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Home My WebLink AboutMiscellaneous - 863 WINTER STREET 4/30/2018 (2)I Q % 0 Ti �� : 2 ) Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. tab serum Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 863 Winter St. Property Address Davies Owner's Name North Andover City/Town MA 01845 State Zip Code 4/20/2013 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. r m® _ A. General Information MAY 0 7 2013 1. Inspector: TOWN OF NORTH ANDOVER Chad Jablonski HEALTH DEPARTMENT Name of Inspector Jablonski & Sons Inc. Company Name 167 Willow Ave Company Address Haverhill MA 01835 City/Town State Zip Code 978-360-9358 4574 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 ature Date YAq /Z-0,3 The system insVector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DERLw In 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 863 Winter St. Property Address Davies Owner's Name North Andover MA 01845 4/20/2013 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: ® 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: SAS and all components in good working order 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 • 09/08 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 Mspec$aon Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 863 Winter St. Property Address Davies Owner's Name North Andover City/Town B. Certification (cont.) B) System Conditionally Passes (cont.): AAA n1AAR QLaLU ciy �,vuc 4/20/2013 Date of Inspection ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ ❑ ❑ broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ❑ Y ❑ Y ❑ Y ❑ N ❑ N ❑ N ❑ ❑ ❑ ND (Explain below): ND (Explain below): ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 official inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 863 Winter St. Property Address Davies Owner's Name North Andover MA 01845 4/20/2013 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for 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/z day flow t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 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 863 Winter St. Property Address Davies Owner's Name North Andover City/Town B. Certification (cont.) Yes No MA 01845 State Zip Code 4/20/2013 Date of Inspection ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts W Title 5 official Inspection Forma Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 863 Winter St. Property Address Davies Owner Owner's Name information is North Andover required for every page. City/Town C. Checklist MA 01845 4/20/2013 State Zip Code Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 660 t5ins • 09/08 Ttle 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 863 Winter St. Property Address Davies Owner Owner's Name information is required for every North Andover MA 01845 4/20/2013 page. City/Town State Zip Code Date of Inspection D. System Information Description: System was design in 2000 for 2 bedrooms. Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required] 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/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: ❑ Yes ® No ❑ Yes ® No ❑ Yes ® No ❑ Yes ® No Private Well ® Yes ❑ No > 1 year Date t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Gallons per day (gpd) ❑ ❑ ❑ Yes ❑ No Yes ❑ No Yes ❑ No t5ins • 09/08 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 4.1 863 Winter St. Property Address Davies Owner Owner's Name information is required for every North Andover MA 01845 4/20/2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other (describe below): General Information Pumping Records: Date Source of information: Home Owner Was system pumped as part of the inspection? If yes, volume pumped: na gallons How was quantity pumped determined? na Reason for pumping: na Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): ❑ Yes ® No t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts W Title 5 official Mspectoon Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 863 Winter St. Property Address Davies Owner Owner's Name information is required for every North Andover MA 01845 4/20/2013 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: As -built dated 11/27/1996 Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: 3711 feet Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: na feet Comments (on condition of joints, venting, evidence of leakage, etc.): Plumbino is in the wall. ❑ Yes ® No Septic Tank (locate on site plan): Depth below grade: 2411eet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: na years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ® No Dimensions: 10'6 x 68 x 64 Sludge depth: 1" t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 0 863 Winter St. Property Address Davies Owner Owner's Name information is North Andover required for every page. CitylTown t5ins • 09/08 MA 01845 State Zip Code 4/20/2013 Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 33" Scum thickness minimal 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 14" How were dimensions determined? measuring tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is structurally sound. Outlet tee has a filter that needs to be cleaned annually. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts W Title 5 official Inspection Forums Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 863 Winter St. Property Address Davies Owner Owner's Name information is North Andover required for every page. City/Town MA 01845 State Zip Code 4/20/2013 Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: Design Flow: gallons gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 863 Winter St. Property Address Davies Owner's Name North Andover MA 01845 4/20/2013 City/7own 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 a 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 is level and distributing equally. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 17 N Commonwealth of Massachusetts w Title 5 official Inspection Forums Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 863 Winter St. Property Address Davies Owner Owner's Name information is North Andover required for every page. City/Town MA 01845 4/20/2013 State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields 1-15'x40' number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No sign of hydraulic failure or ponding. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins - 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 863 Winter St. Property Address Davies Owner Owner's Name information is required for every North Andover MA 01845 4/20/2013 page. City/Town 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 • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 863 Winter St. Property Address Davies Owner Owner's Name information is required for every North Andover MA 01845 4/20/2013 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 ❑ drawing attached separately t5ins • 09/08 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 I Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 863 Winter St. Property Address Davies Owner Owner's Name information is North Andover required for every page. City/Town D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated de th to hi h round water• 01845 Zip Code 4/20/2013 Date of Inspection 4' below bottom of stone V g g feet Please indicate all methods used to determine the high ground water elevation: /1 S Obtained from system design plans on record If checked, date of design plan reviewed: 11/27/1994 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: Soils test performed 4/20/1994 by Marcioda & Sons and witnessed by S. Starr Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts W Title 5 official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 863 Winter St. Property Address Davies Owner Owner's Name information is North Andover MA required for every page. Cityrrown State E. Report Completeness Checklist 01845 4/20/2013 Zip Code Date of Inspection ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. Commonwealth if Massaq�vusa is Title 5""'Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 863 Winter St. Property Address Davies Owner's Name North Andover City/ Town ('11-6 MA 01845 010 Date of 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. A. General Information I nspector: Chad Jablonski Name of Inspector Jablonski & Sons Inc. Company Name 167 Willow Ave Company Address Haverhill Cityrrown 978-360-9358 Telephone Number B. Certification LU State 4574 License Number 01835 Zip Code I certify that 1 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 5 1 r 57,zC,10 Date The systep—ector shall submit a copy of this inspection report to the Approving Authority (Board of Healt DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 r :ter '� _ ' ,�' ,y �. � t, ¢ � :. 11i.-ManolM I Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 863 Winter St. Property Address Davies Owner's Name North Andover MA 01845 5/13/2010 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: ® 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: SAS and all components in good working order 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 - 09/08 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 863 Winter St. Property Address Davies Owner's Name North Andover MA 01845 5/13/2010 Citylrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 1 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 863 Winter St. Property Address Davies Owner's Name North Andover MA 01845 5/13/2010 Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form ~- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 863 Winter St. Property Address Davies Owner Owner's Name information is required for every North Andover MA 01845 5/13/2010 page. City/town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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 the system is within 200 feet of a tributary to a surface drinking water supply tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either `yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 15ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 ' Commonwealth of Massachusetts .. Title 5 Official Inspection Form s+ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 863 Winter St. Property Address Davies Owner Owner's Name information is required for every North Andover MA 01845 5/13/2010 page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 660 t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 Commonwealth of Massachusetts _- _ Title 5 Official Inspection Form 4 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �— 863 Winter St. rruperty Huuress Davies Owner Owner's Name information is North Andover required for every MA 01845 5/13/2010 page. City/Town State Zip Code Date of Inspection D. System Information Description: System was design in 2000 for 2 bedrooms. Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? [if yes separate inspection required] 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/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: n ❑ Yes ® No ❑ Yes ® No ,:Attached.- ® Yes ❑ No Occupied Date Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 863 Winter St. Property Address Davies Owner Owner's Name information is North Andover required for every page. City/Town 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: Home Owner Was system pumped as part of the inspection? If yes, volume pumped: na gallons How was quantity pumped determined? na Reason for pumping: na Type of System: 5/13/2010 Date of Inspection ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form -- u sl Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ARl Wintpr St Property Address Davies Owner Owner's Name information is North Andover MA 01845 5/13/2010 required for every 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: As -built dated 11/27/1996 Were sewage odors detected when arriving at the site? Building Sewer (locate on site plan): Depth below grade: 3711 feet Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: na feet Comments (on condition of joints, venting, evidence of leakage, etc.): Plumbina is in the wall. Septic Tank (locate on site plan): Depth below grade: Material of construction: 0 concrete ❑ metal 24" feet ❑ Yes ® No ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: na years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ® No Dimensions: 10'6 x 68 x 64 Sludge depth: 2" t5ins • 09108 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 M 863 Winter St. Property Address Davies Owner Owner's Name information is required for every North Andover page. CitylTown D. System Information (cont.) Septic Tank (cont.) MA 01845 State Zip Code Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 5/13/2010 Date of Inspection 32" minimal 5" 14" How were dimensions determined. measuring tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is structurally sound. Outlet tee has a filter that needs to be cleaned annually. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness ❑ fiberglass 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: 15ins - 09108 feet ❑ polyethylene ❑ other (explain): Date Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 10 of 17 • Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1 863 Winter St. Property Address Davies Owner Owner's Name information is required for every North Andover MA 01845 5/13/2010 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions.- Capacity: imensions: Capacity: Design Flow: Alarm present: Alarm level: gallons 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 •09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 863 Winter St. Property Address Davies Owner's Name North Andover MA 01845 5/13/2010 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 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.): Box is level and distributing equally. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins • 09/08 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 863 Winter St. Property Address Davies Owner Owner's Name information is required for every North Andover page. City/Town D. System Information (cont.) Type: ❑ leaching pits ❑ leaching chambers ❑ leaching galleries ❑ leaching trenches ® leaching fields ❑ overflow cesspool 11 innovative/alternative system MA 01845 State Zip Code 5/13/2010 Date of Inspection number: number: number: number, length: number, dimensions: 1- 15'x 40' number: Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No sign of hydraulic failure or ponding. 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 t5ins • 09/08 ❑ 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 863 Winter St. Property Address Davies Owner's Name North Andover MA 01845 5/13/2010 City/Town 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 • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 ` Commonwealth of Massachusetts -_- = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M a 863 Winter St. Property Address Davies Owner Owner's Name information is required for every North Andover MA 01845 5/13/2010 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 ❑ drawing attached separately t5ins - 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 863 Winter St. D. System Information (cont.) Site Exam: ® Property Address ® Davies Owner Owner's Name information is required for every North Andover page. Citylrown D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated de th to hi h round water• MA 01845 5/13/2010 Date of Inspection 4' below bottom of stone p g g 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: 11/27/1994 Date 1/27/1994Date 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: Soils test performed 4/20/1994 by Marcioda & Sons and witnessed by S. Starr Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 09108 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 16 of 17 r . Commonwealth of Massachusetts Title 5 Official Inspection Form -- ?l Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' 863 Winter St. Property Address Davies _ Owner Owner's Name information is required for every North Andover MA 01845 page. City/Town State Zip Code E. Report Completeness Checklist 5/13/2010 Date of Inspection ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 09/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 s Form N0.4 Town of North Andover, Massachusetts BOARD OF HEALTH May 29 98 CERTIFICATE OF COMPLIANCE 19 This is to certify that the Individual Soil Absorption Sewage Disposal System constructed (X) or repaired ( ) by INSTALLER at 4 Win has been installed in accordance with Board of Health Regulations as described in the Design _ Approval Site System Permit No. 689 -d ! ated Nov. 27 19 9_ 4 . The issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. BOARD OF HEALTH FOR14 U _ VERIFICATION FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/Permits from Hoards and Departments having jurisdiction have been obtained. This does not relieve the applicant andlor landowner from compliance with any applicable local or state law, regulations or requirements. *-**************-*Applicant fillsd..a�,_th,is section***************** APPLICANT: !%� C'��'� Phone V%-3-76��/ L€CATION: Assessor's Map Number /vy-i5 Parcel ? Subdivision(Z�i/ �r�� r ms' s �r�' Lot (s) Street St. Number G; L ************************Official Use Only************************ RECO,!A/ -i/NS TOWN AGENTS: � �/G Bate Approved (�4� Conservation Administrator Date Reiected Comments Town Planner Comments Food Inffspen/ctor-Health ci}�%" Sp-p`f-ic Inspector -Health Comments Date Approved i ; /�" Date Rejected , Date Approved Date Rejected Date Approved % l Date Rejected Public Works - sewer/water connections - t - . driveway permit \, Fire Department Received by Building Inspector Date I� S-7, a O res • res O co O co L O CDZ Q. O y CD cm D C CO2 0 'a O y O O m m .CD O co O_ H � CD O � � O O CDL !D O a CMQ ca C O 0 D CD C.3 COD C R .0 C cc d CO) O •m C o c � CD ` C H O C CA : : �_ C..2 U U m C = O rL • r i:+ m O D y Ea CD c � m N C C o t �V La rn c.� E acC m v l Q N cm w N A ca v �• ¢ N A y Q `/) u w cz -0 c a atoa w x �: w z v v 00 w 0 o w o G U w o co w w o qj C c4 cn w :j co P4 w w 90 cn cn a O res • res O co O co L O CDZ Q. O y CD cm D C CO2 0 'a O y O O m m .CD O co O_ H � CD O � � O O CDL !D O a CMQ ca C O 0 D CD C.3 COD C R .0 C cc d CO) O •m C o c � CD ` C H O C CA : : �_ C..2 d� m C = O rL • r i:+ m O D y Ea CD c � m N C C o t �V La rn c.� E acC m H N cm m �: mcm N Co �• N A y O m �: nc m = O Z tm E- 1=0 N d C L ' m m O � V H O Z c >cm G O d C_ H y = mm � C fV ~ COD �0+ N m ev Z m c •N C L •E CL=O :- o •— N = O C.3.3 m tm p m C N d m. O-0 ` � O = H A 2 -asm 5 a O res • res O co O co L O CDZ Q. O y CD cm D C CO2 0 'a O y O O m m .CD O co O_ H � CD O � � O O CDL !D O a CMQ ca C O 0 D CD C.3 COD C R .0 C cc d CO) PLAN REVIEW CHECKLIST ADDRESS ZOT 44 Zt)IA172.e �T, ENGINEER /y%,z211G1-11oA/p,q GENERAL 3 COPIES ),0" STAMP LOCUS NORTH ARROW �--'� N SCALE CONTOURS PROFILE ✓ SECTION BENCHMARKS -,. SOIL & PERC INFO �� ELEVATIONS WETS. DISCLAIMER e/ WELLS & WETLANDS ;/ WATERSHED?_�JL DRIVEWAY c.---(Elev) WATER LINE FDN DRAIN SCH40 TESTS CURRENT? SEPTIC TANK MIN 1500G L,"'�.17 INVERT DROP GARB. GRINDER(+200% EDF) 25' TO CELLAR L/ -MANHOLE TO GRADE ELEV `'� GW D -BOX SIZE # LINES FIRST 2' LEVEL STATEMENT INLET/ 3,,d - OUTLET/�3.lJu`�= ./ (2" OR .17 FT) TEE REQ'D? L LEACHING / MIN 660 GPD? C/ RESERVE AREA +/ 4' FROM PRIMARY? L-----2% SLOPE 100' TO WETLANDS t/'100' TO WELLS "" 4' TO S.H.GW 35' TO FND & INTRCPTR DRAINS 325' TO SURFACE H2O SUPP 4' PERM. SOIL BELOW FACILITY ✓ MIN 12" COVERILL? (25'� if above natural elev; 101if below) BREAKOUT MET? �-- TRENCHES MIN 660 SLOPE (min .005 or 6"/100') (/ >31COVER?-VENT SIDEWALL DIST. 2X EFF. W OR D (MIN 61) i/' IS RESERVE BETWEEN TRENCHES?1z IN FILL? L ---MUST BE 10' MIN. �-�'� 4" PEA STONE?_ BOT 400 X LDNG�¢ + SIDE`z�� X LDNG41S = TOT (L x W x #) (G/ft2) (DxLx2x#) (G/ft2) Copyright m 1993 by S.L. Starr For ` "town of North Apiclover) Massachusetts BOARD OF HEALTH µoara___ oE do o " r i ? DISPOSAL WORKS CONSTRUCTION PERMIT 1SS�cNUSEt Applicant --IL!' - TDDP.ES- NAME Site Location wn- yrs individual Soil Ac: ranted to Construct ( ? or Repair Permission is hereby � Sewage Disposal System as shown on the Design Approval S.S.----- N, BOARD of HEALTH D.W,C, No. 2_ _... Fee .��M L� i*. F3 .^J i. "tom+,.i�-..�; i �9.;�..0 ,�� C�).� .'e.�, 1 =. f_M ..'1.�J1. ur DATE: /Q / / _7 _v CL;RREN T INSTA';_,LER'S L,ICENS.E# LOCATION: (n j Z4 //i 1,k)) tA_ LICENSED LNSTALLER: f ►*(Y) KYULt,,L) SIGNATURE: TELEPHONE# CHECK ONE: / REPAIR: NEW CONSTRUCTION: ✓ IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. Administrative Use Only $75.00 Fee Attached? Yes No Foundation As -Built? Yes No Approval Date: f NORTH O+"'.. ,, 'x+ O � F 3 CHUSEt� Town of North Andover, Massachusetts BOARD OF HEALTH Form No. 2 DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant—LMLr4Ln XLN��- Test No - Site Location 1577(1.9 G Reference Plans and Specs. / ENGINEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. Fee 0 CHAIRMAN, BOARD OF HEALTH Site System Permit No. DATE W,00, a 7 Sheet of BOARD OF HEALTH TOWN OF NORTH ANDOVER b / SUBSURFACE DISPOSAL DESIGN REVIEW ` FEE 0 PERMIT # L/p�j o 0 / DATE RECEIVEDIJ/ APPLICANT -DC t —gz5 GSC ADDRESS Dov ENGINEER ADDRESS A,9 --Z ASSESSOR'S MAP_ PARCEL # A LOT # _411 STREET LA)1A-j7-64 5.T: PLAN DATE ( Je-77 /®, /%9'4 REVISION DATE CONDITIONS OF APPROVAL:.--6C--A),---/-//4eZ 70 APPROVED DISAPPROVED New Hampshire Barrington 603-664-2111 Manchester 603-645-0049 Portsmouth 603-436-5818 Plymouth 603-536-2656 Derry 603-437-6854 Laconia 603-524-6317 Maine Portland 207-774-7373 Biddeford 207-282-3522 Mass. Lawrence 508-689-7221 Lowell 508-458-4807 Haverhill 508-374-4020 September 4, 1996 Winter Street Realty Trust Attn: Steven Doherty, Jr. 40 Hunters Run Place Haverhill, MA 01832 REF: Lot #4A, 855 Winter Street, North Andover, MA. To whom it may concern: This letter is to report that Downeast Drilling Company, Inc., has performed a water flow test on lot #4A, 855 Winter Street, in North Andover, MA. Harry Sturtevant ran the 4 hour water flow test and the pump meets the requirements of the FHA/VA at 5 GPM. Should you have any questions, or require additional information, please do not hesitate to call us. Sincerely, ".q I V r George LaRocque Sales Associate Downeast Drilling Company, Inc. General Offices: 23 Pierce Road ® Barrington, NH 03825-3615 i �,e � � p �'�i� �� 5 U� ��3T� North Andover Water Treatment Plant Lab 420 Great Pond Road * North Andover, MA 01845 * (508) 688-9574 Mass Certification No. for Bacterial Analysis * M-21054 Sample Number: A2918 Sample Date: 5/26/98 Submitted By: Winter Street Realty Trust 863 Winter Street North Andover, MA 01845 Sample Source: Private Well - 863 Winter Street - North Andover, Ma. Analysis: MAY 2 8 . Total Coliform Bacteria .......................................... 0 per 100 ml pH................................................................... 7.68 Color..................................................................15 color units Turbidity............................................................. 2.4 turbidity units Nitrate................................................................ 0.03 mg/l Comments: The maximum level for well water turbidity is 1.0 turbidity units, and for color 15 color units. As you can see, this well has exceeded the turbidity levels set by the state and is at the highest level allowed for color. This can, in the future, interfere with chlorination of the well. The nitrate level is well below the standard of 10 mg/l, and the bacteria count is negative. If you have any further questions please call us at the above number. Linda Hmurciak - Lab Director SEP -23-1996 17:25 B I 0MRR I NE P. 01 11" Biomarine Id 16 EAST MAIN STRLe7, p.d. BOX 1153, GLOUCESTER, MA 01931.1153 TELEPHONE: (508) 281-0222 FAX, (508) 283-3374 CERTIFICATE OF RNOLYSIS Report No,: 961811 Mr_ Stephen Doherty Jr- September 28, 1996 ! 4o Hunter's Rqn Haverhill, MA 131832 WRTER QUFILITY ANALYSIS Well Dem: New well, located on Lot 4A, 855 Winter Street, North Andover. MA, Ssmplirt V Samples taken by customer on September 19, 1996 at 3 P.m. Findin-gl: �� parameter Leluel MCL Analysis Detected Guideline* nate Total Coliforrn Bacterial Count/100 mL 0 0 09119!96 1.B (slightly alkaline) - 6:5=6.5 09/20/96 - _ .pH Value ... _ 09/20/96 ill Hardness (CaCO3, rngA-) i08 (moderate} , r 3.75 _ 09/20156 , } t Specific' Conductance (pmhos/cm) i Chloride Content (mg)L) 3,52 250 09/201!96 t I{ 10 09/20/96 F , Nitrate Nitrogen Content (mg1L) c0.1 f iron Content (mg/L) 0,78 0.3 09/22196 � •. Manganese Content (mgti) 0-09 0.05 09/22196 t ;Contdnt m /L 26 09/22/96 • Sodiums, ( 9 ) � , � =�f Qjj,; for tete Examination► of Water & I Meth ds. Analyses performed in acc u { € oontaminant levels recommended by t t�'astewater, 1$th Edition, 1992, "Guidelines are baseQ the Massachusbtts Department of Environmental Pro#action for drinking water. `t Remarks: iroh combines with oxygen from air to form a reddish brown precipitate commonly called rust. Manganese is eery similar, but forms abrownish-black precipitate. The Iron and Manganese levels detected may j utensils. After a pr caLise the water to taste "rusty" and stain fabrics, plumbing and seldines�sThis dbui{dup reduces the available olonoed peno� iron deposits can build up in pressure tanks, water heaters, pipelines. t quantity Gild pressure of the water supply. Care should be taken when using chlorine bleach in the laundry as the chemical reacti(an with the iron and manganese may intensify staining, Non -chlorine bleach is preferred, a ant i 1 The guideline fc>r Sodium, when exceeded, guidelinetar level otf Sodium n water that physicians and Sodium. r t sciverse.health ;:effects. Rather, the g40 2T0 sensitive individuals should be aware of in cases where Sodium exposur®s are being carefully controlled, Up mg/_ is gel, anally considered acceptable for a moderately restricted diet. (4 Filtration is available to correct these levels if continued usage and flushing of the well does not cause #h®m to ab'a'te. •A ! ` r ed 8y1 ApprovJahn Marletta/Lab Director ' 1✓ , '. - d � `� � "` �.. to , Mass Certified Laboratories MA026 and MAI 23 . w 4 i