HomeMy WebLinkAboutMiscellaneous - 878 WINTER STREET 4/30/2018 (2)ti
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
4
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TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: . ;
Owner's Name: O r((z 7— 1!�LSP�..
Owner's Address: Nov 2 3 2004 1,
Date of Inspection: l0 g Ute/
�--r TOWN OF NORT�-3 F.°'
HEALTH DEPAK :.,,r
Name of Inspector: (please print) ,B/Z/h' �Yr/d+�1eEr
Company Name: ,�%O�.J" "z-t5T �,1JU. x,616
Mailing Address: St cc.?'a SrD/tIl ST
D�,vr .S. ,tiiW o/19 23
Telephone Number: Cc)
CERTIFICATION STATEMENT
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:
L�' /Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: / e
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or
DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page I
_age 2 of 11 ,
F '
OFFICIAL INSPECTION FORM — NOT FOR YOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAVSYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Propelyy A dress: R,7
t/l/• !�!./ bilk/
Owner.
Date of Inspection: /U
Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D
A. System Passes:
1/ /1have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes: 1
One or more system components as described in the "Conditional Pass" section need to be replaced or
repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass.
Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please
explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if (with approval of the Board of Health):
ND explain:
broken pipe(s) are replaced
obstruction is removed
2
Page 3 of 11 b
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 97?
1001
/5L •. J bl.�e/
Owner:
Date of Inspection:/- A
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
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 aseptic tank and soil absorption system (SAS) and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet'of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
**This'system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Page 4 of I 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: F7,? . S
/t%O/Jr'l. /�x/CiGfJW
Owner:
Date of Inspection: /b Q
D. System Failure Criteria applicable to all systems: .
You must indicate "yes or "no" to each of the following for all inspections:
Yes No
•1/ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
t,,***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''/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
_ L' Any portion of the SAS, cesspool or privy is below high ground water elevation.
_✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compoaeds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
P6(Yes/rc he 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: N �/�'"
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either "yes" or "no" to each of the following:
(The following criteria apply to large systems in addition to the criteria above) -
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a trmpped
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.
4
Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: �' - l
Owner:
Date of Inspection: /Ola
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, r Board of Health y/9/O Z
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 part of this inspection ?
—If — Were as built plans of the system obtained and examined? (If they were not available note as N/A) -7
,�
/' 7/ O
Was the facility or dwelling inspected for signs of sewage back up
_/ Was the site inspected for signs of break out ?
I, _ 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 theondition
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:
Yo .
Existing information. For example, a plan at the Board of Health.
Determined in the field (if any of the failure criteria related. to Part Cis at issue approximation of distance
is unacceptable) [3 10 CMR 15.302(3)(b)]
5
'a# Page 6 of 11.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 2i79' W1 H / S-1
,t hIl L A,v do r _e_v
Owner:
Date of Inspection: /D G
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): •. Number of bedrooms (actual): -3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms):
Number of current residents:
Does residence have a garbage grinder (yes or no): /
Is laundry on a separate sewage system (yes or no): � �[if yes separate inspection required]
Laundry system inspected (yes or no):
Seasonal use: (yes or no):
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump (yes or no):
Last date of occupancy: CyAefAXiT
COMMERCIAL/INDUSTRIAL PA
of establishment:
Design flow (based on 310 CMR 15.203): _ gpd
Basis of design flow (seats/persons/sgft,etc.):
Grease trap present (yes or no):
Industrial waste holding tank present (yes or no):
Non -sanitary waste discharged to the Title 5 system (yes or no): _
Water meter readings, if available:
Last date of occupancy/use'..
OTHER (describe):
GENERAL INFORMATION
Pumping Records
Source of information: S j% wr4 t2�' S
Was system pumped as part of the in's'pection (yes or no):
If yes, volume pumped: J ?W gallons -- How was quantity pumped. determined?
Reason for pumping:
TYPEPF SYSTEM
'-Septic tank, distribution box, soil absorption system w4o&,,V d =a
_ Single cesspool
_ Overflow cesspool
_ Privy
_ Shared system (yes or no) (if yes, attach previous inspection records, if any)
_ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be
obtained from system owner)
_ Tight tank Attach a copy of the DEP approval
Other (describe):
Approximate age of all components, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site (yes or no): /y
6
V
Page 7 of 11
OFFICIAL INSPECTION FORM —.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection: >D�1l�4SF
BUILDING SEWER (locate on site plan)
Depth below grade: /y" t —
Materials of construction:. _cast iron 1,`40 PVC _other (explain):
Distance from private water supply well or suction line:
Comments (on condition of joints, venting, evidence of leakage, etc.):
SEPTIC TANK: _ (locate on site plan)
Depth below.grade:
Material of construction: oncrete _metal _fiberglass _polyethylene
—other(explain)
If tank is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no): _(attach a copy of
certificate) + r t
Dimensions:
Sludge depth: t �^
Distance from top of sludge to bottom of outlet tee or baffle: Z
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: y
Distance from bottom of scum to bottom of outlet tee or baffle: Fr
How were dimensions determined: r,, /Z I- /) n / 01&AIJI o,(/
Comments (on pumping recommendations, inlet and outlet tee�or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
L- D t/ileo9 e L. c C jL h/TI OA) f 600 4N
j
GREASE TRAP: _(locate on site plan)�jj
Depth below grade:.
Material of construction: - concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
7
Page S of l l
a
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued).
Property Address: 576- Gl1//1/%,Q,
210147-11 A1UX4,CAZ
Owner:
Date of Inspection: A ! o
TIGHT or HOLDING TANK: 20
(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass _polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present (yes or no):
Alarm level: Alarm in working order (yes or no):
Date of last pumping:
Comments (condition of alarm and float switches, etc.):
DISTRIBUTION BOX:(if present must be opened)(locate on site plan)
r�
Depth of liquid level above outlet invert: 6
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.):
PUMP CHAMBER: /(locate on site plan)
Pumps in working order (yes or no): JL ~
Alarms in working order (yes or no): _y
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.) -
8
w-
- Page 9 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: W/0 1 ,
Owner: /
Date of Inspection: /or�FrlG�
s
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required)
If SAS not located explain why:.
Type
leaching pits, number: _
leaching chambers, number:
leaching galleries, number:
leaching trenches, number, length:
v'feaching fields, number, dimensions:�--
overflow cesspool, number:
innovative/alternative system Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
CESSPOOLS: cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth — top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:'
Indication of groundwater inflow (yes or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRIVY: (locate on site plan) 44
Materials of construction:
Dimensions:
Depth of solids:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM'1NFORMATION (continued)
Property Address: g7� LW/Vr "q
�lJ+ /¢lvd6v
Owner:
Date of Inspection: _
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water suoplXente�rs the building.
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Page 11 of I 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 5%! LVjoUTC/QU
Owner:
Date of Inspection:
SITE EXAM
Slope D - 3
Surface water 4O t
Check cellar
Shallow wells ?�5�
t
Estimated depth to ground water feet
Please indicate (check) all methods used to determine the high ground water elevation:
t...05t—ained from system design plans on record - If checked, date of design plan reviewed:
Observed site (abutting property/observation hole within 150 feet of SAS)
..-'Checked with local Board of Health-explain:
Checked.with local excavators, installers- (attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
49.7' • -�' V4tzi4VCE Crl mr TEZ /_ /j3
TOWN OF NORTH ANDOVER
BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
DATE OF COMPLIANCE:
8/23/00
This is to certify that
the individual subsurface disposal system
constructed ( ) or repaired (X)
by
John Soucy
at
878 Winter Street
has been installed in accordance with the provisions of Title V of the State Sanitary Code
and with the North Andover Board of Health regulations.
The Issuance of this certificate shall not be construed as a guarantee that the system will
function satisfactorily.
Board of Health Inspector
TOWN OF NORTH ANDOVER SEWAGE DISPOSAL SYSTEM
INSTALLATION CERTIFICATION
The undersigned hereby certify that the Sewage Disposal System %) constructed;
( ) repaired;
by_- 0,AI C;cy
located at c� •l i v►,� S e/(,r�1—l-i �y��
was installed in conformance with the North Andover Board of Health approved plan,
System Design Permit #1/zfJ, dated /��� �p� , with an approved design
flow of WO gallons per day. The materials used were in conformance with those
specified on the approved plan; the system was installed in accordance with the
provisions of 310 CMR 15.000, Title 5 and local regulations, and the final grading agrees
substantially with the approved plan. All work is accurately represented on the As -built
which has been submitted to the Board of Health.
Bed inspection date: �;bo /0
Final inspection date: 811-71olo
Installer
Design
9-,/ o 1/t
Engineer Representative
13 6&L�rX
FnQ;nPer Representative
Date: E±--}3-?'V
Date: a�
., 2 2 ,
AS -BUILT CHECKLIST
LOT NUMBER, STREET NAME
l/ ASSESSORS MAP & PARCEL NUMBER
A / LOCATION OFF WAR, GAS, ELECTRIC LINES, CABLE
v DISTANCES FROM CORNERS OF HOUSE TO CENTER OF
TANK & D -BOX
ORIGINAL STAMP & SIGNATURE
y
IMPERVIOUS AREAS - DRIVEWAYS, ETC.
NORTH ARROW
L-.CA7ON & ELEVA I,
c'- �z
OF BENCHMARK USED
a 1
LOT LINES & LOCATION OF DWELLINGS
LOCATIONS & DIMENSIONS OF SYSTEM,
INCLUDING RESERVE
_
TIES TO LOT LINES & DWELLING, WELLS
a. FROM SEPTIC TANK
b. FROM LEACH AREA
LOCATIONS OF DEEP HOLES & PERC
TESTS
ELEVATIONS OF DISPOSAL SYSTEM
y
TOP OF FDN ELEVATION
-
LOCATIONS OF WELLS, DRAINS, WATERCOURSES
WITHIN 150' OF SYSTEM
A / LOCATION OFF WAR, GAS, ELECTRIC LINES, CABLE
v DISTANCES FROM CORNERS OF HOUSE TO CENTER OF
TANK & D -BOX
ORIGINAL STAMP & SIGNATURE
y
IMPERVIOUS AREAS - DRIVEWAYS, ETC.
NORTH ARROW
L-.CA7ON & ELEVA I,
c'- �z
OF BENCHMARK USED
a 1
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INSPECTION CHECKLIST FOR SEPTIC SYSTEMS
A. Bottom of Bed
1. Excavation to proper depth
2. With trenches, sides of excavation are beneath B horizon
3. Edge of excavation specified distance from foundation, etc.
Comments:
B. Retaining Wall
1. Wall height and width as specified
2. Waterproofed
3. Wall minimum 10' to leaching facility
4. Wall meets specifications of plan
Comments:
C. Building Sewer
1. Pipe diameter minimum 4"
2. Schedule 40 pipe
3. Watertight joints ;
4. Inlet to tank cemented
5. Slope minimum 0.01 or 1/8" per foot min, iu
6. Pipe properly set on compact firm base
7. Pipe laid on continuous grade in straight line
8. Cleanouts precede all change in alignment and grade
9. Manholes at any 90° change
10. 10' minimum offset to waterline
Comments:
D. Septic Tank
1. Level
2. 1,500 gal minimum
3. Gas baffle present on outlet
4. Manhole to grade
5. Manholes over center and each tee
6. 3-20" manholes
7. Inlet tee minimum 12" under invert
8. Outlet tee minimum 14" under invert
9. Outlet line cemented t
10. Air space 3" above tees
11. 2" - 3" drop from inlet to outlet
12. Pipe set
13. Compact base with 6" of 3/4" crushed stone under tank
14. Tank is watertight
Comments:
Yes NO
-#S
Yes NO
E. Pump Chamber
/
1.
If separate from tank, compact base with 6" of 1/4" stone underneath
2. Minimum 0.1T' (2") drop from inlet to outlet
2.
Minimum 2" pipe to d -box if gravity system
3.
20" access manhole
5. Compact base with 6" of stone beneath box
4.
Tank level
5.
Watertight
ti
6.
Tank size agrees with plan specification
r/
7.
Manhole to grade
G. Soil Absorption system
8.
Check valve and bleeder hole present
9.
Alarm in building on separate circuit
t
10.
Alarm functions
11.
Manual operating switch
?/
12.
Pump delivers liquid to d -box
�~
Comments:
Bucket test done?
2. Minimum 2". of pea stone above distribution lines
3. Minimum 6" stone beneath pipe
4. Distribution lines capped or connected together
5. Grading meets 3:1 slope
6. Minimum of 9" of fill graded over system +�
7. Toe of slope stops minimum 5' from edge of property; if not, then Swale.
Comments:
H. Leach Trenches
1. Minimum 2 trenches
2. Length of trenches agree with plan. (Max. length 100')
3. Width of trenches agree with plan - Minimum 2'; maximum - 4'.
4. Vent present if <50 feet or specified
5. Distance between trenches minimum 4' and maximum of 6'
6. Minimum distance between trenches 10'
7. Pipe slope minimum 0.005 or 6" per 100'
8. Depth of trenches below outlet invert minimum of 6".
F. Distribution Box
1. D -box level
2. Minimum 0.1T' (2") drop from inlet to outlet
�-
3. Minimum 6" sump
4. Outlet pipes show equal distribution
�-
5. Compact base with 6" of stone beneath box
6. Box is watertight
7. All lines cemented with hydraulic cement
8. Schedule 40 pipe
Comments:
G. Soil Absorption system
1. All stone double -washed -'/."-- 1 ''/z"
- pea stone
Bucket test done?
2. Minimum 2". of pea stone above distribution lines
3. Minimum 6" stone beneath pipe
4. Distribution lines capped or connected together
5. Grading meets 3:1 slope
6. Minimum of 9" of fill graded over system +�
7. Toe of slope stops minimum 5' from edge of property; if not, then Swale.
Comments:
H. Leach Trenches
1. Minimum 2 trenches
2. Length of trenches agree with plan. (Max. length 100')
3. Width of trenches agree with plan - Minimum 2'; maximum - 4'.
4. Vent present if <50 feet or specified
5. Distance between trenches minimum 4' and maximum of 6'
6. Minimum distance between trenches 10'
7. Pipe slope minimum 0.005 or 6" per 100'
8. Depth of trenches below outlet invert minimum of 6".
9. Pipes set on stable base.
Comments:
1. Leach Field
1. Maximum length of field 100'
2. Pipe slope minimum 0.005 or 6" per 100'
3. Separation between pipe 6' maximum
4. Pipes connected at end
5. Separation between adjacent fields 10' minimum
6. Pipes set on stable base
7. Maximum 4' separation from edge of field to first line
8. Minimum two distribution lines
9. Maximum perc rate 20 mpi
Comments:
J. Leaching Pits
1. Minimum inlet pipe 4"
2. Pits of concrete
3. Sidewall between 12" and48" wi
4. Access manholes on each pit
5. Pipes cemented with hydraulic cement
Comments:
K. Final Grade
I. Slope over soil absorption system minimum 0.02
2. All system components covered by at least 9" soil
3. Cover soil free of stones larger than 6"
4. Grading slopes away from dwelling
5. No areas over system that may pond
Yes NO
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APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT
DATE: CtiTtR.Ei iT LNSTALLER'S LICENSE
LOCATI N: 9(7 (ir ---
LICENSED Lti'ST� ER: c) L,�
SIGNATURE:11ATELEPHO, `3 —7
CHECK ONE:
REPAIR: rx,
NEW CONSTRUCTION:
IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT.
Administrative Use Only
575.00 Fee Attached? Yes LIX, No
Foundation As-Buiit? Yes /� No
Floor Plans? Yes vo
Approval /a- )
Date:
INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction of the septic system for the property
at 'e"? ,P, relative to the application of 1,6s4virt/co, o ,
dat t(by,or plans by _��� and dated 4 with
revisions dated /—/&/0—co
I understand and agree to the following obligations for management of this project:
1. As the installer I am obligated to call for any and all inspections. If homeowner, contractor,
project manger, or any other person not associated with my company schedules an inspection
and the system is not ready then item two shall be applicable .
2. As the installer I am required to have the necessary work completed prior to the applicable
inspections as indicated below. I understand that requesting an inspection, without completion
of the items in accordance with Title 5 and the Board of Health Regulations may result in a
$50.00 fine being levied against my company.
a) Bottom of Bed — generally first inspection unless there is a retaining wall which should be done first. Installer
must request the inspection but does not have to be present.
b) Final Inspection — Engineer must first do their inspection for elevations, ties, etc. As -built or verbal OK from
engineer must be submitted to BOH, after which installer calls for inspection time. Installer must be present
for this inspection. With pump system all electrical work must be ready and able to cause pump to work and
alarm to function.
c) - Final Grade — Installer must request inspection when all grading is complete. Does not have to be on site.
i) -
3. As the installer I understand that persons or companies not associated with my company may
not perform the work required by my company to complete the installation of the system
identified in the attached application for installation. I further understand that work by others
unlicensed to install septic systems in North Andover can constitute reasons for denial of the
system, and/or revocation -or suspension of my license in the Town of North Andover plus
significant fines to all persons involved.
4. As the Installer I understand that I must be on site during the performance of the following
construction steps:
a) Determination that the proper elevation of the excavation has been reached.
b) Inspection of the sand and stone to be used.
c) Final inspection by Board of Health staff.
d) Installation of tank, D -box, pipes, stone, vent, pump chamber, retaining wall and other components.
5. As the installer I understand that I am solely responsible for the installation of the system as per
the approved plans. No instructions by the homeowner, general contractor, or any other persons
shall absolve me of this obligation.
Undersigne Licensed Septic taller
Date: GO
NOR71y Town Of North Andover
Community Development & Services William J. Scott
~ Director
4,27 Charles Street
� (978) 688-9531
�* •''' North Andover, Massachusetts 01845
SS�1CHUg� '
Fax 978-688-9542
Board of June 23, 2000
Appeals
(978) 688-9541
Ben Osgood, Jr.
New England Engineering Services, Inc
Building
60 Beechwood Drive
Department
North Andover, MA 01845
(978) 688-9545
Re: 878 Winter Street
Conservation
Department
Dear Mr. Osgood:
(978) 688-9530
This letter comes in response to your letter of June 20, 2000 concerning the
Health requested variances for the proposed septic system repair, at the referenced site.
Department
(978) 688-9540
After review of the proposed plan the following variances have been granted:
1. Reduction in the offset distance between the bottom of the stone in the leach
Public Health bed and the water table from 4 feet to 3 feet. (3 10 CMR 15.212(a)
Nurse 2. Use of a of barrier in lieu of a concrete wall. A 9.02
(978) 688-9543 poly � )
3. Reduction in leach bed size from 900 square feet to 660 square feet. (NA
Planning
Department
(978) 688-9535 Your client and any future owners should be made aware that because of the
combination of variances 1 and 3 there may be no additional rooms added to this
dwelling unless there is a connection to municipal sewer or possibly some form
of alternative system.
With the granting of these variances, the septic plans dated June 6, 2000 for the
repair of the septic system at 878 Winter Street are approved. Please call the
Health office at 978-688-9540 if you have any questions.
tSincerely,
1 Sandra Starr, R.S., C.H.O.
Health Director
Cc: L. Carbone
File
NEW ENGLAND ENGNIc EERING SERVICES
June 20, 2000
Sandra Starr, Administrator
North Andover Health Department
Town Hall Annex
27 Charles Street
North Andover, MA 01845
Re: 878 Winter Street, North Andover, Septic system design
Dear Sandra:
Please accept this letter as a request to have the Board of Health consider the following
local upgrade approvals or variances for the above referenced property.
Local Upgrade Approvals:
1. Reduction in the offset distance between the bottom of the stone in the leach bed and
the water table from 4 feet required by Title 5 section 15.212(a) to 3 feet.
Local Variances Required:
1. Allow the use of a poly barrier in lieu of a concrete wall as an impervious barrier.
2. Allow the reduction in leach bed size from 900 square feet required by North
Andover Health Bylaw Section 9.01(1) to 660 square feet.
This letter is being sent to secure my position on the agenda for the 29`". If these
variances and local upgrade approvals can be approved by you, I would appreciate you
making a decision very soon.
If you have any questions please do not hesitate to contact this office.
Sincerely,
Benja C. Osgoo ,/,EIT
President
X4 22,
1
60 BEECHWOOD bRIVE -NORTH ANDOVER, MA 01845-(978) 686-1768- (888) 359-7645 -FAX (978) 685-1099
Of
NORTH Town Of North Andover
�:4+••o � ',1.00p ~-.
Community Development & Services William J. ScottDirector
• * 27 Charles Street (978) 688-9531
-�-�-• •'''' North Andover, Massachusetts 01845
,`TSACHUSEt
Fax 978-688-9542
Board of
June 16, 2000
Appeals
(978) 688-9541
Mr. Ben Osgood, Jr.
Building
New England Engineering
Department
60 Beechwood Drive
(978) 688-9545
North Andover, MA 01845
Conservation Re: 878 Winter Street, No. Andover
Department
(978) 688-9530
Dear Ben:
Health
Department This correspondence is a follow up to the letter sent June 14, 2000. Regretfully,
(978) 688-9540 the plans dated June 6, 2000 have not been approved as previously stated. This is
Public Health due to the pending approval of the requests for local variances and a local upgrade
as stated on the correspondence, dated June 7, 2000 regarding items 3 and 4 (see
Nurse dh
ttace
(978) 688-9543 attached).
As per our conversation, we anticipate your request letter regarding these items to
Planning
Department be placed on the next Board of Health meeting agenda of June 29, 2000, to be
(978) 688-9535 held at the Senior Center at 7:00pm.
Thank you for your anticipated cooperation.
If you have any questions, please do not hesitate to call the Board of Health
Office at 978-688-9540.
Sincerely,
XSandra Starr, R.S., C.H.O.
Health Director
SS/smc
cc: Carbone
File
f NONT►, 1
O 4�..0 ,� •yam
41
�1SS�n+uge�
Fax 978-688-9542
Board of
Appeals
(978) 688-9541
Building
Department
(978) 688-9545
Conservation
Department
(978) 688-9530
Health
Department
(978) 688-9540
Public Health
Nurse
(978) 688-9543
Planning
Department
(978) 688-9535
Town Of North Andover
Community Development & Services
27 Charles Street
North Andover, Massachusetts 01845
June 14, 2000
Mr. Ben Osgood, Jr.
New England Engineering
60 Beechwood Drive
North Andover, MA 01845
Re: 878 Winter Street, No. Andover
Dear Ben:
William J. Scott
Director
(978) 688-9531
This is to inform you that the revised septic system plan dated June 6, 2000 for
the site referenced above has been approved.
If you have any questions, please do not hesitate to call the Board of Health
Office at 978-688-9540.
Sincerely,
Sandra Starr, R.S., C.H.O.
Health Director
SS/smc
cc: Carbone
File
4WII .
NEW ENGLAND ENGINEERING SERVICES
INC
June 7, 2000
Sandra Starr, Administrator
North Andover Health Department
Town Hall Annex
27 Charles Street
North Andover, MA 01845
Re: 878 Winter Street, North Andover, Septic system design
Dear Sandra:
Enclosed are five copies of a revised septic system design plans for the above referenced
property. The following changes have been made to address the comments in the letter
from Port Engineering dated May 19, 2000.
1. The system elevations have been raised .25 feet. This has been done based upon our
conversation regarding the discrepancy in the test logs done by Richard Tangard and
yourself.
2. The elevations of the top and the bottom of the proposed impervious barrier have
been specified.
3. The waiver request for separation distance to the water table has been added.
4. The local waiver request for use of the poly barrier in lieu of the concrete wall has
been added.
5. A note specifying that the distribution lines shall be connected with solid pipe has
been added.
6. A swale has been added at the south end of the property where the toe of the slope is
closer than 5 feet to the property line.
If you have any questions or need additional information please do not hesitate to contact
this office.
Sincerely,
)3? C_
l 2,lift
BenjL C. Osgood,
President
60 BEECHWOOD DRIVE -NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX(978)`685=1'099'-
Jun -12-00, 03:52P Paul D.
June 12, 2000
POURT
ENGINEERING
Civil Engineers lit
Land Surveyors
One Harris Street
Newburylwrt, NIA
01950
(978)465-8594
Turbide, PE/PLS 978-465-0313 P.02
Sandra Starr
North Andover Board of Health Administrator
Office of Community Development and Services
120 Main Street
North Andover, MA 01845
RE: Title V second review for 878 Winter Street
Dear Sandra,
I find that the design plans with revision date of June 6, 2000 adequately address the
concerns outlined in my report dated May 19, 2000.
If you have any questions or comments please feel free to contact us.
Sincerely ,�.)n
Carlton A. Brown, PE/PLS
May -19-00 10:55A Paul D. Turbide, PE/PLS
PORT
ENGINEERING
Civil Engineers &
i.arid Surveyors
One Harris Street
Newburyport, NIA
01950
(978)465-8594
May 19, 2000
Sandra Starr
North Andover Board of Health Administrator
Office of Community Development and Services
120 Main Street
North Andover, MA 01845
RE: Title V review for 878 Winter Street
Dear Sandra,
978-465-0313 P.02
Enclosed find the "Checklist for North Andover Septic System Plans" for the above-
mentioned site. The following is a list of all the 'Problem' areas and deficiencies Port
Engineering has found.
❑ There is a discrepancy in the logging of TP 2. The plan shows mottling at 42" while
the Town Health Agent field notes shows mottling at 36". If it is determined that
the Town Health Agent's information is correct, then the entire leaching bed must
be raised by 0.5'.
❑ The elevation of the top and bottom of the proposed impervious barrier should be
listed. (The DEP report entitled "Guidance of Maximum Feasible Compliance"
suggests that the bottom of the impervious barrier be 4 feet below the bottom of
leaching bed and at least 2 feet into the natural soils.)
❑ A waiver request to reduce the separation between ESHW and the bottom of system
from the required 4 feet to 3 feet must be added.
❑ A local waiver request from NA 9.02 must be added in order to use a poly barrier
rather than the Town of North Andover requirement that impervious barriers be
made of poured concrete.
❑ A note must be added that distribution lines must be connected with solid pipe. NA
15.01
o A swale is required along the south property line as it abuts the leaching bed
because the toe of slope is closer than 5 feet from the property line. 310 CMR
255(2) .
Minor comments:
o Where is a discrepancy in the logging of TP 2. The plan shows the C, and C2
horizons to have a texture of fine sand while the Town Health Agent field notes
show these horizons to have a texture of sandy loam. Either texture will still be a
Class I soil and therefore will have no effect on the design.
o The existing septic tank will continue to be used according to the design plans. I
assume that the capacity of this existing tank is at least 1000 gallons and that the
baffles are adequate.
Post -it® Fax Note 7671
Date�p # of /
7 pages
To ��1t 1 j
'V v
From n
Co./Dept.
Co.A*6 QL1
Phone #
Phone # f�G,.7p�//�
Fax # 6 c� �� p
Fax #
ict us.
NEW ENGLAND ENGINEERING SERVICES
�k INC
May 8, 2000
Sandra Starr, Administrator
North Andover Health Department
Town Hall Annex
27 Charles Street
North Andover, MA 01845
Re: 878 Winter Street, North Andover, Septic system design
Dear Sandra:
Enclosed are five copies of septic system design plans for the above referenced property.
These plans are being submitted for approval. Also enclosed are the following:
1. Draft soil evaluator sheets.
2. Application for approval.
3. Check for review fee.
If you have any questions or need additional information please do not hesitate to contact
this office.
Sincerely,
Benjamin C. Osgo?al,IT
President
MAY g ,
60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099
i
May -27_99 12:45P North Andover Com. Dev. 508 688 9542
SEPTIC PLAN SUBMITTAL FORM
LOCATION: 52 B
-------------
NEW PLANS: YES
$ l 2 i.00/Plan
REVISED PLANS: YES
$ 60.00/Plan _
SITE EVALUATION FORMS INCLUDED: YES_
NO
DATE: b I �l 00
DESIGN ENGINEER:_— n
DATE TO CONSLFL.TANT:
*If you want your plans expedited, please submit three plans and included a
stamped envelope with the correct amount of postage to mail plans to Port
Engineering.
When the submission__sall in place, route to the Health Secretary.
0-H A�in,avc�i'�
�.,..�
MAY 9
P.O1
BOARD OF HEALTH
NORTH ANDOVER, MASS. 01845
APPLICATION,FOR SOIL TESTS
DATE: 3 1 Z `I( 0o
LOCATION OF SOIL TESTS:y 7P w ,.4eA-- -c--A ae!�Lc
Assessor's map & parcel number: M.4 P 10 Li P P'9 rcet 00
TEL. 688-9540
OWNER: ked&R Cp,esoNl-r TEL. NO.: G7, -g -ss -7 - 006 s'
ADDRESS: 0,-,7.0, W LI) -(--E- I F- sTit C
ENGINEER: C -.ev TFL. NO.: 1i 70- 6,BG -1?6 8
CERTIFIED SOIL EVALUATOR:v�-
Intended use of land: residential subdivision, single family home, commercial
Repair testing C Undeveloped lot testing
N. A. Conservation Commission Approval:
THE FOLLOWING MUST BE INCLUDED WITH: THIS FORM:
Proof of land ownership (Tax bill, deed, or letter from owner permitting
tests)
2. Plot plan
3. Fee of $275.00 per lot for new construction. This covers the minimum two deep holes
and two percolation tests required for each disposal area. Fee of $75.00 per lot for
repairs or upgrades.
GENERAL INFORMATION
1. Only Certified Soil Evaluators may perform deep hole inspections.
2. Only Mass. Registered Sanitarians and Professional Engineers can design septic
plans.
3. At least two deep holes and two percolation tests are required for each septic system
disposal area.
4. Repairs require at least two deep holes and at least one percolation test, at the
discretion of the BOH representative.
5. Full payment will be required for all additional tests within two weeks of testing.
6. Within 45 days of testing, a scaled plan (no smaller than 1 "-100') shall be submitted to
the Board of Health showing the location of all tests (including aborted tests).
7. Within 60 days of testing soil evaluation forms shall be submitted.
MAR 2.4 ,
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W-e-(j,j9AJ D5
TCSI`
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MAR 24_
Applicant_
Site Location
Town of North Andover, Massachusetts Form No. 1
BOARD OF HEALTH r J�
�/ .
APPLICATION FOR SITE TESTING/INSPECTION
Engineer I A UJ— r��
Test/Inspection Date and Time
Fee
A
CHAIRMAN, BOARD O�-EALTH4
Test No. ��!¢
S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No.
O
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FROM R. -C. TANGARD •M PHONE NO. 781-334 0115
FORM 11 - SOIL EXALUA'TOR,
�QRAZ�3:
DRAFT ragc2YfQ:
Location Address or Lot No. G v7�t.i1 4p
On-site Review
o—
Oeep Hole Number ../ ,.. Date:.... `,��%v Time: /Weatha�•l�l�
Location (Identify on site plan) j/."...;.7 ....�.,._........ •.. •...... ...�_........, ........ �.
Lend Use „_.. .. Slope (%1 . "'.. Surface Stones
Vegetation`z�¢ ?�........ _ ..w. �.... _. .. �..
Landform ... -
Position on landscape (sketch on the back) ,.... .
Distances from:
Open Water Body feet Drainage way feet
Possible Wet Area feet Property Line ............ feet
Drinking Water Well . feet Other ... , ... ...............
DEEP OBSERVATION HOLE LOG*
Depth from
Surface (inches)
Sall Horizon
Soil Texture
(USDA)
Soil Color
(Munson)
Soil
Mottling
Other
(Structure, Stones, Boulders, Consistency, %
Gravel)
�/ _ -�
�
-•� L'
��j ,ale /
.�-
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orz
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7 y2
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••••••••••�••• �• •-•vti•,a •��uv�r�c�+ r�i avrni rnuru,cu v1.7r%jQA%L HntlH
Parent Material (geologic) DepthtoBedrock:_
Daoth to Groundwater: Standing Water in the Hole: W Weeping from Pit Face:
w�
Ecpmated Sen'sonal High Ground Water:`
DEP APPROVED FORA! - 12107/95 VAY '� 9
Jll
FROM : R. C. TANGARD
APR. 6.2000 9:47PM
PHONE NO. 781 334 0115
FORM 11 - SOIL EVALUATOR p6I2iki
Patgc 2 of 3
Location Address or Lot No. �7�yl/�/V7��-� �d• �rvl��a��
On sLte- Review
Deep Hole Number -2—,. Datg;T.� 6 Time: /U:, Zo Weather a
Location (identify on Site plant
Land Use_... _ c %�, tri' Slope M ... Surface Stones.. ...., , ......
Landform......,_..
Position on landscape (sketch on the back) ..... .
Distances from:
Open Water Body feet Drainage way .. feet
Possible Wet Area feet Property Line .......... .... feet
Drinking Water Well_ . feet Other. � ... _ ......�,. ,.�,,.
DEEP OBSERVATION HOLE LOG -
Depth from
Surface (inches)
Soil Horizon
Soil Texture
(USDA)
Soil color
(Munsall)
Soil
Mottling
Other
(Structure, Stones, Boulders, Coneinency, %
Gravel)
i
7
MINIMUM
OF
P/47.
Parent Matrrial (aeoiogic) DepthtoBadrock:
Qeoth to Groundwater: Standing Water in the Hole: _ Weeping from Pit Face:
Esymated Seasonal High Ground Water.-
DEP
ater:
UP.N "PROVED FORM -12107/95
FROM : R. r, TANGARD
Location Address or Lot -No.
PHONE N0. 781 334 0115
FORM 11 - SOIL EVALUATOR FORM
Page 2 of 3
Ori -site. evzew
Deep Hole Number , , w Date:.... Time: � : �� WeatheKfZp
Y Y
Location (identify on site )an) _
Land Use,-� Slope M .. Surface Stones _ ....w ..:.....
„4..
Vegetation . w ;� .....:... .... .
Landform .... _. M... . , _ :. .._......:.... : ,.
Position on landscape (sketch on the back) :....:.... .... ... ..............._ ... .
Distances from:
Open Water Body feet Drainage way feet
Possible Wet Area feet Property Line feet
Drinking Water Well .... . feet Other ........ , :_.,.
DEEP OBSERVATION HOLE LOG*
Depth from
Surface (inches)
Soil Horizon
Solt Texture
(USDA)
Soil Color
(Munsell)
Soil
Mottling
Ot)�er
(Structure, Stones, Boulders, Consistency, %
Gravel)
p2-
14
s
L
ellz
�� r�
��/C
fil
��
r�C��
l-�I'�•
75
Df -,S7- .
Parent Material (geologic) _ -` Depthtagadrock: L
DeAth ttt Groundwater Standing Water in the Hole: Weeping from Pit Pace:
Esiimatod Seasonal High Ground Water: ti?
DEP APPROVED FORM • 121071PS
FORM 11 - SOIL EVALUATOR FORM
Page I of 3
No.-.
Commonwealth of Massachusetts
I\h. , Massachusetts
*1!A—_ A Irnr I)rl—vito Kpwd
Date:
6
Date:
Performed By.
.5. .. ....
. . ........... .................................... . .............. ................ ........
Witnessed BY: ..... .........
location Address Or
Address, and
LO(I Telephom I
�ew construction El Repair
Office Review Yes
Published Soil Survey Available: No
❑ Scale Soil Map Unit
Year Published . ........... Publication .......
I3--ei011111 ................................ .......... ... . . ...... .....
Drainage Class Soil Limitations .................... .. .......
................
Surficial Geologic Report Available: No FKI Yes ❑
Year Published Publication Scale
Geologic Material (Map Unit) . ........... .............................. ....... . . ................
.......................... ..........................................
..... . . ....
Landform
.. ...................................................................................................
........................................... ..... .............
Flood Insurance Rate Map:
Above 500 year flood boundary No 0 Yes ❑
Within 500 year flood boundary No oYes Fi
Within 100 year flood boundary No E]Yes n
Wetland Area:
...................... ..............
National Wetland Inventory Map (map unit) ............................ .......................
. ..................
Wetlands Conservancy Program Map (map unit) ............... : .. .................. I ............... .............. .. ... ....
Current Water Resource Conditions (USGS): Month
Range :Above Normal ONormal RIBe1cwNormal El
Other References Reviewed:
ki
AEP APPROVED FORA! -12/07195
I
0
FORM 11 - SOIL EVALUATOR FORM
Page 2 of 3
Location Address or Lot too.
On --site Review
Deep Hole Number .. Date: `'� Time ��� Weather�-4ov ./
TS-...
Location(identify on site plan) ...:::..:.....:.:......::...::...:.............:.::,.....,.:�:...::.:...... ..... .......... ....
Land Use ... j���9�' Slope (%) Surface Stones
Vegetation
Landform
Position on landscape (sketch on the back) SGmf -
Distances from:
Open Water Body feet Drainage way l�. feet
Possible Wet Area �"'� feet Property Line .J`— feet
Drinking Water Well ..: _ feet Other.
DEEP OBSERVATION HOLE LOG*
Depth from
Surface (Inches)
Soil Horizon
Soil Texture
(USDA)
Soil Color
(Munsell)
Soil
Mottling
Other
(Structure, Stones, Bounders, Consistency, °Yo
0 7
sg
���
ale—
"Als
MINIMUM UI- Z HULtb HLUUMU Al cvcrn rnvrvacw vwr vvr+ru �r
Parent Material (geologic)_— 7% LL-- DepthtoBedrock:
r'
Depth to Groundwater: Standing Water in the Hole:_ _ Weeping from Pit Face:
Estimated Seasonal High Ground Water: 4A„ —
iiDEP APPROVED FORM - 12/07/95
FORM 11 - SOIL EVALUATOR FORM
Page 2of3
Location Address or Lot No.
On-site Review
Deep Hole Number :.. Date:... Time:/,. Time:,. WeathelC`���.1��.:...
Location (identify on site plan)IZm..N..?X10::...:.....:.:.........::.....:............ .:.:.r....,.:...._..::..:..... ....:........... ....
Land Use .. 4rq� Slope M Surface Stones
Vegetation
Landform...:: ��%� :.:..::...::.... ..
Position on landscape (sketch on the back) �!>� ..�'GO.:P...:•:..
Distances: from:
Open Water Body .4,00 feet Drainage way feet
Possible Wet Area ./��51 feet Property Line..... feet
Drinking Water Well .. - . feet Other ....,...!. :.:
DEEP OBSERVATION HOLE LOG*
Depth from
Surface (Inches)
Soil Horizon
Soil Texture
(USDA)
Soil Color
(Munsell)
Soil
Mottling
Other
(Structure, Stones, Boulders, Consistency, %
q
,4
C'2 %
�w
�L
O
y'�
,
6 14-
y
.s
er
MINIMUM Uh Z MULL,) F{tUU1nCV III cvr-n I rnwv","w
Parent Material (geologic) Cmr�_% L L' DepthtoBedrock:
_Depth to Groundwater: Standing Water in the Hole: Weeping from Pit Face:
Estimated Seasonal High Ground Water: • •--
DEP APPROVED FORM - 12/07/95
4 1
FORM 11 - SOIL EVALUATOR FORM
Page _2 of 3
Location Address or Lot 140J�� G%g/I l r" `✓� /Va.
On-site Review
b
Deep Hole Number Date :', Time Weather(fJG�y,.:...
Location(identify on site plan).:::.::::..::...::.......:...:.::,..:.:...:......,..::....::..:.........:::::,..:.:...,.,.:...:...... ..........:.:.... :...
Land Use /41_ Slope (%? Surface Stones
Vegetation.. /{� :.::..:.. ..:...::::: .....:..,..
Landform ...: ....,.. ::..., :.... .:. :. ::..
Position on landscape (sketch on the back)��
Distances from: �/
Open Water Body 4� r feet Drainage way �7®. feet
Possible Wet Area 1: '5 — feet Property Line ...��.. feet
Drinking Water Well feet Other ....,.... :.i ......... :.... .... ....
:.:::.
DEEP OBSERVATION HOLE LOG"
Depth from
Surface (Inches)
Soil Horizon
Soil Texture
(USDA)
Soil Color
(Munsell)
Soil
Mottling
Other
(Structure, Stones, Boulders, Consistency, %
Gravel)
�'22�
.,
5
�oi4�
.��,vcr
MINIMUM Ur z NULta ntuUMEW 16%1 C V Lan I rnvr
Parent Material (geologic) <::2n%7%�i/J _, /,.G. G DepthtoBedrock:
i
Depth to Groundwater: Standing Water in the Hole: Weeping from Pit Face:
v
Estimated Seasonal High Ground Water: ••—
DEI' APPROVED FORM • 12/07/95
FORM 11 - SOIL EVALUATOR FORM
Page 3 of 3
Location Address or Lot No. NO
T
Determination for Seasonal High Water Table
Method Used:
❑ Depth observed standing in observation hole ................ inches
❑ Depth weeping from side of observation hole ........... .... inches
Depth to soil ;mottles....: inches2 _ -2-
❑El
Ground watet adjustment ................... feet 3 �8
Index Well Number ................. Reading Date .................. Index ,well level ......._..........
Adjustment factor ................... Adjusted ground water level ........................................................
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas
observed throughout the area proposed for the soil absorption system?
If not, what is thedepth of naturally occurring pervious material?
Certification
I certify that on '40Z4/9� {date) I have passed the soil evaluator examination
approved by the Department of Environmental Protection and that the above analysis
was performed by me consistent with the required training, expertise and experience
described in 310 CMR 15.017.
Signatur �� Date `:241�
DEP APPROVED FORM - 12/07/95
N
Town of North Andover, Massachusetts Form No. 2
NORTF, BOARD OF HEALTH
c
� A 7
♦i -iii
DESIGN APPROVAL FOR
ss""Sf� SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Applicantf'Ldt
Site Location ii?
Reference Plans and Specs
Test No.
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
Fee
LOCATION:
NEW PLANS:
52---
f CHAIRMAN, BOARD --UF HEALTH
Site System Permit No. %rO2()
SEPTIC PLAN SUBMITTAL FORM
179
YES
REVISED PLANS: YES
$125.00/Plan
$ 60.00/Plan
SITE EVALUATION FORMS INCLUDED: YES NO
DATE:
DESIGN ENGINEER:
DATE TO CONSULTANT:
*If you want your plans expedited, please submit three plans and included a
stamped envelope with the correct amount of postage to mail plans to Port
Engineering.
When the submission is all in place, route to the Health Secretary.
`t3
COTIIMOINA�TALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON KA 02108 (617) 292-5500
e�
L�
ARGEO PAUL CELLUCCI
Governor
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address:�Pf S Name of Owner_
4AI a v 4-- Address of Owner: 21.,- ,fy c
Date of Inspection: 3- r Y- 9
Name of Inspector: (Please Print) yL &-Y,*
1 am a DEP approved system inspector pursyarrt to S on 15.340 of True 5 (310 CMR 15.000)
Company Name: I �f
Marring Address:
Telephone Number: .% Z �2
TRUDY CONE
Secretary
DAVID B. STRUHS
Commissioner
CERTIFICATION STATEMENT
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 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
�( FailsZ�y
Inspector's Signature: Ulm( Date: / I f
The System Inspectors all submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)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.
NOTES AND COMMENTS
sn
revised 9/2/98 Pagel of 11
+ice Panted or Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
y _ PART A
�7 j CERTIFICATION (continued)
'roperty Address: 8-70 8 yyW rii e -r 5 � ni Rt t&v-a'j,, M ja .
Jwner: .4,Q t cq i.,
Date of Inspection: r
INSPECTION SUMMARY: Check A, B, C, of D:
A. SYSTEM PASSES:
NDI have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES:
go—
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. -
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, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is 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 complying septic tank as
approved by the Board of Health.
_ 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
— M.Y. .
G
revised 9/2/98 1 Page2oftt
h`1
iw r rr,...wi
-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
fj CERTIFICATION (continued)
Property Address: n t'p t � r 4 t 1 ✓f > / % i
Owner: � e y Ct� CAGZ440Yle
Date of Inspection: `el ` D D
J 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 the
public health, safety and the environment.
11 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF ANY) DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS 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. Method used to determine distance (approximation not valid).
3) OTHER
0
revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 6 r O L44 n i per' 5
Owner: .), e 1Gj� CAR(oc7, rid.
Date of Inspection:
D. SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
I have determined that one or more of the following failure conditions exist as described 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.
Yes No
Backup of sewage into facility- or system component due to an 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. n
d 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:
You must indicate either "Yes" or "No" to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 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:
Yes. No •, - � •- ,, . �.,. _ � ••� n :: ,-.,-. . • -a3' -� � �� ;, - -
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone 11 of a public
water supply well) i
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 Page 4ortt.
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART 8
CHECKLIST
Property Address: �f % O 1'✓r`d)fr/Z 7 U t ra tJG2%
Owner: L s 'q 4 C p rt -o e.
Date of Inspection: -3 / <J— 0
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or 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.
_ toe"' As built plans have been obtained and examined. Note if they are not available with NIA.
The facili4y or dwelling was insp4cted for signs of sewage balup. a
f _ The system does not receive non -sanitary or industrial waste flow.
The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined basedon:
Existing information. For example, Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
[15.302(3)(b)1
The facility owner (and occupants, if different from owner) were provided with information on the proper"maintenanc.8-of
SubSurface Disposal Systems.
1
revised 9/2/98 Page 5of11
4 A&
6'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
'roperty Address: // O / �� �/ l7 % P!i
Owner:
Date of Inspecti
FLOW CONDITIONS
RESIDENTIAL:
Design flow: g.p.d./bedroom. f
Number of bedrooms (design):_`7 Number of bedrooms (actual):_
Total DESIGN flow f
Number of current residents: 4�f
Garbage grinder (yes or no):_�r° S
Laundry (separate system) (yes or no):-L/—G% If yes, separate. inspection required
Laundry system inspected (yes or no)
Seasonal use (yes or no):_
Water meter readings, if avai ale (last two year's usage (gpd):
Sump Pump (yes or no):
Last date of occupancy:�Cc P1 f
COMMERCIALANDUSTRIAL"w ' • ( �
Type of establishment: l4J
Design flow: gpd 1 Based on 15.203)
Basis of design flow
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:
nTHFR- (n PSCrihPl
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information: JJ `" y r Al
�
t 3k j� 4 _.
System pumped as part of inspection: (yes or no) /'" Oct
If yes, volume pumped: gallons Q-5
Reason for pumping:
TYPE OF YSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system lyes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Attach coof up to dame operation and maintenance contract
Tight Tank Copy idf T EP Approval
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: _
Sewage odors detected when arriving at the site: (yes or no)[J
revised 9/2/98 Page 6ofIt
r
p 4
M
aF' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
L SYSTEM INFORMATION (contirxwed)
'roperty Address: j�J'% (,s.> i hT e a2 Cj t A AnWa Ve a .121W .
Owner: ,L e ; q h
!' Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
Depth below grade:_
Material of construction: _ cast iron _ 40 PVC _ other (explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage, -etc.)
SEPTIC TANK:t J5 a
(locate on site plan)
Depth below grade:_$
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list/age _ Is age confirmed by Certificate of Compliance _ (Yes/No)
Dimensions: h r % --d f
Sludge depth:_ 41 1
r i
Distance from top of stud a to bottom of outlet tee or baffle:_
Scum thickness:. 1 i I
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom scr of outlet 'tee or baffle:
How dimensions were determined: 0 %% S %" (f
'omments:
(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.)
GREASE TRAP:
(locate on site plan)` I LL
Depth below grade:_
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Scum thickness: - d'
Distance from top of scum to top' of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or be
Date of last pumping:
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 9/2/98 Page 7Of.)I t'
t
Y
r •
s ;M
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
1 t SYSTEM INFORMATION continued)
'roperty Address: / F%79 W r n �f t7.
Owner: A r f/yt tr 11�Zb3z1
Date of Inspectidn
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
(locate on site plan) �—
Depth below grade:_
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order::Yes _ No
Date of previous pumping: 41 5
Comments: tt
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:y'- S
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
PUMP CHAMBER:
(locate on site plan) / r
Pumps In working order: (Yes or No)
Alarms in working order (Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.).,
revised 9/2/98
f
Page 8 0l 11
p
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'roperty Address: S-9 L�rr ��. �r �'r►7�7 YGt'G. /""'n
Jwner: .� e r,,A c,9R4a,-e
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):_
(locate on site plan, if possible; excavation not required, location may be approximated by non -intrusive methods)
If not located,. explain:
Type:
leaching pits, number:_
leaching chambers, number:_
leaching galleries, number:_
leaching trenches, number, length:_
leaching fields, number, dimensions: - PS 7.(J 4- UU
overflow cesspool, number:_ f,
Alternative system: ,r ( r
Nam of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.)
Lci l+ f e5r 7 ;?;ty '9 til q eve -t C ff / U v /'Z d
CESSPOOLS: _
(locate on site plan)
Number and configuration.
Depth -top of liquid to inlet invert:
Depth of solids layer:
)epth of scum Payer:
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 9/2/98
Page 9 of 11
a
•-•-
�P
ST SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
J) SYSTEM INFORMATION (continued)
Noperty Address: g �%� r,r re rZ 3 b I l /= yrcOv VV.? 13,7,4
)wner: Q ,'� (f qx�,,n E.- r
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
revised 9/2/98
Page 10 of 11
� r
f
0
k-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
e . PART C
SYSTEM INFORMATION (continued)
d
operty Address: J
Jwner:
Date of Inspection:
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
_Shallow wellsy fr cIl
I ; ;i ?
Estimated Depth to Groundwater Feet
r ,
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site (Abutting property, observation hole, basement sump etc.)
V/Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators, installers r
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
revised 9/2/98
Page 11 of 11
st .
I
Commonwealth of Massachusetts
Executive Office of Environmental Affairs KIM 17 19%
Department of
Environmental Protection
Willem F. Weld
Governor
Trudy Coxe
u
Sseny EDEA
David B. Struhs
Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION V t
Property Address: Address of Owner:
Date of Inspection: 3 ^ 2 '�--' �! (If different) r
Name of Inspector: sf4
Company Name, Address and Telephone Number:
r
CERTIFICATION STATEMENT
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 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
0
Inspector's Signature: Date:
The System Inspe or 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 summit
the report to,fhe appropriate regional office of the Department of Environmental Protection.
The original should be sent to the s%lstem owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D:
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] 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 rot)
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 a Boston, Massachusetts 02108 a FAX (617) 556-1049 a Telephone (617) 292-5500
0 Printed on Recycled Paper
- � r
N
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner: C) .It" 0'Al
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 t6
Board of Health):
broken pipe(s) are replaced
obstruction is removed p� ../'
distribution box is levelled or replaced /j Pc s
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: ,X
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 INA 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 feel 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:
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 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.
(revised 8/15/95) 2"
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: U
Ve
Owner: el)'I,�
Date of Inspection: 1y
Check if the following have been done:
� Pumping information was requested of the owner, occupant, and Board of Health.
t'< ne 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.
built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
•/_ Tie system does not receive non -sanitary or industrial waste flow
The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
_-/The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
./,lees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
/approximated
e size and location of the Soil Absorption System on the site has been determined based on existing information or
by non -intrusive methods.
_ The facility o,ti 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
.._
Property Address:
Owner:
Date of Inspection:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Gvl// T r/z S�
RESIDENTIAL:
Design flow: stallons
Number of bedrooms:—.V--
Number
edrooms:,Number of current residents:_
Garbage grinder (yes or no):S
Laundry connected to systems or no):
Seasonal use (yes or no):_L. V
Water meter readings, if available:''
Last date of occupancy:'Pl e i
FLOW CONDITIONS
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:
PUMPING
e of in rmation:
c u 7 ("✓ )w
GENERAL INFORMATION
System pumped as part of inspection: (yes or no) -0
If yes, volume pumped gallons
Reason for pumping: i� ff e. 1 f�`�"
TYPE O TEM
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: 20 Yp �yr
Sewage odors detected when arriving at the site: (yes or no) hlo
(revised 8/15/95)
v' .:.•.- - .`,..-....:+�......�-. ..,...,..y ......gin,. •.w-.. .. •...•„ .�.. .. _. -.--r._ ,_.. -.—v:...... ..>.—.._.,. .i.�.r+,*�,�
1
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-.rrt'1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: (p
Owner.:
Date of Inspection:
�* s
SEPTIC TANK:_
(locate on site plan)
�r
Depth below grade:
Material of construction: _concrete _metal _FRP —other(explain)
Dimensions: ' a
Sludge depth: ^ ,�
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
6"
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffler
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.)
1 AP i. -e 5 co(o 0 061,ki41 7'-iuA-1
Nle. ]—Ot '-C T-LIA c. --y TO
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 8/15/95) r" 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued).
Property Address:
Owner: F•-'r►'r/
Date of Inspection:
TIGHT OR HOLDING TANK:_ d-.
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP —other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:je�
(locate on site plan)
Depth of liquid level above outlet invert:_
Comments:
(note if level and distributicr is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 8/15/95)
7
11
.sw1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION continued)
Property Address:
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):_y,05
(locate on site plan, if possible; excavation 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.)
CESSPOOLS: _ 111"4.
(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) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
DEPTH TO GROUNDWATER
Depth to groundwater: P" feet , 7
method of determination or approximation: AS
(revised 8/15/95)
E
J