considered a large system the $ystem must serve a facility with a design flow of 10,000 gpd to 15,000
gPd.
You must indicate eitlter'ygs" or "aa" to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
y no
System
is within 400 feet of a surface drinking watt supply
the system is within 200 feet of a tributary to a surface dri;tkiug water supply
_ the system is located in aYn'
Zone II of a ublic > m smitive area (Interim Wellhead ��on Area - I WPA) or a mapped
P water supply well
If you have answered "yes" to spy question ip Samoa E the aystant is considered a significant threat, or answered
"yes" in Section D above the large system has n4jj S The owner or operator of any large system considered a
significant threat under Section E or failed Wider Section D 1111811 upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
d
Page sof 11
OFFICIAL INSpECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
1`ropCr1yAddMft;-35 Carlton Lane
An o erLPIA"'Oi845
Owner. _Kaadlr
Date of Inspeft on., -
- - ----. --•w. • w wYi� uiolcate es^ 0! "no" aS t0 each of the followin
Y�o Pumping imformatioa was prgvidad by the owner, occupant, or Board ofHeahh
Zw6reanyordmquentcompon-ents Pumped out is theprev► 'o
ata two weeks ?
Hu the system receivod nonwtl flows in the previous two week period ?
'Have largo voluaus of water been introduced to the a
/ ystem recently or as pert of this inspection ?
Were as built alms of the system obtained and examined? (If they were not available note as N/A)
.� Was the facility or dwel '
�1i lrxspecced for signs of sewage back up ?
�-- Was the site inspected for signs of break out ?
were cep system con ts
/components, Cgiudutg the SAS, located on site ?
wo the Septic
of the battles or� manholes umcoye 4 opened, and ttu interior of the tank ins
tees, auuerial of,consauction. dimensions de Pfd for the condition
pth of liquid. depth of sludge and depth of scum ?
_Was the facility owner (sad occupants if different from owner
maintenance of subsurface sewage dispoW systems ? ) pmvidad with information on the proper
The an and loeatton of the Soil Absorption System (SAS) on the site has been determined based ort:
Yqs no
�i1 Existing information. For example, 4.008t at the Board of Health.
_._. Determined in the foldif any y of the failure
Amble) X310 CMR 15.302(3xb)j. criteria related to Part C is at issue approximation of distance
is tunacce.;:
Page 6 of I 1
OFFICIAL INSPECTION FORM = NOT FOR -VOLUNTARY ASSESSMENTS
SUBSURFACESEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C:..,:
SYSTEM INFORMATION
Property Address:. r, Carlton Lane
N_ Andn3rer. MA 01845
Owner:
Date of Inspection:
RESIDENT ONONS
IAL
FLOW CDITI, ..
Number of bedrooms (design): A Number of bedrooms (actual):
DESIGN flow based on 310 C5.203 (for example: 110x # of bedrooms):
Number of current residents: �'
Does residence have a garbage grinder (yes or no): -o &e
Zire
Is laundry on a separatesews sgestein.(yesAr.no): [tyesseparate inspection
Laundry system inspected (yes or no): Nn
Seasonal use: (yes or no):.LO ;
Water meter readings, if available. (last 2 years usage (gpd))
Sump pump (yes or no): ,� L
Last date of occupancy: C
COMMERCUSTRIAL'�`
Type of establishment:
Design flow (based on 310 CMR 15.. 03) d
Basis of design flow (seats/persons/sq-%@ ,):,�. r
Grease trap present (yes or no)
Industrial waste holding tank present (yes. or no):
Non -sanitary waste discharged to the Title;5 system (yes or no):
Water meter readings, if available:
Last date of occupancy/use-
OTHER (describe):
Pumping -Records
G'MM INFORMATION .
Source of infotmation:
Was system pumped as part f the pectiori s o ,%} ,�. -
If yes, volume pumped: he -How was n (ytJf' ('�"
jReasnr pumping; pnped d rm' ed?7-1
SYSTEM
tank, distribution box, soil absorption system ..
_ Single cesspool
_ Overflow cesspogl
_ Privy
_ Shared system (yes or no) (if yes, attach previous inspection records, if any)
_ in dfrom system
ter own -technology, Attach .4 COPY of the current operation and maintenance contract (to be
obtained from system owner)
_•_, Tight tank Attach.a copy of the DEP approval
_ Other (describe):
-------------
Approximate age of all
stalled (if known) and source of information:
Were sewage odors detected when arriving at the site. (yes or no):
6f
Paso .7 of I I
OFFICIAL, INSPEG'TxON FORM
S�SUP'ACI SEWAGE DISPOSAL, SYSOT FOR VOLUNTARY ASSESSMENTS
TEM INSPECTION FORM
SYSTEM O
TION (cwtiaued)
PrOParryAddresss 85 Carlton Lane
Owner: 1L. An over, 1845
Date oit pactioW a. d i r
-
BUILDING SgWgg (gym on sks per)
Depth below Mftd&4 ofgrsde °�
Distance tom f °A' cast ,40 PVC �otberex join .
Comments (oa condition of wpply welt or suction lien: ( ).
venoms, evidence �lakaga� etc.);
SEPTIC TANK; On As
PWS
Depth below;-��...<%
Material of: A
construe ion
—°�i�plw�) " ""'��glass ::,.,P41YethYlene
If teak Is mete! list
certi8cue) �, &- T by a Certiiicete of Compliance ea
Dlmemaions: ��i � : ''; (Y
Sludge depth____(
epth_
Distance Dom lop Of /
Scow thickness; to bpRWm of oyttot tee or We:
------
D from tope
Distance from bottom ofsq � of CHU � or �• �_
How were dimensions to bottom of outlet tee r •�
Commenq (on pumpingdetara°a°d' ,
as related to outlet in i> utd outlet tee a conditio structural irate
' rnde�e.nf >Qrity, liquid levels
or no): (attach a copy of
GREASE TRAP�11�
(locue on sits pw)
Depth below grade;
Material of comstrucdon;
(axpWn):—0*4ante " - - A .,.,.polyetbylane ,___Other
Dimensions:
Scum thickaeu•
Dbume from top of scum -to
tsta= from bottom of of �' --
Date of lou to boohoo toe outlet tea or bale:
Comments (on pump• •---„""'
as nelakd to outlet invert, bap.
a �¢ outlet tee or bIa condition- structural ince
Wiry, liquid levels
7.
Page 8 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
(continued)
PropertyAddrpr:a5 r-arl tnn Lane
Owaer. -
n aP''•a'$tr�.L 01845
Date of Inspeetioa:
TIGHT or HOLDING T tank M" be pumped at time of ins coon ocace on site pe Xl a plan)
Depth below grade
Material of consteuc a�a: 004COO -MOW -L_fibwglm___polyethylene other(explaia):
Dimensions:
Capacity.
Design ow:asday
AlOrta present (y$ or no):
Alarm level; Alam is wot order (yes or no):
Date of last pumping:
Comments (condition of Ilam and float $WhC es, etc.);
DIS . V
DISTRIBUTION 8010. present must be openedXlome on site plan)
Depth of liquid level above outlet iavat; 41,Comments (note if box is kvel _aad distri tuion to outlets equal, any evidence of solids carryover, any evidence of
leakage into or out of box. etc.):Q !_An I,
Page 9 of 11
OFFICIAL INSPECTION FORM _NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE`DISPOSAL SYSTEM INSPECTION FORMPART C
SYSTEM INFORMATION (continued)
Property Addre 5 Carlton Lane
Andover, '"845
Owner: d i r
Date of la=pectioR:
3'...
SOTLABSORPTIONSYSTEM (SAS)...,._ (10 an site plan, excavation not
required)
If SAS not located explain why;
7�tx
— leaching piu, number; _
— ]leaching chambers, number. -
g galleries, number.
S=
oroncqb, number, length;
— och tlelds„ number, dimensi; t _
._ innoVBtivdaj �� y��
Commentsq6tem name oftxhnology:
cote condition of
etc.): ( of hydraulic failure, level of p(linding, damp soilcondition of vegetation,
_ rA n C^1 - A 1% ! n w ,
CESSPOOLS; -64r
esspool must be pumped as part of''
inspection ovate on site plan)
Number and conftguradon:
Depth – top of liquid to inlet invert;
Depth of solids layer.
Depth of scum layer;
Dimensions 6f cesspool.
Materials of construction:
Indication of groundwater iaAow (yes or no):
Comments (note cond'p0A ofaoil, signs ofbydraulie 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 f"ure, level of ponding, condition of vegetation, etc.):
w
r
Page 10 of 11
OFFICIAL INSPECTION FORM _ NOT FOR VOLUNTARY ASSES
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM TS
PART C :.
SYSTEM FORMATION (continued)
t 1,
Prope Addr
Owner: '�"'�1845
Date of
Inspection:°
SKETCH
OF SEWA
Provide
a sketch of the
i4�
benchmarks. M' g, P9 � l 9 4.it.4St two Pe
rmanent reference landmarks or
Locate all We11s wiq 1QQ feet< I:aca� u,6.. o ..,.�.� .= _
e r hP'
}
•n
5
ri
•
r I tri,n•T�n•,
M1}
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5 n
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L
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Pop.11. of 11
OFFICIAL INSPECTION FORM • NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTBM INSPECTION FORM
PART C
SYSTEM 1100 MATION (oaa i we)
Property Addtwr: 81 _ r;4 r 1 on Lane
N- Antic'MC„r,,; MA 01845
Owiter: Karan PaAffir
$ITS &x"
MW_ won
'•
Ck"k NUS/
Shalow welb
Eldomwd depth to WwAd wm „f s,,,, teat
Pkeu todiceto doWain the hiib pound w&W eWvWon:
WM "p AM op MCWd If ob$*A dates of dol p plop reviewed;
=�1 1 i +o0 pt (Wit l Popsy/Ob1et'V *M 4011 wk* 1$0 (W of SAS)
Checked WM bw ldwd of �'
Clw;lood with Iced sxwv#ton, ipaatlbre�.Watt daWpeetasioa)
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COMMONWEALTH OF MASSACHUSETTS
ExECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
,s ONE WINTER STREET, BOSTON, MA 02108 617-292-5500
ARGEO PAUL CELLUCCI
Governor BOB DURAND
Secretary
JANE SWIFT LAUREN A. LISS
Lieutenant Governor Commissioner
October 3, 2000
Local Boards of Health
and
DEP Approved Title 5 System Inspectors
Re: Revised Title 5 System, Inspection Form
Dear Board of Health Members and Title 5 System Inspectors:
The Department of Environmental Protection recently modified the Title 5 System Inspection
Form. The date of this modification Was July 15, 2000. This date is noted at the bottom of the revised
form. Here is a brief overview.of the .changes made to the form:
1. The form is noted as an Official Inspection Form. This form is not to be used for a voluntary
assessment of a Title 5 system. Completion of the form indicates that an official Title 5 system
inspection was performed.
2. The form now contains a disclaimer, at the bottom of the first page, which states that the
inspection indicates the condition of the system at the time of inspection only.
3. The form reiterates the requirement to complete. Section D of part A for all inspections.
4. The.form clarifies language regarding. metal septic tanks (page 2), private well analysis (pages 3
and 4), and large systems (page 4);
5. The form provides more spacing for name and address information and has a cleaner
presentation.
Please discard all other versions of the inspection form and begin using the updated version that is
enclosed with this letter. Should you have any questions or comments regarding the form, please contact
the appropriate DEP Regional Title 5 contact:
- Sincerely,
Lealdon Langley, Director
Watershed Permitting Program
enclosure
cc: DEP Regional Offices Attn: Title 5 contact
DEP Millbury Attn: John Higgins
This laformadon u available Ila alWante format by caUlaq our ADA Coordinator at (617) 574-6872.
DEP on the World Wide Web: htip:1h~.6tate.ma.us/dep
10 Printed on Recycled Paper
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Bill Date: 09/15/98
Bill #: 0009119
Mtr
91 7/1
7
CURRENT WATER RATE $2.60 PER 100 CF. Previous Balance $0.00
CURRENT SEWER RATE $2.75 PER 100 CF. Penalty Charge $0.00
Interest $0.00
:p174.20
Keen 't is nnrrinn t -! m recnrdc
Bill Date:
Bill #:
03/20/98
0003768
Account #: 01-2381000-0
TOWN OF NORTH ANDOVER
Due Date: 04/20/98
Water and Sewer Bill
Svc Addr: 85 CARLTON LN
Mtr Previous
ID. Date ReadingDate
Present Bill Usage
ReadingCode
Water Sewer
001 10/23/97
2648
2/17/98 2683 ACT. 35
$87.15 $0.00.
$87.15
Previous Balance
Penalty Charge
IInt*eriest
Dne.....................................
$0.00
$0.00
$0.00
$87.15
Bill Date: 06/15/99
Bill #: 0009119
Mtr
TOWN OF NORTH ANDOVER `Dunt #: ol-23sl000-o LON
Water and Sewer Bill Due Date: 07/15/99
kk Svc Addr: 85 CARLTON LN
Present Bill Usage ID—A.-_1 ,.-4 g Water Sewer
10011 1/22/991 28741 4/22/991 29291EST 1 55 1 $150.3.5 $0.00 $150.15
i
"Beginning July 1st, a new billing system will Previous Balance
$0.00 I
be put in place. You will be billed quarterly Penalty Charge $0.00
on a 3 -month staggered schedule. Your next bill Interest $0.00
will arrive either Aug 15 Se 15 or Oct 15%
P,
�a1. Due .............................:.::. $150.15
Karn this nnrtion for vour records
Bill Date: 04/14/99 Account #: 01-2381000-0
TOWN OF NORTH ANDOVER
Bill #: 0009119 Due Date: 05/14/99
Water and Sewer Bill
Svc Addr: 85 CARLTON LN
Mtr Previous Present Bill
ID DateReadin Date I Reading Code I Usage Water Sewer
001 12/02/981 28n6 1/22/00 70'7A anm
NEW WATER RATE IS $2.73 PER 100 CF. Previous Balance $1.60
SEWER RATE REMAINS $2.75 PER 100 CF. Penalty Charge $0.00
UNPAID BALANCES WILL BE SUBJECT TO 14% INTEREST Interest S0.00
Bill Date: 01/06/99 Account #: 01-2381000-0
TOWN OF NORTH ANDOVER
Bill #: 0009119 Due Date: 02/05/99
Water and Sewer Bill
Svc Addr: 85 CARLTON LN
Mtr Previous •Present Bill
Usage Water Sewer
ID Date Reading Date Reading Code
001 7/15/98 2766 12/02/98 2806 EST. 40 $109.20 $0.00 $109.20
NEW WATER RATE IS $2.73 PER 100 CF. Previous Balance $0.80
SEWER RATE REMAINS $2.75 PER 100 CF. Penalty Charge $0.00
IJNPATD BALANCES WTT.I. RF. STTR.IF.CT TO 14% TNTF.RFST interest Sn nn
Bill Date:
05/22/98
Bill #: .
0009119
Account#:
01-2381000-0
Service Address: 85 CARLTON LN
Due Date:
06/22/98
Total Due:
$39.84
TOWN OF NORTH ANDOVER
120 MAIN STREET
NO. ANDOVER, MA 01845
Please include this portion with your payment
Water and Sewer Bill
Billing and Service Information:
DEPARTMENT OF PUBLIC WORKS
384 OSGOOD STREET, NO. ANDOVER
TEL: 978-688-9570
HOURS: MON-FRI 8:30 A.M.-4:30 P.M.
Remit to:
TOWN OF NORTH ANDOVER
TREASURER -COLLECTOR'S OFFICE
P.O. BOX 124
PADIR, HALIL & KAREN
85 CARLTON LANE
N. ANDOVER MA 01845
HOURS MON-FRI 8:30-4:30/MON TO 7:30 PM
��a
MAKE PavMENTs Tp TOWN OF NORTH ANDOVER BILL NUMBER 2811
TOWN NQRTH ANi?VR `` .2000 WATER/SEWER BILL CYCLE #12 BILL DATE: 09/27/1999
;':ANO ANDOVERAMA 01$45 q" Account: 2100145
11
Meter: 2100145
w KEViNiF° MAHONEY ,t ' Service: 85 CARLTON LN
„ COLLECTORS �
PADIR, HALIL & KAREN
85 CARLTON LANE
N. ANDOVER MA 01845
Retain this voucher for your. records
DETACH Please detach here and return the bottom voucher with your payment DETACH
PADIR, HALIL & KAREN
85 CARLTON LANE
N. ANDOVER MA 01845
TOWN OF AN
2000 WATER/SEWERTBILLDOVECCYCLE #22 ga ray -m/18/20009
Account: 2100145
Meter: 2100145
Service: 85 CARLTON LN
.Retain this voucher for your records
DETACH Please detach here and return the bottom voucher with your payment DETACH
PADIR, HALIL & KAREN
85 CARLTON LANE
N. ANDOVER MA 01845
6744
2000 WATER/SEWERTBILLDOVER CYCLE #32 PH WAY -554/04/2000
Retain this voucher for your records.
Account: 2100145
Meter: 2100145
Service: 85 CARLTON LN
nFTcru Pla3e dotar,.h_horp.And,return the. bottom voucher with vour navment DETACH
TOWN
OVE
2000 WATERO/SEWERTBILLDCYCLE #42 M WT.96/15/20009
Account: 2100145
Meter: 2100145
Service: 85 CARLTON LN
PADIR, HALIL & KAREN
�l
85 CARLTON LANE
N. ANDOVER MA 01845
Retain this voucher for your records
DETACH Please -detach„ here and return the bottom voucher with your payment
DETACH
PADIR, HALIL & KAREN
85 CARLTON LANE
N. ANDOVER MA 01845
TOWN OF NORTH ANDOVER 2857
2001 WATER/SEWER BILL CYCLE #12 EWL NE�9/15/2000
Account: 2100145
Meter: 2100145
Service: 85 CARLTON LN
Retain this voucher for your records IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
DETACH Please detach here and return the bottom voucher with your payment DETACH
PADIR, HALIL & KAREN.
85 CARLTON LANE
N. ANDOVER MA 01845
TOWN OF NORTH ANDOVER 10602
2001 WATER/SEWER BILL CYCLE #22 BILL 99M.ER2/15/2000
Account: 2100145
Meter: 2100145
Service: 85 CARLTON LN
DETACH Please detach here,and,.return�the bottom. voucher with your payment DETACH
MAKE PAYMENTS TO BILL DATE: 12/15/2000
TOWN OF NORTH ANDOVER BILL NUMBER 10602
2001 WATER/SEWER BILL CYCLE #22
Account: 2100145
Meter: 2100145
Service: 85 CARLTON LN
PADIR, HALIL & KAREN
85 CARLTON LANE
N. ANDOVER MA 01845
Return this voucher with your payment
Retain this
voucher
for your
records:..: Illlllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllulllllllllllllll
DETACH Please detach here,and,.return�the bottom. voucher with your payment DETACH
MAKE PAYMENTS TO BILL DATE: 12/15/2000
TOWN OF NORTH ANDOVER BILL NUMBER 10602
2001 WATER/SEWER BILL CYCLE #22
Account: 2100145
Meter: 2100145
Service: 85 CARLTON LN
PADIR, HALIL & KAREN
85 CARLTON LANE
N. ANDOVER MA 01845
Return this voucher with your payment
TOWN OF NORTH ANDOVER 18720
2001 WATER/SEWER BILL CYCLE #32 ELL WAMBE183/27/2001
PADIR, HALIL & KAREN
85 CARLTON LANE
N. ANDOVER MA 01845
r,
Account: 2100145
Meter: 2100145
Service: 85 CARLTON LN
Retain this voucher for your records IIIIIIIIIIIIIIIilllllll�llllllllllllllllllllllllllllllllll�llllllillllillllllllllllllllllllllllllllllll
PADIR, HALIL & KAREN
85 CARLTON LANE
N. ANDOVER MA 01845
BILL DATE: 03/27/2001
TOWN OF NORTH ANDOVER BILL NUMBER 18720
2001 WATER/SEWER BILL CYCLE #32
Account: 2100145
Meter: 2100145
Service: 85 CARLTON LN
Return this voucher with your payment
MAKE PAYMENTS TO
TOWN OF NORTK ANDOVER 7
P.0 BOX 124
,NO.,,ANDOVER, MA 01845
• z
CHARLES BENEVENTO
TOWN OF NORTH ANDOVER
2001 WATER/SEWER BILL CYCLE #42
COLLECTOR
PADIR, HALIL & KAREN
85 CARLTON LANE
N. ANDOVER MA 01845
Account:
Meter:
Service:
24397
BgLLLL Ml EA/15/2001
2100145
2100145
85 CARLTON LN
Retain this voucher for your records IIIIIIIIIIIII�IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII�IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII�IIIIIIIIII
DETACH Please detach here and return the bottom voucher with your payment DETACH
PADIR, HALIL & KAREN
85 CARLTON LANE
N. ANDOVER MA 01845
TOWN OF NORTH ANDOVER
2001 WATER/SEWER BILL CYCLE #42
Account:
Meter:
Service:
Return this voucher with your payment
BILL DATE: 06/15/2001
BILL NUMBER 24397
2100145
2100145
85 CARLTON LN
PADIR, HALIL & KAREN
85 CARLTON LANE
N. ANDOVER MA 01845
Account:
Meter:
Service:
24397
BgLLLL Ml EA/15/2001
2100145
2100145
85 CARLTON LN
Retain this voucher for your records IIIIIIIIIIIII�IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII�IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII�IIIIIIIIII
DETACH Please detach here and return the bottom voucher with your payment DETACH
PADIR, HALIL & KAREN
85 CARLTON LANE
N. ANDOVER MA 01845
TOWN OF NORTH ANDOVER
2001 WATER/SEWER BILL CYCLE #42
Account:
Meter:
Service:
Return this voucher with your payment
BILL DATE: 06/15/2001
BILL NUMBER 24397
2100145
2100145
85 CARLTON LN
MAKE PAYMENTS TO
TOWN OF'„NORTH ANDOVER
P:O. ` BOX 124
N0, ANDOVER MA 01845 i
CHARLES BENEVENTO
COLLECTOR i
11"�
PADIR, HALIL & KAREN
85 CARLTON LANE
N. ANDOVER MA 01845
TOWN OF NORTH ANDOVER BILL NUMBER 2903
2002 WATER/SEWER BILL CYCLE 012A BILL DATE: 10/31/2001
Account: 2100145
Meter: 2100145
Service: 85 CARLTON LN
Retain this voucher for your records IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII11111111111111111111111111111111INllll
DETACH Please detach here and return the bottom voucher with your payment DETACH
_. .. ...........................
MAKE PAYMENTS TO
TOWN OF NORTH ANDOVER
P.O. BOX 124
NO. ANDOVER MA 01845
CHARLES BENEVENTO ..r
COLLECTOR.
TOWN OF NORTH ANDOVER ' BILL NUMBER 2903
2002 WATER/SEWER BILL CYCLE #12A BILL DATE: 10/31/2001
Account: 2100145
Service: 85 CARLTON LN
Return this voucher with your payment
PADIR, HALIL & KAREN
85 CARLTON LANE
N. ANDOVER MA 01845
TOWN OF NORTH ANDOVER 10786
2002 WATER/SEWER BILL CYCLE 022 ERM Dl BEft/22/2002
Retain this voucher for your records
I
Account: 2100145
Meter: 2100145
Service: 85 CARLTON LN
DETACH. Please, detach here, and return the bottom voucher with your payment DETACH
MAKE PAYMENTS TO TOWN OF NORTH ANDOVERB 10786
TOWN OF NORTH ANDOVER 2002 WATER/SEWER BILL CYCLE #22 BILA IL/22/2002
'P.O; BOX Account: 2100145
NO. ANDOVER.MA 01845 � Service: 85 CARLTON LN
Return this voucher with your payment
MAKE PAYMENT TO:
MAKE PAYMENTS TO
TOWN OF -NORTH ANDOti
P.O. 60X'124
NO... ANDOVER MAw0184
CHARLES BENEVENTO ,
TOWN OF NORTH ANDOVER 20668
C 2002 WATER/SEWER BILL CYCLE #32 Eftt-LL "WPE%/13/2002
Account: 2100145
a"Meter: 2100145
Service: 85 CARLTON LN
COLLECTOR a..
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PADIR, HALIL & KAREN
85 CARLTON LANE
N. ANDOVER MA 01845
Retain this voucher for your records IIIIIIIInIII IN
DETACH Please detach here and return the bottom voucher with your payment DETACH
MAKE PAYMENTS TO
1TOWN'61FNORTH.ANpOVER�
P 0 BOK 124
NO- ANDOVER M&>0184 T;
CHARLES BENEVENTO�'
a^ COLLECTOR'
PADIR, HALIL & KAREN
85 CARLTON LANE
N. ANDOVER MA 01845
Return this voucher with your payment
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II 5o a MYTIC S1STUq
j?qSUJLkT!CK CHBCK LIST LOT li
DATE DIUPPRUM DATIS
12 PEI
Reamnst
OK VU
3`ZPkj%73
Distance Tot
a. Wetlands
b. Drains
0. Well
2. Water Line Location
3. No PVC Pipe
-Septic Tank
-
_a..: -Tees !..-Length & To Glean Oat Covers
b. Cement Pipe to Tank -- On Both Sides of Tank
5. Distribution Box
a. ,Covers & -Box - No Cracks
b. All Lines Flowing Equal Amounts
c. No Back Flow
6.- Leach Field or Trench
a. Dimensions
b. Stone Depth
c, Capped Inds
d. Clem Double Washed Stone
7. Leach Pit
a* Diman Ln s
b. Sto Depth
ca ash Pads
d ees;
e Cement pipe to Pit - Both Sides
Clem Double Washed Stone
8. No Garbage Disposal &Cj- Ar
9. Final Grading Inspection 10
10. Barricading Covered Syslbe,�l
11. As Bunt Submitted Fill 10
a. Lot Location
b. Dimensions of 'System OIJ or '-z-
c. Location with Regard -to Perc Test
d. 'Elevations
a.* Water Table
Board of Health
North AndoversMass
APPROPED�- DATE .'i-lAI- foZ
yFtO�i� �a'�f:..Q�GYtIT�§ Vii=�Q� J
SUBSURFACE DISPOSAL DMCIK CMCK LIST
DISAPPROVED DATE
Reasons s
LOT �9
Title V
Reg 2.5
ear
x
The submitted plan mast show as a minimums
a) the lot to be served-area,dimensions lot #,abattera
b location and log deep observation hoes -distance to ties
c location and results percolation tests -distance to ties
design calculations & calculations showing required leaching area
e) location and dimensions of system -including seserve area
f) existing and proposed contours
g) location any vet areas within 1001 of sewage disposal system or.
. disclaimer -check -wetlands mapping
h) surface and subsurface drains within 1001 of sewage disposal
system or disclaimer
(i) location any drainage easements within 1001 of sewage disposal
system or disclaimer -Planning Board files
known sources of grater supply within 2001 of sewage disposal - _
system or discl.airter
(k) location of any proposed well to serve lot -1001 from leaching facility
(1) location of water lines on property -101 from leaching facility
(m) location of benchmark
(n) driveways
(o) garbage disposals
(p) no PVC to be used in construction
(q) profile of system -elevations of basement, plumb, pipe, septic tank,
distribution box inlets and outlets, distribution field piping and
otter elevations
(r) maximum ground water elevation in area sewage disposal system
s) plan must be prepared by a Professional Engineer or other
professional authorized by law to prepare such plans
✓
--.
IXA,
q
Reg 6 ! Septic Tanks
I(a) capacities -150,% of flow, water table, tees, depth of tees,
access, pumping
(b) cleanout
(c) 101 from collar wall or inground swimming pool -
(d) 251 from subsurface drains
Reg 10.2 Distribution Boxes
(a) slope greater than 0.08
Reg 10.E b) SUMP
TOWNOF ,�,A4� dei
SYSTEM PUMPING RECORD
DATE: I o y'z( "
SYSTEM OWNER & ADDRESS
5 v(
IVA
k -
SYSTEM LOCATION : ....
(example: left front of house) _..
DATE OF PUMPING: QUANTITY PUMPED:
CESSPOOL: NO r YES SEPTIC TANK: NO
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
J
S a -D GALL NS
YES
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste v
commonwealth of Massachusetts
Executive Office of Environmental Affairs -
Department of
•
EnvironmentaU Protection
Wllllam F. Weld
Gowntor
Trudy Coxe
Secretary, EDEA
David B. Struhs
Commissioner
SUBSURFACE SEWAGE DISPOSAL S�STEM INSPECTION FORM L
PART A
pCERTIFICATION
,� /\i
Property Address: 0 P°1uj / �«N� a Address of Owner:
Date of Inspection: V .� �r (If different)
Name of Inspector: S,hm 15 US A
Company Name, Address and Telephone Number:I �' ` �} q,7„' L Ito .4 p
k4o a �v ¢- S ��w� '-�- D 14,4 V. -Vis. i I,
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, amrate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
_ Conditionally Passes
Needs ' Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D:
A] SY TEM PASSES:
i
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 115.303.
Any failure criteria not evaluated are indicated below.
BI SYSTEM CONDITIONALLY PASSES:
One or�more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not)
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
(revised 8/15/95.) 1 .�
One Winter Street • Boston, Massachusetts 02108 • FAX (617) 556-1049 • Telephone (817) 292-5500
i4) Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 0 -
Owner: -Owner:
Date of Inspection:
B] SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the
Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: P k
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is
free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm.
D] SYSTEM FAILS: �1
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Backup of sewage into facility or system component due to an overloaded or dogged 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.
(revised 8/15/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner: APO rk�1"
Date of Inspection:
D) SYSTEM FAILS (continued): � q
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped _
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS: /4 A r
The following criteria apply to large systems in addition to the criteria above:
The design flov� of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety
and the environment because one or more of the following conditions exist:
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 8/15/95)
3
Property Address:
Owner:
Date of Inspection:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
91. kj j4 e
L/,9
/, '# YY4 O U -e✓
Check if the ollowing have been done:
/Pumping information was requested of the owner, occupant, and Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
A -built plans have been obtained and examined. Note if they are not available with N/A.
Ze facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non -sanitary or industrial waste flow
�T a site was inspected for signs of breakout.
I system components, excluding the Soil Absorption System, have been located on the site.
T e septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
es, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
Yhe size and location of the Soil Absorption System on the site has been determined based on existing information or
,pproxlmated by non -intrusive methods.
���/// The facility o,�ner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub -
Surface Disposal System.
(revised 8/15/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 'N' �Jw�1�H �� ,/,/ f7 'Alv0o�'r
Owner: '6rV1 h T
Date of Inspection: t' fes, 6
L( -a1
FLOW CONDITIONS
RESIDENTIAL:
Design flow: U00 gallops
Number of bedrooms: �-1-
Number of current residents:
Garbage grinder (yes or no):- /
Laundry connected to systemyes or no): l�
Seasonal use (yes or no): I.
Water meter readings, if available: �-
Last date of occupancy: 4 p' -e cS
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flow:_gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non -sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of in coon: (yes or no)-XV5
If yes, volume pumped DU allom
Reason for pumping: R -;�Y
4
TYPE SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Other (explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no) -� 0
(revised 8/15/95)
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 0 1 d �K Lam( f y 40 ry
Owner: PN �.-"�•�"
Date of Inspection: h
1I 1
`7 - �y
SEPTIC TANK: P 5
(locate on site plan) f
Depth below grade:
Material of construction: _concrete _metal _FRP —other(explain)
Sludge depth: 2 4i
Distance from top of sludge to bottom of outlet tee or baffle: 3
Scum thickness:. t,
Distance from top of scum to top of outlet tee or baffle:_
Distance from bottom of scum to bottom of outlet tee or baffle:.
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
intoarity avirlonrP of IPakavp atr )
GREASE TRAP:_
(locate on site plan)
Depth below grade:_
Material of construction: _concrete _metal _FRP —other(explain)
Dimensions:
Scum thickness.
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum t- bottom of outlet tee or battle:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 9/15/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
4'y ,S'YSTEM INFORMATION (continued)
Property Address:
Owner: 13 e e
Date of Inspection: L/,
SOIL ABSORPTION SYSTEM (SAS):j '05
(locate on site plan, if possible; excav tion not required, but may be approximated by non -intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:_
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
(J/L.$ A10 11110ypVU IG EP"It'
CESSPOOLS:
(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 (cesspool must be pumped as part of inspection)
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.)
(revised 8/15/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
�+ /� SYSTEM INFORMATION (continued)
Property Address: D C a r � t0 hl �'�`{ �`f 0 U !�
Owner:f�P y y/ •P 14
Date of Inspection: �" L(;z`- C%G
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
Co
DEPTH TO GF
Depth to groundwater: deet
method of determination or approximation:
(revised 6/15/95) 9
30,
r
/
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
�+ /� SYSTEM INFORMATION (continued)
Property Address: D C a r � t0 hl �'�`{ �`f 0 U !�
Owner:f�P y y/ •P 14
Date of Inspection: �" L(;z`- C%G
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
Co
DEPTH TO GF
Depth to groundwater: deet
method of determination or approximation:
(revised 6/15/95) 9
30,
/