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HomeMy WebLinkAboutMiscellaneous - 890 JOHNSON STREET 4/30/2018 (2)�y y A COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 890 Johnson Street _ —North Andover_ Owner's Name: _Craig Wilson _ Owner's Address: _890 Johnson Street North Andover, MA 01845_ Date of Inspection 4/8/2004 Name of Inspector: Neil J Bateson Company Name: Bateson Enterprises Inc._ Mailing Address: _111 Argilla Road_ _Andover, Ma. 01810_ Telephone Number: ( 978 ) 475-4786_ _ F pFc, `. r w or I s 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: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ails Inspector's Signature: > Date: _4/8/2004_ 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. Page 2 of 11 OFFICIAL INSPECTION FORM -- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 890 Johnson Street _ North Andover — Owner: Wilson Date of Inspection: _418/2004_ Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: X 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: 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): broken pipe(s) are replaced obstruction is removed ND explain: ,Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _890 Johnson Street_ _ North Andover — Owner: _Wilson_ Date of Inspection: 4/8/2004 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 a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well* *. Method used to determine distance _ _ **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria 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: 890 Johnson Street _ – North Andover_ Owner: Wilson Date of Inspection: 4/8/2004_ D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: Yes No _ No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool No Liquid depth in cesspool is less than 6" below invert or available volume is'h day flow. –No'- pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ _No Any portion of the SAS, cesspool or privy is below high ground water elevation. –No Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. No Any portion of a cesspool or privy is within a Zone 1 of a public well. _ _No Any portion of a cesspool or privy is within 50 feet of a private water supply well. _No_ 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.] No (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. 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. 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 — T 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. , Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 890 Johnson Street_ _ North Andover Owner: _Wilson_ Date of Inspection: _4/8/2004_ Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No Yes_ — Pumping information was provided by the owner, occupant, or Board of Health No Were any of the system components pumped out in the previous two weeks ? Yes_ — Has the system received normal flows in the previous two week period ? No Have large volumes of water been introduced to the system recently or as part of this inspection ? Yes_ _ Were as built plans of the system obtained and examined? (If they were not available note as N/A) Yes Was the facility or dwelling inspected for signs of sewage back up ? Yes_ _ Was the site inspected for signs of break out ? Yes_ _ Were all system components, excluding the SAS, located on site ? _Yes_ _ 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 ? _Yes_ _ 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: Yes no Yes_ _ Existing information. �_ _No_ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] , Page 6 of 1 l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: _890 Johnson Street _ North Andover— Owner: _Wilson_ Date of Inspection: 4/8/2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): _4_ Number of bedrooms (actual): _4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): _440_ Number of current residents: _4 Does residence have a garbage grinder (yes or no): —No— Is oIs laundry on a separate sewage system (yes or no): _ No Laundry system inspected (yes or no): Seasonal use: (yes or no): _No_ Water meter readings: Yes_ Sump pump (yes or no): Yes_ Last date of occupancy: — Current-C OMMERCIAL/INDUSTRIAL Type 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: Pumped 2001, owner _ Was system pumped as part of the inspection (yes or no): Jes _ If yes, volume pumped: _1000_fflllons -- How was quantity pumped determined? _Measured Tank Reason for pumping: Inspect Tank & Tees_ TYPE OF SYSTEM _X 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: Tank original, D -Boz & SAS installed 6//1996 Were sewage odors detected when arriving at the site (yes or no): No , Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 890 Johnson Street _ North Andover— Owner: _Wilson_ Date of Inspection: 4/8/2004_ BUILDING SEWER _ X _ (locate on site plan) Depth below grade: 20"_ Materials of construction: X cast iron 40 PVC other Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): leaks visible SEPTIC TANK: X _ (locate on site plan) 4" Cast Iron thru wall & in house, no Depth below grade: _8"_ Material of construction: —X—concrete 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) Dimensions: 7' x 5' x 4' Sludge depth 3" Distance from top of sludge to bottom of outlet tee or baffle: —24"— Scum 4"_Scum thickness: _6" Distance from top of scum to top of outlet tee or baffle: _8" Distance from bottom of scum to bottom of outlet tee or baffle: _15"_ How were dimensions determined: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.):_ Pumped septic tank Inlet tee ok. Outlet tee ok. No evidence of septic tank leaking. Depth of liquid at outlet invert. _ GREASE TRAP: (locate on site plan) 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.): Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 890 Johnson Street- - North Andover Owner: _Wilson_ Date of Inspection: 4/8/2004_ TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete metal fiberglass _polyethylene other(explain): Dimensions: Capacity: 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: X (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 level & distribution equal No evidence of leakage out of d -box. Evidence of solid carryover, pumped d -box to clean PUMP CHAMBER: X (locate on site plan) Pump in working order (yes or no): —Yes _ Alarm in working order (yes or no): Yes_ Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): _Pump & pump chamber ok. Alarm both audible & visual _ Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 890 Johnson Street _ North Andover Owner: _Wilson_ Date of Inspection: 4/8/2004_ SOIL ABSORPTION SYSTEM (SAS): `X (locate on site plan, excavation not required) If SAS not located explain why: Type _ leaching pits, number: _ leaching chambers, number: leaching galleries, number: _X leaching trenches, number, length: —4 trenches 40' long_ — leaching 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.): _ Soil ok. Vegetation ok. No sign of ponding to surface_ 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) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): . Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _890 Johnson Street _ _ North Andover_ Owner: _Wilson_ Date of Inspection: _4/8/2004_ 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. Driveway Garage Water Meter House A Porch A to Inlet =18'6" A to Outlet = 21'8" A to Pump Tank = 26'6" A to D -Boz = 2316" B to Inlet = 8 B to Outlet =10'2" B to Pump Tank =16'6" B to D -Boz = 43'4" Septic —r_f Tank D - Bog `A Pump Tank . Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _890 Johnson Street _ North Andover — Owner: _Wilson_ Date of Inspection: _4/8/2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water _ 41 _ Please indicate (check) all methods used to determine the high ground water elevation: X_ Obtained from system design plans on record - If checked, date of design plan reviewed: _6/11/1996_ 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: Design Plan_ dli r .O;2 I_ ;, y i£' k rt �'• ^e. r ,6"t ty1t111f 1t N. 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VN©•00007�OGn®cnQf9®►-'©L5)m� `(j CJI. i* �� •• �, ). aia . s P'r val tP 44 f4 4 9L tV So "Awww V I z m I to Vf t%)�-Aww WWWwW I" co (S) • Ir} FA cc r.M N rr, W4 0 A 1 0 w ML z WNW WC) CZ) Ln w I-LCDWWG -ioz bc awn Mow wwwww wLnoww C43c) c% w�il0% %0 0-4 en Df w R AS, Goomm c GOODS w mm@@m Da LM LM LM CD 14 W Mocma%o 0 WNw13 Pin Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 890 Johnson Street Owner: Wilson Date of Inspection: 4/8/2004 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. Neil J. Bateson Bateson Enterprises, Inc. Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES 146 Main Street North Andover, Massachusetts 01845 TOWN OF NORTH ANDOVER BOARD OF HEALTH CERTIFICATE OF COMPLIANCE This is to certify that to , June 18, 1996 the individual subsurface disposal system constructed ( ) or repaired (X) by MICHAEL REILLY installer at 890 JOHNSON STREET been installed in accordance with the provisions of TITLE 5 of - the State -S rtary Code and with Board of Health regulations as— described s-described in the Design Approval Permit # 839 dated 5/28/96. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY. 41 G rp Board of Health Inspector BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 COMMONWEALTH OF MASSACHUSETTS C� EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDY CORE secretary ARGEO PAUL CELLUCCI DAVID B, STRUHS Governor Conunissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPEC ION FORM PART A CERTIFICATION /� Property Address: 6(c7 �o�rliln� �. Name of owner ojv\ ' 1' Te Lee 11 i01C_A.k x=0j,p�' Address of Owner: Date of it io : �j — —�% lig/ �tx� O�-� C�x� f Name of Inspector: ( PnrW rt) 1 Mailingsen a DEP system purauarrt to Section 15.340 ofTMe S t31 b CMR 16.0001 Company N� Mailing Address: 1 ` / ` '(Gi , om to Telephone Number: r,ER]MCATION STATEMENT I certify that I have personally inspected the sewage dispotial 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: �— asP ses _ Conditionally Passes _ Need F er Ev natio By the Local Approving Authority Fail Inspector's Signature: Date:y✓'— l �= /7 The System Inspector shall 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 settt to the system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS rd�,gQA o � OFy HNDO t JUN 2 51999 revised 9/2/98 Paige lof11 0 Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM PART A CERTIFICATION (contitmed) Property Address. P Owner: Date of Msgeerion: INSPECTION SUMMARY: Check A, S. C, o/ A A. ��SYSEM TPASSES: '^` I 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: 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 pipols) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Hoard 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 revised 92/98 Page 2of11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) v Property Address: Owner: L Date of br qvm--,on: 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. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303111(b) THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE BWi)ONMENT: 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. 21 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 ENVIONMENT: 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 ,. revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: a(� Owner: — 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 of 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 then 112 day flow. Required pumping more then 4 times in the last year NOT due to clogged or obstructed pips(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 less4han 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 the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (interim Wellhead Protection Area - IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further inforjnation. r revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORAM PART B CHECKLIST Property Address: r `i +,c7���+1 U WOcY `+� /`K"`�'-eJ Date of Inspection. co, `1 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes //No V _ Pumping information was provided by the owner, occupant, or Board of Health. _L?" None of the system components have been pumped for at least two weeks and the system has been•rece" normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. l.� As built plans have been obtained and examined. Note If they are not available with N/A. i/ The facility or dwelling was inspected for signs of sewage back-up. L The system does not receive non -sanitary or Industrial waste flow. The site was inspected for signs of breakout. All system components, excluding the Soli 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 based on: 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)) _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SubSurface Disposal Systems. • .,MAP revised 9/20/98 Page Sof11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: eC(C) .SalAAS(� Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: ( 110 g.p.d./bed o m. Number of bedrooms (design): Number of bedrooms (actual): -q Total DESIGN flow -(440 Number of current residents Garbage grinder (yes or no): S Laundry (separate system) (yes or no): If yes, separate.inspection required Laundry system inspected (yes or no) Seasonal use (yes or no): Nei Water meter readings, if a4 able (last two year's usage (gpd): Sump Pump (yes or not: Last date of occupancy: uCCA)----� COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: qpd ( Based on 15.203) Basis of design flow Grease trap present: lyes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non -sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)4es If yes, volume pumped AM, A � � ��&kms` -t4 Reason for pumping: 1 y15QR i TYPE OF S 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other MATE AGE ol all compogents, date installed (if known) and iource of information: b14,Vb_ 9 Sewage odors detected when arriving at the site: lyes or no) J. -Jo I - revised 9/,2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYS719M INSPECTION FORM PART C SYSSTT PA INFORMATION (t�nredl Property Address qn 5 CNJ CXN � WCC `'�'� A',A� owner: Lo -,e Date of Inspection: 0 ✓� BUILDING SEWER: l (Locate on site plan) Depth below grade: DD Material of construction:cam s��t j�ron 40 PVC _ other (explei) �I uZQ `AAA ,�cn, t QD,%_A' c Distance from private water supply well or suction line Diameter L411 Comments:,jconditign of jpints, venting, evidence of leakage, etc.) SEPTIC TANK: L--- (locate -f(locate on site plan) k Depth below grade: Material of construction: 1-4ncrete —metal ,Fiberglass _Polyethylene _otherlexplain) If tank is metal,, list age _ Is age confirmed by Certificate of Compliance _ (Yes/No) Dimensions: 1 i K 5 1 iC Ll ( L<Z.-2iL�CJ- Sludge depth: t`I ^� r Distance from top of sludge to bottom of outlet tee or baffle: �e Scum thickness: l I ( 1 r Distance from top of scum to top of outlet tee or baffle: ?' ") Distance from bottom of scum to bo of Qutllet t DR or baffle: How dimensions were determined:` cic S�v� ti , b C+ E 1- - `�� �•2�Cli Comments: (recommendation for pumpin ditio f inl t ap� outi�e as or 'affles, e-th of li d lav 1 in evidence of leakeae, etc4),, -`� (locate on site plan) 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: (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.) r revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION laandnued) Property Addresst eq l Owner: Date of Inspection: TIGHT OR HOLDING TANKSC (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: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:-� (locate on site plan) Depth of liquid level above outlet invert: Comments:x �Q (note if Ievdl and distribution is egyel, evidence of solid"arryoper, evidenc"f leakage into or out oflkox, etc.) PUMP CHAMBER:_ (locate on site plan) Pumps in working order: (Yes or No) S Al-- ,., ......4:..,. ,,M., rve. — N,.1 /o e revised 9/2/98 Pagegof11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM, IIFORMATION (corntirmed) Property Address°�'(� Date of Inspection: f - 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:_ Q�,� leaching trenches, number, length :`C"��� �Q (i� leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) CESSPOOLS: Y'�C-) (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: nckf�'_ (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 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PARI C SYSTEM INFORMATION I�N�FORM�A/T�I�ON Jeontirm" Propet"Addresti: OqC���y—p ,6c / � • 1 "t�"� "\ 4,4:"^''7 Owner: v p Date of Inspection: SKETCH OF SEWAGEPISPOSAL SYSTEM: include ties at least two permarn locate all wets within 100' (Locate �C�,fiClcQ_,. reference landmarks or benchmarks sere public water supply comes into house) revised 9J2/98 1 tBSc- Page 10 of 11 . Tel: (978) 475-4786 Fax: (978) 475-5451 BATESON ENTERPRISES. INC. Excavating -Water.& sewer Lines -Septic Systems & Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: Ion SOY, s -)L. Owner: Lk)- - Date of Inspection: 6" 18— 9? My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations,and I hereby disclaim any further operation of your current septic system. Neil J. Bateson Bateson Enterprises, Inc. A NORT" O' C 1 w P SACMUS t� Town of North Andover, Massachusetts RnAPn nF HFAI TH Form No. 2 DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant PUP -7-/1U �r 1UAC0k Test No. Site Location 8910 JO�/R/6,o,v �3/ Reference Plans and Specs. IDI CL PUFC65u& —IC -d- /*-Q ENGINEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. Fee ` CHAIRMAN, BOARD OF HTAM Site System Permit No. '3(3 '1 8 90 ic)///V50,v '" �A 7-0 2 01v ��� A a PLAN REVIEW CHECKLIST ADDRESS 89CJ �IO/>�l/SQiU ST ENGINEER GENERAL 3 COPIES STAMP LOCUS NORTH ARROW �~ SCALE CONTOURS PROFILE SECTION BENCHMARK SOIL & PERCS ELEVATIONS WETS. DISCLAIMER LS & WETS c/ WATERSHED?,dLO DRIVEWAY (Elev) WATER LINE FDN DRAIN SCH40 L,"� TESTS CURRENT? L/ SOIL EVAL SEPTIC TANK MIN 1-5'6@x- .17 INVERT -M -OP GARB. GRINDER (+200% EDF ) 25' TO CELLAR MANHOLE ELEV GW # COMPS. D -BOX SIZE # LINES FIRST 2' LEVEL STATEMENT INLET - OUTLET IDD, 7 = ( 2" OR .17 FT) TEE REQ' D? \ �J LEACHING MIN-44G--6-PD? RESERVE AREA1,""4' FROM PRIMARY? OX 2% SLOPE P 100' TO WETLANDS 100' TO WELLS 4' TO S.H.GW °--'(5'>2M/IN) 35' TO FND & INTRCPTR DRAINS 325' TO SURFACE H2O SUPP 4' PERM. SOIL BELOW FACILITY MIN 12" COVER G--' FILL? x(25' if above natural elev; 10' if below) BREAKOUT MET? `, TRENCHES MIN -6 gpd SLOPE (min .005 or 6"/100')SIDEWALL DIST. 3X EFF. W OR D (MIN 6')t"--' RESERVE BETWEEN TRENCHES? L ---'IN FILL? L ---MUST BE 10' MIN r- 4" PEA STONE? VENT? (>3' COVER; LINES >50') BOT 480 + SIDE 3cP-0 X LDNG �` TOT�ti`�4:��(JD (L x W x #) (DxLx2x#) (G/ft2) Copyright 5 1995 by S.L. Starr Town of North Andover, Massachusetts Form No. 3 * MORTOI BOARD OF HEALTH 0.tt�ao .e1.t.O O L p 19 %. .: w: ,>•41 DISPOSAL WORKS CONSTRUCTION PERMIT S�ICHUSE Applicant NAME AD RESS TELEPHONE Site Location_ �� Alt Permission is hereby granted to Construct ( ) or Repair (,4/an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. 15 ^� ��R�1 �0.4RD OF HEALTH 0V Fee D.W.C. No. �� / x "A 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* APPLICANT/ L L G—f': PHONE ZE1Z6 Z LOCATION: Assessors Map Number o PARCEL �`I` SUBDIVISION LOT (S)_ STREET �a "S ST. NUMBER—Z?30 """""OFFICIAL USE ONLY*** RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE, REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS 4 •w FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED TH DATE APPROVED —7 DATE REJECTED ., COMMENTS PUBLIC WORKS - SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE