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HomeMy WebLinkAboutMiscellaneous - 885 FOREST STREET 4/30/2018 (2)fr » to C14 0 # c % k k \ \ 0 2 e � k - � ® � � k 2 § � ■ § a k 0- 2 � Ouj o @ 10 uj C 3 4 uj 2 /CO LL § § E§ U) a. 40. Q 7 � k � 2 2 k / 2 ,2 B) / 2 ® � I m k 2 p kLu § C LL $ k § � ■ � c E ■ � 2 LLo f aLL rL , $ v k k \ co cn » -6 Commonwealth of Massachusetts 0 Tale 5 Official Inspection Form 19 Not for Voluntary Assessments Subsurface Sewage Disposal System Form M y •y`' Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. —1� �eom Inspection results must be submitted on this form or on the official Title 5 Inspection Fere 611512000. Inspection forms may not be altered in any way. A. Certification I RECEIVED 1. Property Information: .895 Forest St N. Andover Property Address Peter Simonson Owner's Name 895 Forest St Owner's Address N. Andover City/Town Date of Inspection: 2. Inspector: N. Timothy White Name of Inspector HomePro Northshore Company Name P.O. Box 101 Company Address Rowley City/Town 1-978-948-8428 Telephone Number Ma. State Date Ma State MAR 0 9 2006 HEALTH DEPARTMENT 01845 Zip Code 01969 Zip Code 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: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority h. �.�w� i.t,J' - 3-4-06 Inspector's Signature NDate The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. TITLE V.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 1 of 16 r ` N Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments M V' Subsurface Sewage Disposal System Form A. Certification (cont.) 895 Forest St Property Address N. Andover Ma Cityrrown State Peter Simonson 3-4-06 Owner's Name Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: 01845 Zip Code ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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: na TITLE V.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M 5w y A. Certification (cont.) 895 Forest St Property Address N. Andover Cityrrown Peter Simonson Owner's Name B) System Conditionally Passes (cont.): Ma State 3-4-06 Date of Inspection 01845 Zip Code ❑ 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: N.a. ❑ 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 ❑ obstruction is removed ND Explain: NA 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 TITLE V.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 3 of 16 Commonwealth of Massachusetts . Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M SVy,• A. Certification (cont.) 895 Forest St Property Address N. Andover City/Town Peter Simonson Owners Name Ma State 3-4-06 Date of Inspection C) Further Evaluation is Required by the Board of Health (cont.): 01845 Zip Code 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: NA ** 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: TITLE V.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (cont.) 895 Forest St Property Address N. Andover Cityrrown Peter Simonson Owner's Name Ma 01845 State ZipCode 3-4-06 Date of Inspection 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 'h 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 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 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.] Yes No ❑ ® 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. TITLE V.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 5 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Sv V ` Subsurface Sewage Disposal System Form A. Certification (cont.) 895 Forest St Property Address N. Andover City/Town Peter Simonson Owner's Name Ma State 3-4-06 Date of Inspection 01845 Zip Code 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. TITLE V.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 6 of 16 Commonwealth of Massachusetts . Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Checklist 895 Forest St Property Address ❑ N. Andover Ma. 01845 City/Town State Zip Code Peter Simonson 3-4-06 Owner's Name 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(3)(b)] TITLE V.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M 5w y C. System Information 895 Forest St Property Address N. Andover Cityrrown Peter Simonson Owner's Name Residential Flow Conditions: 5 Ma State 3-4-06 01845 Zip Code Date of Inspection /j171�-T''l�f �IS"S z S � o•-"�� 5 Number of bedrooms (design): Number of bedrooms (actual): f.L = or> b � DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 150506 gpd— Number of current residents: 2 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 9 ( Y 9 (9p )) 04805 25250 gal=36gpd Sump pump? ❑ Yes ® No still occupied Last date of occupancy: Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non -sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other (describe): TITLE V.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 8 of 16 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 895 Forest St Property Address N. Andover Cityrrown Peter Simonson Owner's Name Pumping Records: Ma State 3-4-06 Date of Inspection General Information 01845 Zip Code Source of information: last pumped Sept. 03 information from owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): Approximate age of all components, date installed (if known) and source of information: 15 years old information from owner Were sewage odors detected when arriving at the site? ❑ Yes ® No TITLE V.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 9 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form H Sy`• C. System Information (cont.) 895 Forest St Property Address N. Andover Citylrown Peter Simonson Ma state 3-4-06 01845 Zip Code Owners Name Date of Inspection Building Sewer (locate on site plan): Depth below grade: 15in feet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: 63 ft from incoming water line to outgoing sewer line in basement Comments (on condition of joints, venting, evidence of leakage, etc.): joints & venting good condition no evidence of leakage Septic Tank (locate on site plan): Depth below grade: lin feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of ❑ Yes ❑ No certificate) Dimensions: 1 Oft long - 5ft deep - 5ft wide Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? 1500gal 2in 30in lin 7in 16in rulers & measurinq rod TITLE V.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cont.) 895 Forest St Property Address N. Andover City/Town Peter Simonson Ma State 3-4-06 01845 Zip Code Owner's Name Date of Inspection 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 does not need to be pumped - inlet baffle good condition outlet baffle in good condition - ligiid at bottom of outlet invert - no evidence of leakage in or out of tank - tank in good condition TITLE V.doc • 11/2004 Grease Trap (locate on site plan): Depth below grade: Material of construction: feet ❑ 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): na Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 11 of 16 N Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M S y C. System Information (cont.) 895 Forest St Property Address N. Andover 'Ma 01845 City/Town State Zip Code Peter Simonson 3-4-06 Owner's Name Date of Inspection Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: 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.): na 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.): d -box was level - no evidence of any solids carryover- no sign of leakage in or out of d -box - d -box 20 in below grade -16 in x 16 in inside depth 15in Pump Chamber (locate on site plan): Pumps in working order: Alarms in working order: TITLE V.doc • 11/2004 ❑ Yes ❑ No ❑ Yes ❑ No Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 12 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ` Subsurface Sewage Disposal System Form M C. System Information (cont.) 895 Forest St Property Address N. Andover Ma 01845 Cityrrown State Zip Code Peter Simonson 3-4-06 Owner's Name Date of Inspection Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): na TITLE V.doc • 11/2004 Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits ❑ leaching chambers ❑ leaching galleries ® leaching trenches ❑ leaching fields ❑ overflow cesspool ❑ innovative/alternative system Type/name of technology: number: number: number: number, length: number, dimensions: number: 3 trenches 50ft long each Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): dry gravel soil - no hydraulic failure - no ponding- system was under right side lawn Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 13 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ` Subsurface Sewage Disposal System Form N C. System Information (cont.) 895 Forest St Property Address N. Andover City/Town Peter Simonson Ma State 3-4-06 01845 Zip Code Owner's Name Date of Inspection 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): na 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.): NA TITLE V.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 14 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 895 Forest St Property Address N. Andover Ma 01845 TITLE V.doc • 11/2004 Citylrown State Peter Simonson 3-4-06 Zip Code Owner's Name 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 supply enters the building. c y 3rrIf G4 Subsurface Sewage Disposal System Page 15 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ` Subsurface Sewage Disposal System Form C. System Information (cont.) 895 Forest St Property Address N. Andover City/Town Peter Simonson Owner's Name Site Exam: Slope Surface water Check cellar Ma State 3-4-06 Date of Inspection 01845 Zip Code Shallow wells Estimated depth to ground water: 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: 4-15-88 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: From plans on file at health dept & last title v report - test pit # 72 102in water at 84in - test pit# 73 11 4i no water fround TITLE V.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 16 of 16 TONVIN OF NORTH AND BUILDING DEPARTMENT APPLICATION TO CONSTRUCT WA!j RENOVATF, OR DEMOLISH A ONE OR TWO FAMILY qj1VTj,LIN`G 00 w7ft BUILDING PERMIT NUMBER DATE ISSUED: SIGNATURE: Building Commissioner/1r of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Man and Para. -1 Ni" ber: L c) 10 Map Number Pared Number 1.3 Zoning Information: 1A Property DimensiMs: 7 U Zoning District Proposed Use Lac Areas o Frontage (ft) 1.6 BUffiDING SETBACKS (ft) Front Yard Side Yard Rear Yard Required Provide Required Provided Re aired Provided 1.7 Wats Supply NCG.L.0 Zone 1.5. Flood 7one, Infonnabon: outside Flood 1.8 Sewerage Disposal System Public X private 0 7me Municipal .11 OaSite Disposal System SECTION 2 - PROPERTY OWNERSEEIP/AUTHORIZED AGENT Historic District: Yes No 2.1 Owner of Record E_ 6='s le __5_ Address for Service :---------- ry NoV M. C) 4_— Signatum--'- Telephone 2.2 Owner of Record: Name Print Address lbrService: Si stare Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable 0 Number Address Signawre 'F,.Iephcnc txpiratio T'2 Re-SistertA f lome Improvement Contractor Not applicable 0 Company Name Rcgistration Number ate /1',',4,x / G j 3 // ?,2 11 0 INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. APPLICANT FILLS OUT THIS SECTION APPLICANT ?GL2 LOCATION: Assessors Map Number 1 SUBDIVISION STREET rV Edi €Sr A/b • 1 AIL)o!I OFFICIAL USE ONL OF TO)NN AGENTS: PHONE_J2 9— -6 R& NO PARCEL_ LOT (S) ST. NUMBER��� DATE APPROVED d��/�Td ZJ DATE REJECTED TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS DATE REJECTED .. �., . S IAC l N-SPECTOk41EAL1Vu DATE APPROVED /'/'7, ��- ,�� � DATE REJECTED -2L) � /7 COMMENT; �r � 7 _ Cf n i v ' - � s %�///, cel )'l C VA -1( /� T (-1 -Zd� r _ ce,-7iz ° I: t _ rti Z`,, PUBLIC WORKS - SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT 'ECEIVED BY BUILDING INSPECTOR DATE Revised IN? IM // .— SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all a llcable New Construction ❑ 1 Existing Building ❑ 1 Repair(s) ❑ Alterations(s) ❑ 1 Addition Accessory Bldg. ❑ 1 Demolition ❑ 1 Other ❑ Specify Brief Description of Proposed Work: �� .t' ��,�j_����;� OSI/ Gf/�,S % ✓%�E or l�/ELli iJ/� iy /r?O/ie ®•utr alb �oo.H >20�4 try oo2 70 .4Al (�/�1 r/iGc �Za fi /�Av *� / 9Pi%C S f ! fi iLo�Yty% jw.vi (Ab,eT-ff 5;1, i I c7.'�+TinN t CCTiMATFrI f'l1NCTRiT!'T7!)N f nCTC Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY 1. BuildingI _ -7 J Co d (a) Building Permit Fee Multiplier 1' �Xlo 2 Electrical 02� 000 (b) Estimated Total Cost of Construction 3 Plumbing 6 00 D Building Permit fee (a) x (b) DIMENSIONS OF POSTS 4 Mechanical (HVAC) 5 Fire Protection 6 Total (1+2+3+4+5) ©pd Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WREN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT Il7RA_/E�� i,�Jt J as Owne Authorized Agent of subject property authorize to act on My be :ill: i .a natters relative t rk authorized by this building permit application. ' Signature of Owirer Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION AJ 5J as Owner/Authorized Agent of subject property Hereby declare that the .statements and information on the foregoing application are true and accurate, to the best of my knowledge Print Name Fi Signature of Owner/.roent NO. OF STORIES w �2 Date SIZE k " BASENIENT OR SI„10 SVE OF PLOOR'fINIB1 RS 1' �Xlo 2' ,? 0 3 SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUI\IDAT10N THICKNESS SI7F. OF FOGMNC /2 X IV M 1TLRLId-. OF CHP4NFY __ IS 13111LDING ON' SOLID OR FILLED LAND IS Bl MDING CONNECTED TO NATZ.!P-,%L GAS LINE �/ I NEW ENGLAND ENGINEERING SERVICES INC November 18, 2005 Susan Sawyer North Andover Board of Health 400 Osgood Street North Andover, MA 01845 06-� Re; -4 3 orest Street, North Andover Septic System location Dear Susan: RECEI EV p NOV 2 2 2005 TOWN OF NORTH ANDOVER HEALTH DEPgRTMENT Enclosed is a septic system location plan for the above referenced property. If you have any questions, or need additional information, please do not hesitate to contact this office. Sincerely, Benjamin C. Osgoo, Jr., P.E. President 60 BEECHWOOD DRIVE - NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645 - FAX (978) 685-1099 BENJAMIN C. Q OSGOOD, JR.} CIVIL N 4 71, ASSESSORS MAP 105D, LOT 10 43,704 SQ. FT. _W FGIST10, $ 4 cv v t • .,.. . N NOTES N 1. DWELLING LOCATION TAKEN USI rn� FROM A SURVEY PERFORMED BY NEW ENGLAND ENGINEERING p N SERVICES, INC. 129.00' ,• 2. SEPTIC SYSTEM LOCATION TAKEN 179'45 01 W FROM AS -BUILT PLANS OF RECORD. N/F DAMS SEPTIC SYSTEM LOCATION PLAN AA9 TiYIprQrp Q1pA7TT, T L� 11/18/2005 17:15 9766851099 NEW ENG ENG v n n n. c -i m PAGE 02 e14 Mr, -%—T N/F IMTO NOV 2'12005 TOWN OF NORTH ANDOVE HEALTH DEPARTMENT SEN.IAIIIN C. 096000, JR, CIVIL 219plt o ING LOCATION VEPFEN OMA SURVEY EROftEo 81' EW ENGLAND ENGINEERING ERVICES, INC. EM SYSTEM LOCATION TAKEN ROM AS -BUILT PLANS OF ECORD, SEPTIC SYSTEM LOCATION PLAN 885 FOREST STREET NORTH ANDOVER, NA ASSESSORS NAP 106D, LOT IO 1' 40' DATE: NOVEMBER !8, 2005 NEW ENGLAND ENCINEERINO SERVICES, INC. 60 HEECHWOOD DRIVE NORTH ANDOVER, VA01845 (978) GN -1768 N 11-18-Q5 3.C.H. oy: B.C.O. Jr. r FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *************** APPLICANT FILLS OUT THIS SECTION* (ci�hi�/q tP-HONE ("9 �6p 7C l ✓ Op (79/ `iQ l�I P� (79/ )A ,?y— LOCATION: Assessor's Map Number. SUBDIVISION PARCEL 7-'C �O LOT (S) (� VSTREET mars- ST. NUMBERS USE ONLY********* RECOM NDATIONS OF TOWN AGENTS: yr v NSERVATION ADMINISTRATOR DATE APPROVED DATE -REJECTED 1 COMMENTS 1�=,L a,- TOWN PLANNER COMMENTS FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED BPEICTOR-REALTH DATE APPROVED s ' DATE REJECTED COMMENTS��"`�� PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE 1S L2" Al D Cie-, d )L /9 IV /.z -- F — c? % S4-REE7- L/NE 9L•�S Cie-, d )L /9 IV /.z -- F — c? % S4-REE7- ( RD 4F H,,F�OLTi-I LOT &/O STH Di5,vp); q5D (�A'C�� Sc� �►'iy �] Tbwnl ❑ WEc.c:_ ,aP�ouCD 11�TC . 5tPric sy STE" stc�J �,z-q -5�7 /JMW 1^-L� /urtjoKiry PtAtJ D651 &AJC— K J .13, ti DATA 'I - I2- 87 Cc��►�plr�o�s R SONS = 44L5 -r -*vw pc4N5({�(�qRo� 96- �icc,etJ, 1 IT vlc., r3� I-�L(,�1� Div N�iGH13bi��N6 6�N�Pit•� lSG S �— SYS — � S p � DwC (2 S5 Prf c SY5TC1tt I tj STA w, 4TioAj 4 Y 4V4T(ol-J )NSPEGTpoAj 94rC FINAL IVSPF�TIOA) Q PPRdVED 0/3T c- 2, i 5 'k AVP(-FJOMAL 1,�JsFbz., SNS 6 may) DASA PP1ZDvF,p R�,5Ns FV AL APP NAL Da T-5 ❑ 1945S Q F4►L- APPt�Dv(tiG APP)30,1 A)G WELL DATABASE ADDRESS: 8 SS� 7'� ),(014 / y y AGE OF WELL: WELL DRILLER: WELL PERNIIT T: WELL LOCATION: —W-= PERIVilT DATE: DEPTH OF WELL TYPE OF WELL: a.. DRILLED TYPE OF WATER BEARING ROCK. WATER ANALYSIS DATE: HIGH IRON: Y N OT o �� l b. DUG C. L40WN MANGANESE: Y ,COAMIl`jA1�ITS: Y Iq �.k rr WELL DATABASE t.' ADDRESS: AGE OF WELL: WELLDRILLER: WELL PERNET 7: WELL LOCATION: WELL PERMIT DATE_ DEPTH OF WELL: TYPE OF WELL: a.. DRILLED b. DUG c. UNKNOWN TYPE OF WATER BEARING ROCK: WATER ANALYSIS DATE: HIGH -MANGANESE: Y HIGH IRON: Y N OTHER CONTAMINANTS: Y N 0 N North Andover Board of Assessors Public Access Parcel ID: 210/105.D-0010-0000.0 SKETCH Click on Sketch to Enlarge Community: North Andover PHOTO Click on Photo to Enlarge Click on Photo to Enlarge Location: . 885 FOREST STREET Owner Name: OINES, PER-ARNE JANE L RUNNING Owner Address: 885 FOREST STREET City: NORTH ANDOVER State: MA ZIP: 01845 Neighborhood: 6 - 6 Land Area: 1 acres Use Code: 101- SNGL-FAM-RES Total Finished Area: 2584 soft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 498,200 476,800 Building Value: 303,900 291,700 Land Value: 194,300 185,100 (Market Land Value: 194,300 Chapter Land Value: LATEST SALE Sale Price: 267,000 Sale Date: 07/26/1989 Arms Length Sale Code: Y -YES -VALID Grantor: PIKE CONSTRUCTION CO Cert Doc: Book: 02970 Page: 0049 http://csc-ma.us/NandoverPubAcc/j sp/Home.j sp?Page=3&LinkId=467221 Page 1 of 1 5/3/2005 ;;;6 Q k0Q�u 2 § \ a u .... 2 6 CLm[2 2 _��-= o �m2o« o £�woS o CD tea■ 2 w $5 � we§��L cc LU c ?: \ m of of 7 $ 0m y « o (D X-- E e CO) w w IL jLit W� ce ZLUw�o� < 0 §-g"2c I § co cc U 0 < \ o o \ �w0 CD k k L) M = a Q ■ O '2 S< 2 2 w Iws2 0 § O =2 to t.� � ■ CL 2 c"oa>- E CL bi hi �\CL\E j \2 �cR>] 5 20 &2�am ƒ/ $$$$6 J O -i CD E o � �eC- � cc CD d)< _\ m $ w2 $ 0m y « o (D X-- E e CD w IL jLit W� � ZLUw�o� < §-g"2c I 3o�2s2 % \ a E 3G cc CD § \ S $ w2 $ LU z0 �w CD k/ w e> 2§ /LLjD J§ U)2 IL jLit W� w ZLUw�o� U §-g"2c < 3o�2s2 I 0 < % \ a 3G 0 k/ \\ w ;7 > RR 2 k/ 2 2_2 0�3 «55 bz9 2\\ 0 Zkk LL nn- © -o '0$q. �..LL 2 6-n « wee 7■�« j3] 7 I4) U) SG 2 %R e =_ $\ . ■Uk ke CL %# SPI // g z }) I 0 22� d ƒ © k �o §_ n �le N_ R � .. e® )f 'Fa kms 7 o <g3 \#/7//2 d\f\ E/\kLL «ILL= w�(»mo\«= k § 28co $ co Go § 2Ln@$ » E( . cc CO$ E e�2ii2 co rr � zz <m�m� �.. ESE �) U. LL ��i§2 §=22E §%\\oo � wk==cs t;,o2o ■0 Q==<=e u»ooa.y Q 2 VC14ro - 10 LU E .. v%� $# §..W}�_ EE:EE %km ON ooa`aOO 03% 22 a 2101 52§\x )k- e=LLII=YI =m« 3 3 �dC40LL 20_2 0 ( k & § e .. ƒ \ � # >1 L) Q ®fig/k\ \\±� /5 fLL a / % \ a I 11 a yr ti a U e 't W °r 4 'Q � 4'�°m0 w��qV Qu ol Q Fii ` O v � 1. Q v 0 O v I 11 a yr ti a U e 't in II °r 4 'Q � 4'�°m0 w��qV in II s � r t N \ I .,.,..,_.,_:_;,,,,�., .1 Y, I��� ��� �_ .: �----- Lf., I.-- � V 4 W SCOTT L. GILLS, R.P.L.S. Registered Land Surveyor 50 Deer Meadow Road North Andover, Ma. 01845 (617) 683-2645 Commonwealth of Massachusetts G Title 5 Official Inspection F ACEIVE� Not for Voluntary Assessments Subsurface Sewage Disposal System Form NOV 2 2 2005 TOWN OF NORT Aron -- Inspection results must be submitted on this form or on the offiWa0W dated 6/15/2000. Inspection forms may not be altered in any way. A. Certification Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. _Q ISI 1. Property Information: 885 Forest St N. Andover Property Address Per Oines Owner's Name 885 Forest St Owner's Address N. Andover Citylrown Date of Inspection: 2. Inspector: N . Timothy White Name of Inspector Homepro Northshore Company Name P.O. Box 101 Company Address ROWLEY Citylrown 1-978-948-8428 Telephone Number Ma State 5-7-05 Date Ma State �1 01845 Zip Code 01969 Zip Code 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: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority N "�' �'�^^^��91 5-7-05 Inspector'§ Signature I Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc - 11/2004 'Rle 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 1 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 885 Forest St Property Address N. Andover City/Town Per Oines Owner's Name Ma 01845 State Zip Code 5-7-05 Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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: N/A t5insp.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 885 Forest St Property Address N. Andover Ma 01845 Citylrown State Zip Code Per Oines 5-7-05 Owner's Name Date of Inspection 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 ND Explain: NA. ❑ 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 ❑ obstruction is removed ND Explain: NA 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 t5insp.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 3 of 16 Commonwealth of Massachusetts . Title 5 Official Inspection Foran Not for Voluntary Assessments Subsurface Sewage Disposal System Form M • A. Certification (cont.) 885 Forest St Property Address N. Andover City/Town Per Oines Owner's Name Ma 01845 State Zip Code 5-7-05 Date of Inspection C) Further Evaluation is Required by the Board of Health (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: NA ** 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: t5insp.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts Title 5 Official -Inspection Form ug Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 885 Forest St Property Address N. Andover Cityfrown Per Oines Owner's Name Ma State 5-7-05 Date of Inspection D) System Failure Criteria Applicable to All Systems: 01845 ZipCode 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 ❑ ® 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 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.] Yes No ❑ ® 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. t5insp.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 5 of 16 Commonwealth of Massachusetts lugTitle 5 Official Inspection Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 885 Forest St Property Address N. Andover City/Town Per Oines Owner's Name Ma State 5-7-05 Form Date of Inspection 01845 Zip Code 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. t5insp.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 6 of 16 =moi— Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Checklist 885 Fortest St Property Address N. Andover Ma 01845 City/Town State Zip Code Per Oines 5-7-05 Owner's Name 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(3)(b)] t5insp.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information 885 Forest St Property Address N. Andover Ma City/Town State Per Oines 5-7-05 Owner's Name Residential Flow Conditions: Date of Inspection 01845 Zip Code Number of bedrooms (design): 4 Number of bedrooms (actual): 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? 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)): 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: Last date of occupancy/use: Other (describe): NA Gallons per day (gpd) Date 600 gpd 5 ® Yes ❑ No ❑ Yes ® No ❑ Yes ® No ❑ Yes ® No ❑ Yes ® No still occupied Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5insp.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 8 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ` Subsurface Sewage Disposal System Form G. System Information (cont.) 885 Forest St Property Address N. Andover City/Town Per Oines Owner's Name Pumping Records: Source of information: Ma State 5-7-05 Date of Inspection General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: 01845 Zip Code last pumped 2 years information from owner gallons ❑ Yes ® No 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): Approximate age of all components, date installed (if known) and source of information: 16 years information from owner Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 9 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 885 Forest St Property Address N. Andover Ma Cityrrown State Per Oines 5-7-05 Owner's Name Date of Inspection Building Sewer (locate on site plan): Depth below grade: 22in feet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): joints & venting good condition no sign of leakage Septic Tank (locate on site plan): 01845 Zip Code Depth below grade: 16in with riser at grade feet Material of construction: ® concrete ❑ metal n fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of El Yes El No certificate) Dimensions: 1 Oft long 5ft deep 5ft wide 1500 gal Sludge depth: 2in Distance from top of sludge to bottom of outlet tee or baffle 32in Scum thickness lin Distance from top of scum to top of outlet tee or baffle 8in Distance from bottom of scum to bottom of outlet tee or baffle 24in How were dimensions determined? rulers measuring rod t5insp.doc • 11!2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form c. System Information (cont.) 885 Forest St rroperEy moaress N. Andover Ma City/Town State Per Oines 5-7-05 01845 Zip Code Owner's Name Date of Inspection 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 does not need to be pumped- inlet &outlet baffels in good condition structural sound - liquid at bottom of outlet invert no sign of leakage in or out of tank Grease Trap (locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El 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 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: NA Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other (explain): t5insp.doc - 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 16 Commonwealth of Massachusetts ui Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 885 Forest St Property Address N. Andover Ma City/Town Per Oines Owner's Name Tight or Holding Tank (cont.) Dimensions: Capacity: Design Flow: Alarm present: Alarm level: Date of last pumping: State 5-7-05 Date of Inspection gallons gallons per day ❑ Yes ❑ No Alarm in working order: Date Comments (condition of alarm and float switches, etc.): na Distribution Box (if present must be opened) (locate on site plan): 01845 Zip Code ❑ Yes ❑ No 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.): d- box was level - distribution was equal - no evidence of any solids carryover - no evidence of leakage in or out of d- box C-4 13/(f3F,-Lc-u— sr j,� o� p- �ilV/C.I /nslai; DzPCt-k ►H q Pump Chamber (locate on site plan): Pumps in working order. Alarms in working order: ❑ Yes ❑ No ❑ Yes ❑ No t5insp.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 12 of 16 Commonwealth of Massachusetts . Title 5 Official Inspection Form o Not for Voluntary Assessments ,ySubsurface Sewage Disposal System Form M C. System Information (cont.) 885 Forest St Property Address N. Andover City/Town Per Oines Ma 01845 State Zip Code 5-7-05 Owner's Name Date of Inspection Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): NA 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: ® leaching fields number, dimensions: 1200 SQ FT ❑ 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.): Sandy dry soil - no hydraulic failure - system was under rear lawn t5insp.doc - 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 13 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 885 Foresty St Property Address N. Andover Ma 01845 Cityrrown Per Oines Owner's Name State Zip Code 5-7=05 Date of Inspection 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): NA Privy (locate on site plan): Materials of construction: Dimensions NA Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc • 1112004 Title 5 official Inspection Form: Subsurface Sewage Disposal System Page 14 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 885 Forest St Property Address N. Andover Ma 01845 state zip code cityrrown Per Clines5-7-05 Owner's Name 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 supply enters the building. t5insp.doc • 112004 We 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 15 of 16 A Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 885 Forest St Vroperty address N. Andover Cityrrown Per Oines Owner's Name Site Exam: Slope Surface water Check cellar Shallow wells Ma State 5-7-05 Date of Inspection 01845 Zip Code Estimated depth to ground water: Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: from plans showes ground water at 7ft t5insp.doc • 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 16 of 16